Ring avulsion injuries managed with homodigital and heterodigital Venous Island Conduit (VIC) flaps.

Ring avulsion injury frequently results in vascular insufficiency (venous or arterial) and soft tissue injury. We report four cases requiring revascularization where venous congestion and dorsal skin cover were achieved using a composite pedicled venous flow-through flap. We have termed this a Venous Island Conduit (VIC) Flap. Two types of flaps, homodigital and heterodigital, were used, depending on the severity of the injury. The techniques and results are discussed. Venous island conduit flaps are ideally suited to the management of ring avulsion injury and have several advantages over the alternatives.

Island flaps including the Bezier type in the treatment of malignant melanoma.

Despite the trend in current surgical practice in the treatment on melanoma to produce smaller excisional defects, any technique which can introduce a surgical closure that does not require split skin grafting must be of benefit. This paper introduces and illustrates a range of island flap techniques that employ no skin grafting for the treatment of malignant melanoma defects. The new cutaneous island flap described, termed the Bezier or the French Curve, employs a double V-Y appositional closure method, thus giving a more refined reconstructive result that fits into the line of the body curves aesthetically. The design of the Bezier flap is almost identical in size and shape to the excisional defect, with a facial or muscular base for vascular support. Appropriate guidelines that determine the design and application of this island flap technique are listed. They are illustrated both diagrammatically and clinically. Other flaps illustrated include fasciocutaneous island flaps and myocutaneous island flaps that use a single V-Y flap appositional closure technique. All these flaps were designed with special reference to the dermatomes, which act as an aid memoire upon which the flaps are marked.

Fasciocutaneous island flaps for orthopaedic management in lower limb reconstruction using dermatomal precincts.

This paper describes a technique of fasciocutaneous island flaps used in reconstruction of the lower limb. It is very versatile and some 26 individual flaps in 22 patients have been used to reconstruct skeletal and soft tissue problems from the popliteal fossa to the ankle joint. These longitudinally designed flaps made up of a trilaminate of skin, subcutaneous fat and fascia are aligned within the dermatomal precincts. The most important location for such flap design is along the peroneal compartment sitting within the L5 dermatome and incorporating the superficial peroneal nerve. It can be lengthened as far as the lateral malleolus and is an excellent reconstructive method to close defects over the lower third of the tibia. The medial compartment of the leg employing the saphenous nerve (L4 dermatome) is another area for fasciocutaneous island flap reconstruction, but use is restricted to the upper two-thirds of the tibial area. Posteriorly the island flap design sits along the S2 dermatome, this time incorporating the sural nerve to reconstruct defects of the calf and can be extended to include problems of the popliteal fossa. In the overall flap technique, the age of the patient is not a contraindication and cases with peripheral vascular disease have been treated successfully. The flaps may extend up to a 5:1 ratio in dimension. The operating time can be considerably shortened.

The fasciocutaneous island flap: an extension of the angiotome concept.

The concept of the fasciocutaneous island flap (FCIF) has been established as a result of clinical experience in which over 180 cases have been compiled. It is a reconstructive design principle based on vascular and neural anatomy. Even though the flap pattern varies from region to region, it is the trilaminate composition of skin, fat and fascia supplied by fasciocutaneous, musculocutaneous and septocutaneous vessels, which is the basis for its success. Sometimes regional variations in this arrangement occur, for example: there is no deep fascia evident in the trigeminal nerve (CN-V); and in the hand and the foot, the local vascular anatomy still supports this island flap idea without any defined fascial lining. Following their use in the head and neck region, and as more successful ones were designed, the flaps seemed to follow the circumferential layout on the trunk and the longitudinal distribution in the limbs, similar to the dermatomal markouts. Such dermatomal charts thus became the basis of unexplored flap potentials with or without axial vessels. In the past, the clinical word 'angiotome' (which means a vascularized segment) has been used in world literature to describe flap vasculature with axial input. Thus flaps with a fasciocutaneous basis may well be described as a fasciocutaneous angiotome.