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An arterialised venous flap using the long saphenous vein
BritishJoumal of Plastic
II 9911.44.23-26
An arterialised venous flap using the long saphenous vein I. Koshima,
S. Soeda, Y. Nakayama,
H. Fukuda
Departments of Plastic and Reconstructive of Tsukuba, Ibaraki, Japan
and J. Tanaka
Surgery and Oral Surgery, Institute of Clinical Medicine, University
SUMMARY. Free arterialised venous flaps and an arterialised osteocutaneous venous flap, fed by an arterialised long saphenous vein, were used successfully in three cases. This flap has a larger skin territory tban those previously reported and the incorporation of bone into such a flap has not been reported before.
Since Nakayama et al. (1981) reported his experimental work on the venous flap, a clinical application of the arterialised venous flap was reported by Yoshimura (1984). Thereafter, several authors (Yoshimura et al., 1987; Inoue et al., 1989; Nakashima, 1989) have further developed its clinical application. At the present time, however, reports regarding clinical applications of the arterialised venous flap have been very few. Furthermore, the flaps used by these authors were very small and were transferred only for defects on the extremities. To increase the applications of this type of flap, an arterialised venous flap using the long saphenous vein was designed, to repair large skin defects and even bone defects. Three cases are reported in which free arterialised venous flaps were used successfully.
et al., 1990). One branch of the communicating vein reaches the skin and the other lies in contact with the medial aspect of the tibia. By including this communicating vein in the flap it is possible to obtain an osteocutaneous flap because the bone appears to survive by the retrograde circulation of arterialised blood from the cutaneous branch to the bony branch of this communicating vein (Fig. 1). Case reports Case 1 A 48-year-old man complained of severe pain, scar contracture and a full thickness defect on the instep of his right foot (Fig. 2A). After releasing the compression of the medial plantar nerve and the skin contracture, the defect was covered with a venous flap measuring 8 x 5 cm, which was obtained from the medial aspect of the knee (Fig. 2B). The recipient artery was the dorsalis pedis artery and the recipient vein was the concomitant vein of the posterior tibia1 artery. The donor defect was covered with a split skin graft (Fig. 2C, D).
Operative technique The long saphenous vein runs up the medial aspect of the leg. A skin flap is first outlined on the medial side of the proximal lower leg. The first incision is made in front of the medial malleolus to expose the long saphenous vein, and extended upwards through the mid-medial line of the lower leg. After the presence of the vein under the outlined flap is confirmed, the incision is extended around the flap. After the distal and proximal ends of the vein are dissected, the distal end is transected at the level of the medial malleolus. Thereafter the flap including the vein is raised carefully, including the deep fascia. Transecting the proximal end of the dissected vein provides an afferent venous perfusion flap which can be brought to the prepared recipient site. Finally, this venous flap is arterialised, the distal end of the vein being anastomosed to the recipient artery and the proximal end joined to the recipient vein. Where there is a bony defect, the flap can be elevated with part of the tibia as an osteocutaneous flap. A communicating vein, originating from the posterior tibia1 venae comitantes and passing upwards across the medial border of the tibia, divides just above the fascia at the middle of the lower leg (Hung
Case 2 A 78-year-old woman suffered a full thickness defect in the dorsal aspect of her tongue, resulting from glossectomy for tongue cancer (Fig. 3A). A venous flap measuring 9 x 4 cm
Fig. 1 Fipre l-Schematic drawing for obtaining an osteocutaneous venous flap. (A) A communicating branch [A] from the posterior tibia1 venae comitantes [T] divides into two branches at the fascia level; one branch reaches the skin and the other connects to the medial portion of the tibia. (B) Ligation of the proximal side of the communicating branches can make the tibia1 bone graft [G] vascularised by retrograde circulation coming through the arterialised long saphenous vein [VI. 23
British Journal of Plastic Surgerv
24
Fig. 2 Figure t-Case 1. (A) Skin defect and contracture in the medial saphenous vein. (C)Seven months after surgery. (D) Donor scar.
plantar
region.
(B) The flap measuring
8 x 5 cm, including
only the long
Fig. 3 Figure &Case vein. (C)Three
2. (A) Full thickness defect of the anterior months after transfer.
dorsal aspect of the tongue.
