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Plastic Surgical Reconstruction in Foot and Ankle Trauma and
the Diabetic Foot: STSG to Free Flap
Paul M. Glat, MDDrexel University School of Medicine
Philadelphia, PA
Open Fractures
4th Annual International External Fixation Symposium
December 11-14, 2008
1
General Concepts of Wound Management
• Complete wound closure – Reconstructive Ladder = simple to more complex
• Complete coverage with well vascularized tissue is imperative
• Wound bed preparation is vital – serial debridements until clean
Reconstructive LadderReconstructive Ladder
4th Annual International External Fixation Symposium
December 11-14, 2008
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Pedicled Flaps
Free Flaps
Integra
Simple skin grafts are usually inadequate
Reconstruction of Open Fractures
PEDICLED FLAPS
4th Annual International External Fixation Symposium
December 11-14, 2008
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Pedicled Flaps: Pedicled Flaps:
Flap With Defined Blood Supply
Consists Of Any Combination Of – Skin – Fascia – Muscle – Bone
Pedicled Flaps: Pedicled Flaps:
Advantages
–Ankle Block –Short Operation –No Icu
Disadvantages
– Limited Reach – Limited Bulk – Requires More Precise Anatomic Knowledge – High Complication Rate (34%)
–Shorter Hospital Stay –Palpable Or Tri-
phasic Flow Not Needed
–Minimal Loss Of Function
4th Annual International External Fixation Symposium
December 11-14, 2008
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Gastrocnemius/Soleus FlapsGastrocnemius/Soleus FlapsBlood Supply:Branches of Popliteal Artery (Post tib and Peroneal for SoleusIndications:Gastroc – proximal 1/3 of lower leg – medial and lateral headsSoleus – middle 1/3 of lower legAdvantages:Fast, easy dissectionLarge amount of muscle - Gastroc can reach above kneeReliable Disadvantages:Needs STSG Peroneal n at risk
Gastrocnemius/Soleus FlapsGastrocnemius/Soleus Flaps
4th Annual International External Fixation Symposium
December 11-14, 2008
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Gastrocnemius/Soleus FlapsGastrocnemius/Soleus Flaps
Gastrocnemius/Soleus FlapsGastrocnemius/Soleus Flaps
4th Annual International External Fixation Symposium
December 11-14, 2008
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Reverse Sural Flap Reverse Sural Flap
Blood Supply:Perforating Br. Of Peroneal Artery Pivot Point: 5 Cm. Above The Lateral Malleolus
Reverse Sural Flap Reverse Sural Flap
Indications:
Advantages:
Disadvantages:
Large Defects (8x12 Cm.) Heel, Ankle & Forefoot Defects Lower Leg Defects
Easy To Dissect May Be Used W/o Pulses
Partial Flap Loss (Venous)
Pedicle Compression Supine Donor Site Stsg (?Bka ?) Sural Nerve Deficit / Neuroma Dog Ear
4th Annual International External Fixation Symposium
December 11-14, 2008
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Reversed sural flap
LESSER PERFORATING SAPHENOUS
BRANCH VEIN
WIDE PEDICLE
PERFORATING BRANCH
Reversed sural flap
4th Annual International External Fixation Symposium
December 11-14, 2008
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Reversed sural flapReversed sural flap
Reversed sural flapReversed sural flap
4th Annual International External Fixation Symposium
December 11-14, 2008
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Reversed Sural Flap: Reversed Sural Flap: Complications Complications
1) PAINFUL PROXIMAL SURAL N. NEUROMA 2) DONOR SITE SCAR IF BKA NEEDED 3) DISTAL FLAP DEATH
Reversed Sural Flap:Reversed Sural Flap:Avoiding Pitfalls Avoiding Pitfalls
Delay Flap Include Skin In Pedicle Use Ilizarov To Protect Flap As It Heals
4th Annual International External Fixation Symposium
December 11-14, 2008
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Lateral Calcaneal Flap:
Blood Supply: Lateral Calcaneal Artery
Pivot Point: Upper Lateral Malleolus
Lateral Calcaneal Flap: Lateral Calcaneal Flap:
Posterior Heel / Achilles Tendon Defects Lat. Malleolus Defects
Local Tissue
Hard To Dissect ( Pedicle Deep) Loss Of Distal Sensation Short Reach Not Pliable
Indications:
Advantages:
Drawbacks:
4th Annual International External Fixation Symposium
December 11-14, 2008
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Lateral Calcaneal Flap: Lateral Calcaneal Flap: Sural N.
