Dan Preece DPM, PGY-1
The Best Plastic Surgery?
Wound Prevention:

Puncture vs Crush: skin hooks and toothed pick ups instead of
flat.

Tension: think undermining, blanching is bad, more suture lines
= crossing wound less force per suture

Vasculature: check perfusion, adequate vasc supply?, vasc
consult if necessary prior to intervention.

Protection: trust pt to remain NWB?, offload potential
wounds.

Soft Tissue Envelope: fractures etc, this envelope needs
protection, key to healing.
1. Levin, S. Nunley, J. Soft Tissue Reconstruction for the Foot and Ankle. Foot and Ankle Surgery. Ch 34,
pg 1869-90.
Tissue Planes:

The soft tissue envelope is composed of several tissue layers,
each with a specific function and its own vascular supply.
 Skin, which consists of epidermis and dermis.
 Subcutaneous tissue, is less vascular, provides a cushion around
bony prominences.
 Fascia surrounds muscle compartments and neurovascular canals,
tendons, ligaments, contains a rich vascular plexus.
 Muscles are richly vascularized, can be manipulated as transposition
flaps, island pedicle flaps, and free tissue transplantations (free flaps).
 Periosteum surrounds all long bones and is vital to the response of
bone to injury and repair. Can be used as a free flap to augment
conventional methods of bone grafting.
Skin Layers:
2. http://upload.wikimedia.org/wikipedia/commons/3/34/Skin.jpg
Deep Fascia:
3.
http://www.somaxsports.com/
images/analysis/fascia_of_thi
gh.jpg
4. http://www.cals.ncsu.edu/course/zo250/bone-structure-2.jpg
Wound Preparation:

Irreversibly damaged or nonviable tissues need to be replaced.

Marginally viable tissue left behind can subsequently desiccate, infarct, and
become infected, adding further delay in healing.

Bone debridement: until “paprika sign” is found (punctate bleeding).

Options: Ultrasound, versajet, pulse lavage, sharp debridement.
5. http://wound.smith-nephew.com/ca_en/Standard.asp?NodeId=3169
Skin Grafts

Site Candidates: Full thickness wounds.

Full thickness wounds: if allowed to heal by primary intention
will lack dermal appendages anchoring epidermis with dermis.
Wounds experience contraction and reepithelialization from the
wound periphery, leaving central tissue that is relatively unstable
in terms of long-term durability.
6.http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19083.jpg
Skin Graft Keys:

Thickness:



Sweat glands (both apocrine and eccrine):


Split thickness: 0.008-0.02 in, less durable.
Full thickness: >0.02 in, or the full thickness of dermis/epidermis. More stable/durable.
Grafts/flapswill temporarily lose nervous control in grafts, newly grafted skin may be dry,
requiring moisturizing with common over-the-counter preparations.
Wound bed:


Bad: Exposed bone, tendon, nerve and cartilage, necrotic tissue, and devascularized fat.
Good: muscle, periosteum, perichondrium, fascia, healthy fat, and epitenon will all accept
skin grafts, any highly fascular surface.
7. Malay, S. Plastic
Surgery Techniques. The
PI Manual. Ch 6, Page
126.
Flaps:

Rotation, Transitional, Advancement Flaps:
 May include muscle, skin, and fascia, or a




combination.
Can add much-needed vascularized tissue
Obliterate dead space
Close the wound without tension
May be limited by location and donor site options.
Rotational Flap
Flap Types:
Advancement Flap
Transposition Flap
16. http://emedicine.medscape.com/article/1284569-overview
V-Y Advancement Flap: BCC excision
V-Y Advancement Flap: Undermine deeply to
preserve vascular tissue and increase distance allowed to move flap.
V-Y Advancement Flap:
Rotational Flap: BCC Excision
Rotational Flap:
Rotational Flap:
Free Flaps

Compound types:
 Fasciocutaneous, musculocutaneous, bone
with or without other tissues and vascular
supply intact (example target: AVN of talus).
 Require microvascular surgical techniques.
Muscular Flap Classification:





Type 1: one vascular pedicle (extensor digitorum brevis, tensor fascia lata)
Type 2: dominant pedicle and minor pedicles (abductor hallucis gracilis)
Type 3: two dominant pedicles (rectus abdominis, serratus anterior)
Type 4: segmental vascular pedicles (none)
Type 5: one dominant and secondary vascular pedicles (latissimus dorsi,
pectoralis major, pectoralis minor)
8.
http://emedicine.medscape.com/article/1284776-overview
Muscle Flaps Examples:

Flexor Digitorum Brevis: used in heel
deficit reconstruction.
15. Malay, S. Plastic Surgery
Techniques. The PI Manual.
Chap 6, pg 131.
•PT Fasciocutaneous Flaps:
-Designed on the medial aspect of the leg from the knee to the
medial malleolus.
-Based on septocutaneous perforators of the posterior tibial artery.
The pedicle is 2-4 cm long.
-It is used for coverage of defects of the middle and lower third of
the leg and foot can include the saphenous nerve for sensory innervation

