Innervated radial thenar flap combined with radial forearm flap transfer for thumb reconstruction

A radial thenar flap combined with radial forearm flap was used for the reconstruction of the ipsilateral thumb in four patients. Vascular supply of the combined flap was based on the radial artery and extending the vascular pedicle to the superficial palmar branch of the radial artery. The flap was sensated by the palmar branch of the superficial radial nerve. The size of the flap averaged 15 x 5 cm and the innervated region of the thenar eminence was an area approximately 5 x 3 cm located over the proximal parts of the abductor pollicis brevis and opponens pollicis muscles. The flap was transferred as a free flap in three patients and as an advancement flap in one patient. The flaps survived completely without complications. Satisfactory restoration of sensation was achieved in the flap area, as shown by 6 mm of average moving two-point discrimination. This combined flap may be a feasible reconstructive option for large palmar defects of the fingers such as degloving injuries.     

Reversed forearm island flap supplied by the septocutaneous perforator of the radial artery: anatomical basis and clinical applications

The cutaneous perforators of the radial artery adjacent to the superficial branch of the radial nerve and the lateral antebrachial cutaneous nerve were investigated, and the vascular anatomical features of the reversed forearm island flap supplied by those accompanying perforators were documented. Ten fresh cadavers were systemically injected with lead oxide, gelatin, and water. Twenty forearms were then dissected, and an overall map of the cutaneous vasculature and source vessels was constructed. The accompanying arteries were observed to lie along the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve and to nourish the skin through cutaneous branches. Vascular communication among these cutaneous vessels was evaluated, to determine the cutaneous vascular territory of the radial forearm flap. This anatomical information facilitates flap design in the forearm region. Clinical experience regarding the usefulness of the reversed forearm island flap for hand reconstruction for a series of five patients is presented.     

Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers

The distal portion of the flexor aspect of the forearm has been used as the donor site of full-thickness skin grafts, venous skin grafts, and Chinese forearm flaps. This article describes the use of a free flap harvested from the flexor aspect of the wrist and based on the superficial palmar branch of the radial artery to repair skin defects of the hand and fingers. The advantages of this flap are as follows: (1) the operative field is the same; (2) the radial artery is preserved; (3) it is thin, pliable, and hairless and thus can supply a gliding surface for tendons beneath it; (4) when it involves a palmaris longus tendon and/or the palmar cutaneous branch of the median nerve, it can be used as a vascularized tendon or nerve graft; and (5) in view of the flow-through type of the pedicle of the flap, the digital artery can be reconstructed simultaneously. However, it should be noted that a hypesthesia in the proximal central carpal area remains when the palmar cutaneous branch of the median nerve is harvested as a vascularized nerve graft. The scar of the donor site should be left in the distal wrist crease. If it is not lying in the distal wrist crease, it may suggest that the patient has tried to commit suicide.     

The harvest and clinical application of the superficial peroneal sensory nerve for grafting motor and sensory nerve defects.

Potential donor nerves for autografting are finite and usually limited to cutaneous nerves of the extremities. The superficial peroneal nerve is the major lateral branch of the common peroneal nerve that innervates the peroneus longus and brevis muscles and provides sensation to the lateral aspect of the lower leg and the dorsal foot. It has generally been overlooked as a potential donor of nerve autografts. Cadaver dissections were performed on 10 fresh lower extremity specimens to investigate the anatomic characteristics of the superficial peroneal nerve and to refine a harvesting technique for the nerve. Thirty-one patients underwent nerve grafting of 39 upper and lower extremity nerves using the superficial peroneal donor. There were nine median nerves, four ulnar nerves, two radial nerves, two brachial plexus lesions, 16 digital nerves, and six lower extremity nerves grafted. The superficial peroneal nerve provided a consistently long donor, comparable in length to the sural nerve. The anatomic pattern is consistent, the patient positioning is simple, the surgical harvesting technique is straightforward, and the donor defect is acceptable. The superficial peroneal nerve provides a safe and valuable donor nerve, particularly in cases where multiple or very long nerve grafts are required.     

