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Operative Procedures in

Plastic,Aesthetic and Reconstructive Surgery

EDITED BY

ARI S. HOSCHANDER CHRISTOPHER J. SALGADO WROOD KASSIRA SETH R.THALLER

and Reconstructive Surgery EDITED BY ARI S. HOSCHANDER • CHRISTOPHER J. SALGADO WROOD KASSIRA • SETH
and Reconstructive Surgery EDITED BY ARI S. HOSCHANDER • CHRISTOPHER J. SALGADO WROOD KASSIRA • SETH

Operative Procedures in

Plastic,Aesthetic and Reconstructive Surgery

Operative Procedures in

Plastic,Aesthetic and Reconstructive Surgery

EDITED BY

ARI S. HOSCHANDER

UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE MIAMI FL

WROOD KASSIRA

UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE MIAMI FL

CHRISTOPHER J. SALGADO

UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE MIAMI FL

SETH R.THALLER

UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE MIAMI FL

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Dedications

Shira, your support, motivation, and love have made this possible. You inspire me daily. No words can express my gratitude for all you do.

Jacob, Ezra, and Levi, the greatest kids in the world. Thank you for giving up some of our time together so that I could pursue this endeavor.

Mordechai and Rebecca Hoschander, my parents who have given me everything, I thank you.

Mentors and Colleagues, the only way to repay you for the knowledge and experience that you have

given to me is to pass that education on to the next generation of plastic and reconstructive surgeons.

I hope this book will repay part of that debt.

Ari S. Hoschander

I would first like to thank my family, who I love

more than anything in this world. It is with their support that time was allowed to invest in this book, which I feel is a significant addition to any plastic surgeon’s library. Second, my mentors in plastic surgery, Professors Hung-Chi Chen,

Fu-Chan Wei, Steve Evans, Chris Attinger, and Samir Mardini, have made the most impact on my academic surgical career; it is their influence on my career that has given me the encouragement to accomplish the editorial work for this magnifi- cent book. Lastly, my mother, Margarita Salgado, and father, Juan Salgado, have instilled in me the importance of dedication, hard work, and educa- tion; without this early teaching, this editorial process would not have been possible.

Christopher J. Salgado

For my mentors, who have taught me, and resi- dents, who inspire me every day.

Wrood Kassira

To the center of my life: wife, Pat; and kids, Steven Cody and Alexandra Lee. They make it all worthwhile.

Seth R. Thaller

Contents

 

Foreword

ix

Preface

xi

Editors

xiii

Contributors

xv

 

Part 1

GENEraL rECONStrUCtION

1

1 Skin grafting and dermal substitute placement Giorgio Pietramaggiori, Saja S. Scherer-Pietramaggiori, and Dennis P. Orgill

3

2 Component separation Harvey Chim, Karen Kim Evans, and Samir Mardini

9

3 Lower extremity reconstruction Jeremy C. Sinkin, Christopher J. Salgado, Karen Kim Evans, Varsha R. Sinha, and Kristin J. Blanchet

17

4 Chest wall reconstruction with pectoralis major muscle flaps Ryan Ter Louw and Karen Kim Evans

37

 

Part 2

BrEaSt rECONStrUCtION

49

5

Breast reduction: Inferior pedicle, wise pattern Tarik M. Husain and Seth R. Thaller

51

6

Gynecomastia Devra B. Becker, Shaili Gal, and Christopher J. Salgado

59

7

Implant-based breast reconstruction: Tissue expander placement after mastectomy Ari S. Hoschander and John Oeltjen

69

8

Implant-based breast reconstruction: Exchange of tissue expander for permanent implant Ari S. Hoschander, Michael P. Ogilvie, and John Oeltjen

75

9

Breast reconstruction with abdominal flaps Maurice Y. Nahabedian and Ketan M. Patel

79

10

Nipple reconstruction Dennis C. Hammond, Elizabeth A. O’Connor, and Johanna R. Sheer

87

Part 3

MaXILLOFaCIaL

99

viii Contents

12 Cleft palate repair: The Furlow double-opposing Z-plasty, the Von Langenbeck palatoplasty, and the V-Y pushback palatoplasty Jason W. Edens, Samuel Golpanian, Kriya Gishen, and Seth R. Thaller

111

13 Orbital floor fracture Urmen Desai, William Blass, and Henry K. Kawamoto

123

14 Mandible fracture management Larry H. Hollier Jr., Amy S. Xue, and Edward Buchanan

133

15 Zygomatic and zygomaticomaxillary complex (ZMC) fractures David E. Morris and Mimis N. Cohen

139

Part 4

COSMEtIC

147

16 Non-surgical facial rejuvenation with neuromodulators and dermal fillers Haruko Okada and David J. Rowe

149

17 Upper lid blepharoplasty Ari S. Hoschander and Amie J. Kraus

159

18 Lower eyelid blepharoplasty Urmen Desai, Andrew Rivera, and Richard Ellenbogen

165

19 Brow lift Christopher J. Salgado, Tuan Tran, Steven Schuster, and Elizabeth Yim

173

20 Facelift: The extended SMAS technique Ari S. Hoschander and James M. Stuzin

181

21 Rhinoplasty Tara E. Brennan, Thomas J. Walker, and Dean M. Toriumi

187

22 Correction of prominent ear Alejandra Garcia de Mitchell and H. Steve Byrd

201

23 Breast augmentation Elliot M. Hirsch and John Y.S. Kim

207

24 Mastopexy Leila Harhaus and Ming-Huei Cheng

213

25 Abdominoplasty, panniculectomy, and belt lipectomy * Ari S. Hoschander, Jun Tashiro, and Charles K. Herman

223

26 Brachioplasty Anselm Wong, Samantha Arzillo, and Wrood Kassira

229

27 Medial thigh lift Dennis J. Hurwitz

233

28 Liposuction Alan Matarasso and Ryan M. Neinstein

247

Part 5

HaND

259

29 Carpal tunnel release: Open Ali M. Soltani, Jose A. Baez, and Zubin J. Panthaki

261

30 Endoscopic carpal tunnel release: Anterograde single incision * Ari S. Hoschander, Matthew Mendez-Zfass, and Patrick Owens

265

31 Open trigger finger release for stenosing tenosynovitis Benjamin J. Cousins and Haaris S. Mir

271

32 Surgical approaches to the hand and wrist Ross Wodicka and Morad Askari

275

* Video available on line. See chapter for link.

Foreword

How does a surgeon learn to operate? I hope the old adage of “see one, do one, teach one” is in the past. Substitutes for training always fall short when measured against excellent teaching, reading, introspective analysis, and subsequent experience. Plastic surgery, unlike other surgical special- ties, is more about problem solving than seeking a specific operation. For me, applying fundamen- tal conceptual principles similar to those champi- oned early by Gillies and Millard 1 usually pointed toward a pleasing resolution. Operative Procedures in Plastic, Aesthetic, and Reconstructive Surgery provides detailed descriptions of the most com- monly used plastic surgical procedures. All operations follow an orderly set of moves. Experience allows seamless deviations as unex- pected events arise. A lesson from my mentor, Paul L. Tessier, illustrates the merit of following a defined path. The organizers of the 1975 International Society of Plastic Surgery meeting in Paris asked Tessier to perform a LeFort III operation for live transmission. He was allotted 75 minutes to operate on half of the face to complete the operation. Tacked on an operating room wall was a list of approxi- mately 275 steps needed to complete the procedure. He completed a flawless operation with time to spare. Recalling this story, I posted a list of steps to help separate craniopagus twins at the University of California at Los Angeles in 2002.

This text leads the reader through detailed, step-by-step depictions of operations. Applicable illustrations complement the text. In addition, a list of the essential equipment required for the operations is provided. Thus, the efficiency of the entire operating staff increases, and patient safety is enhanced. To complete the management of the patient, postoperative instructions as well as measures to diminish complications are pro- vided. Finally, unfortunately demanded by today’s health industry and not taught in any curricu- lum, there are handy lists of the most commonly accepted CPT codes associated with the described procedures. Ari Hoschander and his collaborators are to be congratulated for crafting a refreshing, concise guide for all levels of students of plastic surgery.

REFERENCE

1. Gillies HD, Millard DR Jr. The Principles and Art of Plastic Surgery. 2 vols. Boston, MA:

Little, Brown; 1957.

Henry K. Kawamoto Jr., DDS, MD Clinical Professor of Plastic and Reconstructive Surgery, University of California Los Angeles Medical Center, Los Angeles, California

Preface

We set out to compile this book because we felt there was a need for its content in the plastic surgery literature. The goal was to create a list of the most commonly performed plastic and reconstructive procedures and then dedicate an entire chapter to teaching the reader how to perform the operation. We focus on the technical aspects of the operation and deemphasize the disease process and patho- physiology, which are covered extensively in vari- ous other texts. We sought authors from around the world who are considered experts in specific aspects of plastic and reconstructive surgery to write the chapters on topics in their specialty. We are thank- ful that we were successful. Notice that the list of authors includes editors of major plastic surgery journals as well as chairs, professors, and educators in plastic surgery departments and divisions, all of whom dedicated their time to contribute to this project to further the education of the readers. This volume provides a comprehensive, step-by- step description of how to perform the most com- mon plastic, aesthetic, and reconstructive surgical procedures. The focus is on preoperative markings, intraoperative details, avoidance of complications, and postoperative instructions. Authors take the reader through the operation with multiple photo- graphs, drawings, and detailed descriptions. Each chapter centers on a well-documented technique for a specific clinical diagnosis. Exactly how to perform each of the most com- monly encountered operations is presented. Every plastic surgeon has a handful of procedures that

he or she performs regularly and a host of other procedures that are performed only occasion- ally. This list differs from surgeon to surgeon and locale to locale. Our goal is to provide a guide for the performance of all of these operations to level the playing field. This will inevitably improve patient safety and outcomes. The focus here is intraoperative detail. Authors assume readers already have an understanding of specific indications to perform the procedure and of the underlying pathophysiology of the disease. The chapters provide detailed explanations and descriptions of the techniques involved in the suc- cessful performance of the operations. Individual chapters provide a table delineating the equipment necessary to complete the procedure. The book may be used as a preoperative guide for operating room staff, improving their ability and efficiency to have the patient and room ready in a timely fashion. Also, the most commonly accepted CPT (Current Procedural Terminology) codes are avail- able for the operations described. This book will be an asset to any practicing plas- tic surgeon, fellow or resident in plastic surgery, as well as residents from surgical subspecialties who rotate through plastic surgery services. My coeditors and I thoroughly enjoyed compiling and contribut- ing to it, and we hope this will be an educational source of material for the future of plastic, aesthetic, and reconstructive surgery.

Ari S. Hoschander, MD

Editors

ari S. Hoschander, MD Division of Plastic, Aesthetic and Reconstructive Surgery, the DeWitt Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Christopher J. Salgado, MD, FaCS Department of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Wrood Kassira, MD, FaCS Division of Plastic, Aesthetic and Reconstructive Surgery, the DeWitt Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Seth r. thaller, MD, DMD, FaCS Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Contributors

Samantha arzillo University of Miami, Miller School of Medicine, Miami, Florida

Morad askari Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida; Division of Hand & Upper Extremity Surgery, Department of Orthopedics, University of Miami, Miller School of Medicine, Miami, Florida

Jose a. Baez Atlanta Hand Specialists Smyrna, Georga

Devra B. Becker Case Western Reserve University Hospitals/Case Medical Center and the Louis Stokes VA Medical Center, Lyndhurst, Ohio

Kristin J. Blanchet Comprehensive Foot & Ankle Surgery, Jupiter, Florida

William Blass Department of General Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida

tara E. Brennan Department of Otolaryngology-Head and Neck Surgery, University of Illinois College of Medicine at Chicago, Chicago, Illinois

Edward Buchanan Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas

H. Steve Byrd Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

Ming-Huei Cheng Division of Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan

Harvey Chim Department of Plastic Surgery, Case Western Reserve University, Cleveland, Ohio

Mimis N. Cohen Division of Plastic, Reconstructive, and Cosmetic Surgery, University of Illinois at Chicago, Chicago, Illinois

Benjamin J. Cousins South Florida Hand Surgery, Miami Beach, Florida

Urmen Desai Desai Plastic Surgery of Beverly Hills, Beverly Hills, California

Jason W. Edens Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, Florida

richard Ellenbogen Beverly Hills Body, Beverly Hills, California

Karen Kim Evans Department of Plastic Surgery, Georgetown University Medical Center, Division of Wound Healing, Washington, DC

Shaili Gal Department of Plastic and Reconstructive Surgery, UC Davis Medical Center, Sacramento, California

alejandra Garcia de Mitchell Department of Surgery, Division of Plastic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas

xvi Contributors

Kriya Gishen Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Samuel Golpanian Department of General Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida

Catherine Gordon University of Miami, Miller School of Medicine, Miami, Florida

Dennis C. Hammond Department of Surgery, Michigan State University College of Human Medicine, East Lansing, Michigan; Plastic and Reconstructive Surgery, Grand Rapids Medical Education and Research Center for Health Professions, Grand Rapids, Michigan

Leila Harhaus Department of Hand, Plastic and Reconstructive Surgery, Burn Care Unit, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany

Charles K. Herman Division of Plastic and Reconstructive Surgery, Pocono Health Systems/Pocono Medical Center, East Stroudsburg, Pennsylvania; Department of Surgery, The Commonwealth Medical College, Scranton Pennsylvania; Division of Plastic and Reconstructive Surgery, Albert Einstein College of Medicine New York, New York

Elliot M. Hirsch Division of Plastic Surgery, Northwestern University, Chicago, Illinois

Larry H. Hollier Jr. Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas

Elan Horesh (Illustrations) University of Miami, Miller School of Medicine, Miami, Florida

ari S. Hoschander Division of Plastic, Aesthetic and Reconstructive Surgery, The DeWitt Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Dennis J. Hurwitz Department of Plastic Surgery, University of Pittsburgh; Hurwitz Center for Plastic Surgery, Pittsburgh, Pennsylvania

tarik M. Husain MOSA Plastic/Aesthetic Surgery, Miami, Florida University of Miami Plastic Surgery, Miami, Florida; OrthoNOW Orthopaedic/Hand Surgery, Doral, Florida

Wrood Kassira Division of Plastic, Aesthetic and Reconstructive Surgery, The DeWitt Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Henry K. Kawamoto University of California Los Angeles Medical Center, Los Angeles, California

