Download PDF
J Reconstr Microsurg 2019; 35(02): 090-096
DOI: 10.1055/s-0038-1667167
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Evaluating Venous Drainage in Reverse Flow Pedicles: Available Evidence and Mechanisms

Sarah Karinja
1   Columbia University College of Physicians and Surgeons, Columbia University, New York, New York, United States
,
Johanna Riesel
2   Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
,
Matthew L. Iorio
3   Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, University of Colorado, Aurora, Colorado, United States
› Author Affiliations
Further Information

Publication History

20 January 2018

22 May 2018

Publication Date:
29 July 2018 (online)

Also available at
    Permissions and Reprints

Abstract

Background The anatomy and physiology of venous drainage in the reversed flow vascular pedicle is controversial and there have been few well-designed, controlled studies to effectively evaluate the physiology. We evaluated the available evidence for venous drainage to synthesize the conclusions of these studies, and to identify areas in need of further research.

Methods Electronic databases were searched for articles published from January 1, 1950 to November 1, 2017. A total of 316 citations were screened for inclusion. Fifty articles met inclusion criteria and underwent review, yielding 12 articles for final data analysis. Three principal study types were found: human cadaveric (7), animal (3), human clinical (1), and mixed (1).

Results We identified two main theories regarding the mechanism of venous drainage in reverse flow flaps. The “avalvular bypass” theory is based on the findings of intact valves of the venae comitantes, and venous outflow through the crossover pattern of the communicating branches and bypass pattern of the collateral branches. Alternatively, the “valvular incompetence” theory implies that pedicle dissection, proximal ligation, and insetting of the flap cause physiologic changes, such as increased venous pressure, denervation, and simultaneous proximal and distal filling, which together result in valvular insufficiency.

Conclusion The mechanism by which retrograde venous outflow occurs in reverse flow flaps remains controversial. Nonetheless, a few well-designed studies have contributed to the understanding of venous anatomy and outflow. Most likely, the true mechanism is based on venous outflow that occurs via the “avalvular bypass” route initially and the “valvular incompetence” route later.

Keywords

extremity reconstruction - venous outflow - flap congestion - vein

Disclosures

The authors did not receive any funding for this study. The authors have no financial interests in any of the products or techniques mentioned and have received no external support related to this study


 

