Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 984e989

Palmar contracture release with arterialized

venous instep flap: An anatomical and
clinical study
lent Yalc
n b, Levent Tekin c, Muhitdin Eski a,
Fatih Zor a,*, Bu
Selcuk Isk a, Mustafa Sengezer a
a
Gulhane Military Medical Academy, Department of Plastic and Reconstructive Surgery,
Ankara, Turkey
b
Gulhane Military Medical Academy, Department of Anatomy, Ankara, Turkey
c
Gulhane Military Medical Academy, Haydarpasa Training Hospital,
Department of Physical Medicine and Rehabilitation, Istanbul, Turkey

Received 13 June 2014; accepted 19 March 2015

KEYWORDS
Arterialized venous
flap;
Instep flap;
Palmar contracture
release;
Glabrous skin flap

Summary Background: Plantar skin has similar histologic features to the palmar area and appears to be the ideal tissue for reconstruction of the palmar region. In this study, an anatomic
examination was performed to determine the superficial venous architecture of the instep
area, and the use of arterialized venous instep flaps for palmar contracture release was assessed.
Methods: The anatomical study was performed on 12 fresh cadaver feet. The arterialized
venous instep flap, including the skin, subcutaneous tissue and superficial venous plexus,
was harvested. To determine the venous structure, dissection (n Z 6) and injectioncorrosion (n Z 6) techniques were used. In the clinical study, nine arterialized venous instep
flaps were used for palmar contracture release. All flaps were harvested above the deep fascia
and included skin, subcutaneous fat, and the superficial venous plexus. At the plantar site of
the flap, two or three veins, one of which was used, were dissected for a sufficient length for
the arterial anastomosis. The saphenous vein was used for the venous anastomosis.
Results: Dissection and injection-corrosion techniques revealed that the flap had 7e12 and
4e6 veins at its plantar and superior edges, respectively, with numerous anastomoses and interconnections between the veins.
The flap dimensions were between 3
5 cm and 4
6 cm. All flaps survived, with two partial
flap necrosis that healed with spontaneous epithelization. No debulking procedures were undertaken and all flaps adapted well to the recipient site.

* Corresponding author. GATA Plastik Cerrahi Klinigi, Etlik/Ankara, Turkey. Tel.: 90 3125425406; fax: 90 3125425402.
E-mail address: fatihzor@yahoo.com (F. Zor).
http://dx.doi.org/10.1016/j.bjps.2015.03.024
1748-6815/ 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Palmar contracture release with arterialized venous instep flap

985

Conclusions: The arterialized venous instep flap is a good alternative to reconstruct palmar
contractures by adding similar tissue that is thin and pliable with minimal donor site morbidity.
2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Introduction
Patients with palmar contractures may encounter difficulties when performing normal daily activities. Although
mild forms of palm contracture can be treated with grafts
and local flaps,1 the only alternative for severe forms of
this condition are distant or free flaps.2 The ideal flap
should have several features that facilitate the reconstruction of defects due to palmar contracture release. In
particular, the ideal flap must have similar histological
characteristics similar to those of the palmar region.
Moreover, the ideal flap should be thin and pliable (but not
wobbly) to adapt to the palmar region. Additionally, it must
cause minimal donor site morbidity while having an
appropriate pedicle for microsurgical anastomosis.3,4
To date, several flaps have been used for this purpose,
including the medial plantar flap.2,4e6 The glabrous skin of
the plantar area is very similar to palmar skin. The
epidermis and dermis are much thicker, and the fibrous
septa that binds the plantar skin to the plantar aponeurosis
results in the formation of fat loculations.7 However, these
flaps are bulky and require a major artery to be sacrificed
for harvesting.
An arterialized venous flap is a skin flap that has arterial
inflow through an afferent vein, which allows perfusion of
the flap, as well as venous outflow through the efferent
veins, which permits drainage of the flap. The main
advantage of arterialized venous flaps is that the sacrifice
of a major artery is not required. Moreover, they are very
thin and pliable and can be harvested easily in a short
time.1,6 Based on the advantages of arterialized venous
flaps the histologic similarity between plantar skin and
palmar skin, an arterialized venous flap harvested from a
non-weight bearing area is considered to be a good alternative for palmar reconstruction.
In this study, an anatomic examination was performed to
determine the superficial venous architecture of the instep
area, and the use of arterialized venous instep flaps for
palmar contracture release was assessed.