John Y.S. Kim Division of Plastic Surgery, Northwestern University, Chicago, Illinois

amie J. Kraus Department of Surgery, Hofstra University North Shore-Long Island Jewish Health System, Manhasset, New York

rizal Lim Division of Plastic Surgery, University of Miami, Miami Florida

Samir Mardini Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota

alan Matarasso Department of Plastic Surgery, Manhattan Eye, Ear & Throat Hospital/Lenox Hill Hospital/North Shore-Long Island Jewish Health System, New York, New York

Matthew Mendez-Zfass Department of Orthopaedics, University of Miami, Miller School of Medicine, Miami, Florida

Haaris S. Mir Joseph M. Still Burn Center, Burn and Reconstructive Centers of Florida, Miami, Florida

David E. Morris Division of Plastic, Reconstructive, and Cosmetic Surgery, University of Illinois at Chicago, Chicago, Illinois

Maurice Y. Nahabedian Department of Plastic Surgery, Georgetown University Hospital, Washington, DC

Contributors xvii

ryan M. Neinstein Department of Plastic Surgery, Manhattan Eye, Ear and Throat Hospital/Lenox Hill Hospital/ North Shore-Long Island Jewish Health System, New York, New York

Elizabeth a. O’Connor BayCare Clinic Plastic Surgery, Green Bay, Wisconsin

John Oeltjen Division of Plastic, Aesthetic and Reconstructive Surgery, The DeWitt Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Michael P. Ogilvie Division of Plastic, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina

Haruko Okada Department of Plastic Surgery, Case Western Reserve University, Cleveland, Ohio

Dennis P. Orgill Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts

Patrick Owens Division of Hand Surgery, Department of Orthopaedics, University of Miami, Miller School of Medicine, Miami, Florida

Zubin J. Panthaki Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Ketan M. Patel Department of Plastic Surgery, Georgetown University Hospital, Washington, DC

Giorgio Pietramaggiori Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospitals of Lausanne, Switzerland

andrew rivera University of Miami, Miller School of Medicine, Miami, Florida

David J. rowe Department of Plastic Surgery, Case Western Reserve University, Cleveland, Ohio

Christopher J. Salgado Department of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Saja S. Scherer-Pietramaggiori Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospitals of Lausanne, Switzerland

Steven Schuster Department of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Miller School of Medicine, Miami Florida

Johanna r. Sheer Grand Rapids Medical Education Program, Michigan State University, Grand Rapids, Michigan

Varsha r. Sinha University of Miami, Miller School of Medicine, Miami, Florida

Jeremy C. Sinkin Georgetown University Hospital, Department of Plastic Surgery, Washington, DC

ali M. Soltani Department of Plastic Surgery, Kaiser Permanente Orange County, Irvine, California

James M. Stuzin University of Miami, Miller School of Medicine, Miami, Florida

Jun tashiro The DeWitt Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida

ryan ter Louw Department of Plastic Surgery, Georgetown University Medical Center, Washington, DC

Seth r. thaller Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, Florida

Dean M. toriumi Department of Otolaryngology-Head and Neck Surgery, University of Illinois College of Medicine at Chicago, Chicago, Illinois

tuan tran Department of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Miller School of Medicine, Miami, Florida

thomas J. Walker Department of Otolaryngology-Head and Neck Surgery, University of Illinois College of Medicine at Chicago, Chicago, Illinois

xviii Contributors

ross Wodicka University of Miami, Miller School of Medicine, Miami, Florida

anselm Wong Division of Plastic and Reconstructive Surgery, University of Miami, Miller School of Medicine, Miami, Florida

amy S. Xue Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas

Elizabeth Yim University of Miami, Miller School of Medicine, Miami, Florida

PART 1

General Reconstruction

1 Skin grafting and dermal substitute placement Giorgio Pietramaggiori, Saja S. Scherer-Pietramaggiori, and Dennis P. Orgill

03

2 Component separation Harvey Chim, Karen Kim Evans, and Samir Mardini

09

3 Lower extremity reconstruction Jeremy C. Sinkin, Christopher J. Salgado, Karen Kim Evans, Varsha R. Sinha, and Kristin J. Blanchet

17

4 Chest wall reconstruction with pectoralis major muscle flaps Ryan Ter Louw and Karen Kim Evans

37

1

Skin grafting and dermal substitute placement

GIORGIO PIETRAMAGGIORI, SAJA S. SCHERER-PIETRAMAGGIORI, AND DENNIS P. ORGILL

Introduction

4

Postoperative details

6

Preoperative markings

4

Recipient site

6

Intraoperative details

4

Donor site

6

Partial-thickness skin donor site

4

Notes

6

Full-thickness skin donor site

5

CPT coding

7

Application of the skin graft

6

References

7

INDICatIONS

1. Partial-thickness skin graft: loss of skin coverage without tendon, nerve, bone, or synthetic material (i.e., silicone, titanium, polytetrafluoroethylene) exposure

2. Full-thickness skin graft: loss of skin coverage without tendon, nerve, bone, or synthetic material (i.e., silicone, titanium,

polytetrafluoroethylene) exposure in aesthetic or functional areas (i.e., face, hand) 3. Partial-thickness skin graft plus dermal substitute graft: loss of skin coverage eventually with limited tendon, nerve, or bone exposure; loss of extensive skin area; loss of full-thickness skin in aesthetic or functionally important areas

Table 1.1 Special equipment

Powered dermatome (e.g., Wagner [electric], Zimmer [compressed air] dermatome [standard], Weck dermatome [for small grafts, i.e., <5 cm 2 ] Skin mesher (with or without a plastic carrier template) Lubricating material (mineral oil or water-soluble gel) Adrenaline (1 mg/mL, dilution in 1000 mL NaCl 0.9%) Skin stapler or sutures Donor site dressing material (petroleum-impregnated interface, gauze, bandages) Recipient site dressing material (petroleum-impregnated interface, gauze, bandages, or non-adherent dressing)

4 Skin grafting and dermal substitute placement

Table 1.2 Optional equipment

Fibrin glue Integra MatriDerm ® Sub-atmospheric pressure device Non-adherent dressing

INTRODUCTION

Skin grafting is one of the most frequently per- formed interventions in plastic surgery. This review is based on previous reviews but with more emphasis on surgical technique. 1,2 Tables 1.1 and 1.2 provide lists of the specialized and optional equipment, respectively. As a relatively simple procedure, skin grafting provides rapid and reli- able skin coverage. Skin grafting is defined as skin transfer from a healthy donor site to cover skin loss at the recipient site. As the avascularized tissue is freely transferred, the skin graft take (successful union) largely depends on rapid revasculariza- tion. The recipient site should be clear of necrotic, infective, or avascular elements to maximize skin graft take. When materials such as blood, serum, or purulent discharge exist at the interface, revas- cularization of the graft is inhibited. High levels of bacteria in the wound result in infection and loss of the graft. The thickness of dermis in the graft influences the quality of the grafted skin. Thicker dermis results in higher primary con- traction (contraction of the detached graft), takes longer to engraft, and counters secondary wound contraction. Full-thickness skin grafts result in an excellent aesthetic and functional result; split- thickness skin grafts often result in a less aesthetic and less functional outcome. In contrast, thin skin grafts rapidly revascularize but often provide unstable coverage and can undergo significant secondary contraction.

PREOPERATIVE MARKINGS

The skin graft donor site should be marked to best match the size of the recipient site.

INTRAOPERATIVE DETAILS

Disinfect donor and recipient sites with antiseptic skin preparation (e.g. povidone-iodine).

Partial-thickness skin donor site

1. Infiltration of the designated area with adrena- line solution to reduce bleeding (Figure 1.1).

2. A lubricating material (water-soluble gel or mineral oil) is applied on the donor site and on the dermatome to improve gliding.

3. The surgeon passes the dermatome (usually set at 0.2 mm or 0.0012 to 0.0014 in.) with

a 45° angle and constant pressure and speed

with a fixed pressure (Figure 1.2a; a manual dermatome is shown).

4. Small slits can be made in the graft using

a meshing machine (Figure 1.2b). This allows

for expansion of the size of the graft as well as holes for egress of blood and serum (Figure 1.2c). The expansion size can be varied

Wheals at the edge of the graft area
Wheals at the edge
of the graft area

Area of graft in ltrated through wheals

Figure 1.1 Donor site preparation. Bleeding is one of the complications most currently encountered at the donor site. Subcutaneous infiltration with diluted epinephrine (tumes- cent technique) significantly reduces blood loss. (From Scherer SS, Pietramaggiori GP, Orgill DP. Skin graft. In Gurthner GC, Neligan PC, eds. Principles. New York, NY: Elsevier; 2012:319–338. Plastic Surgery, Vol. 1. With permission.)

Intraoperative details 5

B A C D
B
A
C
D

Figure 1.2 Split-thickness skin graft harvesting and grafting. (a) Split-thickness skin graft harvested with manual or electrically driven dermatome. (b) The skin graft is positioned flat on the mesh template with the dermal site facing upward. (c) The skin graft can be expanded up to six times the original size with a skin mesher or with a sharp knife. (d) The split-thickness skin graft is fixed on the recipient wound bed by sutures, surgical staples, or fibrin glue. (From Scherer SS, Pietramaggiori GP, Orgill DP. Skin graft. In Gurthner GC, Neligan PC, eds. Principles. New York, NY: Elsevier; 2012:319–338. Plastic Surgery, Vol. 1. With permission.)

from 1:1 to 6:1 (1.5:1 is commonly used). The graft is kept moist using normal saline.

5. The donor site can be covered with a variety of dressing materials depending on the surgeon’s preference.

6. The skin graft is affixed with sutures, staples, or fibrin glue (Figure 1.2d). A compressive dress- ing is applied to prevent shear between the graft and recipient site.

Full-thickness skin donor site

The full-thickness skin donor site is usually ellip- tical and in the inguinal, lower abdominal fold; elbow fold; or retro-auricular, superior eyelid, or upper eyebrow region:

1. Infiltration with local anesthetic with dilute epinephrine solution

6 Skin grafting and dermal substitute placement

2. Sharp dissection of the skin with the entire dermis using a large scalpel blade

3. Complete defatting of the dermal site with scissors (Reynolds or face-lift)

4. Manual perforation of the graft with a pointed scalpel blade to allow for fluid drainage

5. Careful hemostasis of donor site

6. Sharp liberation of donor site wound margins if necessary

7. Direct closure

8. Simple wound dressing

Application of the skin graft

1. After careful wound bed preparation and hemostasis, the graft is placed on the raw recipient site area.

2. The graft can be preferably fixed by sutures or surgical staples in full-thickness skin grafts. Fibrin glue is especially useful in large split-thickness grafts that cover uneven surfaces.

3. If additional stabilization is required (as for full-thickness skin grafts) or early mobilization

is a goal (i.e., joint wounds), two options can be considered:

a. Bolster dressing: The graft is sutured in place, and the ends of the sutures are left intentionally long. A non-adherent layer (i.e., petroleum-impregnated gauze) is placed on the graft and covered with bolstered cotton or gauze. Sutures are secured across the second layer to maintain fixed pressure on the wound site.

b. Sub-atmospheric pressure dressing wound-healing device: A non-adherent dressing is placed on the graft (i.e., petroleum-impregnated gauze or a silicone sheet) under the wound bed interface. The vacuum should be set between 50 and 125 mmHg. Sub-atmospheric pressure dressings are especially useful to fix large skin grafts onto uneven surfaces.

Integra (Integra LifeSciences, Plainsboro, NJ) and MatriDerm (MedSkin Solutions, Billerbeck, Germany) are commonly used to augment the dermal layer. Both dermal substitutes are available in different thicknesses. Thin dermal substitutes allow simultaneous skin grafting

(one-step procedure); thick dermal layers need to be revascularized, usually over 2–3 weeks, followed by a thin split-thickness skin graft (two-step procedure).

POSTOPERATIVE DETAILS

Recipient site

1. The skin graft should be left in a fixed position (as much as possible) for at least 3 to 5 days. Shearing forces cause partial/total graft loss.

2. The bolster or compressive dressing is usually removed between 5 and 7 days after grafting.

3. Following the first evaluation, a dressing composed of petroleum-impregnated gauze can be used. Regular dressing changes should be continued until complete reepithelialization.

Donor site

1. If a semi-permeable polyurethane dressing has been used, serum accumulation should be periodically evacuated via a drain or a syringe.

2. If a petroleum-impregnated gauze has been used, it can be allowed to dry and spontaneously come off (generally in 14 to 21 days).

NOTES

Optimal donor sites for facial wounds are above the clavicle for best color match. Ideal donor sites are adjacent to the wound bed for texture and color. The donor site of split-thickness skin grafts heals by reepithelialization over 2–3 weeks and leaves a scar, the visibility of which is dependent on patient factors as well as the thickness of der- mis that was removed. Non-exposed areas are usually selected as donor sites (i.e., thigh, trunk, and buttocks). If the graft is too large for the recipient site, it is possible to re-place the graft onto the donor site, but the cosmetic results are poor (patchwork-like). It should be noted that a skin graft can be pre- served on moist gauze at 4°C for up to 2 weeks and then successfully grafted. Dermal substitutes can be grafted over small areas of exposed bone or tendon. In this case, it is

References 7

recommended to prepare the cortical bone with several holes by drilling to induce more efficient vascularization and cell engraftment in the dermal template. In the skull, burring down to the diploic space is effective.

CPT CODING

15002–15005 Initial wound preparation of recipient site (burn and wound preparation or incisional or excisional release of scar con- tracture resulting in an open wound requiring a skin graft)

15100–15261 Autologous skin grafts (e.g., split-thickness skin graft, full-thickness skin graft, epidermal graft)

REFERENCES

1. Orgill DP. Excision and skin grafting of thermal burns. N Engl J Med.

2009;360(9):893–901.

2. Scherer SS, Pietramaggiori GP, Orgill DP. Skin graft. In Gurthner GC, Neligan PC, eds. Principles. New York, NY: Elsevier; 2012:319–338. Plastic Surgery, Vol. 1.