Breast reconstruction using the sensate latissimus dorsi musculocutaneous flap

The authors performed immediate breast reconstruction on four patients using a sensate latissimus dorsi musculocutaneous flap accompanied by neurorrhaphy during the past 6 years. In the neurorrhaphy, the lateral cutaneous branch of the dorsal primary divisions of the seventh thoracic nerve, which controls the sensation of the myocutaneous flap, was anastomosed to the lateral cutaneous branch of the fourth intercostal nerve, which controls the sensation of the breast. The subjects consisted of four patients whose postoperative follow-up period was 14 to 29 months, with an average of 19.3 months. The control subjects consisted of 10 cases with a latissimus dorsi musculocutaneous flap whose sensory nerve had not been reconstructed (postoperative follow-up period, 15 to 49 months; average, 26.9 months). The sensory examination included tests of touch, pain, and temperature. The innervated musculocutaneous flap sensation showed gradual recovery at about 6 months after surgery and reached the value of the normal side after about 1 year. In the control subjects, the recovery was gradual after more than 1 year and reached the value of the normal side in only some of the control subjects. On the basis of these findings, the authors consider the present technique to be useful for the recovery of sensation in immediate breast reconstruction.     

The arteria radialis superficialis. An unusual variation of the arteria radialis of man and its phylogenetic significance

During the clinical investigation of 570 soldiers of the German army, we were not able to feel the pulse in 5 cases at the typical place of the radial pulse in the distal part of the forearm. In these 5 cases we were able to find a subcutaneous artery which coursed superficial to the anatomical snuffbox and crossed superficial to the tendon of the extensor pollicis longus muscle. This superficial radial artery enters the deep aspect of the palm between the first and the second metacarpale bones. In three cases we found a bilateral occurrence of this artery, the other variations were observed unilaterally, two on the right side and one on the left side of the forearm. In the family of two patients other members were found who had the same variation of the radial artery. In one of the cases an arteriography of the vessels was made to find the exact anatomical course of the observed variation. We compared our results with the literature on this variation of the radial artery and found agreement on the following course for this vessel. The radial artery divides in the distal fourth of the forearm (5-7 cm proximal to the wrist joint) into two branches. The dorsal branch courses subcutaneously over the tendon of the brachioradialis muscle and runs over the tendon of the extensor pollicis longus muscle to enter the deep aspect of the palm in the first metacarpal space. This dorsal branch courses parallel to the superficial branch of the radial nerve. The palmar branch can be regarded as the 'normal' radial artery, which continues along the medial border of the brachioradialis muscle and courses deep under the tendons of the dorsal muscles of the thumb. The rare appearance (frequency approximately 1%) of a superficial radial artery in man has probably some phylogenetic importance. This is proven by studies on the comparative anatomy of mammals. This variation of the radial artery seems to be homologous to the superficial radial artery which is described in many lower mammals. In human embryos a superficial radial artery is found as well which courses parallel to the superficial branch of the radial nerve and ends on the dorsal side of the hand. Taking all the anatomical and embryological facts into consideration we propose to name this variation of the radial artery the 'arteria radialis superficialis'.     

Anatomic basis of plantar flap design: clinical applications

Closure of plantar defects with local rotation flaps was studied in 10 patients with 11 plantar defects. Ages ranged from 15 to 66 years, and the average defect was 3.0 X 3.6 cm. Two patients were diabetics. Etiology was variable and included trauma, tumors, and breakdown in patients with anesthetic plantar surfaces. Plantar flaps were designed superficial to the plantar fascia based on the proximal plantar subcutaneous plexus blood supply. Sensation was provided by including the medial calcaneal nerve territory within the flap and by performing a limited intraneural dissection of the medial and lateral plantar nerves. Flaps were medially based, although laterally based designs are also possible when sensation is absent. The follow-up period averaged 20.8 months. Patients with normal sensation preoperatively had full sensation postoperatively and were able to bear weight on the flap without limitation. There was minor breakdown in one patient with incomplete sensation. One patient developed a hematoma. Sensate plantar flaps can be designed superficial to the plantar fascia. These flaps are durable and allow normal weight-bearing on the reconstructed surface.     

Anatomical consideration of reverse-flow island flap transfers from the midpalm for finger reconstruction.