(B) Venous flap measuring
9 x 4 cm raised with the
An Arterialised Venous Flap using the Long Saphenous Vein
25
Fignre 4-Case 3. (A) Skin defect and osteomyelitis of the carpal bones in the replanted hand. (B) Osteocutaneous venous flap including the segment of tibia, measuring 11 x 7 cm, elevated with the vein. (C) A perforator, running through the space between the medial tibia and the anterior tibial muscle. divided into two branches: one nourished the skin and the other [arrow] fed the tibia [T]. (D) Five months after the transfer. (E) Bone scan 2 weeks after surgery shows good vascularity of the transferred bone graft.
was transferred to fill the defect (Fig. 3B, C). The recipient artery was the superior thyroid artery and the recipient vein was the external jugular vein. The donor defect was closed directly. Case 3 A 45-year-old man sustained amputation of his left hand due to severe crushing in a press machine. A defect of the palmar arterial arch was reconstructed with the use of the dorsal venous arch of the foot. Following this replantation, however, a skin defect involving osteomyelitis of the carpal hones remained in the anatomical snuff box (Fig. 4A). An osteocutaneous venous flap measuring 11 x 7 cm and including a segment of the tibia was obtained from the medial aspect of the leg (Fig. 4B, C). The infected carpal bones were replaced by the tibia1 hone graft and the skin defect was covered with the flap. The radial artery at the wrist was chosen as the recipient artery and the concomitant vein of the ulnar artery was used as the recipient vein (Fig. 4D). The donor defect was covered with a split skin graft.
Results Postoperatively, the colour of the flap was pink in the first week in Case 1 only, while that of the other flaps was relatively white. There was slight oedema in all of them but nothing resembling engorgement or superficial skin necrosis in any of the flaps. All patients were satisfied with the results obtained with these flaps and had no major problems such as flap necrosis, oral fistula or dysfunction of the donor leg. There has been no resorption of the transferred tibia1 bone graft in Case 3, and good vascularisation of the grafted bone was apparent on postoperative bone scans (Fig. 4E).
Although the postoperative electrocardiographical findings of these patients were normal, the proximal ends of the anastomosed artery of these flaps were ligated about one year after surgery. In spite of ligating the pedicles there have been no complications or even colour changes in these flaps.
British Journal of Plastic Surgery
26 Discussion
References
Recently, experimental and clinical investigations of the “flow-through” venous flap, which has only venous flow, have created much interest (Baek et al., 1985; Thatte and Thatte, 1987a, b; Amarante et al., 1988; Foucher and Norris, 1988; Thatte et al., 1989a, b). However, several authors (Nakayama et al., 1981; Fukuietal., 1989; Inoueetal., 1989) havedocumented, from experimental work, that the arterialised venous flap is more reliable. Regarding the donor site of the arterialised venous flap, it has been reported that the distal third of the flexor side of the forearm (Yoshimura, 1984; Yoshimura et al., 1987; Inoue et al., 1989; Nakashima, 1989), the dorsum of the foot (Yoshimura, 1984; Yoshimura et al., 1987; Inoue et al., 1989) and the distal half of the anterior aspect of the lower leg (Nakashima, 1989) were suitable for ensuring vascularity. However, these donor sites in the distal parts of the extremities are exposed and are too restricted to obtain large flaps. The proximal half of the medial aspect of the lower leg is more suitable from the cosmetic point of view and for the possibility of obtaining a large flap. As regards the skin territory of the arterialised venous flap, Nakashima (1989) demonstrated that the maximum size of the flap, obtained from the forearm, was 8 cm long and 3 cm wide. We have shown that a flap measuring 11 x 7 cm or more can survive without even superficial necrosis. Regarding the haemodynamics of this flap, as mentioned by Chavoin et al. (1987) it is considered that vasoparalysis after surgical denervation may account for the failure of the venous valves and opening of arteriovenous shunts so that the arterial inflow can pass in a reverse direction against the intact venous valves through the shunt to reach the arterioles, and finally the flow from this arterial system may pass through the capillaries to the distal drainage vein (Thatte et al., 1989b). The advantages of this flap are that the vascular pedicle, the long saphenous vein, is anatomically constant, long and large and the elevation of the flap is technically safe. There is no possibility of the postoperative vascular problem and functional limitation of the donor leg which are potential complications of the removal of an artery. Furthermore, its greatest advantage is that the elevation of the flap takes a very short time, less than 15 minutes. There is also the possibility of an osteocutaneous flap involving a vascularised tibia graft such as in Case 3. However, the authors accept that a much larger bone segment would need to be used to confirm its good vascularity. This flap, including the saphenous nerve, could also be used as a vascularised neurocutaneous flap for the one-stage reconstruction of a skin defect accompanied with nerve loss. The possible disadvantages of this flap are that postoperatively there were temporary lymphoedema and paraesthesia in the donor leg after sacrificing the lymphatic vessels and the saphenous nerve. The pedicle veins become an arteriovenous shunt and could lead to heart failure. In our cases, however, there were no abnormal findings in the postoperative ECGs.