Calcaneal Br. Peroneal Art.
DISSECTION: NEED TO LIFT FLAP OFF OF PERIOSTEUM!!!
Lateral Calcaneal Flap: Lateral Calcaneal Flap:
TRAUMATIC ACHILLES TENDON DEFECT IN A HEALTHY PATIENT
4th Annual International External Fixation Symposium
December 11-14, 2008
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Lateral Calcaneal Flap: Lateral Calcaneal Flap: COMPLICATION COMPLICATION
DISSECTION TOO SUPERFICIAL = DAMAGE TO PEDICLE
Lateral Calcaneal Flap: Lateral Calcaneal Flap: Avoiding Pitfalls Avoiding Pitfalls
Doppler Out Calcaneal Branch Of Peroneal Artery Start Distally & Stay On Top Of Periosteum
4th Annual International External Fixation Symposium
December 11-14, 2008
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Supra-malleolar Flap:
Blood Supply: Anterior Perforating Branch Of Peroneal Artery Pivot Point: Anterior Portion Of Lateral Malleolus
SupraSupra--malleolar Flap: malleolar Flap:
Indications:
Advantages:
Drawbacks:
Anterior Ankle Defects Lat. Malleolus Defects
Thin No Donor Site Deficit (Fascial Flap)
Insensate Limited Reach Tedious Dissection
4th Annual International External Fixation Symposium
December 11-14, 2008
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SupraSupra--malleolar Flap: malleolar Flap:
FRACTURED ANKLE & OSTEOMYELITIS SUPRA-MALLEOLAR FLAP COVERAGE ANKLE
AT, EHL, EDL Flap
Blood Supply: Anterior Tibial Artery Pivot Point: Variable
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December 11-14, 2008
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AT, EHL, EDL Flap AT, EHL, EDL Flap : :
NON UNION FIBULA WITH OSTEO EHL FLAP HARVESTED
AT, EHL, EDL Flap AT, EHL, EDL Flap
Anterior Medial And Lateral Ankle Defects
Rapid Good Blood Flow
Sacrifice Major Artery Insensate Need Stsg Loose Function
Indications:
Advantages:
Drawbacks:
4th Annual International External Fixation Symposium
December 11-14, 2008
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AT, EHL, EDL Flap: AT, EHL, EDL Flap:
Abductor Hallucis Muscle Flap:
Artery: Medial Plantar Artery
Pivot Point: Distal Tarsal Tunnel
4th Annual International External Fixation Symposium
December 11-14, 2008
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Abductor Hallucis Muscle Flap: Abductor Hallucis Muscle Flap:
Indications:
Advantages:
Drawbacks:
Calcaneus Osteomyelitis Plantar Heel Defects Medial Ankle Defects
Easy & Quick Dissection Excellent Donor Site
Small Amt. Distal Tissue Limited Reach Needs Stsg
Abductor Hallucis Muscle Flap Abductor Hallucis Muscle Flap & Local Flap& Local Flap
OSTEO ANKLE JOINT
4th Annual International External Fixation Symposium
December 11-14, 2008
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Abductor Hallucis Muscle Flap Abductor Hallucis Muscle Flap & Local Flap& Local Flap
FREE FLAPS
4th Annual International External Fixation Symposium
December 11-14, 2008
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Wound Closure: Wound Closure: Microsurgery Microsurgery Muscle And Stsg For Plantar Foot and Leg
Fascicutaneous For Dorsal Foot
Large Enough To Cover Defect And Pedicle
Free FlapsFree Flaps: :
Brings Fresh Healthy Tissue To Wound
Excellent Option when local tissue inadequate eg. Distal 1/3 of lower leg
Failure Rate ≤ 5%
6-8 Hours Of Surgery
Week Long Hospital Stay
4th Annual International External Fixation Symposium
December 11-14, 2008
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Free Flaps: Free Flaps: Principles Principles
Angiogram Think Pedicle Length And Avoid Vein Graft Artery: End To Side Two Veins Distal To Defect Is Ok Tailor Flap Tightly
Free Flaps:Free Flaps:
Disadvantage – Need Palpable Or Tri-phasic Flow
– Longer Op
– Icu Stay
– Longer Hospital Stay
-Flap loss can be disasterous – create 2nd
wound
Advantage – Choice Of Tissue
– Choice Of Size
– Minimal Loss Of Function
– Low Complication Rate (17%)
4th Annual International External Fixation Symposium
December 11-14, 2008
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Free Flaps in Trauma: Free Flaps in Trauma: Know A Few Options Well Know A Few Options Well
Muscle Flaps with STSG are best to cover hardware– Rectus Abdominus M. – Gracilis M. – Serratus M.
