hansen 2017 limb salvage the plastic surgeons role on the limb salvage · pdf...
TRANSCRIPT
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The Plastic Surgeons Role on the Limb Salvage Team
Scott L. Hansen, M.D., F.A.C.SAssociate Professor of Surgery
University of California, San Francisco
Limb SalvageHansen 2017
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Complex Lower Extremity InjuriesHansen 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
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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**
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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
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What we are trying to avoidHansen 2017
What we are trying to avoidHansen 2017
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Soft Tissue Deficits• Reconstructive Ladder
– Direct closure– Skin Graft– Local Flap– Distant Flap
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Negative PressureAnd Skin Substitutes
Negative Pressure TherapyHansen 2017
Time to Coverage• Within 1-(2) week(s)• Negative pressure: Allows delayed coverage?
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Flap Considerations• Type of Reconstruction
– Local vs. regional vs. distant flap– Muscle vs. fasciocutaneous/perforator flap– Muscle vs. musculocutaneous flap
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Random Pattern Flap
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Lateral Calcaneal artery flap
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ForefootV-Y advancement flaps
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ForefootV-Y advancement flaps
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Charcot FootHansen 2017
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V-Y advancement flapsHansen 2017
Sural Flap: Regional FlapHansen 2017
Sural FlapHansen 2017
Sural FlapHansen 2017
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Microsurgical ReconstructionHansen 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
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Amputation: Lower ExtremityHansen 2017
Plain films/Angiogram
Angiogram
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Microvascular Tissue TransferHansen 2017 Hansen 2017
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Below Knee Amputation Salvage Hansen 2017
Plain films and AngioHansen 2017
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Post-opHansen 2017 Hansen 2017
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Now 11 years post-flap
Mid-Distal Tibia DefectsHansen 2017
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Mid-Tibia DefectsHansen 2017
Mid-Tibia Defects
Flap vessel to perforator
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Latissimus Free Tissue Transfer
6 month f/u
Hansen 2017 Limb Salvage Case
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Limb Salvage Case• Flow Through Flap
Hansen SL. Flaps, Plastic Surgery, Mathes SJ, HentzVR (eds), Saunders and Co., New York 2005.
Limb Salvage Case• Forearm vein only flap
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Limb Salvage Case Heel ReconstructionHansen 2017
Muscle vs. fasciocutaneous flap coverage
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Gracilis MuscleHeel Reconstruction
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Foot ReconstructionHansen 2017
Foot ReconstructionHansen 2017
After Wound VAC TreatmentHansen 2017
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Foot ReconstructionHansen 2017
Post-opHansen 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
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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