2

Component separation

HARVEY CHIM, KAREN KIM EVANS, AND SAMIR MARDINI

Introduction

9

Postoperative details

13

Preoperative markings

11

Notes

13

Intraoperative details

11

CPT coding

15

Technique modification: Component

Suggested Readings

15

separation with preservation of perforators

13

INDICatIONS

1. Large ventral hernias that cannot be closed primarily by apposition of the anterior rectus sheath

2. Large abdominal wall defects after extirpative surgery or flap harvest that cannot be closed primarily by apposition of the anterior rectus sheath

Table 2.1 Special equipment

Warm saline bath not to exceed 37°C Cefoxitin 2 g IV given prior to incision Jackson-Pratt #10 flat drains, 2 per side Sterile antiseptic skin preparation Choice of synthetic versus biologic mesh

INTRODUCTION

Large abdominal hernias pose a reconstructive challenge. Component separation provides a means of recruiting innervated, vascularized autologous tissue for closure of ventral hernias or for immedi- ate closure of large abdominal wall defects result- ing from resection of the midline rectus abdominis complex or harvest of a vertical rectus abdominis

myocutaneous (VRAM) flap. Key to successful surgery is thorough understanding of the anatomy of the anterior abdominal wall. Release of the external oblique muscles and the posterior rectus sheath allows the paired rectus abdominis muscles to come together in the midline to form a dynamic muscular sling (Figure 2.1). Special equipment for the procedure is shown in Table 2.1.

10 Component separation

10 Component separation (a ) (b) (c ) Figure 2.1 Cadaver dissection. (a) The rectus abdominis

(a

)

10 Component separation (a ) (b) (c ) Figure 2.1 Cadaver dissection. (a) The rectus abdominis

(b)

10 Component separation (a ) (b) (c ) Figure 2.1 Cadaver dissection. (a) The rectus abdominis

(c )

Figure 2.1 Cadaver dissection. (a) The rectus abdominis muscle, inferior margin of the ribs, anterior superior iliac spine, inguinal ligament, and external oblique muscles are marked. (b) Skin and sub- cutaneous tissue elevated off the abdominal wall fascia; an incision is made in the external oblique

fascia lateral to the semilunar line, and the external oblique is separated from the internal oblique laterally to the midaxillary line. (c) Posterior rectus sheath release 2 cm lateral to the medial edge of

the rectus muscle.

(Continued)

Intraoperative details 11

Intraoperative details 11 (d ) Figure 2.1 (Continued) Cadaver dissection. (d) Posterior rectus sheath dissected free

(d )

Figure 2.1 (Continued) Cadaver dissection. (d) Posterior rectus sheath dissected free from the rectus muscle.

PREOPERATIVE MARKINGS

1. Lateral border of rectus abdominis muscle (semilunaris line)

2. Anterior superior iliac spine

3. Inguinal ligament

4. Inferior margin of the ribs

5. External oblique muscles

INTRAOPERATIVE DETAILS

1. Incision is made on the margin of the skin graft or scar tissue overlying the ventral hernia (Figure 2.1a and b).

5. The semilunar line is identified and marked.

A longitudinal line is marked 2 cm lateral to the

semilunar line running 5 to 10 cm above and 5

to 10 cm below the level of the hernia. An inci- sion is made through the external oblique fascia. The external oblique is separated from the internal oblique muscle and fascia medially

to laterally to the midaxillary line.

6. For hernias that extend close to the xiphoid, advancement of the rectus muscles medially can be a challenge. In these cases, the inci- sion through the external oblique is extended above the ribs and then goes in an oblique fashion across the anterior rectus sheath. The

2. Sharp dissection laterally is used to under- mine the skin and subcutaneous tissue over

3. If a skin graft overlies the hernia, it is removed

4. The dissection is carried laterally up to 6 to

rectus muscle is undermined over the ribs and advanced medially (see Figure 2.2a and b). Care

the abdominal wall (anterior rectus sheath

is

taken to identify the deep superior epigastric

medially, then external oblique laterally). Care is taken to prevent inadvertent enterotomies.

vessels so they are not injured during dissection.

7. Release of the external obliques bilaterally allows advancement of approximately 3 to

with a #10 blade. If the surgeon is not confi-

5

cm in the upper third of the abdominal wall,

dent that closure of the hernia is possible, the

7

to 10 cm in the middle third, and 3 cm in

skin graft is left in place until it is clear that

the lower third.

closure is possible. Care is taken not to injure the underlying intestine. If an enterotomy is made, it must be recognized and closed.

8. Adequacy of release and residual tension are assessed by pulling the paired rectus abdomi- nis muscles to the midline.

Copious irrigation is performed. In the case of an enterotomy, we avoid use of prosthetic

9. Excess skin and scar overlying the ventral hernia are excised.

mesh; biologic mesh can be used.

10 cm lateral to the semilunar line.

10. Another component of the release involves a longitudinal cut in the posterior rectus sheath (Figure 2.1c and d). Intestinal tissue

12 Component separation

12 Component separation (a ) (b) Figure 2.2 (a) Release of the external oblique muscle is

(a )

12 Component separation (a ) (b) Figure 2.2 (a) Release of the external oblique muscle is

(b)

Figure 2.2 (a) Release of the external oblique muscle is completed bilaterally, and the midline is closed. (b) To move the upper rectus muscles medially, the external oblique fascia is released over the level of the ribs, and the superior aspects of the muscles are mobilized and moved medially (different patient than in Figure 2.2a).

and adhesions are released from the posterior

12. The midline structures (medial edge of the

13. If the posterior rectus sheath can be approxi-

14. If the posterior rectus sheath cannot be

rectus sheath all the way lateral to the lateral margin of the rectus muscles. Going further laterally is beneficial in most circumstances to be able to secure a piece of mesh if that is to be used. A line is marked on the poste- rior rectus sheath 2 cm lateral to the medial margin of the rectus muscle. An incision is made in the posterior rectus sheath. The posterior rectus sheath is then separated from the rectus muscles medially to laterally to the lateral margin of the rectus muscle. This allows further advancement of approximately

rectus fascia) are brought together using running #1 PDS ® sutures (polydioxanone, Ethicon, Norderstedt, Germany).

mated, then a prosthetic or biologic mesh is placed in the retrorectus space followed by approximation of the rectus muscles.

approximated, a large piece of prosthetic or biologic mesh is placed in the abdominal cav- ity as an underlay spanning the abdominal wall from the anterior axillary line on one

2

cm in the upper third of the abdominal wall,

side to the anterior axillary line on the other

2

to 4 cm in the middle third, and 2 cm in the

side and from the inferior rib margin cepha-

lower third.

lad to the iliac spine caudad.

11. The intraperitoneal cavity is irrigated with warm saline prior to closure.

15. If the anterior rectus sheath and rectus muscles will not come together in the

Notes 13

midline, a biologic or prosthetic mesh is placed as an underlay to the abdominal wall. Another piece of mesh can be used as an inlay or overlay as well to support the repair. This is anchored to the anterior rectus fascia with multiple horizontal mattress sutures using #1 PDS suture. If biologic mesh is used, Strattice (LifeCell , Branchburg, NJ) is preferred to AlloDerm ® (LifeCell) as it has a decreased capacity to stretch. Synthetic mesh should be avoided if the surgical site is contaminated and in patients with comorbidities that cause an unacceptably high risk for developing surgical site infection. Often, following anchoring of the underlay, the anterior rectus sheath can be closed in the midline due to redistribution of tension.

16. The anterior rectus sheath is then apposed using multiple #1 or 0 PDS sutures placed in a vertical or figure-of-eight mattress fashion.

17. Two #10 flat Jackson-Pratt (JP) drains are placed on each side to drain the subcutaneous pocket.

18. The skin is closed in layers.

19. A petroleum-based ointment is placed over the incisions, followed by a dressing. An abdominal binder is applied for support, par- ticularly when the patient is ambulating or coughing. In patients with a large pannus, we will use a Steri-Drape (3M , St. Paul, MN) placed from one side of the abdominal wall to the other while taking tension off the mid- line incision. One person will come from the lower end and use both hands to bring the pannus together from one side of the patient to the other. The Steri-Drape is placed on the abdominal wall while the pannus is squeezed in the midline. This allows for the tension to be on the Steri-Drape instead of the midline incision. Multiple layers of Steri-Drape can be placed. This is removed in 2 to 3 days. Maceration of the skin does occur with this type of dressing.

TECHNIQUE MODIFICATION:

COMPONENT SEPARATION WITH PRESERVATION OF PERFORATORS

All steps for component separation with pres- ervation of the perforators are similar to those outlined except during the elevation of the skin and subcutaneous tissues over the rectus

abdominus muscles. The incision is made on the margin of the skin graft or scar tissue overly- ing the ventral hernia. Sharp dissection laterally is used to undermine the skin and subcutane- ous tissue over the abdominal wall (anterior rectus sheath medially, then external oblique laterally). Perforators supplying the overlying subcutaneous tissues are identified and preserved (Figure 2.3). Clusters of perforators are easier to preserve. A cuff of tissue around the perforators should be preserved to prevent inadvertent dam- age to the perforators by retraction on the skin flaps. There is no exact number of perforators that should be preserved—the more the better. However, a key element is the size and pulsatil- ity of a perforator. Larger ones have better supply to tissues. Venous drainage through perforators could be a critical factor in survival of skin flaps and therefore should be preserved and not dam- aged during dissection and retraction. Most of the perforators that are preserved traverse the rectus abdominus muscles. Lateral to the semi- lunar line, the skin and subcutaneous tissue are separated from the external oblique muscles. This is required for making the incision through the external oblique fascia. Once the incision is made, follow steps 6 through 19 above.

POSTOPERATIVE DETAILS

Drains are kept in until output is <30 to 40 cc per drain over a 24-hour period. In some cases, drains may stay in as long as 4 weeks. Patients are instructed to wear the abdominal binder at all times for 6 weeks and should not engage in any moderate-to-heavy lifting for at least 6 weeks. The abdominal binder can produce compression that hinders blood supply; therefore it should not be placed tightly.

NOTES

Patients should be advised to avoid any heavy lift- ing if possible for the rest of their life and should not perform heavy weight-lifting or sit-ups. Other authors practice endoscopic or minimally inva- sive component separation aimed at decreasing the amount of undermining to reach the lateral edge of the rectus abdominis muscles. Each is a viable option and can be technically challeng- ing alternatives to open component separation,

14 Component separation

14 Component separation (a ) (b) (c ) Figure 2.3 Preservation of perforators: (a) The skin

(a )

14 Component separation (a ) (b) (c ) Figure 2.3 Preservation of perforators: (a) The skin

(b)

14 Component separation (a ) (b) (c ) Figure 2.3 Preservation of perforators: (a) The skin

(c )

Figure 2.3 Preservation of perforators: (a) The skin and subcutaneous tissue are elevated medially to laterally over the anterior rectus sheath and over the external oblique fascia and muscle. Perforators preserve blood supply yet allow access to release the external oblique fascia. (b) An incision is made in the rectus fascia. (c) The external oblique fascia is elevated from the internal oblique while preserving perforators.

Suggested readings 15

with the advantage of preserving most perforators supplying the midline abdominal skin and reduc- ing the incidence of wound-healing complications.

CPT CODING

SUGGESTED READINGS

Buck DW 2nd, Khalifeh M, Redett RJ. Plastic surgery repair of abdominal wall and pelvic floor defects. Urol Oncol. 2007

Mar–Apr;25(2):160–4.

49565

Herniorrhaphy, recurrent, reducible

Halvorson EG. On the origins of components

43566

Herniorrhaphy, recurrent, incarcerated

separation. Plast Reconstr Surg. 2009

13101-51 Complex repair, trunk; first 7.5 cm

Nov;124(5):1545–9. doi: 10.1097/

13102

Complex repair, trunk; additional 5 cm

PRS.0b013e3181b98ab8.

15734

Muscle flap of the trunk (component

Mathes SJ, Steinwald PM, Foster RD,

Oct;232(4):586–96.

separation)

Hoffman WY, Anthony JP. Complex

15777

Implantation of biologic implant (list

abdominal wall reconstruction: a comparison

separately in addition to code for primary procedure)

of flap and mesh closure. Ann Surg. 2000

49568 Implantation of mesh or other prosthesis

for open incisional or ventral hernia repair or mesh for closure of debridement for necrotiz-

ing soft tissue infection (list in addition to code for the incisional or ventral hernia) Repair of a recurrent, incarcerated hernia using component separation and release of the poste- rior rectus sheaths bilaterally (20 cm each side) would be coded as 43566, 13101-51, 13102 × 3,

15734 × 2 (one code for each side). If Strattice

was used as well to reinforce the closure, then

15777 would be added to the CPT coding.

Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990 Sep;86(3):519–26. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components tech- nique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limita- tions revisited. Plast Reconstr Surg. 2000 Feb;105(2):731–8; quiz 739.