Dorsalis Pedis flap: based on the dorsal skin of the medial
two thirds of the foot from the ankle to the toes.
 Blood supply is from the septocutaneous perforators of the dorsalis pedis artery
and first dorsal metatarsal artery.
 Its pedicle length is 6-10 cm.
 This flap can be used for defects around the ankle, foot, and lower leg, and it is
often used as a free flap.
Lateral Tarsal Artery
Flap (free flap), shows
How flaps in this region
can be developed 
9. http://emedicine.medscape.com/article/1284631-overview
10. http://www.cmj.org/periodical/images/200909/200991516139475.jpg

Medial plantar artery flap:
 Located on the instep of the foot and based on
the medial plantar artery.
 The pedicle is 12 cm long and has a diameter of
1.5 mm.
 Use this flap for coverage of plantar foot and
ankle defects.

Sural artery flap:
 Based on the sural artery direct cutaneous branch of
the popliteal artery.
 The pedicle is 3 cm long and has a diameter of 1.4
mm.
 It is located between the popliteal fossa and the
midposterior leg between the medial and lateral
heads of the gastrocnemius muscle.
 The flap can measure 15 x 6 cm and may include
the sural nerve as a neurosensory flap. Use this flap
for wounds around the knee and upper leg.
Sural fascioneurocutaneous flap:
Chronic DM
foot ulcer.
11. http://www.owm.com/files/owm/imagecache/normal/files/photo
s/owm_0604_f2i1b.gif
Sural Fasciocutaneous Flap:
24. Menke, C. Reverse Sural Fasciocutaneous Flap. PI Update 2010. Ch 21, Pg 111-114.
Sural Fasciocutaneous Flap:
Delay Phenomenom:

Once flap has been created it can be
transferred immediately or transfer can
be delayed. Delay will result in
increased blood flow to the flap and
increased flap survivability.
23. Ghali S, et al. A modified technique for transposition of the reverse
sural artery flap. Plastic Reconstruction Surgery 2006;117:2488-92.
•A meta-analysis of 50 papers that report the use of the unmodified distally
based sural flap was performed.
•587 of 720 flaps (82%) were reported to heal without necrosis or any
other flap-related complications.
•Complete flap necrosis was reported as a complication in only 24 of 720
flaps (3.3%),
•Partial or marginal flap necrosis was reported in 76 of 720 flaps (11%).
•Other flap-related complications, such as venous congestion, edema,
infection, and recurrent osteomyelitis, were reported in 33 of 720 flaps
(4.6%).
•18% experienced significant complications overall.
12. Donski PK, Fogdestam I: Distally based fased fasciocutaneous flap from the sural region: A
preliminary report. Scand J Plast Reconstr Surg 17:191-196, 1983.
Flap Failure:

Acute complications occur usually in the
first 48 hours and include:
 venous thrombosis
 arterial thrombosis
 hematoma, and hemorrhage
 excessive flap edema.
Flap Arterial Insufficiency:

Arterial insufficiency can be recognized by:




decreased capillary refill
pallor,
reduced temperature
the absence of bleeding after pinprick
Causes:
-arterial spasm,
-vessel plaque,
-torsion of the pedicle,
-pressure on the flap,
-technical error with injury to the pedicle,
-a flap that is too large for its blood supply,
-small vessel disease (due to smoking or diabetes).
Flap Viability Monitoring:
pH monitoring and transcutaneous oxygen tension
(PO2) can aid in early detection of flap ischemia.
 Doppler ultrasound.
 Laser Doppler.
 Surface temperature monitoring.

17.
18.
19.
20.
21.
22.
Serafin D, Lesesne CB, Mullen RY, Georgiade NG. Transcutaneous PO2 monitoring for assessing viability and predicting survival of skin flaps: experimental and clinical correlations. J
Microsurg. Mar 1981;2(3):165-78.
Hirigoyen MB, Blackwell KE, Zhang WX, Silver L, Weinberg H, Urken ML. Continuous tissue oxygen tension measurement as a monitor of free-flap viability. Plast Reconstr
Surg. Mar 1997;99(3):763-73.
Levinsohn DG, Gordon L, Sessler DI. Comparison of four objective methods of monitoring digital venous congestion. J Hand Surg [Am]. Nov 1991;16(6):1056-62.
Solomon GA, Yaremchuk MJ, Manson PN. Doppler ultrasound surface monitoring of both arterial and venous flow in clinical free tissue transfers. J Reconstr Microsurg. Oct 1986;3(1):39-41.
ones BM, Mayou BJ. The Laser Doppler flowmeter for microvascular monitoring: a preliminary report. Br J Plast
Surg. Apr 1982;35(2):147-9.
Sloan GM, Sasaki GH. Noninvasive monitoring of tissue viability. Clin Plast Surg. Apr 1985;12(2):185-95.
Arterial Compromise Management:
13.

