FREE-FLAP VALVULAR TRANSPLANTATION FOR REFRACTORY VENOUS ULCERATION

Purpose: Nonoperative therapeutic approaches to chronic venous ulcerat ion, although effective, often require prolonged dressing care and imm obilization with leg elevation. Results of skin grafting, perforator l igation, and valve interpositions and reconstructions improve results of ulcer healing but have not uniformly prevented ulcer recurrence. Ou r hypothesis is that reconstruction of chronic venous ulcers by excisi on of the diseased tissue bed and replacement with a free flap contain ing multiple competent microvenous valves and a normal tissue microcir culation will result in long-term cure of these debilitated patients. Methods: Six patients with chronic venous insufficiency and recurrent ulceration (class 3) underwent excision of ulcers and surrounding lipo sclerotic tissue beds and reconstruction with fasciocutaneous free fla ps (two bilateral). Preoperative and postoperative photoplethysmograph y was used to assess venous refilling times. Duplex scanning was perfo rmed to assess deep venous reflux. Results: There were no flap failure s. Photoplethysmographic venous refilling times measured on flaps demo nstrated significant immediate and long-term increases from preoperati ve values (all results +3 by Society of Vascular Surgery outcome gradi ng). Long-term maintenance of tissue integrity is shown by absence of recurrent ulceration and no evidence of recurrent tissue lipodermatosc lerosis in all flaps at follow-up (8 months to 7.5 years; mean 24 mont hs). No recurrent lipodermatosclerosis was seen on flap biopsy at 2 an d 7 years. Separate cadaveric injection studies, including scanning el ectron microscopy; revealed numerous microvenous valves directed towar d the draining pedicle in the flaps used for reconstruction. Conclusio ns: This is the first comprehensive report providing combined laborato ry and clinical evaluation, anatomic rationale, and long-term outcome of surgical rehabilitation of patients with chronic venous ulceration who have undergone microsurgical flap reconstruction.