3

Lower extremity reconstruction

JEREMY C. SINKIN, CHRISTOPHER J. SALGADO, KAREN KIM EVANS, VARSHA R. SINHA, AND KRISTIN J. BLANCHET

Introduction

18

Intraoperative details of the medial plantar

Diabetic foot wound reconstruction

19

artery flap

24

Preoperative markings

19

Notes

25

Intraoperative details of debridement

19

Skin substitutes

25

Postoperative details

20

Intraoperative details of Integra Bilayer

Forefoot plantar ulcers: Achilles

Matrix wound dressing application

26

lengthening, fillet of toe flaps

20

Postoperative details

26

Preoperative markings

20

Traumatic lower extremity wound

Intraoperative details of percutaneous

reconstruction

26

tendo-Achilles lengthening

20

Timing of lower extremity trauma

26

Intraoperative details of gastrocnemius

Intramedullary nail versus external fixation

27

recession

21

Fasciotomies for compartment syndrome of

Postoperative details

21

the lower leg

27

Intraoperative details of a toe fillet flap

21

Knee and upper third of leg coverage:

Postoperative details Midfoot plantar ulcers: Primary closure, skin

21

Medial or lateral gastrocnemius flap Middle third of lower extremity defect:

27

grafting, local flaps

22

Soleus flap

29

Intraoperative details of primary closure (rare)

22

Free-flap reconstruction of lower extremity

Intraoperative details of split-thickness skin

wounds

30

grafting

22

Rectus abdominis free flap

30

Intraoperative details of the V-Y

Gracilis muscle free flap

31

advancement flap

23

Latissimus dorsi free flap

33

Postoperative details

23

Anterolateral thigh flap

34

Intraoperative details of random pattern

CPT coding

35

rotation plantar foot flaps

23

Suggested readings

36

Postoperative details of a random pattern rotation plantar foot flap

24

Hindfoot plantar ulcers: abductor hallucis, abductor digiti minimi, flexor digitorum brevis, calcenectomy, medial plantar artery flaps

24

18 Lower extremity reconstruction

INDICatIONS

1. Contaminated or infected ulcer in a diabetic patient

2. An acute or subacute trauma to the lower extremity resulting in soft tissue defect with or without underlying fractures

3. Other lower extremity wound etiologies, such as autoimmune, venous stasis, or ischemic causes or following tumor resection

Table 3.1 Special equipment

Pneumatic extremity tourniquet and padding Handheld Doppler and sterile Doppler probes Two sterile setups (one for pre- and one for post debridement) and instrument trays Culture swabs (two sets – pre- and post debridement) Methylene blue and hydrogen peroxide Curettes (pre debridement) Rongeurs (pre debridement) Osteotomes (pre debridement) (Versajet™ hydrosurgery system) Pulse lavage and 3 liters of normal saline

Optional Products (Integra, apligraf) Dermatome and mesher and mineral oil for split thickness skin graft Negative pressure wound therapy machine

Dressings Plaster splint material Compression dressings Offloading shoewear

INTRODUCTION

Plastic surgeons often help reconstruct or salvage lower extremities that have been severely trau- matized, whether by chronic disease processes or by an acute injury. The goal of lower extrem- ity reconstruction is to heal the soft tissues over vital structures, such as bone, nerve, tendon, and vessel and to provide a durable, pain-free, and functional limb for ambulation. The focus of this chapter is diabetic and traumatic lower extremity reconstruction. Diabetic foot wounds are troublesome for the patient and care provider alike. Diabetic patients are prone to developing foot wounds secondary to neu- ropathy and loss of protective senses, biomechanical

abnormalities, and tissue ischemia. The most com- mon location for diabetics to develop foot ulcers is the plantar forefoot. Foot ulcers tend to be chronic and recurrent and may go unnoticed by affected individ- uals until the wounds are large or infected. Diabetic foot wounds are associated with increased risk for limb loss. Regular surveillance and primary preven- tion of foot ulcers in diabetic patients is vital; however, when wounds develop, early and aggressive therapy should be initiated. Thorough vascular examina- tion with handheld Doppler and noninvasive testing should be done prior to any reconstruction. Vascular surgery should be consulted for input regarding the need for bypass or endovascular surgery. Closure is usually delayed up to 2 weeks after bypass to ensure adequate blood supply prior to reconstruction. With thorough knowledge of wound pathophysi- ology, familiarity with topical agents, and expertise in surgical reconstruction, the plastic surgeon is uniquely qualified to assess healing potential and provide surgical debridement and staged closure of diabetic foot ulcers. Numerous techniques are available for the plastic surgeon to close diabetic foot wounds. The reconstructive procedure chosen should be the simplest indicated for each particu- lar wound location and characteristic. Paramount to successful treatment of diabetic foot ulcers is a thorough initial neurovascular and biomechanical examination. Infected wounds should be debrided of all nonviable tissue and culture-directed anti- biotics initiated. Liberal use of x-rays or magnetic resonance imaging aids in evaluation of biomechan- ical abnormalities, foreign bodies, and the presence of osteomyelitis. For stable, clean wounds, optimi- zation of the limb’s vascular status should be pur- sued prior to reconstruction. A multidisciplinary approach is needed to effectively treat all aspects of the diabetic foot pathology, including pedor- thotists, prosthetists, infectious disease, endocrine, medicine, podiatry, orthopedics, vascular surgery, wound nursing, and plastic surgery.

Diabetic foot wound reconstruction 19

With respect to acutely traumatized lower extremities, the majority are first treated by ortho- pedic surgeons, who prioritize bony stabilization. Many studies have demonstrated the importance of

early intervention to preserve soft tissues and cover open fractures in preventing complications, such as infection, delayed wound healing, or amputation.

A multidisciplinary approach utilizing orthopedic,

trauma, vascular, and plastic surgery teams is crucial

to achieve the goal of preserving a functional lower

limb. Treatment considerations include assessing the degree of vascular injury, contamination, frac-

ture patterns and the amount of comminution, and

the size of the soft tissue defect. Ideally, bones will

be stabilized, aggressive wound debridement will be

performed, and soft tissue reconstruction will then follow. Close communication with the physician treating the bony injury is critical to avoid unneces- sary amputations as often plastic surgery capabili- ties in wound coverage are not divulged early in the treatment period. Other wound etiologies include venous stasis, autoimmune processes, and ischemia. Reconstruction of these wounds typically starts with debridement, followed by simpler techniques for wound closure. If bypass is required, this should be done first, and debridement and reconstruction should be performed at least 2 weeks after bypass. Partnering with rheumotology is paramount for the autoimmune wounds. Wound nurses can be helpful with venous stasis patients who require compression dressings to promote healing. This chapter outlines a stepwise approach to the surgical treatment of lower extremity wounds, beginning with diabetic foot ulcers and followed by soft tissue reconstruction of the traumatized lower extremity.

DIABETIC FOOT WOUND RECONSTRUCTION

Preoperative markings

Doppler and trace the course of the anterior tib- ial/dorsalis pedis artery and the posterior tibial artery with its medial and lateral plantar branches. Handheld Doppler can be used to evaluate antero- grade flow in either the anterior or posterior tibial arteries by listening for signal in one vessel while compressing the other. Compression prevents retrograde flow through communicating branches.

Intraoperative details of debridement

1. Place patient supine on the operating room table for all wounds except wounds to the posterior heel or Achilles.

2. Wrap upper thigh with 3–5 layers of soft cot- ton roll substitute.

3. Place an appropriately sized pneumatic tour- niquet on the upper thigh over the cotton pad- ding. Set the tourniquet to 285 mmHg but do not inflate. The tourniquet is placed as a safety measure only. Tourniquets should be avoided in vascular patients.

4. Swab the wound with aerobic and anaerobic culture swabs. Label these cultures as “pre- debridement.” These pre-debridement cultures should be obtained prior to the prep.

5. Prep and drape the foot and ankle circumfer- entially to the knee.

6. Wipe the prep solution off the wound with a saline-moistened laparotomy pad.

7. Apply methylene blue to the wound using a Q-tip or laparotomy pad until the wound is coated with a thin layer of blue staining. If the wound has a sinus tract, a small amount of methylene blue can be injected into the sinus tract with a blunt angiocatheter. This will stain the tissue to ensure that the debridement is complete. Follow this maneuver with hydro- gen peroxide, which will facilitate the staining of the tissues with the dye.

8. Using a scalpel, sharply excise the edge of the wound until healthy, bleeding tissue is noted. Excise at least a depth of 5 mm so that any penetrating biofilm is excised adequately.

9. If Versajet (Smith & Nephew, London, UK) hydrosurgery system is available, debride the base of the wound until healthy, bleeding tissue is noted. Be sure to remove all blue- stained tissue.

10. If Versajet is unavailable, use curettes or a knife to debride the base of the wound, ensuring all blue-stained tissue is removed.

11. If bone is involved in the wound, use rongeurs to debride the bone, making sure to send the bone to both microbiology for culture and pathology for determination of osteomyelitis (pre-debridement). Any uneven bone edges should be smoothed with either a bone rasp

20 Lower extremity reconstruction

or pineapple mechanical burr, using water irrigation during the process to avoid thermal injury.

12.

Obtain hemostasis using judicious electrocautery.

13.

Pressure irrigate the wound with a minimum of 3 L of normal saline.

14.

Put on new sterile gloves. Place new sterile drapes.

15.

For the remainder of the case, use clean instruments.

16.

Swab the wound again for aerobic and anaero- bic cultures (post-debridement). It is best to obtain tissue for culture.

17.

If

bone is involved in the wound, use a ron-

geur to biopsy the bone and send for culture (post-debridement).

18.

If

the wound was grossly infected or had bac-

terial growth on previous post-debridement cultures, the wound should not be closed at

this time. Place either wet-to-dry dressings or

a

negative-pressure wound therapy (NPWT)

device and plan for return to the operating

room in next couple of days for staged closure.

19.

If

the wound has no growth from previous

post-debridement cultures, it is ready for closure.

20.

Apply a plaster posterior splint with the foot in 90° dorsiflexion, taking care to pad the heel well if reconstruction was performed.

Postoperative details

Patients should maintain non-weight-bearing status on the affected extremity. Postoperative x-rays can be helpful in osteomyelitis patients, particularly after large bone resections, so that the new bone anatomy may be delineated. Limb elevation is encouraged to reduce edema. Limitations of ambulation and mobility place patients at risk for thromboembolic events. As such, mechanical and chemoprophylactic measures should be taken to reduce the risk of deep vein thrombosis (DVT). Antibiotics are tailored according to operative cultures. NPWT dressings should be changed cleanly at the bed- side every 3 days to assess wound healing. Serial operative debridements spaced 24–72 hours apart are performed until all necrotic tissue and odor are absent from the wound.

FOREFOOT PLANTAR ULCERS:

ACHILLES LENGTHENING, FILLET OF TOE FLAPS

Forefoot plantar ulcers typically develop under metatarsal heads and are associated with increased pressures during gait as a result of stiffness of the Achilles tendon (triceps surae) and equinus defor- mity. Often, if the ulcer does not directly involve the bony prominence, tendo-Achilles lengthening or gastrocnemius recession along with thorough soft tissue debridement of the ulcer are sufficient to allow healing by secondary intention. Patients who are unable to dorsiflex beyond neutral with the knee in either the flexed or extended posi- tion should undergo tendo-Achilles lengthening, whereas patients able to dorsiflex beyond neutral only with the knee flexed demonstrate stiffness of the gastrocnemius portion of the tendon and should undergo gastrocnemius recession. It is important to avoid excessive lengthening because this may lead to calcaneal gait and heel ulcers. When forefoot wounds involve one or more phalanges, it can be helpful to preserve the soft tis- sues of each toe for the purposes of flap closure. Depending on the anatomy, the fifth toe may be small, and this tissue may not be enough to use for closure.

Preoperative markings

1. Identify the insertion of the Achilles tendon on the posterior calcaneal tuberosity.

2. Mark the medial and lateral edges of the Achilles tendon.

3. Mark three points along the central raphe of the tendon at 3, 6, and 9 cm proximal to the calcaneal insertion (percutaneous tendo- Achilles lengthening).

4. Mark the distal extent of the gastrocnemius muscle belly (gastrocnemius recession).

Intraoperative details of percutaneous tendo-Achilles lengthening

1. The patient may be positioned supine on the operating room table.

2. The foot and leg are prepped and draped circumferentially to the knee.

Forefoot plantar ulcers: Achilles lengthening, fillet of toe flaps 21

3. Elevate the leg and gently dorsiflex the foot.

4. Using a #15 scalpel, make the first stab incision at the 3-cm mark in a longitudinal fashion.

5. Turn the blade 90° medially and hemisect the tendon.

6. Make a stab incision at the 6-cm mark and turn the blade laterally to hemisect the tendon.

7. Make a stab incision at the 9-cm mark and turn the blade medially again to hemisect the tendon.

8. Maximally dorsiflex the foot until the tendon is released. Indentations along the edge of the tendon corresponding with each stab incision will be palpable when the hemisections are complete.

9. Close each stab incision with a single simple stitch using 3-0 or 4-0 Prolene ® (Ethicon, Somerville, NJ).

10. Apply sterile dressing to each incision and a plaster posterior splint with foot in 90 ° dorsi- flexion, taking care to pad the heel.

Intraoperative details of gastrocnemius recession

1. The patient may be positioned supine on the operating room table.

2. The foot and leg are prepped and draped cir- cumferentially to the knee.

3. Elevate the leg and dorsiflex the foot.

4. Make a 5-cm posteriomedial longitudinal incision, beginning just distal to the gas- trocnemius indentation and extend proximally.

5. Dissect through subcutaneous tissues to the deep fascia, taking care to preserve saphenous vein.

6. Incise the deep fascia longitudinally.

7. Bluntly dissect the soleus muscle from the gastrocnemius tendon medially to laterally, taking care to protect the sural nerve if identified deep to the fascia at this point.

8. Transversely transect the gastrocnemius tendon completely. The tendon edges will separate 1–2 cm, indicating complete release.

9. If the plantaris tendon is felt medially, it should be transected as well.

10. Close the deep fascia with 2-0 Vicryl ® (Ethicon).

11. Close the skin incision with 3-0 Prolene in a vertical mattress fashion.

12. Apply sterile dressings and a plaster posterior splint with foot in 90° dorsiflexion, taking care to pad the heel.

Postoperative details

Patients are kept non-weight bearing for 1 week, then in a CAM (controlled ankle motion) walker boot for the next 5 weeks.

Intraoperative details of a toe fillet flap

1. Prep, drape, and debride the wound as previ- ously described, removing all necrotic tissue.

2. Measure the size of the wound for proper flap planning.

3. Plan to take your flap from a toe adjacent to the wound.

4. Map the medial and lateral plantar digital neurovascular bundles.

5. Make a plantar longitudinal incision and elevate the flap beginning distally off the distal phalanx and flexor tendons back to the metarsophalangeal joint (MPJ). Follow the neurovascular bundles back to the adjacent web spaces.

6. Make a connecting incision to the wound, to be covered if needed.

7. Disarticulate the toe at the metatarsal phalan- geal joint and use the dorsal skin to flap down and cover the donor site. Ensure removal of the nail plate, nail bed, and any phalangeal bone within the flap tissue.

8. Carefully place the remaining flap over the wound, making sure to not cause excess tension or pressure on the neurovascular bundles.

9. Use skin sutures to secure the flap to the wound.

Postoperative details

Avoid compression on the local flap. Viability of the flap should be regularly monitored with fre- quent capillary refill checks to ensure there is no excessive pallor or congestion.