  • References

  • 1 Tagliacozzi G. The Surgery of Deformities by Transplantation. Venetiis: G. Bindonum; 1597
    Google Scholar
  • 2 Bostwick J, Briedis J, Jurkiewicz MJ. The reverse flow temporal artery island flap. Clin Plast Surg 1976; 3 (03) 441-445
    CrossrefPubMedGoogle Scholar
  • 3 Biemer E, Stock W. Total thumb reconstruction: a one-stage reconstruction using an osteo-cutaneous forearm flap. Br J Plast Surg 1983; 36 (01) 52-55
    CrossrefPubMedGoogle Scholar
  • 4 Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg [Br] 1988; 13 (02) 130-135
    CrossrefPubMedGoogle Scholar
  • 5 Yoshimura M, Imura S, Shimamura K, Yamauchi S, Nomura S. Peroneal flap for reconstruction in the extremity: preliminary report. Plast Reconstr Surg 1984; 74 (03) 402-409
    CrossrefPubMedGoogle Scholar
  • 6 Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg 1993; 92 (02) 285-293
    CrossrefPubMedGoogle Scholar
  • 7 Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992; 89 (06) 1115-1121
    CrossrefPubMedGoogle Scholar
  • 8 Rajacic N, Darweesh M, Jayakrishnan K, Gang RK, Jojic S. The distally based superficial sural flap for reconstruction of the lower leg and foot. Br J Plast Surg 1996; 49 (06) 383-389
    CrossrefPubMedGoogle Scholar
  • 9 Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg 2002; 109 (02) 583-591
    CrossrefPubMedGoogle Scholar
  • 10 Guyuron B, Dinner MI, Dowden RV, Labandter HP. Muscle flaps and the vascular detour principle: the soleus. Ann Plast Surg 1982; 8 (02) 132-140
    CrossrefPubMedGoogle Scholar
  • 11 Wee J. Reconstruction of the leg and foot with the reverse-pedicled anterior fasciocutaneous flap. Presented in: The 5th Congress of the European Section of International Confederation of Plastic and Reconstructive Surgery. Stockholm: Sweden; June 16–20; 1985
    PubMedGoogle Scholar
  • 12 Chuenkongkaew T, Chayakula N, Srirojanakul S. Reverse-flow posterior tibial island flap: preliminary report of a new fasciocutaneous flap. Ann Plast Surg 1990; 25 (04) 306-311
    CrossrefPubMedGoogle Scholar
  • 13 Satoh K, Sakai M, Hiromatsu N, Ohsumi N. Heel and foot reconstruction using reverse-flow posterior tibial flap. Ann Plast Surg 1990; 24 (04) 318-327
    CrossrefPubMedGoogle Scholar
  • 14 La Scala GC, Carroll SM, Forrest CR, Zuker RM. Use of a mechanical leech in a reverse-flow radial forearm flap: case report. J Reconstr Microsurg 2001; 17 (05) 335-340
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Orgill DP, Pribaz JJ. Reverse peroneal flaps: two surgical approaches. Ann Plast Surg 1994; 33 (01) 17-22
    CrossrefPubMedGoogle Scholar
  • 16 Akinci M, Ay S, Kamiloglu S, Erçetin O. The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases. J Plast Reconstr Aesthet Surg 2006; 59 (02) 148-152
    CrossrefPubMedGoogle Scholar
  • 17 Yildirim S, Avci G, Akan M, Aköz T. Complications of the reverse homodigital island flap in fingertip reconstruction. Ann Plast Surg 2002; 48 (06) 586-592
    CrossrefPubMedGoogle Scholar
  • 18 Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse sural artery flap: caveats for success. Ann Plast Surg 2002; 48 (05) 496-504
    CrossrefPubMedGoogle Scholar
  • 19 Buluç L, Tosun B, Sen C, Sarlak AY. A modified technique for transposition of the reverse sural artery flap. Plast Reconstr Surg 2006; 117 (07) 2488-2492
    CrossrefPubMedGoogle Scholar
  • 20 Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg 1994; 93 (05) 1012-1020
    CrossrefPubMedGoogle Scholar
  • 21 Yilmaz M, Karatas O, Barutcu A. The distally based superficial sural artery island flap: clinical experiences and modifications. Plast Reconstr Surg 1998; 102 (07) 2358-2367
    CrossrefPubMedGoogle Scholar
  • 22 de Almeida OM, Monteiro Jr AA, Neves RI. , et al. Distally based fasciocutaneous flap of the calf for cutaneous coverage of the lower leg and dorsum of the foot. Ann Plast Surg 2000; 44 (04) 367-373 , discussion 373–374
    CrossrefPubMedGoogle Scholar
  • 23 del Pinal F, Taylor GI. The deep venous system and reverse flow flaps. Br J Plast Surg 1993; 46 (08) 652-664
    CrossrefPubMedGoogle Scholar
  • 24 Chang SM, Gu YD, Li JF. Comparison of venous drainage in reverse-flow island flaps: an experimental study of the rabbit saphenous fasciocutaneous flap. Ann Plast Surg 2003; 51 (02) 177-181
    CrossrefPubMedGoogle Scholar
  • 25 Jing ZZ, Chang SM, You MR, Yu GR. Venous drainage in retrograde island flap: an experimental study using fluorescence tracing technique. Microsurgery 2010; 30 (01) 50-54
    CrossrefPubMedGoogle Scholar
  • 26 Piza-Katzer H, Weinstabl R, Firbas W. The venous blood-flow of the flexor aspect of the human forearm. Clinical relevance to the distally-pedicled forearm flap. Surg Radiol Anat 1988; 10 (03) 229-232
    CrossrefPubMedGoogle Scholar
  • 27 Tanaka Y, Tajima S. The influence of arterial inflow and venous outflow on the survival of reversed-flow island flaps: an experimental study. Plast Reconstr Surg 1997; 99 (07) 2021-2029
    CrossrefPubMedGoogle Scholar
  • 28 Imanishi N, Nakajima H, Fukuzumi S, Aiso S. Venous drainage of the distally based lesser saphenous-sural veno-neuroadipofascial pedicled fasciocutaneous flap: a radiographic perfusion study. Plast Reconstr Surg 1999; 103 (02) 494-498
    CrossrefPubMedGoogle Scholar
  • 29 Nakajima H, Imanishi N, Aiso S, Fujino T. Venous drainage of the radial forearm and anterior tibial reverse flow flaps: anatomical and radiographic perfusion studies. Br J Plast Surg 1997; 50 (06) 389-401
    CrossrefPubMedGoogle Scholar
  • 30 Satoh K, Okabe K, Matsui A. Anatomical consideration for the venous drainage of the reverse-flow island flaps in the extremities (in the upper versus in the lower extremity). Eur J Plast Surg 1989; (12) 171-174
    PubMedGoogle Scholar
  • 31 Timmons MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg 1986; 77 (01) 80-92
    CrossrefPubMedGoogle Scholar
  • 32 Torii S, Namiki Y, Mori R. Reverse-flow island flap: clinical report and venous drainage. Plast Reconstr Surg 1987; 79 (04) 600-609
    CrossrefPubMedGoogle Scholar
  • 33 Lin SD, Lai CS, Chiu CC. Venous drainage in the reverse forearm flap. Plast Reconstr Surg 1984; 74 (04) 508-512
    CrossrefPubMedGoogle Scholar
  • 34 Timmons MJ. William Harvey revisited: reverse flow through the valves of forearm veins. Lancet 1984; 2 (8399): 394-395
    PubMedGoogle Scholar
  • 35 del Piñal F. Venous drainage of the reverse-flow flap. Plast Reconstr Surg 1998; 102 (01) 267-268
    CrossrefPubMedGoogle Scholar
  • 36 Valdatta L, Congiu T, Thione A, Buoro M, Faga A, Dall'Orbo C. Do superficial epigastric veins of rats have valves?. Br J Plast Surg 2001; 54 (02) 151-153
    CrossrefPubMedGoogle Scholar
  • 37 Costa Teixeira RK, Yamaki VN, Valente AL. , et al. Do the femoral veins of female Wistar rats have valves?. J Vasc Bras 2015; 14 (04) 368-371
    CrossrefPubMedGoogle Scholar