-Latissimus M. for very large defect
Osteocutaneous fibula flap for large bone defects
Latissimus Flap
4th Annual International External Fixation Symposium
December 11-14, 2008
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INTEGRA
IntegraINTEGRA Dermal Regeneration Template
• biosynthetic, implantable, bilayered membrane system for skin replacement
• composed of a dermal regeneration layer and a temporary epidermal layer.
4th Annual International External Fixation Symposium
December 11-14, 2008
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Integra– Dermal Regeneration Layer:
• Three-dimensional porous matrix of cross-linked bovine collagen and glycosaminoglycan (chondroitin-6-sulfate)
• Controlled porosity• Defined degradation rate• Promotes cellular in-growth
– Temporary Epidermal Substitute Layer:• Composed of synthetic polysiloxane polymer
(silicone)• Controls moisture loss from wound• Mechanically protects the wound
Mechanism of Action• Integra allows successful revascularization and
engraftment followed by organized regeneration of autologous dermal tissue
• Eventually a Neodermis of autologous connective tissue is created that has a 3-D structure that resembles dermis, not scar
• When the dermal layer is vascularized, the temporary silicone layer is removed and a thin epidermal autograft is placed
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December 11-14, 2008
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Histology of IntegraHistology of Integra
Cellular infiltration of matrix
Cellular infiltration of matrix Histology of neodermis following
silicone removal at 21 daysHistology of neodermis following
silicone removal at 21 days
Epidermis
Dermis
Fibroblast
Matrix
New collagen
Basement membrane
Advantages
– Minimize size/number of reconstructive procedures– Immediate physiologic wound closure– No temporary coverings– No risk of rejection– Early ambulation/rehabilitation– Delay creating donor site wounds – Faster donor site healing
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Disadvantages
– Requires multiple operations (minimum 2)– Requires rigorous surgical technique and
monitoring– Labor intensive post-operatively– Cost
Acute Traumatic Wounds
• Eliminates need for large reconstructive procedure – flap or graft
• May cover exposed tendons, nerve, bone• Eliminates immediate need for donor site• Earlier rehabilitation, discharge
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December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
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Acute Traumatic Wounds
Acute Traumatic Wounds
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Acute Traumatic Wounds
Acute Traumatic Wounds
4th Annual International External Fixation Symposium
December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
4th Annual International External Fixation Symposium
December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
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December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
4th Annual International External Fixation Symposium
December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
4th Annual International External Fixation Symposium
December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
4th Annual International External Fixation Symposium
December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
4th Annual International External Fixation Symposium
December 11-14, 2008
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Acute Traumatic Wounds
Acute Traumatic Wounds
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December 11-14, 2008
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New ConceptsDelay
New ConceptsDelay
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New ConceptsDelay
New ConceptsDelay
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New ConceptsDelay
New ConceptsBridging
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New ConceptsBridging
New ConceptsBridging
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New ConceptsBridging/Delay
New ConceptsBridging/Delay
4th Annual International External Fixation Symposium
December 11-14, 2008
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New ConceptsBridging/Delay
New ConceptsBridging/Delay
4th Annual International External Fixation Symposium
December 11-14, 2008
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Plastic Surgical Reconstruction in Foot and Ankle Trauma and
the Diabetic Foot: STSG to Free Flap
Paul M. Glat, MDDrexel University School of Medicine