Amaraate, J., Costa, H., Reis, J. and Soarea, R. (1988). Venous skin flaps: an experimental study and report of two clinical distal island flaps. British Journal of Plostic Surgery, 41, 132. Baek, S. M., Weinburg, H., Song, Y., Park, C. G. and BBIer, H. F. (1985). Experimental studies in the survivalof venous island flaps without arterial inflow. Plastic and Reconstructive Surgery, 75,88. Chavohr, J. P., Rouge, D.,Vachaud, M., Boeeplon, H. audCostaglioia, M. (1987). Islands flaps with an exclusively venous pedicle. A report of eleven cases and a preliminary haemodynamic study. British Journal of Plastic Surgery, 40, 149. Foucher, G. and Norris, R. W. (1988). The venous dorsal digital island flap or the “neutral” flap. British Journal of Piostic Surgery, 41,337. Fukui, A., Inada, Y., Maeda, M., Tam& S., Miznmoto, S., Yaxima, H. and Sempuku, T. (1989). Pedicled and “flow-through” venous flaps: clinical applications. JournalofReconstructive Microsurgery, 5,235. Hung, L. K., Cheo, S. Z. and Leung, P. C. (1990). Resurfacing difficult wounds: selective use of the posterior tibia1 flap. Journal of Reconstructive Microsurgery, 6, 13. Inoue, G., Nakamura, R., Maeda, N. and Suzuki, K. (1989). Arterialized venous flap coverage of a big toe defect resulting from a wrap-around flap transfer. Japanese Journol of Plastic and Reconstructive Surgery, 32,1013. Nakashbna, H. (1989). Experiences with the venous skin graft. Japanese Journalof Plastic and Reconstructive Surgery, 32, 11. Nakayama, Y., Soeda, S. and KasaI, Y. (1981). Flaps nourished by arterial inflow through the venous system; an experimental investigation. Plastic and Reconstructive Surgery, 67,328. Thatte, R. L. and Thatte, M. R. (1987a). A study of the saphenous venous island flap in the dog without arterial inflow using a nonbiological conduit across a part of the length of the vein. British Journal of Plastic Surgery, 40, 11. Thatte, R. L. and Thatte, M. R. (1987b). Cephalic venous flap. British Journal of Plastic Surgery, 40, 16. Thatte, M. R., Kamdar, N. B., Khakkar, M. A., Varade, M. A. and Thatte, R. L. (1989a). Static and dynamic computerised radioactive tracer studies, vital dye staining and theoretical mathematical calculations to ascertain the mode of survival of single cephalad channel venous island flaps. British Joumalof Plastic Surgery, 42, 405. Thatte, M. R., Kmnta, S. M., Purohit, S. K., Deabpaade, S. N. and Thatte, R. L. (1989b). Cephalic venous flap: a series of 8 cases and a preliminary report on the use of 99mTc labelled RBCs to study the saphenous venous flap in dogs. British Joumol of Plastic Surgery, 42, 193. Yoshimura, M. (1984). A venous skin graft in the treatment of injured fingers. Joponese Journal of Plastic and Reconstructive Surgery, 27,474. Yoshimura, M., Shimada, T., Imura, S., Shimamura, K. and Yamauchi, S. (1987). The venous skin graft method for repairing skin defects of the fingers. Plastic and Reconstructive Surgery, 79, 243.
The Authors Isao Koahhna, MD, Associate Professor of Plastic and Reconstructive Surgery, Kawasaki Medical School, Okayama; formerly Assistant Professor of Plastic and Reconstructive Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki. Shugo Soeda, MD, Professor of Plastic and Reconstructive Surgery, University of Tsukuba. YoshIo Nakayama, MD, Assistant Professor of Plastic and Reconstructive Surgery, University of Tsukuba. Hiroshi Fukuda, DDS, Assistant Professor of Oral Surgery, University of Tsukuba. JunsukI Taaaka, MD, Chief of Orthopaedic Surgery, Natogaya Hospital, Chiba. Requests for reprints to: Dr Isao Koshima, Department of Plastic and Reconstructive Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki City, Okayama, 701-01 Japan, Paper received 5 March 1990. Accepted 18 June 1990. This paper was presented at the 16th Annual Japanese Society of Reconstructive Microsurgery.