a dissection microscope at 1.6
magnification. Dissection

was performed from the great saphenous vein to the veins
at the lower border of the flap. Exposed veins were colored
blue and then photographed (Figure 1). The remaining six
flaps were investigated via the injection-corrosion technique. The veins at the lower border of the flap were
chosen for injection and cannulated (Figure 2a). The veins
were flushed with a solution of sodium chloride (0.09%) and
sodium citrate (3.8%). A polyester mix, consisting of polyester (10 mL), catalyst (0.5 mL), and accelerator (0.5 mL),
was used for injection and diluted sulfuric acid (40%) was
used for corrosion.
The polyester mix was placed in a bottle and stirred with
a glass rod for 20 s. The working life of the prepared solution was about 7 min, which allowed enough time for injection. The solution was injected into the veins at a
starting pressure of 50 mm Hg; however, after 2e3 min, the
pressure increased to 80e100 mm Hg. The flaps were hung
for about 4e6 h to allow solidification of the polyester and
then carefully put in diluted sulfuric acid solution for
24e48 h. When the corrosion was complete, they were
gently washed under cold tap water until all remnant tissue
was removed. Finally, they were dried at room temperature
and photographed (Figure 2b). Measurements were performed with a Vernier caliper.

Clinical study
Patients
The study was performed at the Gulhane Military Medical
Academy, Department of Plastic and Reconstructive Surgery. The Local Ethics Committee approved the study
protocol.
A total of nine patients were operated on for palmar
contracture release due to burns. The median age of the

Materials and methods

Anatomical study
The study was performed on 12 feet obtained from four
male and two female cadavers. The borders of the flaps
were marked like the medial plantar flap, and flaps,
including skin, subcutaneous tissue and the subcutaneous
venous network, were harvested from the non-weight
bearing area of the feet. The dimensions of the flaps
were 50e55
70e80 mm. To show the venous architecture
of the flap, dissection and injection-corrosion techniques
were used. Six flaps were carefully dissected with the aid of

Figure 1

The venous plexus of instep region.

986

Figure 2 a: The cannulation of superficial veins at the

plantar border. b: The appearance of the venous plexus after
injection and corrosion.

patients was 20 (18e24) years and all of them were male.

All patients were suffering from palmar burn contracture
due to a burn during childhood. None had previous
operations.
Surgical technique
Following the release of the palmar contracture, the
resulting defect was measured. The flap harvest was performed under venous tourniquet (100 mm Hg) for better
visualization of the superficial veins. The venous architecture was marked on the skin, and the skin island of the flap
was marked at the center of the area that had the most
abundant venous plexus (Figure 3a). The veins that were at
the plantar side of the skin island were designated as
afferent, and the saphenous vein was prepared for the
efferent anastomosis.
The cadaver study showed that the veins are superficial
to superficial fascia. Thus, the flap was harvested in a
plane, which is just above the superficial fascia. This plane
provided easy dissection and a thin flap. There were vertical septa in the flap and we thought that there could be
adequate stability without fascia because of the presence
of the septae and the specific skin histology. The flaps were
dissected superior to the muscle fascia and included skin
and subcutaneous tissues with veins. During the dissection,
the subcutaneous veins and venous plexus were protected.

F. Zor et al.

Figure 3 a: The planning of the arterialized venous instep

flap. b: The appearance of the harvested flap, afferent (arrows) and efferent vessels.