Philadelphia, PA
4th Annual International External Fixation Symposium
December 11-14, 2008
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Diabetic Foot
General Concepts of Wound Management
• Wound bed preparation is vital • Excision of devitalized tissue and exposure
of clean wound bed• Coverage of wound bed• Complete wound closure – Reconstructive
Ladder = simple to more complex
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December 11-14, 2008
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Reconstructive LadderReconstructive Ladder
Diabetic limb salvage: Diabetic limb salvage: Team approach Team approach
• Diabetologist • Podiatrist • Pedorthetist • Surgical correction of biomechanical abnormalities
• Wound healing team & VNA • Vascular surgeon • Foot & ankle surgeon • Infectious disease • Plastic surgeon • Diabetologist • Hyperbarist
4th Annual International External Fixation Symposium
December 11-14, 2008
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Diabetic limb salvage: Diabetic limb salvage: • Etiology of diabetic ulcers
• Optimize the wound bed
• Need adequate blood flow & skeletal stability
• Simple & sound biomechanical reconstr
• Must individualize for each patient
Chronic wound: Chronic wound: MUST CHECK PULSES FIRST!MUST CHECK PULSES FIRST!
Vascularity NO issue • Palpable pulses
Vascularity an issueCompressible vessels
• A.B.I. < 0.9 • Tri-phasic or biphasic doppler signals Non-compressible vessel
• Flat pulse volume recordings
• Monophasic doppler signal • Toe pressures < 30 mm Hg • TCPO2 < 40 mm Hg
4th Annual International External Fixation Symposium
December 11-14, 2008
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Vascular Surgery vs. Vascular Surgery vs. Endovascular Intervention Endovascular Intervention
Percutaneous atherectomy
Angioplasty
Angioplasty + Stenting Excimer laser
Goal: Goal: AAchieving a healthy chieving a healthy wound base or healed wound wound base or healed wound
correct dx medical rx good blood flow debridement antibiotics modern wound care adjuncts: VAC growth factor cultured skin hyperbaric oxygen
4th Annual International External Fixation Symposium
December 11-14, 2008
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Healing soft tissue: Healing soft tissue:
• Debridement • Control of infection • Stimulation of healthy granulation tissue • Close wound
Debridement: Debridement: Sharp = Nonselective Sharp = Nonselective
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Serial excision
More precise: VersajetMore precise: Versajet
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Most preciseMost precise: Biosurgery eg. Maggots : Biosurgery eg. Maggots
• Indications • Awaiting revascularization • Too sick to go to OR • MRSA, VRE
Sherman Ra; Arch Phys Med & Rehab. 81:1226, 2001
BiosurgeryBiosurgery
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Post debridement: Post debridement: wait for signs of healing wait for signs of healing
• Wrinkled skin edges • Healthy granulation
tissue • Neo-epithelialization at
border • Increased peri-wound
TcO2
Wound healing adjuncts: Wound healing adjuncts: options options
• Negative pressure therapy • Xenograft / cadaver skin • Cultured skin • Growth factor • Hyperbaric oxygen
4th Annual International External Fixation Symposium
December 11-14, 2008
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Post debridement dressing Post debridement dressing NPWTNPWT
• Principle effects of VAC • Peri-wound edema • Blood flow • Granulation • Bacterial count
Xenograft: Xenograft: Preparation of Preparation of STSG bed STSG bed
4th Annual International External Fixation Symposium
December 11-14, 2008
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Apligraf: Apligraf: BiBi--layer live skin substitute layer live skin substitute
• Epidermis / dermis • Fibroblast and keratinocyte derived from foreskin • Fresh culture • 7 day ‘shelf life’• FDA approved • Diabetic foot ulcers (May 1998) • Venous leg ulcers (June 2000) • 7.5cm round single use
Apligraf Apligraf -- CytokinesCytokinesHuman Keratinocytes
Human Skin
Human Dermal Fibroblasts
+ + + + + + + + + + + + + + + +
+ + + + –+ + + ––+ –+ + + –
+ ––––– + + + + ––––– +
FGF-1 FGF-2 FGF-7 ECGF IGF-1 IGF-2
* PDGF-A * PDGF-B * TGF-α IL-1α IL-6 IL-8 IL-11
* TGF-β1 TGF-β3 VEGF *Enzyme-linked immunosorbent assay confirmation. FGF = fibroblast growth factor; ECGF = endothelial cell growth factor; IGF = insulin-like growth factor; PDGF = platelet-derived growth factor; TGF = transforming growth factor; IL = interleukin; VEGF = vascular endothelial growth factor.