Meeting
of the
II 9911.44.23-26
An arterialised venous flap using the long saphenous vein I. Koshima,
S. Soeda, Y. Nakayama,
H. Fukuda
Departments of Plastic and Reconstructive of Tsukuba, Ibaraki, Japan
and J. Tanaka
Surgery and Oral Surgery, Institute of Clinical Medicine, University
SUMMARY. Free arterialised venous flaps and an arterialised osteocutaneous venous flap, fed by an arterialised long saphenous vein, were used successfully in three cases. This flap has a larger skin territory tban those previously reported and the incorporation of bone into such a flap has not been reported before.
Since Nakayama et al. (1981) reported his experimental work on the venous flap, a clinical application of the arterialised venous flap was reported by Yoshimura (1984). Thereafter, several authors (Yoshimura et al., 1987; Inoue et al., 1989; Nakashima, 1989) have further developed its clinical application. At the present time, however, reports regarding clinical applications of the arterialised venous flap have been very few. Furthermore, the flaps used by these authors were very small and were transferred only for defects on the extremities. To increase the applications of this type of flap, an arterialised venous flap using the long saphenous vein was designed, to repair large skin defects and even bone defects. Three cases are reported in which free arterialised venous flaps were used successfully.
et al., 1990). One branch of the communicating vein reaches the skin and the other lies in contact with the medial aspect of the tibia. By including this communicating vein in the flap it is possible to obtain an osteocutaneous flap because the bone appears to survive by the retrograde circulation of arterialised blood from the cutaneous branch to the bony branch of this communicating vein (Fig. 1). Case reports Case 1 A 48-year-old man complained of severe pain, scar contracture and a full thickness defect on the instep of his right foot (Fig. 2A). After releasing the compression of the medial plantar nerve and the skin contracture, the defect was covered with a venous flap measuring 8 x 5 cm, which was obtained from the medial aspect of the knee (Fig. 2B). The recipient artery was the dorsalis pedis artery and the recipient vein was the concomitant vein of the posterior tibia1 artery. The donor defect was covered with a split skin graft (Fig. 2C, D).
Operative technique The long saphenous vein runs up the medial aspect of the leg. A skin flap is first outlined on the medial side of the proximal lower leg. The first incision is made in front of the medial malleolus to expose the long saphenous vein, and extended upwards through the mid-medial line of the lower leg. After the presence of the vein under the outlined flap is confirmed, the incision is extended around the flap. After the distal and proximal ends of the vein are dissected, the distal end is transected at the level of the medial malleolus. Thereafter the flap including the vein is raised carefully, including the deep fascia. Transecting the proximal end of the dissected vein provides an afferent venous perfusion flap which can be brought to the prepared recipient site. Finally, this venous flap is arterialised, the distal end of the vein being anastomosed to the recipient artery and the proximal end joined to the recipient vein. Where there is a bony defect, the flap can be elevated with part of the tibia as an osteocutaneous flap. A communicating vein, originating from the posterior tibia1 venae comitantes and passing upwards across the medial border of the tibia, divides just above the fascia at the middle of the lower leg (Hung
Case 2 A 78-year-old woman suffered a full thickness defect in the dorsal aspect of her tongue, resulting from glossectomy for tongue cancer (Fig. 3A). A venous flap measuring 9 x 4 cm
Fig. 1 Fipre l-Schematic drawing for obtaining an osteocutaneous venous flap. (A) A communicating branch [A] from the posterior tibia1 venae comitantes [T] divides into two branches at the fascia level; one branch reaches the skin and the other connects to the medial portion of the tibia. (B) Ligation of the proximal side of the communicating branches can make the tibia1 bone graft [G] vascularised by retrograde circulation coming through the arterialised long saphenous vein [VI. 23
British Journal of Plastic Surgerv
24
Fig. 2 Figure t-Case 1. (A) Skin defect and contracture in the medial saphenous vein. (C)Seven months after surgery. (D) Donor scar.
plantar
region.
(B) The flap measuring
8 x 5 cm, including
only the long
Fig. 3 Figure &Case vein. (C)Three
2. (A) Full thickness defect of the anterior months after transfer.
dorsal aspect of the tongue.