Two or three veins of sufficient length that had large diameters were preserved during dissection for the arterial
anastomosis, although only one of them was used. We always chose one digital artery in the area of the flap to
restore arterial circulation after the vein to be arterialized
in the flap was selected. The saphenous vein was dissected
along a length sufficient enough to enable the venous
anastomosis (Figure 3b).
At the recipient site, a digital artery was prepared for
anastomosis. Following the transfer of the flap, an efferent
vein anastomosis was performed first between the saphenous vein and a superficial vein of the hand. Then an endto-end anastomosis with 10/0 etilon sutures was performed
between a proximal vein of the flap and the prepared digital artery. The flow direction of this arterialized venous
flap was not changed from the original blood flow in the
veins. The flap was inserted into the recipient area and the
donor site was closed with a split thickness skin graft.
Postoperative follow-up and evaluation
During the postoperative period, high molecular weight
dextran was used at a dose of 0.5 mL/kg for five days. The
follow-up of the flaps was performed with capillary refill,
ultrasonic Doppler, and laser flowmeter. During the edematous phase of the flap we only used elevation and tulle

Palmar contracture release with arterialized venous instep flap

gras dressing. When the flap was congested and capillary
refill was obscured, Doppler evaluation and bleeding patterns from the stab wounds in the flap were the most useful
tools for differentiating typical congestion of the venous
flaps from true thrombosis of the anastomosed vessels.
Passive and active motions of the hand were respectively started at 10 days and 21 days postoperatively. A
dynamic splint was applied for three months. The median
follow-up period was 9 (6e16) months. A two-point
discrimination test was performed at six months.

Results
Results of the anatomical study
In the dissection technique, seven to 12 veins were
observed at the lower border of the flap. Their mean diameters, from anterior to posterior respectively, were
0.78  0.24, 0.83  0.15, 0.76  0.35, 0.83  0.12,
0.86  0.21, 0.79  0.13, 1.02  0.45, 0.79  0.27,

987

0.92  0.45, 0.95  0.62, 1.18  0.22, and 1.09  0.67 mm.
During their course from proximal to distal, many anastomoses were observed between adjacent veins. The mean
diameter of the anastomotic branches was 1.05  0.65 mm.
Four to six veins draining into the great saphenous vein
were observed at the upper border of the flap. Their mean
diameters, from anterior to posterior respectively, were
1.60  0.32, 1.25  0.25, 1.38  0.21, 1.33  0.47,
0.98  0.37, and 1.45  0.90 mm (Figure 4a).
In the injection-corrosion technique, seven to 12 veins
were also observed at the lower border of the flap. Their
mean diameters, from anterior to posterior respectively,
were 0.84  0.38, 0.85  0.23, 0.74  0.12, 0.84  0.23,
0.88  0.21, 0.77  0.23, 1.05  0.37, 0.82  0.30,
1.08  0.67, 1.27  0.56, 1.35  0.8, and 1.65  0.23 mm.
As in the dissection technique, many anastomoses were
observed between the veins, and the mean diameter of the
anastomotic branches was 1.16  0.34 mm. Four to six veins
draining into the great saphenous vein were observed at the
upper border of the flap. Intravenous valves were generally
present at the point where the veins joined with the great

Figure 4 a: Measurement of venous architecture following the dissection technique. b: Measurement of venous architecture
following the injection-corrosion technique.

988
saphenous vein. Mean diameters of the veins at the upper
border of the flap, from anterior to posterior respectively,
were 1.55  0.09, 1.11  0.32, 1.18  0.15, 1.27  0.57,
1.05  0.42, and 1.54  1.34 mm (Figure 4b).