4th Annual International External Fixation Symposium
December 11-14, 2008
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Diabetic foot ulcer: Diabetic foot ulcer: Topical growth factor Topical growth factor -- PDGF PDGF
Becaplermin/RegranexBecaplermin/Regranex
• PDGF on 382 diabetic wounds in phase 3 trial
• 43% improvement in wound closure • 50% PDGF healed completely • vs. 35% placebo
• 32% shorter time to heal • PDGF85 days • vs. placebo 127 days
Steed D, J Vasc Surg 1995, 21:79
Hyperbaric Oxygen TherapyHyperbaric Oxygen Therapy
GRADIENT TCPO2
• Oxygen gradient • Main signal for initiation of wound healing cascade • Stimulates neo-vascularization • Key to laying down wound healing matrix • Potentiate WBC killing of bacteria
4th Annual International External Fixation Symposium
December 11-14, 2008
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Grafts-STSG or FTSG
Pedicled Flaps
Free Flaps
Integra
Surgical Options
PEDICLED FLAPS
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December 11-14, 2008
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Reverse Sural Flap Reverse Sural Flap
Blood Supply:Perforating Br. Of Peroneal Artery Pivot Point: 5 Cm. Above The Lateral Malleolus
Reversed sural flap
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December 11-14, 2008
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Lateral Calcaneal Flap:
Blood Supply: Lateral Calcaneal Artery
Pivot Point: Upper Lateral Malleolus
Lateral Calcaneal Flap: Lateral Calcaneal Flap:
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Supra-malleolar Flap:
Blood Supply: Anterior Perforating Branch Of Peroneal Artery Pivot Point: Anterior Portion Of Lateral Malleolus
AT, EHL, EDL Flap
Blood Supply: Anterior Tibial Artery Pivot Point: Variable
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AT, EHL, EDL Flap: AT, EHL, EDL Flap:
Medial Plantar Flap: Medial Plantar Flap:
Indications:
Advantages:
Drawbacks:
Plantar Heel Defect Medial Ankle Defect
Glabrous Skin Sensate No Major Vessels Excellent Donor Site
Vessel Not Always There Tedious Dissection Graft donor site
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Medial Plantar Flap
Artery: Superficial or Deep Branch Of Medial Plantar Artery Pivot Point: Distal Tarsal Tunnel
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Toe Flaps:
Artery: Digital Artery
Pivot Point: Distal Plantar Transverse Crease
Toe Flaps: Toe Flaps:
Indications:
Advantages:
Drawbacks:
Small Forefoot Defects
Easy & Quick (Filet) Excellent Donor Site (Island)
Small Amt. Distal Tissue Limited Reach Sacrifice Toe (Filet) Tedious Dissection (Island)
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TOE ISLAND FLAP
OSTEO HALLUX IP JOINT
Toe Island Flap: Toe Island Flap:
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Toe Island Flap: Toe Island Flap:
DX: OSTEO 3RDMTP HEAD
Filet Of Toe: Filet Of Toe:
DX: OSTEO 1STMETATARSAL
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Filet Of Toe: Filet Of Toe:
DX: OSTEO 1STMTP HEAD
Extensor Digitorum Brevis Flap: Extensor Digitorum Brevis Flap:
Indications:
Advantages:
Drawbacks:
Anterior Ankle Defects Lat. Calcaneus Defects Lat. Malleolus Defects
Easy To Dissect Increase Reach By Cutting Dp Distally
Donor Site Problems Limited Mobility Tedious Dissection
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Extensor Digitorum Brevis Flap:
Blood Supply: Lateral Tarsal Artery
Pivot Point: Takeoff Lateral Tarsal A.
