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

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

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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

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4/8/2017 1

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

Limb Salvage

Hansen 2017 Hansen 2017

Complex Lower Extremity Injuries

Hansen 2017

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Role of the Plastic Surgeon?

  • Provide stable soft-tissue coverage

– Oftentimes can be challenging!

  • Team effort= success

– Vascular – Orthopaedics – Podiatry – Plastic Surgery

  • Indications expanding

Hansen 2017

Limb Salvage

  • Indications for limb salvage surgery are

expanding

– Wound irrigation and debridement strategies – “Tissue friendly” fracture fixation techniques and instrumentation – Development of 2nd and 3rd generation antibiotics – Improvements in microsurgical technique – Improvements in wound management**

Hansen 2017

Considerations

  • Location

– Upper Extremity – Upper leg (thigh) – knee – Lower leg – Ankle/foot

  • Size of soft tissue defect
  • Components

– Bone, nerve, vessels

  • Age and co-morbidities of patient
  • Mechanism

Hansen 2017

General Management

  • Staged debridement's with Orthopaedic and

Vascular Surgery

  • Assess components of defect
  • Continue until wound clean
  • Wound VAC used as bridge
  • Amputation vs. Limb salvage vs. preservation of

length

  • Need inflow!

– Primary concern – Angiogram essential

Hansen 2017

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Hansen 2017

What we are trying to avoid

Hansen 2017

What we are trying to avoid

Hansen 2017

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Soft Tissue Deficits

  • Reconstructive Ladder

– Direct closure – Skin Graft – Local Flap – Distant Flap

Hansen 2017

Negative Pressure And Skin Substitutes

Negative Pressure Therapy

Hansen 2017

Time to Coverage

  • Within 1-(2) week(s)
  • Negative pressure: Allows delayed coverage?

Hansen 2017

Integra + Skin Graft

Hansen 2017

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SLIDE 5

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Hansen 2017 Hansen 2017

Flap Considerations

  • Type of Reconstruction

– Local vs. regional vs. distant flap – Muscle vs. fasciocutaneous/perforator flap – Muscle vs. musculocutaneous flap

Hansen 2017 Hansen 2017

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Random Pattern Flap

Hansen 2017 Hansen 2017 Hansen 2017

Lateral Calcaneal artery flap

Hansen 2017

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Hansen 2017 Hansen 2017 Hansen 2017 Hansen 2017

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Hansen 2017

Forefoot

V-Y advancement flaps

Hansen 2017

Forefoot

V-Y advancement flaps

Hansen 2017

Charcot Foot

Hansen 2017

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V-Y advancement flaps

Hansen 2017

Sural Flap: Regional Flap

Hansen 2017

Sural Flap

Hansen 2017

Sural Flap

Hansen 2017

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Microsurgical Reconstruction

Hansen 2017 Ian Taylor, MD

Free Tissue Microvascular Transplantation (MVT)

  • Myriad of Flaps Available
  • Muscle
  • Skin
  • Combination
  • Complex Flaps
  • Perforator flaps
  • Venous flaps
  • Composite flaps
  • Local tissues not available

Hansen 2017

Amputation: Lower Extremity

Hansen 2017

Plain films/Angiogram

Angiogram

Hansen 2017

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Microvascular Tissue Transfer

Hansen 2017 Hansen 2017 Hansen 2017 Hansen 2017

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Below Knee Amputation Salvage

Hansen 2017

Plain films and Angio

Hansen 2017 Hansen 2017 Hansen 2017

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Post-op

Hansen 2017 Hansen 2017 Hansen 2017 Hansen 2017

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4/8/2017 14 Now 11 years post-flap

Mid-Distal Tibia Defects

Hansen 2017 Hansen 2017 Hansen 2017

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Mid-Tibia Defects

Hansen 2017

Mid-Tibia Defects

Flap vessel to perforator

Hansen 2017 Hansen 2017 Hansen 2017

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Latissimus Free Tissue Transfer

6 month f/u

Hansen 2017

Limb Salvage Case

62

Hansen 2017

Limb Salvage Case

  • Flow Through Flap

Hansen SL. Flaps, Plastic Surgery, Mathes SJ, Hentz VR (eds), Saunders and Co., New York 2005.

Limb Salvage Case

  • Forearm vein only flap
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SLIDE 17

4/8/2017 17

Limb Salvage Case

Heel Reconstruction

Hansen 2017

Muscle vs. fasciocutaneous flap coverage

Hansen 2017

Gracilis Muscle

Heel Reconstruction

Hansen 2017

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Foot Reconstruction

Hansen 2017

Foot Reconstruction

Hansen 2017

After Wound VAC Treatment

Hansen 2017

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Foot Reconstruction

Hansen 2017

Post-op

Hansen 2017

Recipient Vessels

  • Based on angiogram/flow to foot
  • Antegrade end-to-side

– Limited flow to foot – Thigh/knee

  • Perforator vessels
  • Bypass graft
  • Superior medial geniculate vessels

– Knee or below knee – Vein loop

Hansen 2017

Summary

  • Team approach
  • Use the reconstructive ladder
  • Initial soft tissue management is critical

– Recognize the complex/problem wound – Respect the soft tissues – Assess and address inflow and bone issues first – Thorough debridement – Negative pressure used as a bridge – Aggressive wound care