Limb Salvage The Plastic Surgeons Role on the Limb Salvage Team - PowerPoint PPT Presentation

4/8/2017 Hansen 2017 Limb Salvage The Plastic Surgeons Role on the Limb Salvage Team Scott L. Hansen, M.D., F.A.C.S Associate Professor of Surgery University of California, San Francisco Hansen 2017 Hansen 2017 Complex Lower Extremity Injuries 1

4/8/2017 Hansen 2017 Hansen 2017 Limb Salvage Role of the Plastic Surgeon? • Provide stable soft-tissue coverage • Indications for limb salvage surgery are expanding – Oftentimes can be challenging! – “ Tissue friendly ” fracture fixation techniques – Wound irrigation and debridement strategies • Team effort= success – Vascular and instrumentation – Orthopaedics – Development of 2 nd and 3 rd generation – Podiatry antibiotics – Plastic Surgery – Improvements in microsurgical technique • Indications expanding – Improvements in wound management** Considerations Hansen 2017 Hansen 2017 General Management • Location • Staged debridement's with Orthopaedic and – Upper Extremity Vascular Surgery – Upper leg (thigh) – knee • Assess components of defect • Continue until wound clean – Lower leg • Wound VAC used as bridge – Ankle/foot • Amputation vs. Limb salvage vs. preservation of • Size of soft tissue defect • Components length • Need inflow! – Bone, nerve, vessels – Primary concern • Age and co-morbidities of patient – Angiogram essential • Mechanism 2

4/8/2017 Hansen 2017 Hansen 2017 Hansen 2017 What we are trying to avoid What we are trying to avoid 3

4/8/2017 Hansen 2017 Hansen 2017 Soft Tissue Deficits Negative Pressure Therapy • Reconstructive Ladder – Direct closure – Skin Graft – Local Flap – Distant Flap Negative Pressure And Skin Substitutes Hansen 2017 Hansen 2017 Time to Coverage Integra + Skin Graft • Within 1-(2) week(s) • Negative pressure: Allows delayed coverage? 4

4/8/2017 Hansen 2017 Hansen 2017 Hansen 2017 Hansen 2017 Flap Considerations • Type of Reconstruction – Local vs. regional vs. distant flap – Muscle vs. fasciocutaneous/perforator flap – Muscle vs. musculocutaneous flap 5

4/8/2017 Hansen 2017 Hansen 2017 Random Pattern Flap Hansen 2017 Hansen 2017 Lateral Calcaneal artery flap 6

4/8/2017 Hansen 2017 Hansen 2017 Hansen 2017 Hansen 2017 7

4/8/2017 Hansen 2017 Hansen 2017 Forefoot V-Y advancement flaps Hansen 2017 Hansen 2017 Forefoot Charcot Foot V-Y advancement flaps 8

4/8/2017 Hansen 2017 Hansen 2017 V-Y advancement flaps Sural Flap: Regional Flap Hansen 2017 Hansen 2017 Sural Flap Sural Flap 9

4/8/2017 Hansen 2017 Hansen 2017 Free Tissue Microvascular Microsurgical Reconstruction Transplantation (MVT) • Myriad of Flaps Available • Muscle • Skin • Combination • Complex Flaps • Perforator flaps • Venous flaps • Composite flaps • Local tissues not available Ian Taylor, MD Plain films/Angiogram Hansen 2017 Hansen 2017 Amputation: Lower Extremity Angiogram 10

4/8/2017 Hansen 2017 Hansen 2017 Microvascular Tissue Transfer Hansen 2017 Hansen 2017 11

4/8/2017 Hansen 2017 Hansen 2017 Below Knee Amputation Salvage Plain films and Angio Hansen 2017 Hansen 2017 12

4/8/2017 Hansen 2017 Hansen 2017 Post-op Hansen 2017 Hansen 2017 13

4/8/2017 Hansen 2017 Mid-Distal Tibia Defects Now 11 years post-flap Hansen 2017 Hansen 2017 14

4/8/2017 Hansen 2017 Hansen 2017 Mid-Tibia Defects Mid-Tibia Defects Flap vessel to perforator Hansen 2017 Hansen 2017 15

4/8/2017 Hansen 2017 Hansen 2017 Limb Salvage Case Latissimus Free Tissue Transfer 6 month f/u 62 Limb Salvage Case Limb Salvage Case • Forearm vein only flap • Flow Through Flap Hansen SL. Flaps, Plastic Surgery, Mathes SJ, Hentz VR (eds), Saunders and Co., New York 2005. 16

4/8/2017 Hansen 2017 Limb Salvage Case Heel Reconstruction Muscle vs. fasciocutaneous flap coverage Hansen 2017 Hansen 2017 Heel Reconstruction Gracilis Muscle 17

4/8/2017 Hansen 2017 Hansen 2017 Foot Reconstruction Foot Reconstruction Hansen 2017 After Wound VAC Treatment 18

4/8/2017 Hansen 2017 Hansen 2017 Foot Reconstruction Post-op Hansen 2017 Summary Recipient Vessels • Based on angiogram/flow to foot • Team approach • Antegrade end-to-side • Use the reconstructive ladder – Limited flow to foot • Initial soft tissue management is critical – Thigh/knee – Recognize the complex/problem wound • Perforator vessels – Respect the soft tissues • Bypass graft – Assess and address inflow and bone issues first • Superior medial geniculate vessels – Thorough debridement – Negative pressure used as a bridge – Knee or below knee – Aggressive wound care – Vein loop 19