22 Lower extremity reconstruction

MIDFOOT PLANTAR ULCERS:

PRIMARY CLOSURE, SKIN GRAFTING, LOCAL FLAPS

The medial plantar midfoot is normally a non- weight-bearing region. Soft tissue defects in this area can be easily treated with skin grafting; how- ever, in diabetic patients, plantar ulcers of the midfoot generally occur in the setting of Charcot deformity and bony arch collapse. Skin grafts provide inadequate soft tissue coverage and are prone to breakdown when ulcers are associated with exostosis or other bony prominences but are easy and reliable options for non-weight-bearing regions. After midfoot stabilization and exostec- tomy, pressure points may be fully neutralized, and small ulcers can heal by skin graft or secondary intention. Although wounds may close by second- ary intention, this can result in an unstable scar and recurrent breakdown. Due to the relatively inelastic quality of plantar foot skin, only small ulcers tend to be amenable to primary closure, and more generally local flaps, including V-Y and rota- tion flaps, are employed for durable wound cov- erage and replacement of “like tissue with like.” Appropriate utilization of pedal local flaps requires knowledge of normal vascular anatomy and angio- somes. Perforating vessels should be identified and marked with a handheld Doppler. In addition, rotation flaps, although a random pattern, may be based on blood flow from axial vessels.

Intraoperative details of primary closure (rare)

1. Prep, drape, and debride the wound as previ- ously described.

2. The weight-bearing region of the plantar foot has thick glabrous skin with fibrous subcu- taneous adhesions. To close a plantar foot wound primarily without tension, judicious undermining of skin flaps using electrocau- tery or sharp dissection may be necessary.

3. Interrupted vertical mattress sutures using 2-0 Prolene on a CT-1 (Ethicon) taper needle are placed to evert skin edges and obtain tension-free wound edge approximation. Avoid excessive pressure on the skin edge with forceps.

4. Dry, sterile dressings are applied. Antibacterial ointments or

petroleum-moistened gauze dressings can cause maceration and are avoided on the plan- tar foot incision.

5. Apply a plaster posterior splint with the foot in 90° dorsiflexion, taking care to pad the heel and non-weight-bearing areas postoperatively.

Intraoperative details of split-thickness skin grafting

1. Clip the hairs and prep the upper thigh (donor site).

2. Prep, drape, and debride the wound as previ- ously described.

3. Measure the dimensions of the wound; ensure there is no denuded bone or tendon exposed.

4. Mark the size of the skin graft needed on the donor site.

5. Assemble the power dermatome with appro- priate size guard, setting the thickness of the graft at 0.014–0.018 in.

6. Optional step: Infiltrate the donor site with 1% lidocaine with 1:100,000 epinephrine diluted in normal saline.

7. Wipe away the prep solution from the thigh with a saline-dampened laparotomy pad.

8. Lubricate the donor site and dermatome with mineral oil.

9. Have an assistant apply traction to the donor site to create a flat, even donor surface.

10. Using slow/steady pressure on maximum power, harvest the split-thickness skin graft. If using the thigh as a donor site, always har- vest the graft from a more superior position to further conceal the graft if the patient wears shorts or a skirt (female).

11. Place the graft on a dermal carrier and mesh the skin graft using the mesher in a 1:1.5 ratio or “piecrust” the graft with a #11 scalpel.

12. The thigh can be closed primarily if the width of the skin graft is small enough to allow for skin closure. Primary closure of thigh donor sites should be done if at all possible as they heal with much less pain. Alternatively, if the patient is a female and there is redundant abdominal wall tissue, a mini-abdominoplasty may be performed and skin graft harvested from the specimen.

13. Apply the skin graft to the wound bed, mini- mizing the separation of the interstices.

Midfoot plantar ulcers: Primary closure, skin grafting, local flaps 23

14. Secure the skin graft with either skin staples or 3-0 running Monocryl ® (Ethicon) or chromic suture.

15. Apply a nonstick barrier such as Mepitel ® (Mölnlycke, Gothenburg, Sweden), xeroform, or Adaptic ® (Systagenix, San Antonio, TX) to the skin graft, followed by NPWT if desired.

16. Apply a plaster posterior splint with the foot in 90° dorsiflexion, taking care to pad the heel.

17. Apply sterile, semi-occlusive dressing to the skin graft donor site.

Intraoperative details of the V-Y advancement flap

1. Prep, drape, and debride the wound as previ- ously described.

2. To maintain a bloodless field and allow for easy identification of perforators, flap dissec- tion is performed under tourniquet control.

3. Elevate and gravity exsanguinate the extrem- ity for 2 minutes.

4. Inflate the tourniquet to 285 mmHg in patients who have not undergone a distal bypass procedure.

5. Orient the V flap in a manner such that it will advance in the direction of greatest skin elasticity, incorporating any known cutaneous perforators and respecting known angiosome boundaries.

6. The wound may need to be excised along the axis of the V flap to increase the width of the flap, which will increase the blood supply to the V flap.

7. Incise skin and subcutaneous tissues down to and including plantar fascia.

8. If necessary for flap mobility, judiciously undermine the flap in the subfascial plane,

judiciously undermine the flap in the subfascial plane, (a ) releasing fascial septations but preserving perforating

(a

)

releasing fascial septations but preserving perforating vessels.

9. Advance the flap to oppose wound edges without tension.

10. Deflate the tourniquet and obtain hemostasis.

11. Close the skin with 2-0 Prolene in an inter- rupted vertical mattress fashion, beginning with the distal flap.

12. Apply a sterile dressing.

13. Apply a plaster posterior splint with the foot in 90° dorsiflexion, taking care to pad the heel.

14. Commonly, only 1–2 cm is gained for a V-Y flap advancement procedure in the plantar foot.

Postoperative details

When NPWT devices are used to secure skin grafts, they are removed carefully at the bedside on postoperative day 4 to assess skin graft take. A petroleum-impregnated gauze is applied to the graft and changed daily to keep it moist. Donor site dressings are left in place for 10–14 days to allow undisturbed epithelialization.

Intraoperative details of random pattern rotation plantar foot flaps

1. Prep, drape, and debride the wound as previ- ously described.

2. Design a semicircular arc flap close to the wound that can be rotated around a pivot point to cover the wound (Figure 3.1a).

3. Make an incision along the planned flap lines with a #15 blade down to and including the plantar fascia.

with a #15 blade down to and including the plantar fascia. (b) Figure 3.1 (a) Plantar

(b)

Figure 3.1 (a) Plantar rotational flap based medially on the medial plantar artery blood supply to close a culture-negative diabetic plantar ulcer. (b) Flap rotated into place with split-thickness skin graft to the donor defect.

24 Lower extremity reconstruction

24 Lower extremity reconstruction Figure 3.2 Four months after surgical inter- vention. A total-contact cast was

Figure 3.2 Four months after surgical inter- vention. A total-contact cast was used for 2 months prior to allowing the patient to ambulate independently.

4. Gently free the flap in this subfascial plane so that it can be rotated to cover the defect.

5. If there is excessive tension on the flap, a back cut can be made at the end of the arc opposite from where the defect is to reduce tension.

6. The new defect created by rotating the flap should be closed with a split-thickness skin graft as closing this primarily will put tension on the flap away from the defect (Figure 3.1b).

Postoperative details of a random pattern rotation plantar foot flap

Nonstick sterile dressings are applied to the flap. Care is taken to avoid compression of the flap. Patients should be strictly non-weight bearing. Monitor the flap closely for signs of ischemia. Figure 3.2 shows a patient 4 months posteroperatively.

HINDFOOT PLANTAR ULCERS:

ABDUCTOR HALLUCIS, ABDUCTOR DIGITI MINIMI, FLEXOR DIGITORUM BREVIS, CALCENECTOMY, MEDIAL PLANTAR ARTERY FLAPS

Plantar heel ulcers in diabetic patients present a par- ticularly difficult reconstructive challenge (loupe magnification is strongly advised for all intrinsic flaps of the foot). The heel is weight bearing, and in ambulatory patients, the presence of an ulcer may indicate laxity of the Achilles tendon complex and

calcaneal gait (Figure 3.3a). In addition, because of the dual blood supply to the heel, nonhealing ulcers may reflect severe vascular disease. Depending on the depth of heel ulcers and the presence of osteomy- elitis, distally based V-Y advancement flaps as well as intrinsic muscle flaps with skin graft can be used for soft tissue reconstruction. Free flap reconstruction is commonly performed for large heel ulcers when there are no other options. Local muscle flaps used for the reconstruction of plantar foot wounds have included abductor hallucis, abductor digiti minimi, and flexor digitorum brevis. Source vessel patency and ante- grade flow should be confirmed prior to muscle har- vest. Intraoperative use of Doppler should occur after the muscle is mobilized and rotated into the defect

to ensure viability of the muscle. For nonambulators,

aggressive calcenectomy can be performed to allow

for more soft tissue mobilization and primary closure

of superficial wounds. If the medial plantar artery is

patent, a medial plantar artery flap may be one of the best options for closure of heel wounds because it can be sensate and highly durable (Figure 3.3b). Ilizarov frames or external fixators are useful adjuncts for immobilization and pressure offloading following local pedal flaps.

Intraoperative details of the medial plantar artery flap

The medial plantar artery flap is commonly used

for heel defects since the flap, which is based on the medial plantar artery, is readily transferred poste- rior upon harvest. A Doppler should be used to con- firm patency of the medial plantar artery or MRA/ angiogram is performed preoperatively as well.

A skin graft is then placed on the midfoot donor site.

1. Prep, drape, and debride the wound as previ- ously described.

2. Outline the recipient site defect so that these dimensions are marked on the midfoot plan- tar skin (Figure 3.3a).

3. A Doppler should be used intraoperatively to confirm the preoperative examination of medial plantar artery patency.

4. The skin paddle is then incised down to the plantar fascia and the flap raised from distal to proximal (Figure 3.3b).

5. The medial plantar vascular pedicle must be raised with the flap and identified distally if pos- sible (loupe magnification is strongly advised).

Skin substitutes 25

Skin substitutes 25 (a ) (b) Figure 3.3 (a) Calcaneal osteomyelitis defect (following debridement and negative

(a

)

Skin substitutes 25 (a ) (b) Figure 3.3 (a) Calcaneal osteomyelitis defect (following debridement and negative

(b)

Figure 3.3 (a) Calcaneal osteomyelitis defect (following debridement and negative final histopathol- ogy) planned medial plantar artery flap in diabetic male. (b) Medial plantar artery flap raised on its vascular pedicle.

Medial plantar artery flap raised on its vascular pedicle. Figure 3.4 Patient shown 5 months after

Figure 3.4 Patient shown 5 months after the surgery with a healed flap; the patient ambulates without assistance.

6. The vascular pedicle is encountered between the heads of the flexor hallucis brevis and abductor hallucis muscles.

7. A cutaneous nerve may be harvested with the flap to provide sensation.

8. The flap is rotated posteriorly into the defect, and a meshed skin graft is placed in the mid- foot defect (Figure 3.4).

Notes

Vascular optimization of the affected limb is essential for healing. Wound location and charac- teristics will dictate the appropriate reconstructive procedure. Loupe magnification is necessary when performing local pedal muscle flaps.

SKIN SUBSTITUTES

Skin substitutes have a variety of indications for difficult-to-heal wounds. These may include chronic diabetic foot ulcers, venous leg wounds, or even full-thickness wounds. These products are more useful in the sick patients who can- not undergo more definitive closure techniques. The three major skin substitutes commonly used are Apligraf ® (Organogenesis, Canton, MA); Dermagraft ® (Organogenesis); and Integra (Integra LifeSciences, Plainsboro, NJ). Apligraf is a bilayer living cell product made from fetal foreskin. Dermagraft is a cryopreserved human fibroblast-derived dermal substitute that also comes from neonatal foreskin. Integra bilayer wound dressing is an acellular porous matrix of cross-linked bovine tendon collagen and glycos- aminoglycan and a semi-permeable polysiloxane (silicone layer). The silicone layer adds strength, moisture control, and a flexible adherent dress- ing. Integra is the only substitute of the three that is indicated for full-thickness wounds and is use- ful to obtain dermal coverage of tendons and bone with intact periosteum.

26 Lower extremity reconstruction

Intraoperative details of Integra Bilayer Matrix wound dressing application

1. Prep, drape, and debride the wound as previ- ously described, removing all necrotic tissue.

2. Achieve hemostasis.

3. Measure the dimensions of the wound; bone with intact periosteum or exposed tendon is acceptable for this product.

4. Check the expiration date on the Integra and open onto the sterile field.

5. Peel open the foil pouch and, while holding the center tab, carefully remove the two poly- ethylene sheets.

6. Use the center tab to move the graft to the saline bath and carefully separate the graft into the saline to soak for 1–2 minutes.

7. The graft may be meshed with a mesher in the same way as for a split-thickness skin graft as described previously.

8. Apply the graft to the wound silicone side up.

9. Staple or suture the periphery of the graft to the wound edges approximately every 1–2 cm apart.

10. Trim the edges of the graft and apply gentle pressure with a sponge to press the center of the graft down against the wound base.

11. Apply a moist antimicrobial dressing followed by sterile gauze dressing and a moderate com- pressive dressing and offload if needed.

Postoperative details

Inspect the wound in 48 hours by changing the outer dressing to assess for hematoma. Drain if necessary. Continue to change the outer dress- ing at least every 72 hours to assess for infection and to remoisten antimicrobial dressings. The Integra should be fully vascularized by 21 days (salmon pink appearance), at which time the sili- cone layer is removed, and the wound is ready for a split-thickness skin graft (Figures 3.5a, b).

TRAUMATIC LOWER EXTREMITY WOUND RECONSTRUCTION

A soft tissue reconstructive option for the lower extremity can be guided by dividing the leg into proximal, middle, and distal thirds. Proximal- and middle-third defects are more easily treated

Proximal- and middle-third defects are more easily treated (a ) (b) Figure 3.5 (a) Well-vascularized appearance

(a )

and middle-third defects are more easily treated (a ) (b) Figure 3.5 (a) Well-vascularized appearance of

(b)

Figure 3.5 (a) Well-vascularized appearance of Integra. The superficial silicone layer is ready to be removed after 3 weeks. Previously exposed exten- sor hallucis longus and anterior tibialis tendon. (b) Split-thickness skin graft applied to dorsal foot wound following treatment with Integra.

with local flap options than distal-third defects. Options for distal-third open tibial fractures with soft tissue defects have traditionally been free tis- sue transfer; however, many defects are now man- aged with distally based flaps, such as the sural fasciocutaneous and soleus muscle.