(B) Venous flap measuring
9 x 4 cm raised with the
An Arterialised Venous Flap using the Long Saphenous Vein
25
Fignre 4-Case 3. (A) Skin defect and osteomyelitis of the carpal bones in the replanted hand. (B) Osteocutaneous venous flap including the segment of tibia, measuring 11 x 7 cm, elevated with the vein. (C) A perforator, running through the space between the medial tibia and the anterior tibial muscle. divided into two branches: one nourished the skin and the other [arrow] fed the tibia [T]. (D) Five months after the transfer. (E) Bone scan 2 weeks after surgery shows good vascularity of the transferred bone graft.
was transferred to fill the defect (Fig. 3B, C). The recipient artery was the superior thyroid artery and the recipient vein was the external jugular vein. The donor defect was closed directly. Case 3 A 45-year-old man sustained amputation of his left hand due to severe crushing in a press machine. A defect of the palmar arterial arch was reconstructed with the use of the dorsal venous arch of the foot. Following this replantation, however, a skin defect involving osteomyelitis of the carpal hones remained in the anatomical snuff box (Fig. 4A). An osteocutaneous venous flap measuring 11 x 7 cm and including a segment of the tibia was obtained from the medial aspect of the leg (Fig. 4B, C). The infected carpal bones were replaced by the tibia1 hone graft and the skin defect was covered with the flap. The radial artery at the wrist was chosen as the recipient artery and the concomitant vein of the ulnar artery was used as the recipient vein (Fig. 4D). The donor defect was covered with a split skin graft.
Results Postoperatively, the colour of the flap was pink in the first week in Case 1 only, while that of the other flaps was relatively white. There was slight oedema in all of them but nothing resembling engorgement or superficial skin necrosis in any of the flaps. All patients were satisfied with the results obtained with these flaps and had no major problems such as flap necrosis, oral fistula or dysfunction of the donor leg. There has been no resorption of the transferred tibia1 bone graft in Case 3, and good vascularisation of the grafted bone was apparent on postoperative bone scans (Fig. 4E).
Although the postoperative electrocardiographical findings of these patients were normal, the proximal ends of the anastomosed artery of these flaps were ligated about one year after surgery. In spite of ligating the pedicles there have been no complications or even colour changes in these flaps.
British Journal of Plastic Surgery
26 Discussion
References
Recently, experimental and clinical investigations of the “flow-through” venous flap, which has only venous flow, have created much interest (Baek et al., 1985; Thatte and Thatte, 1987a, b; Amarante et al., 1988; Foucher and Norris, 1988; Thatte et al., 1989a, b). However, several authors (Nakayama et al., 1981; Fukuietal., 1989; Inoueetal., 1989) havedocumented, from experimental work, that the arterialised venous flap is more reliable. Regarding the donor site of the arterialised venous flap, it has been reported that the distal third of the flexor side of the forearm (Yoshimura, 1984; Yoshimura et al., 1987; Inoue et al., 1989; Nakashima, 1989), the dorsum of the foot (Yoshimura, 1984; Yoshimura et al., 1987; Inoue et al., 1989) and the distal half of the anterior aspect of the lower leg (Nakashima, 1989) were suitable for ensuring vascularity. However, these donor sites in the distal parts of the extremities are exposed and are too restricted to obtain large flaps. The proximal half of the medial aspect of the lower leg is more suitable from the cosmetic point of view and for the possibility of obtaining a large flap. As regards the skin territory of the arterialised venous flap, Nakashima (1989) demonstrated that the maximum size of the flap, obtained from the forearm, was 8 cm long and 3 cm wide. We have shown that a flap measuring 11 x 7 cm or more can survive without even superficial necrosis. Regarding the haemodynamics of this flap, as mentioned by Chavoin et al. (1987) it is considered that vasoparalysis after surgical denervation may account for the failure of the venous valves and opening of arteriovenous shunts so that the arterial inflow can pass in a reverse direction against the intact venous valves through the shunt to reach the arterioles, and finally the flow from this arterial system may pass through the capillaries to the distal drainage vein (Thatte et al., 1989b). The advantages of this flap are that the vascular pedicle, the long saphenous vein, is anatomically constant, long and large and the elevation of the flap is technically safe. There is no possibility of the postoperative vascular problem and functional limitation of the donor leg which are potential complications of the removal of an artery. Furthermore, its greatest advantage is that the elevation of the flap takes a very short time, less than 15 minutes. There is also the possibility of an osteocutaneous flap involving a vascularised tibia graft such as in Case 3. However, the authors accept that a much larger bone segment would need to be used to confirm its good vascularity. This flap, including the saphenous nerve, could also be used as a vascularised neurocutaneous flap for the one-stage reconstruction of a skin defect accompanied with nerve loss. The possible disadvantages of this flap are that postoperatively there were temporary lymphoedema and paraesthesia in the donor leg after sacrificing the lymphatic vessels and the saphenous nerve. The pedicle veins become an arteriovenous shunt and could lead to heart failure. In our cases, however, there were no abnormal findings in the postoperative ECGs.