Primary soft-tissue coverage for large palmar defects of the fingers is a difficult problem for cases in which homodigital or heterodigital flaps cannot be used. The aim of this study was to explore the vascular and neural anatomy of the midpalmar area to assess the possibility of reverse island flaps from this area. In 24 cadaver hands perfused with a silicone compound, the arterial pattern of the superficial palmar arch and common palmar digital artery was examined. The cutaneous perforating arteries and nerve branches supplying the midpalmar area were dissected, and the number, location, and arterial diameter of these branches were measured. In six other specimens, the common palmar digital artery was injected to determine the skin territory supplied by the artery. The superficial palmar arch contained the three common palmar digital arteries and its terminal branch coursed along the radial margin of the index metacarpus. This terminal branch had three to six cutaneous perforators (diameter range, 0.1 to 0.5 mm) and supplied the radial aspect of the midpalmar area located over the ulnar half of the adductor pollicis muscles. The midpalmar area was divided into two regions-the proximal and distal-according to the vascular distributions. The proximal region contained dense aponeurosis and thin subcutaneous tissue, and the cutaneous perforators were rather sparse (between three and nine) and had a small diameter (0.1 to 0.3 mm). The distal region, which had loose aponeurosis and abundant subcutaneous tissue, had a rich vascular supply from the common and proper digital artery. Perforating arteries of this region coursed frequently in an oblique fashion and the number of perforators (between eight and 15) and their arterial diameters (diameter range, 0.1 to 0.5 mm) were higher than those of the proximal region. The area of skin perfused by the common palmar digital artery was 5 x 3 cm at the distal midpalmar region. There were three to five cutaneous nerve branches from the palmar digital nerve supplying the midpalmar area. From this study, two different reverse flaps were proposed. First, a 5 x 2 cm flap from the distal midpalmar region was elevated on the basis of the common and proper palmar digital artery. Measurement of the rotation arc revealed that the pivot point of this flap was located at the proximal interphalangeal joint level and could cover the finger pulp of the digits. The second flap candidate was that from the radial aspect of the midpalm, which was supplied by the terminal branch of the superficial palmar arch. In studies with cadaver hands, connection of this artery with the deep arterial system enabled this flap to reach the thumb pulp. These flaps may be a useful reconstruction option for significant palmar soft-tissue loss of the fingers.     

Two new cutaneous free flaps: the medial and lateral thigh flaps

Two new cutaneous free-flap donor areas are described on the medial and lateral sides of the thigh. The medial thigh flap is supplied by an unnamed artery from the superficial femoral artery and is drained by the accompanying venae comitantes. Its nerve supply is from the medial femoral cutaneous nerve. The lateral thigh flap has its vascular pedicle from the third perforating artery of the profunda femoral artery and its accompanying vein. The lateral femoral cutaneous nerve provides sensation over the area. These flaps provide a large surface area of both skin and subcutaneous tissue without the usual bulk of subcutaneous fat and muscle. Their desirable features include long vascular pedicles with large vessel diameters and potential of being neurovascular flaps with specific sensory nerve supply and predictable anatomy. The principal disadvantage is that the donor site may leave a slight contour defect with primary closure or require grafting when a large flap is taken. We predict that these flaps will become important donor sites for reconstructive problems requiring resurfacing of cutaneous defects in various anatomic areas.     

Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brent's technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term "temporoparietal myofascial flap" would, therefore, be more accurate than "temporoparietal fascial flap." Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well-vascularized, four-layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required.     

Ramification pattern of intermetacarpal branches of the deep branch (ramus profundus) of the ulnar nerve in the human hand.

The branching pattern of the deep branch (ramus profundus) of the ulnar nerve and its relation with the target were analyzed in the human hand by an improved dissection method. After sending off branches to the hypothenar muscles, the r. profundus branched off an ulnar stem and a radial stem to the fourth, to the third and to the second intermetacarpal spaces, respectively, in this order, and an ulnar stem to the first to become terminal branches. The ulnar stems included an ulnar interosseous branch and a superficial articular branch in addition to a lumbrical branch in the third and fourth intermetacarpal spaces. The radial stems included only a radial interosseous branch. The branching pattern of the ulnar stems as well as its topographical relationship with the radial stems indicated a fundamental spatial arrangement of the branches in the intermetacarpal spaces: the lumbrical, superficial articular, ulnar interosseous and radial interosseous branches were arranged fundamentally in this order from ulnar to radial in each space; the first three branches may form a common trunk. The present observations demonstrate that individual nerves in the extremities may have a regular branching pattern, contrary to most of the previous observations.     

