Local procedures such as the cross-finger flap, island flap, and flag flap, etc. are well described for the treatment of soft tissue defects of the hand. Their effectiveness is, however, limited in cases of multi-digit injury, defects greater than 5cm in length, and defects located on the radial side of the index, ulnar side of the small finger and tip of the thumb. The bulkiness of conventional microvascular tissue transplantation can limit its overall effectiveness. We present our experience with the transplantation of venous flaps for reconstruction of thin soft tissue cover of the hand.

A retrospective study between 6/2000 and 5/2004 involved 44 venous flaps that were transplanted for reconstruction of soft tissue defects of the hand. Patient charts were reviewed to document multiple parameters of the cases. Indications for the venous flap included location, size, multi-digit injury, need for cover over vital structures, need for digital revascularization/replantaion or reconstruction of tendon, nerve, or bone with composite venous flaps. The flaps were classified as AVA, AVV, AVA/A, AVA/V, or VVV depending on their vascular anastomoses. Donor sites included SAPH (saphenous vein and overlying soft tissue), CEPH (cephalic vein and overlying soft tissue), VPF (volar proximal forearm), VDF (volar distal forearm), DH (dorsal hand), and DF (dorsal finger). Outcome was classified as successful in cases where there was 100% survival of the flap, partial thickness (PT) survival where there was loss of epidermis with maintenance of subcutaneous cover, and partial full thickness (PFT) if epidermis and subcutaneous tissue was lost but went on to heal by secondary intention. The flap was considered a failure if there was complete loss of the flap or significant loss that lead to exposure of vital structures and need for an alternate procedure.

Thirty-five flaps had 100% survival (80%), 4 flaps were considered PT (9%), 3 flaps were considered PFT (7%), and 2 were considered failures (4%). There were often multiple indications for the venous flap in individual cases. Coverage of vital structure was the indication in 22, revascularization of the hand or a digit in 14, multi-digit injury in 4, location of the defect in 15, and digit replantation in 10 cases. Twenty-four flaps were classified as AVA, 14 as AVV, 1 as VVV. Five flaps had multiple in-flow and/or outflow anastomoses to nourish larger flaps, to reconstruct simultaneous arterial inflow and venous out flow in ring avulsion replants, or to provide cover and revascularization for multiple digits by creation of digital syndactyly. The donor was the VDF in 35 patients (80%), VPF in 5 patients (12%), SAPH in 2 patients (4%), DH in 1 (2%), and the DF in 1 (2%). Size of the flaps ranged from 2X2 cm to 9X6 cm. The majority of flaps were 2X3 cm.

Venous flaps can provide reliable coverage for small and medium sized soft tissue defects of the hand when convention methods are less effective. Venous flaps have the additional benefit of reconstructing vascular in-flow and/or outflow to amputated and devitalized components.
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