American Association for Hand Surgery
Theme: Beyond Innovation

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Arterialized Venous Free Flaps with Shunt Restriction for Soft Tissue Reconstruction of the Hand and Digits
John T Heineman, MD, MPH; University of Virginia, Charlottesville, VA; Andrei Odobescu, MD, CM
University of Iowa, Iowa City, IA

Background:
Arterialized venous free flaps are useful in reconstructing small soft tissue defects of the hand and digits. Venous free flaps were first introduced Nakayama et al. (1981), yet they remain poorly understood and underutilized. The wide variety of flaps grouped within the "venous flap" category and their abnormal flap physiology are likely reasons for their continued low popularity. Lin et al. (2010) first introduced the concept of shunt restriction, which allows venous flaps to more closely mimic the physiology of normal flaps through enhanced peripheral perfusion and reduced venous congestion.
Methods:
Our study was a retrospective review of eight patients who underwent arterialized venous free flaps for tissue defects in the hand, including four defects to the digits. All patients were treated at the University of Iowa by a single surgeon from February 2017 to May 2018. The flap design for all patients was artery-vein (A-V) configuration with arterialized vein retrograde, outflow vein antegrade, and connecting branch clipped for shunt restriction. Flap sizes ranged from 2.5 x 3 cm to 6 x 8 cm. All patients underwent general anesthesia. Average operating time was 185 minutes. Outcomes analyzed included flap edema, venous congestion, sloughing, flap survival, donor site complications, and length of hospital stay.
Results:
Moderate flap edema, venous congestion, and sloughing were seen in one of eight patients. All flaps were hyperemic when compared to the surrounding skin; however, capillary refill remained at approximately 2 seconds. Seven patients had complete flap survival with one patient having 90% survival. Six patients had no donor site complications with one patient having a wide scar and another having partial skin graft loss. The average length of stay was 3.3 days.
Discussion:
We show that arterialized venous free flap design with A-V configuration arterialized vein retrograde, outflow vein antegrade, and connecting branch clipped for shunt restriction is effective and consistent for reconstruction of soft tissue defects of the hand and digits.
References:
Lin et al. The shunt-restricted arterialized venous flap for hand/digit reconstruction: Enhanced perfusion, decreased congestion, and improved reliability. J Trauma. 2010; 69:399-404.
Nakayama et al. Flaps nourished by arterial inflow through venous system: An experimental investigation. Plas Reconstr Surg. 1981; 67(3):328-334.


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