Pharmacologic intervention at the time of exploration
includes vasodilators, calcium channel blockers, and
systemic anticoagulants.

If the above measures fail, anastomosis should be redone to
rule out intraarterial thrombus.
Pang CY, Forrest CR, Morris SF: Pharmacological augmentation of skin flap viability: A hypothesis to mimic the surgical delay phenomenon or a wishful thought. Ann Plast
Surg 22:293-306, 1989.
Venous Outflow Obstruction:

Signs:
 violaceous color
 brisk capillary refill
 normal or elevated temperature
 and production of dark blood after pinprick.

Venous insufficiency can occur due to:
 torsion of the pedicle, flap edema, hematoma, or tight closure of the
tissue over the pedicle.

The venous outflow obstruction can result in:
 extravasation of red blood cells, endothelial breakdown,
microvascular collapse, thrombosis in the microcirculation, and flap
death.
Venous Congestion:

Clinical observation and the monitoring of the patient (such as
with laser Doppler) should alert the surgeon.

Conservative treatment may include drainage of the hematoma
at the bedside.

Release of a few sutures to decrease pressure.

Leeches may be helpful if insufficient venous outflow cannot be
established despite a patent venous anastomosis. (The
leeches inject a salivary component (hirudin) that inhibits
platelet aggregation and the coagulation cascade.)
Leech Tx for Venous Congestion or Arterial Compromise of Flaps…
14. Utley DS, Koch RJ, Goode RL: The failing flap in facial plastic
and reconstructive surgery: Role of the medicinal leech.
Laryngoscope 108:1129-1135, 1998.
Bottom Line:
Be Prepared…
Sources:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Levin, S. Nunley, J. Soft Tissue Reconstruction for the Foot and Ankle. Foot and Ankle Surgery. Ch 34, pg 1869-90.
http://upload.wikimedia.org/wikipedia/commons/3/34/Skin.jpg
http://www.somaxsports.com/images/analysis/fascia_of_thigh.jpg
http://www.cals.ncsu.edu/course/zo250/bone-structure-2.jpg
http://wound.smith-nephew.com/ca_en/Standard.asp?NodeId=3169
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19083.jpg
Malay, S. Plastic Surgery Techniques. The PI Manual. Ch 6, Page 126.
http://emedicine.medscape.com/article/1284776-overview
http://emedicine.medscape.com/article/1284631-overview
http://www.cmj.org/periodical/images/200909/200991516139475.jpg
http://www.o-wm.com/files/owm/imagecache/normal/files/photos/owm_0604_f2i1b.gif
Donski PK, Fogdestam I: Distally based fased fasciocutaneous flap from the sural region: A preliminary report. Scand J Plast
Reconstr Surg 17:191-196, 1983.
Pang CY, Forrest CR, Morris SF: Pharmacological augmentation of skin flap viability: A hypothesis to mimic the surgical delay
phenomenon or a wishful thought. Ann Plast Surg 22:293-306, 1989.
Utley DS, Koch RJ, Goode RL: The failing flap in facial plastic and reconstructive surgery: Role of the medicinal leech.
Laryngoscope 108:1129-1135, 1998.
Malay, S. Plastic Surgery Techniques. The PI Manual. Chap 6, pg 131.
http://emedicine.medscape.com/article/1284569-overview
Serafin D, Lesesne CB, Mullen RY, Georgiade NG. Transcutaneous PO2 monitoring for assessing viability and predicting
survival of skin flaps: experimental and clinical correlations. J Microsurg. Mar 1981;2(3):165-78.
Hirigoyen MB, Blackwell KE, Zhang WX, Silver L, Weinberg H, Urken ML. Continuous tissue oxygen tension measurement
as a monitor of free-flap viability. Plast Reconstr Surg. Mar 1997;99(3):763-73.
Levinsohn DG, Gordon L, Sessler DI. Comparison of four objective methods of monitoring digital venous congestion. J Hand
Surg [Am]. Nov 1991;16(6):1056-62.
Solomon GA, Yaremchuk MJ, Manson PN. Doppler ultrasound surface monitoring of both arterial and venous flow in clinical
free tissue transfers. J Reconstr Microsurg. Oct 1986;3(1):39-41.
Jones BM, Mayou BJ. The Laser Doppler flowmeter for microvascular monitoring: a preliminary report. Br J Plast
Surg. Apr 1982;35(2):147-9.
Sloan GM, Sasaki GH. Noninvasive monitoring of tissue viability. Clin Plast Surg. Apr 1985;12(2):185-95.
23.. Ghali S, et al. A modified technique for transposition of the reverse sural artery flap. Plastic Reconstruction
Surgery 2006;117:2488-92.
24. Menke, C. Reverse Sural Fasciocutaneous Flap. PI Update 2010. Ch 21, Pg 111-114.