Evaluation of abdominal sensibility after TRAM flap breast reconstruction

One commonly expressed concern regarding transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction surgery is the return of sensation to the abdomen. Although many studies have focused on abdominal wall muscle incompetence or herniation, there is limited literature discussing postoperative abdominal sensation. The purpose of this study was to assess abdominal sensation a minimum of 1 year after pedicled TRAM flap surgery for breast reconstruction. Twenty-five female patients who underwent TRAM flap breast reconstruction a minimum of 1 year before the study were compared with 10 female volunteer controls. Subject and control abdomens were specifically divided into 12 zones, then assessed for superficial touch, superficial pain, temperature, and vibration using various techniques. Fischer's exact test was used for analysis with the p value set at p = 0.05. The degree to which superficial touch was affected was then tested using Semmes-Weinstein monofilaments. Student's t test was used for analysis with the p value set at p = 0.05. For all four sensory modalities, subjects were found to have decreased sensation in zones 5 and 8, the supraumbilical and infraumbilical regions. This was statistically significant. When assessed with Semmes-Weinstein monofilaments, the sensation of the subjects' abdomens was significantly decreased compared with controls. Significance was found in all zones. This study clearly demonstrates that there is a significant and persistent reduction in abdominal sensibility following TRAM flap surgery. The distribution of the deficits is consistent and involves the midline supraumbilical and infraumbilical regions. The TRAM flap has become the procedure of choice for postmastectomy autogenous breast reconstruction. It provides the plastic surgeon with a relatively safe, reliable, and aesthetically pleasing method of breast reconstruction. Since its inception, the TRAM flap and its abdominal closure have undergone numerous modifications designed to minimize donor-site morbidity and create a natural-looking breast. In addition to creating an aesthetically pleasing breast, the TRAM flap has the potential advantage of postoperative improvement in abdominal contour.     

Anatomic basis of plantar flap design

Safe planes exist for plantar incisions that minimize the possibility of subcutaneous nerve injury and are therefore useful in flap design. Nerve branch orientation in the plantar subcutaneous tissue is specific and guides dissection so as to avoid producing anesthesia in weight-bearing areas. An extensive proximal plantar subcutaneous plexus exists that permits elevation of plantar flaps in a superficial plane. This is due to the major contribution that the dorsal circulation makes to the skin of the plantar surface. The blood supply to the non-weight-bearing midsole area is not from the medial plantar artery exclusively. This is a watershed area with important lateral plantar artery and dorsalis pedis artery contributions as well. It is not necessary or desirable to base plantar flaps on a myocutaneous or fasciocutaneous supply with its required deep dissection. Local plantar flaps can be designed to include sensation and abundant blood supply without the need for "subfascial" dissection. Subcutaneous sensory plantar flaps designed in accordance with these principles promise a more ideal solution for the treatment of plantar defects.     

Reestablishment of sensitivity in the latissimus dorsi transplant through anastomosis of the thoracodorsal nerve with sensitive nerves

The question as to whether anastomosis of sensory nerves is recommended for free transplants of the myocutaneous latissimus dorsi flap, reanastomosed by microvascular surgery, remains a controversial issue. In this study, a microsurgical nerve anastomosis was performed to sensitize a latissimus dorsi transplant. To determine sensation in the transplanted tissue, six patients were examined clinically. All patients had free transplants of latissimus dorsi flaps reanastomosed by microvascular surgery after tumor resection in the oral cavity. An anastomosis of the sensible auricular magnus nerve with the motor thoracodorsalis nerve was performed. Resulting sensation was determined clinically by testing for pain, temperature, pressure, two-point discrimination, and vibration. All patients showed sensation in the latissimus dorsi flap beginning between the third and the fifth month postoperatively. Therefore, resensitization of a large and voluminous myocutaneous latissimus dorsi flap should be attempted by a nerve anastomosis in this transplant.     

Use of an innervated skin graft to provide sensation to the reconstructed heel.

An innervated skin graft--a full-thickness skin graft with its nerve supply intact--is presented. In the case described, the sural nerve was preserved and an island of skin supplied by it was transposed to provide sensation to a heel pad, which had first been reconstructed by a cross-thigh flap. This transposed sensation has allowed full activity for 3 years in a young boy wearing normal footwear. This suggests that ulceration of all, or most, heel reconstructions is due to lack of sensation and, further, that the necessary sensation can be provided by this technically simple transposition of an innervated skin graft.     

Silicone gel infiltration of a peripheral nerve and constrictive neuropathy following rupture of a breast prosthesis.