X
X (Reach Can Be Extended If D.P. Art. Or A.T. Art. Ligated)
Abductor Digiti Minimi Flap: Abductor Digiti Minimi Flap:
Calcaneal Osteomyelitis Plantar Heel Defects Lateral Ankle Defects
Easy & Quick Dissection Excellent Donor Site
Small Amt. Distal Tissue Limited Reach Needs Stsg
Indications:
Advantages:
Drawbacks:
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Abductor Digiti Minimi Flap:
Artery: Lateral Plantar Artery Pivot Point: Distal Tarsal Tunnel
DOMINANT PEDICLE
Flexor Digitorum Brevis Flap: Flexor Digitorum Brevis Flap:
Indications:
Advantages:
Drawbacks:
Calcaneous Osteomyelitis Plantar Heel Defect
Easy & Quick Dissection Excellent Donor Site
Small Amt. Distal Tissue Limited Reach May Need Stsg
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December 11-14, 2008
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Flexor Digitorum Brevis Flap:
Artery: Lateral Plantar Artery
Pivot Point: Distal Plantar Heel
FREE FLAPS
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Wound Closure: Wound Closure: Microsurgery Microsurgery Muscle And Stsg For Plantar Foot and Leg
Fascicutaneous For Dorsal Foot
Large Enough To Cover Defect And Pedicle
Free Flap: Free Flap:
Muscle – Rectus Abdominus M. – Gracilis M. – Serratus M.
Not The Latissimus M. - need upper extremity strength
Fasciocutaneous Flap – Radial Forearm – Lateral Arm – Parascapular – Anterolateral Thigh Flap (Thin Pt.)
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Rectus Abdominal Muscle: Rectus Abdominal Muscle: 12 Cm Pedicle 12 Cm Pedicle
Rx: RECTUS ABDOMINUS FLAP & STSG
Gracilis Muscle: Gracilis Muscle: 8 Cm Pedicle 8 Cm Pedicle
GRACILIS MUSCLE FLAP & STSG
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Serratus Muscle: Serratus Muscle: 18 Cm. Pedicle 18 Cm. Pedicle
SERRATUS M. + STSG
ParaPara--scapular Free Flapscapular Free Flap: : 12 Cm Pedicle 12 Cm Pedicle
Rx: PARA-SCAPULAR FLAP
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Lateral Arm Free FlapLateral Arm Free Flap: : 8 Cm. Pedicle 8 Cm. Pedicle
Rx: LATERAL ARM FLAP + TRICEPS TENDON
Radial Forearm Free FlapRadial Forearm Free Flap:: 10 Cm Pedicle 10 Cm Pedicle
Rx: RADIAL FOREARM FLAP
PALMARIS TENDON
ANTE-BRACHIAL CUTANEOUS
NERVE
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Radial Forearm Free FlapRadial Forearm Free Flap:: 10 Cm Pedicle 10 Cm Pedicle
DONOR SITE
SENSATE NORMAL FLEXION & EXTENSION OF TOES
EXCEPT
INTEGRA
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IntegraINTEGRA Dermal Regeneration Template
Chronic Wounds
• Often contaminated• Donor sites frequently high morbidity• May cover exposed tendons, nerve, bone• Eliminates need for large reconstructive
procedure – flap or graft
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Chronic Wounds
Chronic Wounds
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Chronic Wounds
Chronic Wounds
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Chronic Wounds
Chronic Wounds
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Chronic Wounds
Chronic Wounds
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Chronic Wounds
Chronic Wounds
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Chronic WoundsVenous Ulcers
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Chronic WoundsVenous Ulcers
Chronic WoundsVenous Ulcers
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Chronic WoundsVenous Ulcers
Chronic WoundsVenous Ulcers
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Chronic WoundsVenous Ulcers
Chronic WoundsVenous Ulcers
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Chronic WoundsVenous Ulcers
Chronic WoundsVenous Ulcers
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Chronic WoundsVenous Ulcers
THANK YOU
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