Results of clinical study

All flaps survived with no total flap loss. Edema and venous
congestion were observed in all flaps with a peak at 48 h
postoperatively. Despite the venous congestion, the circulation of the flap was good. Partial flap necrosis was
encountered in two flaps. In three of the cases, following
the venous congestion, bullae formation and epidermolysis
were observed. These areas healed with secondary intention without additional surgical procedure. The flap dimensions were between 3
5 cm and 4
6 cm, and the
average surface area was 18 cm2.
The arterialized venous instep flaps were observed to
adapt well to the recipient area with a good color and
texture match. None of the flaps needed the debulking
procedure (Figure 5a,b). The donor sites healed without
problems.
The two-point discrimination test at six months postoperatively revealed averages of 5.7 mm and 9.7 mm in the
healthy hand and flaps, respectively.

Figure 5 Preoperative appearance and postoperative results

at nine months.

F. Zor et al.

Discussion
Various techniques have been described for reconstructing
palmar defects, and each technique possesses its own advantages and disadvantages.5,7e9 Alhtough skin grafts are a
good alternative for mild contractures, the release of
moderate and severe contractures results in the exposure
of tendons and other vital structures, which makes flap
coverage inevitable. In most cases, free tissue transfer
remains the only reconstructive option.2
The ideal flap for palmar reconstruction must have histological characteristics similar to the palmar region and be
thin and pliable to adapt well to the contours of the
hand.2,3 The currently used flaps do not fulfill these
reconstructive aims because of their bulkiness, whereas
some alternatives have disadvantages related to the donor
site.10 Since the first study by Nakayama in 1981, various
studies on arterialized venous flaps have been published.6,11,13e15 In addition to being thin and pliable, such flaps
are easy to harvest and do not require the sacrifice of a
major artery during harvesting.6
Previous studies have shown that, for successful tissue
transfer, the skin island should be centered at the most
abundant part of the venous plexus.12 In the present study,
an anatomical study was performed prior to the clinical
study to assess the venous architecture of the instep region
and to determine whether it could serve as a suitable
venous flap. The results showed that the instep region has a
rich venous plexus and that the calibers of the veins are
suitable for microsurgical tissue transfer. To our knowledge, no previous study has reported the structure of the
venous plexus of a venous flap.
The average caliber of the proximal veins was 0.8 mm.
Although an anastomosis between these veins might appear
challenging, the blood flows from high to low pressure in
arterialized venous flaps, similar to that in an arteriovenous
fistula. Accordingly, this type of blood flow makes the
anastomoses reliable. Previous studies have not reported
any arterial problem in arterialized venous flaps, and the
present study did not observe total flap necrosis due to
anastomosis failure. Nonetheless, the major problem of
these flaps is venous congestion. The literature advocates
performing more than one efferent venous anastomosis to
help reduce venous congestion.12 However, instead of
performing more than one anastomosis, we preserved the
main branches of the saphenous vein and used it as the
efferent vein of the flap.
Fine movements are important in hand function, and
reconstructing the palmar region with a thin and glabrous
flap is crucial for good esthetic and functional results. The
recent advances in perforator free flaps make it possible to
obtain wide and thin cutaneous free flaps for resurfacing of
the hand.4 However, harvesting a perforator flap is much
more complicated and time-consuming than harvesting
venous flaps. Moreover, debulking of perforator flaps requires expertise.6 Thus, it seems logical and advantageous
to use venous flaps in particular situations. In our study, the
arterialized venous flap was used successfully to reconstruct palmar contractures. The flap was histologically
similar to the palmar tissue with an excellent texture and
color match, and was sufficiently thin to adapt well to the

