MicroVascular Techniques for Limb Salvage Plastic & - - PowerPoint PPT Presentation

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MicroVascular Techniques for Limb Salvage

Charles K Lee, MD, FACS

Chief of Plastic Surgery & Microsurgery, St.Mary’s Medical Center, San Francisco Assistant Clinical Professor of Surgery, University of California, San Francisco (UCSF)

Plastic & Reconstructive MicroSurgery

Angiosomes

Ian Taylor, MD San Francisco (Harry

Buncke, MD, Stephen Mathes, MD)

Perforator Flaps Local Fascial Flaps Local Propellar Flaps Arterial Flow Through Free

Flap

Venous Flow Through Free

Flap

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Ian Taylor, MD, Plastic Surgery, Australia, 1987

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Angiosome Map

Multiple Perforators throughout Body Septal IntraMuscular Flap Harvest (Soft Tissue + Artery and Vein) Expanded the Repetoire of Free Tissue Transfer

Lower Extremity Reconstruction with Local Perforator Fascial Flaps and Skin Graft

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4 weeks postop

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Propellar Flaps based on Perforators

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ALT Perforator Flap

AnteroLateral Thigh Perforator Flap (Arterial Flow Through Flap) 1984—Song, et al; Br. Jo. of Plastic Surgery “Thin” and pliable

Patient population differs

Reliable anatomy

Long pedicle (20cm) Large surface area (40X20cm) Sensate (Lateral femoral cutaneous nerve)

Chimeric/composite Easy harvest Minimal Donor Site Ideal Soft Tissue Flap

Medial Dissection first

Septocutaneous perforator

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Lateral circumflex femoral

Lateral descending branch

Vastus Lateralis Rectus Femoris

80% muscular perforators (Wei 2002) 20% septocutaneous perforators Perforator can be wrapped around branches of femoral nerve to Vastus

ALT Perforator Flap

Advantages:

Workhorse flap Consistent Anatomy-septocutaneous,

musculocutaneous

Long pedicle (20cm), Large surface area

(20X40cm)

Contoured/thinned Neurotized (sensate) Composite/Chimeric Donor Site—Primary Closure (<8cm)

Disadvantages:

Tedious dissection if muscular perforator Not always thin (female vs. male) Technical considerations insetting

Pedicle orientation and pressure

Unsitely donor site if not closed primarily

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Venous Flow Through Flap

Cephalic Vein/ Saphenous Vein

Calcaneal Wound, CLI

Flow through flap

Skin Replacement - Flap Skin Replacement - Flap

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Venous Flow Through Free Flap

Flow through flap

Skin Replacement - Flap Skin Replacement - Flap

Skin Replacement - Flap

Flow through flap

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Expanding Role of Microsurgery & Vascular Surgery

Angiosome Concept Perforator LOCAL Flaps Perforator FREE Flaps

Arterial Flow Through

Venous Flow Through FREE Flaps

• -Simultaneous Soft Tissue and Vascular

Reconstruction

Thank you!