Timing of lower extremity trauma

Although many trauma cases are treated as soon as possible, the literature reveals that only com- partment syndrome must be treated emergently. This means that fasciotomies should be performed within 6 hours. This also means that open frac- ture reduction and debridement do not necessar- ily need to be performed within 6 hours of the injury. These cases can easily be delayed up to 24 hours, and some literature reports delays of up

Traumatic lower extremity wound reconstruction 27

to and beyond 72 hours without adverse effects. This should be taken into consideration in cases of polytrauma or when scheduling is difficult.

Intramedullary nail versus external fixation

Intramedullary nail and external fixation can both be used successfully for rapid fixation of tibial frac- tures without the need for extensive soft tissue dis- section. Intramedullary nails have been shown to have lower rates of infection, malunion, and non- union, except for cases with severe comminution or for proximal tibial fractures. In the acute set- ting, complex, comminuted open fractures can be brought out to length and stabilized with external fixation at the time of first debridement. Often, fix- ation can be converted to an intramedullary nail by the orthopedic surgeon at the time of definitive soft tissue closure.

Fasciotomies for compartment syndrome of the lower leg

PREOPERATIVE MARKINGS

1. Anterolateral incision is placed longitudi- nally 2 cm anterior to the fibula shaft and is approximately 15 cm in length.

2. Posteriomedial incision is placed longitudi- nally 2 cm posterior to the posterior medial palpable edge of the tibia and is 15 cm in length.

INTRAOPERATIVE DETAILS OF FASCIOTOMIES OF THE LOWER LEG

1. Place the patient supine on the operating room table.

2. Prep and drape in the standard fashion.

3. Plan and make incisions as described previ- ously with a #15 blade.

4. Through the anterolateral incision, use blunt scissors to dissect down to the level of the intermuscular septum.

5. Release the anterior compartment by mak- ing a small nick in the anterior intermuscular septum midway between the septum and the tibial crest.

7. Release the lateral compartment by making a nick posterior to the intermuscular septum in line with the fibula shaft.

8. Extend the release for 15 cm using blunt-tip scissors by aiming for the lateral malleolus distally to ensure that dissection will be posterior to the superficial peroneal nerve.

9. Through the posteriomedial incision, use blunt scissors to dissect down to fascia.

10. Identify and retract the saphenous nerve and vein.

11. Release the superficial posterior compartment approximately 15 cm with blunt-tip scissors in a linear fashion.

12. Through the same incision, detach the soleal bridge at the origin of the soleus muscle and retract it to expose the fascia covering the tibialis posterior and flexor digitorum longus muscles.

13. Release the deep posterior compartment in a linear fashion by following the course of the flexor digitorum longus muscle.

14. Fascial layers are not closed.

15. Options for skin closure include primary closure of the skin, NPWT over open wounds until delayed closure with a split-thickness skin graft, or assisted wound closure tech- niques (the medial incision is commonly closed prior to the lateral incision).

POSTOPERATIVE DETAILS FOR FASCIOTOMIES OF THE LOWER EXTREMITY

If skin incisions are left open, proper wound care and follow-up are imperative. Regular dressing changes or use of NPWT will help reduce inci- dences of infection. If compartmental pressures were elevated for a significant time prior to sur- gery, muscle death and other soft tissue necrosis must be thoroughly debrided prior to skin closure.

Knee and upper third of leg coverage: Medial or lateral gastrocnemius flap

INDICATION

Proximal-third complex leg wound with exposed bone, hardware, or patella tendon.

PREOPERATIVE MARKINGS

28 Lower extremity reconstruction

INTRAOPERATIVE DETAILS OF MEDIAL GASTROCNEMIUS FLAP

1. Place the patient supine or prone on the oper- ating room table.

2. Place a well-padded thigh tourniquet on the correct limb.

3. Prep and drape in the standard fashion.

4. Gravity exsanguinate the limb and inflate tourniquet if desired.

5. Debride wound site as needed (Figure 3.6a).

6. Plan and make incisions as described with a #15 blade. If a skin island is planned, it is placed over the distal muscle belly in either the longitudinal or transverse orientation.

7. Deepen the incision down to the superficial surface of the muscle.

8. Proximally, the medial gastrocnemius is easily separated from the underly- ing soleus in a natural plane. The plan- taris tendon is visualized in this space.

plane. The plan- taris tendon is visualized in this space. (a ) Take care to protect

(a

)

Take care to protect the greater saphenous vein in the subcutaneous tissues medial to the medial gastrocnemius muscle belly.

9. Dissection proceeds from proximal to the distal insertion on the Achilles tendon.

10. Transect the medial aspect of the Achilles tendon for a medial gastrocnemius flap and laterally for a lateral gastrocnemius flap (if harvesting a lateral gastrocnemius flap, be careful to look for and not injure the common peroneal nerve).

11. The midline raphe is identified on the under- surface and superficial surface of the muscle. Care is taken to identify and protect the lesser saphenous vein and sural nerve along the midline raphe.

12. Sharply incise the midline to separate the medial gastrocnemius from the lateral (Figure 3.6b).

13. Rotate the flap to the area to be covered.

3.6b). 13. Rotate the flap to the area to be covered. (b) (c ) Figure 3.6

(b)

3.6b). 13. Rotate the flap to the area to be covered. (b) (c ) Figure 3.6

(c )

Figure 3.6 (a) Freshly debrided proximal-third leg wound with tibial fracture and exposed hardware. (b) Harvested medial and lateral gastrocnemius muscle bellies. (c) Well-healed medial gastrocnemius muscle.

Traumatic lower extremity wound reconstruction 29

14. The tunnel can be opened and the muscle drapes over this, or the muscle can be rotated under a subcutaneous tunnel (if this is performed, ensure that there is plenty of space in the tunnel so that undue compression is not placed on the muscle as it will lead to venous congestion of the muscle flap).

15. If a greater arc of rotation is required (to reach the proximal knee or distal thigh), the pedicle can be skeletonized along the proximal undersurface of the muscle and its origin transected.

16. Suture in place with absorbable sutures.

17. A split-thickness skin graft can be used to cover the muscle flap or donor site if a skin island is used.

POSTOPERATIVE DETAILS

Flexion and extension of the knee should be lim- ited with use of a knee immobilizer for 4 weeks. If skin grafting was necessary, bolster or NPWT dressing is continued for 4 days and then removed to assess graft take (Figure 3.6c).

Middle third of lower extremity defect: Soleus flap

INDICATION

Middle- or distal-third complex leg wound with exposed bone or hardware.

PREOPERATIVE MARKING

Longitudinal incision 2 cm medial to the medial tibial border.

INTRAOPERATIVE DETAILS OF THE SOLEUS FLAP

1. Place the patient supine or prone on the oper- ating room table.

2. Place a well-padded thigh tourniquet on the correct limb if desired.

3. Prep and drape in the standard fashion.

4. Gravity exsanguinate the limb and inflate tourniquet if desired.

5. Debride wound as needed (Figure 3.7a).

6. Plan and make incisions as described with a #15 blade or use existing wound and extend incision in line along medial border of tibia.

and extend incision in line along medial border of tibia. (a ) (b) (c) Figure 3.7

(a )

extend incision in line along medial border of tibia. (a ) (b) (c) Figure 3.7 (a)

(b)

incision in line along medial border of tibia. (a ) (b) (c) Figure 3.7 (a) Middle-third

(c)

Figure 3.7 (a) Middle-third complex leg wound with exposed tibial hardware and injured but intact gastrocnemius muscle (intact posterior tibial artery on preoperative angiogram). (b) Soleus muscle is transposed to cover the previously exposed hardware. The muscle is then covered with a split- thickness skin graft. (c) Patient is shown with healing after 7 months; the patient was ambulating without difficulty.

30 Lower extremity reconstruction

7. The soleus is located deep to the gastrocne- mius and plantaris tendons in the superficial compartment of the leg.

8. Divide the muscle at the midline if perform- ing a hemisoleus flap and dissect it away from the deeper flexor digitorum longus.

9. Distally, separate the soleus from the Achilles tendon on the superficial surface of the muscle.

10. Ligate distal perforators from the posterior tibial artery.

11. Rotate the flap to the area to be covered (fascial incisions may be made to increase the surface area of the transferred flap as shown in Figure 3.7b).

12. Suture in place with absorbable sutures.

13. A split-thickness skin graft can be used to cover the muscle flap.

POSTOPERATIVE DETAILS

If NPWT is used to secure a split-thickness skin graft, it is continued for 4 days postoperatively and then removed to assess graft take. Muscle is assessed for signs of ischemia or congestion. Leg elevation and non-weight bearing with strict knee immobilization are mandatory in the immediate postoperative period. Figure 3.7c shows a patient ambulating 7 months postoperatively.

Free-flap reconstruction of lower extremity wounds

Free tissue transfer has commonly been the method of choice for defects that are distal in the leg and foot. Commonly used free flaps have been both muscle and fasciocutaneous, with the harvest covered in many plastic surgery textbooks. Recipient vessels are commonly the anterior tibial artery and vein and the posterior tibial artery and vein. Anastomosis outside the level of injury in either an end-to-side fashion or end- to-end fashion has not been shown to provide any different outcome. In cases of Gustilo IIIC injuries, commonly used recipient vessels are the injured vessel proximal to the zone of injury. Computerized tomographic angiography, mag- netic resonance angiography, or angiography should be performed to delineate the arterial vas- culature prior to surgery, particularly in cases of tibial fractures.

Rectus abdominis free flap

INDICATION

Free muscle transfer is indicated for the treatment of complex distal leg wounds where local options for durable soft tissue coverage is limited. The rec- tus abdominis muscle is relatively quick and easy to harvest. It provides moderate muscle bulk; how- ever, there is associated donor site morbidity in the form of abdominal wall weakness with flexion and bulging. This flap is not commonly used now that perforator-based fasciocutaneous flaps with much less donor site morbidity are more popular. However, in the plantar aspect of the foot, some surgeons prefer a muscle-based flap with skin graft and not a perforator fasciocutaneous flap.

PREOPERATIVE MARKINGS

1. Mark the abdominal midline from xyphoid to pubis symphysis.

2. The choice of skin incisions includes midline, paramedian, or low extended Pfannenstiel incision.

INTRAOPERATIVE DETAILS FOR RECTUS ABDOMINIS MUSCLE HARVEST

1. Position the patient supine on the operating table.

2. Prep and drape the abdomen widely, from the upper thighs to above the xyphoid. Include the recipient site as well in the preparation.

3. Sharply cut skin and subcutaneous tissue down to the abdominal fascia along the previ- ously marked incision, which can be via an extended Pfannenstiel, midline, or parame- dian approach.

4. Judiciously undermine the skin and subcu- taneous flaps to expose the anterior rectus sheath along the length of the muscle.

5. Incise the anterior rectus fascia longitudinally over the middle of the muscle.

6. Dissect the anterior rectus fascia off the mus- cle to expose the medial and lateral borders of the muscle, taking care not to traumatize the fascia at the three inscriptions. If using Bovie cautery, it should be on low energy; bipolar cautery should also be used so that the muscle is not traumatized. We recommend the use of loupe magnification during the dissection.

7. Note that the motor nerves enter the muscle laterally.

Traumatic lower extremity wound reconstruction 31

8. Bluntly dissect the muscle away from the posterior rectus sheath.

9. Disoriginate the muscle from the xyphoid and anterior sixth, seventh, and eighth costal cartilages.

10. Superiorly, identify and ligate the deep supe- rior epigastric artery and vein on the under- surface of the muscle cephalad.

11. Identify the deep inferior epigastric artery and vein entering the muscle inferiolaterally on the undersurface of the muscle.

12. Disinsert the muscle from the pubic symphysis.

13. Dissect out and hemaclip/ligate the pedicle as close to the external iliac vessels as possible.

14. Transpose the flap to the recipient site for microvascular anastomosis and flap insetting.

15. Close the anterior rectus sheath with figure- of-eight permanent sutures, followed by a running suture.

16. Close the abdominal subcutaneous tissue and skin in layers over closed-suction drains (Figure 3.8a–f).

Gracilis muscle free flap

INDICATION

Free muscle transfer is indicated for the treat- ment of complex distal leg wounds where local options for durable soft tissue coverage is limited.

local options for durable soft tissue coverage is limited. (a ) (b) (c ) Figure 3.8

(a

)

options for durable soft tissue coverage is limited. (a ) (b) (c ) Figure 3.8 (a)

(b)

for durable soft tissue coverage is limited. (a ) (b) (c ) Figure 3.8 (a) and

(c )

Figure 3.8 (a) and (b) Preoperative view of traumatic injury to plantar aspect of foot. Exposed first and fifth metatarsal bones. (c) Intraoperative view of rectus abdominus muscle harvesting via an

extended Pfannenstiel incision.

(Continued)

32 Lower extremity reconstruction

32 Lower extremity reconstruction (d) (e) (f ) Figure 3.8 (Continued) (d) and (e) Injury site

(d)

32 Lower extremity reconstruction (d) (e) (f ) Figure 3.8 (Continued) (d) and (e) Injury site

(e)

32 Lower extremity reconstruction (d) (e) (f ) Figure 3.8 (Continued) (d) and (e) Injury site

(f )

Figure 3.8 (Continued) (d) and (e) Injury site 2 years postoperatively; patient was ambulating without assistance with durable reconstruction. (f) Donor site 2 years after surgery.

The gracilis muscle provides small-to-moderate bulk, can be easily harvested, and is associated with minimal donor site morbidity. Note that the pedicle has variable length and circumference.

PREOPOPERATIVE MARKING

Draw a line from the origin of the adductor lon- gus on the pubic tubercle to the medial tibial con- dyle. The gracilis is two finger breadths inferior to this line.

INTRAOPERATIVE DETAILS FOR GRACILIS MUSCLE HARVEST

1. The patient is positioned supine on the operat- ing table with leg abducted and hip and knee flexed (frog-legged).

2. Prep and drape the entire leg circumferentially.

3. Make a skin incision directly over the gracilis muscle in the proximal thigh, inferior to the adductor longus muscle.

Traumatic lower extremity wound reconstruction 33

4. Identify and preserve the greater saphenous vein.

5. Incise the deep fascia over the gracilis muscle belly.

6. Expose the muscle along the entire length of the gracilis on the superficial surface.

7. Retract the adductor longus muscle laterally.

8. Identify the neurovascular bundle entering the gracilis laterally and on the deep surface.

9. Dissect the medial femoral circumflex arterial pedicle proximally, ligating branches that go to the adductor longus and adductor magnus.