Palmar contracture release with arterialized venous instep flap

contours of the hand. No debulking procedure was needed.
For palmar reconstruction, an arterialized venous flap
shares the advantages of the medial plantar flap but not its
disadvantages, including bulkiness and the need for sacrifice of a major artery of the foot.7,10
Protective sensory recovery is important for a successful
palmar reconstruction.5 Anatomically, it is possible to
include a cutaneous branch of the medial plantar nerve
with the instep flap. However, studies in the literature
suggest that venous flaps can achieve sensory restoration
without neurorrhaphy.1,13,14 In our study, neural repair was
not performed, but adequate protective sensation was
restored. A flap can be harvested with an attached sensory
nerve, but the flap then becomes thicker. We believe that
nerve coaptation may improve two-point discrimination.
However, We believe that an ultra-thin flap is essential in
palmar reconstruction. Because of the thin pliable flap
pattern, possible nerve coaptation was not thought to
improve the result and therefore was not performed. During follow up some restoration of sensation was observed in
the flap without nerve coaptation possibly due to the rich
venous plexus that carries small nerve branches. However,
no formal evaluation using for example Semmes Weinstein
Monofilament measurements was done.

Conclusion
An arterialized venous instep flap has an abundant venous
network, which makes it reliable. It is a good alternative to
reconstruct palmar contractures by adding similar tissue
that is thin and pliable with minimal donor site morbidity.

Ethical approval
N/A.

Funding
None.

Conflict of interest
None.

989

References
1. Nakazawa H, Nozaki M, Kikuchi Y, Honda T, Isago T. Successful
correction of severe contracture of the palm using arterialized
venous flaps. J Reconstr Microsurg 2004;20:527e31.
2. Woo SH, Seul JH. Optimizing the correction of severe postburn
hand deformities by using aggressive contracture releases and
fasciocutaneous free-tissue transfers. Plastic Reconstr Surg
2001;107:1e8.
3. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flap for
extremity reconstruction: clinical experience and functional
assessment of donor site. Plastic Reconstr Surg 2001;107(7):
1766e71.
4. Adani R, Tarallo L, Marcoccio I, Cipriani R, Gelati C,
Innocenti M. Hand reconstruction using the thin anterolateral
thigh flap. Plastic Reconstr Surg 2005;116:467e73.
lku
5. U
kel C, Eren F, C
eliko
z B. Use of dordal unlar neur E, Ac
rocutaneous island flap in treatment of chronic postburn
palmar contractures. Burns 2005;31:9e104.
6. Woo SH, Kim KC, Lee GJ, et al. A retrospective analysis of 154
arterialized venous flaps for hand reconstruction: an 11-year
experience. Plastic Reconstr Surg 2007;119:1823e38.
7. Duman H, Er E, Isik S, et al. Versatility of the medial plantar
flap: our clinical experience. Plastic Reconstr Surg 2002;109:
1007e12.
8. Giesen T, Forster N, Ku
nzi W, Giovanoli P, Calcagni M. Retrograde arterialized free venous flaps for the reconstruction of
the hand: review of 14 cases. J Hand Surg Am 2014;39(3):
511e23.
9. Yan H, Fan C, Zhang F, Gao W, Li Z, Zhang X. Reconstruction of
large dorsal digital defects with arterialized venous flaps: our
experience and comprehensive review of literature. Ann Plast
Surg 2013;70(6):666e71.
10. Ninkovic MM, Weshselberger G, Schwabegger AH, Anderl H. The
instep flap to resurface palmar defects of the hand. Plastic
Reconstr Surg 1996;97:1489e93.
11. Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial
inflow through the venous system: an experimental investigation. Plastic Reconstr Surg 1981;67:328e34.
12. Ayad HM. Free arterialized venous flaps. Ann Burns Fire Disasters 1999;12:158e64.
13. Yokoyama T, Hosaka Y, Kusano T, Morita M, Takagi S. Finger
palmar surface reconstruction using medial plantar venous
flap. Possibility of sensory restoration without neurorrhaphy.
Ann Plastic Surg 2006;57:552e6.
14. Hirase Y, Kojima T. The use of innervated digital island flaps for
sensory recovery in fingertip reconstructions: considerations
for the surgeon. Jpn J Plastic Reconstr Surg 1993;36:627e34.
15. Yan H, Brooks D, Ladner R, Jackson WD, Gao W, Angel MF.
Arterialized venous flaps: a review of the literature. Microsurgery 2010;30(6):472e8.