Following rupture of a subpectoral breast prosthesis, massive amounts of silicone gel migrated into the arm of a patient. The patient developed painful paresthesias and decreased sensation in the cutaneous distribution of the superficial radial nerve. Nerve conduction studies showed both an increase in distal latency and decreased amplitude in this nerve compared with the normal opposite side. Subsequent neurolysis confirmed dense fibrosis surrounding the nerve. Silicone droplets also were observed within the thickened epineurium of the median nerve, but no electrophysiologic evidence of neuropathy occurred. Multiple debridements of the subcutaneous tissue of the arm were necessary. In one of these specimens, histologic sections demonstrated silicone gel infiltration of a subcutaneous nerve. This is the first reported case of silicone gel infiltration of a nerve and constrictive neuropathy associated with a prosthesis rupture.     

The blood supply of the reverse temporalis muscle flap: anatomic study and clinical implications

Although the reverse temporalis muscle flap has been used clinically, the exact vascular connection between the superficial and deep temporal vessels has not been clearly defined. The purpose of this study was to investigate the vascular territory of the reverse temporalis muscle supplied by the superficial temporal vessels. Six cadaver heads were studied using a colored lead oxide injection through the superficial temporal artery. The specimens were examined macroscopically and radiographically. The reverse temporalis muscle flap was then applied to a clinical case presenting with traumatic anterior skull base defect communicating with the nasal cavity. The cadaver specimens demonstrated that the superficial temporal artery formed an average 1.3 +/- 0.2 cm in width of dense vascular zone, which was located within 1.8 cm below the superior temporal line. The dense vascular network further perfused the anterior and posterior deep temporal arteries and the muscular branch of the middle temporal artery to supply the temporalis muscle. The mean perfused area of the temporalis muscle was 83 percent, ranging from 79 to 89 percent, in five cadaver heads. One cadaver revealed only 55 percent of perfused area in the absence of the muscular branch of the middle temporal artery. The consistent area without perfusion was located in the distal third of the posterior portion of the reverse temporalis muscle. In clinical cases, the reverse temporalis muscle flap was used successfully to obliterate the anterior skull base defect without evidence of muscle flap necrosis. The exact blood supply to the distal third of the posterior portion of the reverse temporalis muscle flap needs to be investigated further in vivo. Particular attention was paid to the inclusion of the muscular branch of the middle temporal artery in this flap to augment the blood supply to the temporalis muscle.     

Penile reconstruction: combined use of an innervated forearm osteocutaneous flap and big toe pulp

The use of a radial forearm flap has become the most popular method to reconstruct a phallus in recent years. This method of reconstruction, however, is plagued with problems such as urethral fistula and loss of phallic girth as a result of tissue atrophy, rendering a phallic contour that is cosmetically unsatisfactory. We had the opportunity of modifying the technique of penile reconstruction using a forearm osteocutaneous flap to minimize these problems. Specifically, a segment of the big toe pulp is used to reconstruct a glans penis. Sensory restoration in the "glans" and "penile shaft" is restored by coapting the digital and the antebrachial nerves to the penile nerve remnants. A segment of flexor carpi radialis muscle is included in the design of a forearm flap to reinforce the coaptation site of the urethral tract. An arteriovenous shunt is incorporated in the shaft as a mechanism to elicit erection of the penis by compressing the root of the neophallus. We had used these technical modifications in a 51-year-old man who had undergone penile amputation because of cancer. The cosmetic appearance and erotic and tactile sensation in the shaft and glans were proper and satisfactory at the end of fourth year after the surgery. The coital function was also satisfactory.     

Reconstruction of heel and sole defects by free flaps

One latissimus dorsi musculocutaneous flap and five radial forearm flaps were used in reconstruction of weight-bearing parts of the heel and sole, the follow-up period being 7 to 38 months. Additional injuries such as forefoot amputations or amputations of the other leg were present in four patients. There was no flap loss. The latissimus dorsi flap proved to be too bulky and showed recurrent ulcerations, several reoperations were necessary, and definite healing has not occurred. The five forearm flaps gave good results, with a walking range from 2 hours to unimpeded walking. Complications included fissuring at the edges of one large flap and a local infection which was successfully treated. Cutaneous sensation returned in all but one flap, where it was reduced preoperatively due to a meningomyelocele. The results indicate that the fasciocutaneous radial forearm flap should be taken into consideration for reconstruction of weight-bearing areas of the heel and sole. Shortcomings of this flap include an unsightly donor defect and possible hair growth on the flap.