Amaraate, J., Costa, H., Reis, J. and Soarea, R. (1988). Venous skin flaps: an experimental study and report of two clinical distal island flaps. British Journal of Plostic Surgery, 41, 132. Baek, S. M., Weinburg, H., Song, Y., Park, C. G. and BBIer, H. F. (1985). Experimental studies in the survivalof venous island flaps without arterial inflow. Plastic and Reconstructive Surgery, 75,88. Chavohr, J. P., Rouge, D.,Vachaud, M., Boeeplon, H. audCostaglioia, M. (1987). Islands flaps with an exclusively venous pedicle. A report of eleven cases and a preliminary haemodynamic study. British Journal of Plastic Surgery, 40, 149. Foucher, G. and Norris, R. W. (1988). The venous dorsal digital island flap or the “neutral” flap. British Journal of Piostic Surgery, 41,337. Fukui, A., Inada, Y., Maeda, M., Tam& S., Miznmoto, S., Yaxima, H. and Sempuku, T. (1989). Pedicled and “flow-through” venous flaps: clinical applications. JournalofReconstructive Microsurgery, 5,235. Hung, L. K., Cheo, S. Z. and Leung, P. C. (1990). Resurfacing difficult wounds: selective use of the posterior tibia1 flap. Journal of Reconstructive Microsurgery, 6, 13. Inoue, G., Nakamura, R., Maeda, N. and Suzuki, K. (1989). Arterialized venous flap coverage of a big toe defect resulting from a wrap-around flap transfer. Japanese Journol of Plastic and Reconstructive Surgery, 32,1013. Nakashbna, H. (1989). Experiences with the venous skin graft. Japanese Journalof Plastic and Reconstructive Surgery, 32, 11. Nakayama, Y., Soeda, S. and KasaI, Y. (1981). Flaps nourished by arterial inflow through the venous system; an experimental investigation. Plastic and Reconstructive Surgery, 67,328. Thatte, R. L. and Thatte, M. R. (1987a). A study of the saphenous venous island flap in the dog without arterial inflow using a nonbiological conduit across a part of the length of the vein. British Journal of Plastic Surgery, 40, 11. Thatte, R. L. and Thatte, M. R. (1987b). Cephalic venous flap. British Journal of Plastic Surgery, 40, 16. Thatte, M. R., Kamdar, N. B., Khakkar, M. A., Varade, M. A. and Thatte, R. L. (1989a). Static and dynamic computerised radioactive tracer studies, vital dye staining and theoretical mathematical calculations to ascertain the mode of survival of single cephalad channel venous island flaps. British Joumalof Plastic Surgery, 42, 405. Thatte, M. R., Kmnta, S. M., Purohit, S. K., Deabpaade, S. N. and Thatte, R. L. (1989b). Cephalic venous flap: a series of 8 cases and a preliminary report on the use of 99mTc labelled RBCs to study the saphenous venous flap in dogs. British Joumol of Plastic Surgery, 42, 193. Yoshimura, M. (1984). A venous skin graft in the treatment of injured fingers. Joponese Journal of Plastic and Reconstructive Surgery, 27,474. Yoshimura, M., Shimada, T., Imura, S., Shimamura, K. and Yamauchi, S. (1987). The venous skin graft method for repairing skin defects of the fingers. Plastic and Reconstructive Surgery, 79, 243.
The Authors Isao Koahhna, MD, Associate Professor of Plastic and Reconstructive Surgery, Kawasaki Medical School, Okayama; formerly Assistant Professor of Plastic and Reconstructive Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki. Shugo Soeda, MD, Professor of Plastic and Reconstructive Surgery, University of Tsukuba. YoshIo Nakayama, MD, Assistant Professor of Plastic and Reconstructive Surgery, University of Tsukuba. Hiroshi Fukuda, DDS, Assistant Professor of Oral Surgery, University of Tsukuba. JunsukI Taaaka, MD, Chief of Orthopaedic Surgery, Natogaya Hospital, Chiba. Requests for reprints to: Dr Isao Koshima, Department of Plastic and Reconstructive Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki City, Okayama, 701-01 Japan, Paper received 5 March 1990. Accepted 18 June 1990. This paper was presented at the 16th Annual Japanese Society of Reconstructive Microsurgery.
Meeting
of the