10. Disoriginate the gracilis from the pubic tubercle proximally.

11. Transect the gracilis tendon distally.

12. Hemaclip and cut the pedicle as proximally as possible and transpose the flap to the recipient site for microvascular anastomosis and flap insetting.

13. Close the donor site in layers over large-bore, closed-suction drains.

14. For added muscle coverage, the gracilis can be stretched by scoring the epimysium.

Latissimus dorsi free flap

INDICATIONS

Free muscle transfer is indicated for the treat- ment of complex distal leg wounds where local options for durable soft tissue coverage are lim- ited. The latissimus dorsi is a large, superficial muscle of the back that can be used to cover large

soft tissue defects and is easily tailored. Harvest of the latissimus dorsi can be quick but requires lateral decubitus positioning. Donor site morbid- ity includes weakness of shoulder adduction and upper arm extension and internal rotation. This flap is not recommended in patients who are in a wheelchair.

PREOPERATIVE MARKINGS

1. Mark the tip of the scapula, midline of the back, iliac crest inferiorly, and anterior border of the latissimus along the posterior axillary line.

2. If a skin paddle is needed, it is designed along the axis of the muscle (Figure 3.9).

INTRAOPERATIVE DETAILS FOR LATISSIMUS DORSI MUSCLE HARVEST

1. Position the patient in lateral decubitus with the operative site up, arm abducted, and elbow flexed.

2. Be sure to place an axillary roll and pad pres- sure points.

3. Prep and drape the arm and back widely.

4. Incise skin along the skin paddle.

5. Dissect down to the muscle.

6. Widely expose the superficial surface of the muscle, undermining skin and subcutaneous flaps.

7. Identify the anterior border of the muscle and begin to dissect the undersurface of the latis- simus away from the serratus anterior.

of the latis- simus away from the serratus anterior. Figure 3.9 Preoperative marking of the latissimus

Figure 3.9 Preoperative marking of the latissimus dorsi muscle.

34 Lower extremity reconstruction

8. Identify and protect the thoracodorsal pedicle on the undersurface of the muscle in the fatty connective tissue near the axilla.

9. Disoriginate the latissimus from the thoraco- lumbar fascia inferiorly and medially.

10. Inferiorly, take care not to violate the lumbar fascia deep to the latissimus; otherwise, lum- bar herniation may result.

11. Dissect the vascular pedicle on the undersur- face of the latissimus as proximally as possible.

12. Identify the serratus branch (Figure 3.10) and ligate.

13. Disinsert the latissimus.

14. Hemaclip and ligate the thoracodorsal pedicle.

15. Transpose the flap to the recipient site for microvascular anastomosis and flap insetting.

16. Close the donor site in layers over at least two large-bore, closed-suction drains.

POSTOPERATIVE DETAILS

For the gracilis, rectus, and latissimus free flaps, there are no strict limitations on the donor site. Coughing and straining should be kept to a minimum for patients who undergo rectus abdominis muscle har- vest. The recipient extremities should be kept elevated for 10 days and non-weight bearing. Postoperative flap monitoring involves a stay in the intensive care unit for 3 days, where flap color, temperature, turgor, and Doppler signal can be checked with frequency.

Anterolateral thigh flap

INDICATIONS

Free anterolateral thigh (ALT) flap transfer is indicated for the treatment of complex distal leg wounds where local options for durable soft tis- sue coverage is limited. The ALT flap has become a workhorse flap for many institutions because of its ease of harvest, minimal donor morbidity, and predictability. Indications commonly include any large soft tissue defect of the leg and foot except for the plantar aspect due to its bulk and risk of perforator shear injury compromising the skin paddle. Care must be taken to avoid harvest in a previously injured thigh. Patients with significant atherosclerotic disease compromising the arterial vasculature require preoperative evaluation using angiography.

PREOPOPERATIVE MARKINGS

1. Markings for the ALT flap are based on the location of the skin vessels that supply the skin territory of the flap.

2. Important landmarks for the flap include the anterior superior iliac spine and the superior lateral border of the patella.

3. The flap is centered at the midpoint of a lon- gitudinal line drawn between these two land- marks. A circle with a 3-cm radius defines

these two land- marks. A circle with a 3-cm radius defines Figure 3.10 Serratus branch of

Figure 3.10 Serratus branch of the thoracodorsal artery.

CPT coding 35

the area at which the skin vessels, either septocutaneous vessels or musculocutaneous perforators, exit.

4. The skin vessels are often found in the inferior lateral quadrant of the circle.

5. The skin paddle is then designed around the defined skin vessels.

INTRAOPERATIVE DETAILS FOR ANTEROLATERAL THIGH FLAP HARVEST

1. Loupe magnification during dissection is rec- ommended as it aids in locating the skin vessels, avoids unnecessary injury to the pedicle, and helps clearly visualize branches of the vessels.

2. The flap may be harvested as a suprafascial or subfascial flap.

3. The medial incision is made down to and through the thigh fascia, exposing the rectus femoris muscle.

4. The epimysium of this muscle is preserved, and the dissection proceeds in a lateral direc- tion until the septum separating the rectus femoris from the vastus lateralis is visualized.

5. The entire septum is exposed by retracting the rectus femoris medially.

6. Branches of the descending branch of the lateral femoral circumflex are observed either perforating the vastus lateralis muscle or traveling within the septum to reach the skin of the anterolateral aspect of the thigh.

7. If the skin vessel is a musculocutaneous perforator, then intramuscular dissection is performed in the following manner: The point of exit of the perforator is exposed, and the muscle fibers anterior to the vessel are “lifted up” using teeth forceps. The tenotomy scissors are used to spread in a transverse plane over the perforator, and the muscle fibers are cut.

8. Perforator dissection proceeds until its takeoff from the descending branch of the lateral femoral circumflex artery (LFCA) or further until adequate pedicle length is achieved.

9. Once the cutaneous perforator has been safely identified and dissected, the lateral skin island incision is made and flap dissection completed.

12. If the flap width precludes tension-free closure of the donor site, a skin graft is placed.

POSTOPERATIVE DETAILS

1. Drain output is monitored postoperatively, and drains are removed when output is less than 30 mL per day to decrease chance for seroma formation.

2. If a skin graft was placed at the donor site, bed rest is typically instituted until graft take.

3. Physical therapy rehabilitation of the lower extremity is initiated once the donor site has healed.

CPT CODING

11044 Debridement; skin, subcutaneous tissue,

muscle, and bone (first 20 sq cm) 11046 Next 20 sq cm

15004 Surgical preparation or creation of recipient

site by excision of open wounds, burn eschar, or scar including subcutaneous tissue or incisional release of scar contracture face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet

and/or multiple digits; first 100 sq cm or 1 per- cent body area of infants and children

15120 Split-thickness autograft, face, scalp, eye-

lids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

15342 Application of bilaminate skin substitute/

neodermis; 25 sq cm

15350 Application of allograft, skin; 100 sq cm

or less

14350 Adjacent tissue transfer or rearrangement,

finger or toe

14040 Adjacent tissue transfer or rearrangement,

forehead, cheeks, chin, mouth, neck, axilla,

genitalia, hands, and/or feet; defect 10 sq cm or less

14041 Adjacent tissue transfer or rearrangement,

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands, and/or feet; defect 10.1 to 30 sq cm

15738 Muscle, myocutaneous, or fasciocutaneous

flap; lower extremity

10. The pedicle is ligated proximally and the flap transposed to the recipient site for microvas- cular anastomosis.

10. The pedicle is ligated proximally and the flap transposed to the recipient site for microvas-
10. The pedicle is ligated proximally and the flap transposed to the recipient site for microvas-

15756

27602

Muscle or myocutaneous free flap

Decompression fasciotomy, leg; anterior

and/or lateral, and posterior compartment(s)

and/or lateral, and posterior compartment(s)

11. The thigh donor site is closed primarily in lay- ers over large-bore closed-suction drains.

15271 Application of skin substitute graft to

trunk, arms, legs, total wound surface area up

36 Lower extremity reconstruction

to 100 sq cm; first 25 sq cm or less of wound surface area

15272 Each additional 25 sq cm wound surface

area or part thereof (list separately in addition to code for primary procedure)

15273 Application of skin substitute graft to

trunk, arms, legs, total wound surface greater than or equal to 100 sq cm; first 100 sq cm wound surface area or 1% of body area of infants and children

15274 Each additional 100 sq cm wound surface

area, or part thereof, or each additional 1% of body area of infants and children, or part

thereof (list separately in addition to code for primary procedure)

15275 Application of skin substitute graft to face,

scalp, feet, etc., total wound surface area up to

100 sq cm; first 25 sq cm or less

15276 Each additional 25 sq cm wound surface

area, or part thereof (list separately in addition to code for primary procedure)

15277 Application of skin substitute graft to face,

scalp, feet, etc., total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

15278 Each additional 100 sq cm wound surface

area, or part thereof, or each additional 1% of body area of infants and children, or part

thereof (list separately in addition to code for primary procedure)

15170 Acellular dermal replacement

(i.e., Integra), trunk, arms, legs; first

100 sq cm or less, or 1% of body area of

infants and children

15171 Acellular dermal replacement, trunk,

arms, legs; each additional 100 sq cm, or each

additional 1% of body area of infants and chil-

dren, or part thereof (list separately in addition to code for primary procedure)

15175 Acellular dermal replacement, face, scalp, eye-

lids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

15176 Acellular dermal replacement, face, scalp, eye-

lids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (list sepa-

rately in addition to code for primary procedure) Q4101 Skin substitute, Alpigraf, per sq cm [sup- plied in 44 sq cm] Q4104 Skin substitute, Integra Bilayer Matrix Wound Dressing, per sq cm Q4106 Skin substitute, Dermagraft, per sq cm

SUGGESTED READINGS

Clemens MW, Attinger CE. Functional recon- struction of the diabetic foot. Semin Plast Surg. 2010;24:43–56. Ducic I, Attinger C. Foot and Ankle Reconstruction:

pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg. 2011;128:173–180. Hallock GG. Evidence-based medicine: lower extremity acute trauma. Plast Reconstr Surg.

2013;132:1733–1741.

Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg. 2010;125:924–934.

4

Chest wall reconstruction with pectoralis major muscle flaps

RYAN TER LOUW AND KAREN KIM EVANS

Introduction

38

Notes

46

Preoperative markings

39

CPT coding

46

Intraoperative details

39

References

46

Postoperative details

46

INDICatIONS

1. Deep sternal wound infections

2. Mediastinitis following open heart surgery

3. Soft tissue coverage of large sternal defects following trauma or oncologic resection

4. Dehisced median sternotomy wounds

5. Intrathoracic dead space or bronchopleural fistula

6. Chest wall reconstruction

7. Head and neck reconstruction

Table 4.1 Special equipment

Supine, tuck arms Preoperative culture-directed intravenous antibiotics (tailored for gram-positive, gram-negative, and anaerobic coverage) Irrigation: 3 L warm normal saline +/− antibiotic or dilute iodine or plain Pulse irrigator 2.0 Prolene suture for skin Retractors: Richardson’s, sweetheart, appendiceal Rigid internal fixation system such as the Synthes or KLS system (if needed) Electrocautery, long electrocautery tip Rongeur and curettes Periosteal elevator Hemoclips: medium/large Pencil Doppler probe 2 Blake drains Abdominal binder, sized for chest wall

38 Chest wall reconstruction with pectoralis major muscle flaps

INTRODUCTION

The pectoralis major flap was popularized in 1980 by Jurkiewicz for chest wall reconstruction; its most notable contributions have been in decreasing mortality and morbidity associated with sternal wound infections following open heart surgery. 1 The latissimus dorsi and rectus abdominus mus- cles are other local reconstruction options; how- ever, the pectoralis muscle remains the workhorse flap for chest wall reconstruction due to its versa- tility. 2 The incidence of sternal wound infections

tility. 2 The incidence of sternal wound infections (a) or mediastinitis is approximately 1–5% following open

(a)

or mediastinitis is approximately 1–5% following open heart surgery 3 and will typically increase length of hospitalization by 20 days and increase the cost by three times compared to an uncompli- cated postoperative course. 4,5 Keeping the reconstructive ladder in mind, local wound care does have its role in managing sternal wound infections. Patients with wound depth of less than 4 cm, negative blood cultures, and minimal sternal exposure or instability can be successfully managed with negative-pressure vac- uum therapy (see Figure 4.1). The most important

vac- uum therapy (see Figure 4.1). The most important (b) (c ) Figure 4.1 Smaller superficial

(b)

vac- uum therapy (see Figure 4.1). The most important (b) (c ) Figure 4.1 Smaller superficial

(c )

Figure 4.1 Smaller superficial sternal wounds can be closed with VAC therapy, appropriate debridement, and primary or secondary closure. (a), (b) Superficial clean sternal wound treated with VAC therapy. (c) Two weeks after primary closure of this defect.

Intraoperative details 39

predictor of vacuum-assisted closure (VAC) suc- cess is wound depth less than 4 cm. 6 Numerous studies have shown that early cov- erage of sternal wounds with pectoralis flaps pro- motes wound closure and sternal stability. The most common indication for surgery is culture-positive median sternotomy wound dehiscence. 2 In a recent study reviewing 211 sternal wound infec- tions, 95% of wounds were successfully closed with an overall mortality rate of 5.7%. Mortality rates for deep sternal wound infections prior to pectora- lis coverage approached 50%. 7,8 Table 4.1 indicates the equipment necessary for this surgery.

PREOPERATIVE MARKINGS

Borders of the pectoralis (see Figure 4.2):

Superior: clavicle

Lateral: anterior axillary line

Medial: sternum

Inferior: sixth rib

The thoracoacromial artery arises from the mid- point of the clavicle and courses medially. The axis of the pedicle follows a line drawn from the acro- mion to the xiphoid. The thoracoacromial pedicle arises from the second portion of the axillary artery and travels underneath the pectoralis major in the subfascial plane.

underneath the pectoralis major in the subfascial plane. Figure 4.2 The thoracoacromial artery arises from the

Figure 4.2 The thoracoacromial artery arises from the midpoint of the clavicle and courses medially. The axis of the pedicle follows a line drawn from the acromion to the xiphoid. The tho- racoacromial pedicle arises from the second por- tion of the axillary artery and travels underneath the pectoralis major in the subfascial plane.

INTRAOPERATIVE DETAILS

Introduction: There are several common varia- tions of pectoral muscle flaps:

Advancement: The unipedicled pecto- ralis major advancement flap is based on the thoracoacromial artery. This will advance the overlying skin component along with the muscle (see Figure 4.3).

Turnover: The turnover pectoralis major muscle flap is based on the internal mam- mary artery (IMA) perforators penetrating rib spaces 2 through 5 (see Figure 4.4).

Combinations of all have been used for sternal reconstruction and closure with excellent results.

Due to the success of rotation/advancement flaps in this area, microvascular surgery is rarely necessary in sternal wound management.

In planning a pectoralis flap, it is important to understand what vessels were used in cardiac surgery (see Figure 4.5).

The majority of bypass patients have at least the left and on occasion the right IMA harvested, limiting the use of the turnover pectoralis major muscle flap to one or neither side.

If the IMA is preserved, a turnover pecto-

ralis flap is valuable as it fills the inferior defect of the chest wound.

For large sternal defects, one turnover flap is placed into the sternal defect, and the ipsilateral pectoralis is advanced for coverage.

This is also important for planning a rectus abdominus flap for sternal coverage.

Anesthetic requirements:

Appropriate resuscitation with blood or fluids.

Cardiac anesthesia if available is helpful.

Cardio-thoracic surgery as well as the pump team should be in the hospital if

a cardiac emergency occurs during the procedure.

Maximal paralysis is helpful during the muscle harvest and closure.

Anatomy:

The pectoralis muscle is considered

a Mathes and Nahai type V muscle

flap with one dominant pedicle,

40 Chest wall reconstruction with pectoralis major muscle flaps

Chest wall reconstruction with pectoralis major muscle flaps (a) (b) (c ) (d) (e) Figure 4.3

(a)

wall reconstruction with pectoralis major muscle flaps (a) (b) (c ) (d) (e) Figure 4.3 (a)

(b)

reconstruction with pectoralis major muscle flaps (a) (b) (c ) (d) (e) Figure 4.3 (a) Large

(c )

with pectoralis major muscle flaps (a) (b) (c ) (d) (e) Figure 4.3 (a) Large sternal

(d)

with pectoralis major muscle flaps (a) (b) (c ) (d) (e) Figure 4.3 (a) Large sternal

(e)

Figure 4.3 (a) Large sternal wound following CABG after multiple debridements. Separate incisions made for sternal insertion division. (b) Pectoralis myocutaneous advancement performed. (c) Closure of muscle layer. (d), (e) Successful closure of large sternal wound following pectoralis myocutaneous advancement.

the thoracoacromial artery, and several medial perforators originating from the IMA (Figure 4.6). The thoracoacromial artery provides the dominant axial supply to the pectoralis major and originates from the second part of the axillary artery, directly deep to the pectoralis minor, and courses laterally to reach

the pectoralis major. This pedicle has little variability, and the whole muscle can be reliably raised without disrupting the underlying pectoralis minor.

The origin is the sternum, anterior surface of ribs 1 through 6, and the clavicle. The inser- tion is the bicipital groove of the proximal humerus.

Intraoperative details 41

Intraoperative details 41 (a) (b ) Figure 4.4 Turnover flaps. Pectoralis major insertions are divided, and

(a)

Intraoperative details 41 (a) (b ) Figure 4.4 Turnover flaps. Pectoralis major insertions are divided, and

(b )

Figure 4.4 Turnover flaps. Pectoralis major insertions are divided, and the muscles are based on the secondary IMA blood supply and turned and inferiorly rotated in to fill sternal wound defects. (a) Pectoralis major turnover flaps after dissection. (b) Flaps after inset into sternal defect.

Operative steps:

1. Debridement: The indication for pectoralis flaps often involves an infectious process; thus, thorough debridement of any infected or non-viable soft tissue, cartilage, or bone is the first step of the operation. Debridement of the wound is arguably the most important element to this operation as one of the most common postoperative complications is con-

tinued infection and dehiscence (Figure 4.7).

a. Removal of any skin, subcutaneous tis- sue, bone, or cartilage that is necrotic helps achieve sternal union and wound closure.

b. Irrigation with pulse lavage aids in decreasing the bacterial load of the

wound (at least 3 L of saline with or without antibiotic or dilute iodine).

c. A rongeur and periosteal elevator allow for debridement of the affected sternum and cartilage.

d. Debridement and closure are usually done in stages, with initial deep intra- operative cultures to guide long-term antibiotics.

e. All foreign bodies, including sutures and sternal wires, must be removed to achieve a clean wound prior to closure.

f. Careful hemostasis must be obtained without the use of bone wax, which has been shown to increase the risk of persistent osteomyelitis.

42 Chest wall reconstruction with pectoralis major muscle flaps

Chest wall reconstruction with pectoralis major muscle flaps Figure 4.5 This patient had failed sternal wound

Figure 4.5 This patient had failed sternal wound coverage with bilateral pectoralis major muscle flap advancement. Patient has recurrent infection in the inferior portion of his wound. The left IMA (LIMA) was used for the CABG, and the right IMA (RIMA) was damaged during debridement, so rather than a rectus abdominus flap, he will undergo a pedicled omental flap for coverage.

2. Considering sternal fixation (Figure 4.8):

After debridement of the sternum and costal cartilage, there often remains a well-vascularized portion of bone that yields the opportunity for sternal fixation. 9 If viable bone and cartilage remain in the setting of paradoxical chest wall movement and sternal insta- bility, rigid sternal fixation can be a part of chest wall reconstruction. 10

Rigid fixation offers the benefit of acceler- ated healing and sternal union while decreasing the incidence of mediastinal hernia. 11

a. Undermine the chest wall both superficial and deep to the pectora- lis muscles. Preserve these muscles as they will be used as advancement flaps for sternal closure on top of the fixation system.

b. Identify at least three healthy ribs for the sternal fixation system.

at least three healthy ribs for the sternal fixation system. Figure 4.6 Pectoralis major reflected displaying

Figure 4.6 Pectoralis major reflected displaying its dominant blood supply, the thoracoacromial artery.

its dominant blood supply, the thoracoacromial artery. Figure 4.7 Example of a sternal wound that requires

Figure 4.7 Example of a sternal wound that requires debridement. Brown and black bone and yellow fibrinous exudate must be removed.

c. Place bone fixation hooks on the edge of the sternum to allow for reduction.

d. Size the plates depending on rib size.

e. Place three or four plates on the ribs.

f. Use bicortical screws on the sternum and unicortical screws on the ribs. 12

Intraoperative details 43

Intraoperative details 43 (a) (c) (e) (b) (d) (f) Figure 4.8 A healthy patient with sternal

(a)

Intraoperative details 43 (a) (c) (e) (b) (d) (f) Figure 4.8 A healthy patient with sternal

(c)

Intraoperative details 43 (a) (c) (e) (b) (d) (f) Figure 4.8 A healthy patient with sternal

(e)

Intraoperative details 43 (a) (c) (e) (b) (d) (f) Figure 4.8 A healthy patient with sternal

(b)

Intraoperative details 43 (a) (c) (e) (b) (d) (f) Figure 4.8 A healthy patient with sternal

(d)

Intraoperative details 43 (a) (c) (e) (b) (d) (f) Figure 4.8 A healthy patient with sternal

(f)

Figure 4.8 A healthy patient with sternal painful malunion following sternotomy for coronary artery bypass graft (CABG) who underwent sternal fixation and pectoralis muscle flaps for closure.

(a)

Sternal malunion; (b) identification of right rib segments; (c) identification of left rib segments.

(d)

Reduction of sternal dehiscence; (e) placement of fixation system; (f) closure with bilateral

pectoralis major myocutaneous advancement flaps.

44 Chest wall reconstruction with pectoralis major muscle flaps

3. Myocutaneous advancement flaps (see Figure 4.3):

a. Minimal subcutaneous flaps are raised off the surface of the muscle from the midline sternal defect.

b. The muscle is elevated off the chest wall medial to lateral, taking care to ligate the intercostals and internal mammary perforators medially (Figure 4.9).

c. It is important to leave some perforators from the pectoralis muscle to the overlying skin to maximize

healing potential and skin closure of the midline and to minimize the risk of seroma.

closure of the midline and to minimize the risk of seroma. Figure 4.9 Harvested pectoralis myocutaneous

Figure 4.9 Harvested pectoralis myocutaneous advancement with clamp holding pectoralis medial border.

d. Care is also taken to avoid elevating the pectoralis minor with the flap (Figure 4.10).

e. There is a relatively avascular plane both superficial and deep to the pectoralis major muscles. By detaching the muscle from its sternal, rib, humeral, and medial clavicular attachments and separating it from the clavicular head of the deltoid, the pectoralis can usually be extended to the level of the xiphoid.

f. Lateral dissection at the insertion on the humerus may be done until the flaps reach midline without significant tension. This can be done through a separate incision near the humeral insertion.

g. If further advancement is needed caudally, back cutting the superior medial aspect of the pectoralis muscle up to 6 cm maintains its blood supply.

h. Another option for additional mobility involves detaching the sternocostal head from the clavicular head of the muscle.

i. When a significant amount of mediastinal dead space is a problem, bilateral flaps are usually necessary.

j. After the pectoral flaps have been raised, suture them in the midline with figure-of-eight sutures (strong monofilament such as 0-0 Prolene ® ; Ethicon, Somerville, NJ).

such as 0-0 Prolene ® ; Ethicon, Somerville, NJ). Figure 4.10 Elevated pectoralis major muscle with

Figure 4.10 Elevated pectoralis major muscle with pectoralis minor muscle deep and attached to chest wall.

Intraoperative details 45

Intraoperative details 45 (a) (b) (c ) Figure 4.11 Pectoralis myocutaneous rotation advancement flap for coverage

(a)

Intraoperative details 45 (a) (b) (c ) Figure 4.11 Pectoralis myocutaneous rotation advancement flap for coverage

(b)

Intraoperative details 45 (a) (b) (c ) Figure 4.11 Pectoralis myocutaneous rotation advancement flap for coverage

(c )

Figure 4.11 Pectoralis myocutaneous rotation advancement flap for coverage of fistula postesophagectomy. (a) Preoperative photograph with VAC on open wound. (b) Division of insertion and origin of pectoralis major muscle allows it to reach to the contralateral clavicular chest and neck region. (c) Immediate postoperative photograph following closure of wound.

 

k.

Place drains under flaps in the midline and under the bilateral subcutaneous undermined area.

b. Fold the lateral portion of the muscle into the mediastinum while maintain- ing its vascular supply by means of

l.

Suture skin closed with horizontal mattress monofilament suture. Avoid buried sutures.

perforators from the IMA and anterior intercostal arteries. This maneuver may result in a contour deformity of the

m.

Use a light compression chest binder.

anterior chest wall, causing tension on

4.

Turnover flaps (Figure 4.4):

the skin closure. However, it nicely fills

a.

The humeral insertion must first be divided. This can be done either by

dead space in the appropriately selected deep sternal wound.

 

undermining the skin superficial to the muscle laterally over to the insertion or by a separate incision. A separate incision will commonly preserve chest skin viability.

c. One can also use a combination of the turnover pectoralis flap on the side in which the IMA has not been harvested and a unipedicled rotational advancement flap on the ipsilateral side.

46 Chest wall reconstruction with pectoralis major muscle flaps

d. The rotating end of the turnover flap may be sutured in place at the adjacent costal cartilage and intercostal fascia.

e. Close and place drains as described previously.

f. Use a light compression chest binder.

g. The disadvantage of the turnover flap is that the muscle is harvested on its non-dominant blood supply and if a midline sternotomy is needed again, the muscle may be damaged.

POSTOPERATIVE DETAILS

Postoperative complications are on the order of 15–20%, with the most common complications recurrent wound infections, hematoma, wound dehiscence, skin necrosis, or partial flap loss. The rates of wound infection, hematoma, and seroma are all similar at about 5%; partial flap loss is a rare occurrence. 1 Wound dehiscence and hematoma are more common in patients with additional comor- bidities, such as smoking, obesity, and necessity for anticoagulation. If medically acceptable, postop- erative anticoagulation is delayed 72 hours. Drain placement is critical in helping to avoid postoperative complications. Leaving a surgical drain in until post- operative day 22 has been shown to decrease seroma formation from 24 to 3.5% when compared to drain removal at day 11. 2 When the thoracic cavity has been entered, thoracostomy tubes are recommended in the early postoperative period to evacuate postoperative effusion and pneumothorax and are typically managed by the thoracic surgery team. Thoracic binders are used occasionally for soft tissue com- pression. In addition, patients are instructed to limit range-of-motion exercises to minimize har- vested muscle movement. If the pectoralis muscle insertion into the humerus remains intact, then a sling and swathe have been shown to be beneficial to prevent muscle dehiscence. Postoperative antibiotics are commonly used, especially in the setting of mediastinitis or infected/ dehisced median sternotomy incisions.

NOTES

Pectoralis major muscle flaps are among the most versatile and reliable flaps in our armamentarium. However, the main

limitation is the most inferior aspect of the sternal wound. This area is usually under a considerable degree of tension. If a large defect exists in the inferior portion, then a rectus abdominis, latissimus dorsi, or omental flap should be considered (see Figure 4.5).

If sternal fixation is required, make sure that the wound is clean and cultures are negative prior to hardware placement.

In complex cases with deep sternal mediastinitis, it is helpful to have cardio-thoracic surgery assist or perform the debridement.

Do not underestimate the critical nature of these patients as they are usually in the intensive care unit, and some may require prolonged intubation and pressors. Occasionally, these procedures may need to be performed while the patients are on cardiac pressor support.

Some surgeons have advocated keeping ster- nal wound flap closure patients intubated and paralyzed to aid in healing. This is not required, although it is the practice of some surgeons.

Negative-pressure wound therapy (NPWT) is helpful as a stable dressing in between debridements prior to closure. One should be careful to place non-adherent dressings on the mediastinal structures prior to placing the NPWT sponge. We do not change the sponge dressing in the intensive care unit, but typically change this in the operating room.

CPT CODING

10180 Incision and drainage of complex

postoperative wound infection

21627

Sternal debridement

21750

Closure of median sternotomy separation

with or without debridement

15734 Muscle, myocutaneous, or fasciocutaneous

flap; trunk

49904 Omental flap, extra-abdominal for

reconstruction of sternal defects

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