A Closer Look At Plastic Surgery Techniques

Clinical Editor: Lawrence Karlock, DPM

Plastic and reconstructive surgery techniques can be a significant adjunct for podiatric surgeons in managing diabetic foot wounds and tissue loss. With this in mind, the panelists discuss a variety of techniques (including split-thickness skin grafting and muscle flaps) and indications for chronic ulcers, the neuropathic foot and pressure-induced heel ulcerations. Q: When do you consider reconstructive plastic surgical techniques in the management of diabetic foot ulcers? A: Peter Blume, DPM, says he considers plastic surgery techniques for these ulcers when offloading and conservative measures do not address the underlying soft tissue loss. Dr. Blume says you may employ local flap construction, split-thickness skin grafting, pedicle and muscle flaps including free tissue transfers in treating chronic diabetic foot ulcers as long as you address the underlying bony pathology. Tod Storm, DPM, concurs. In cases in which surgery is indicated to fix an osseous cause of an ulcer, Dr. Storm considers plastic surgery techniques to achieve ulcer closure at the same time. He adds that adequate blood flow to the area is essential when contemplating any surgery. It’s only a matter of time before a chronically open wound will become infected, emphasizes Dr. Storm. For this reason, Drs. Blume and Storm say they use plastic surgery closure techniques for large defects that are contracting slowly and may take several months to close on their own. If the patient has undergone an incision and drainage procedure of the arch in addition to the medial or lateral foot, Dr. Blume says skin grafting is the primary choice for reconstruction. Dr. Storm says he’ll also consider plastic surgery techniques on areas that have broken down several times in the past and have resulted in a significant amount of scar tissue. Employing these techniques can help replace the ulcer prone tissue and reduce recurrence, according to Dr. Storm. Dr. Blume emphasizes that converting chronic wounds into acute wounds helps to stabilize the wound flora, which aids in facilitating desirable results. If possible, Dr. Blume says you may fully excise chronic wounds and perform reconstruction with local suprafascial random flaps, especially in the plantar arch region. If a chronic wound is localized to a metatarsal head, Dr. Blume says you can excise the metatarsal head and proceed to inset a local flap, such as a rhomboid or bilobed flap. If the sesamoids are involved, he notes that you can complete a sesamoidectomy in addition to local flap advancement. Dr. Blume says that flaps are especially useful for reconstruction of the plantar aspect of the foot as skin grafting is not seen as a reconstructive option for weightbearing tissues. If the patient is experiencing a chronic wound to the dorsum of the foot, Dr. Blume recommends debridement and aggressive wound care with split-thickness skin grafting as the primary plastic reconstructive technique. He cautions that local flaps do not elevate and inset easily to the dorsum of the foot. Due to the fact that they are “truly nonweightbearing,” split-thickness skin grafts are the primary reconstructive option, according to Dr. Blume. He strongly emphasizes the necessity of addressing mechanical concerns before considering plastic surgery techniques to treat chronic diabetic foot wounds. Lawrence Karlock, DPM, says he would consider referring to a reconstructive limb salvage plastic surgeon after a failed Charcot foot reconstruction, a failed midfoot exostectomy or for needed soft tissue coverage. Q: What plastic surgery techniques do you commonly use to treat the neuropathic foot? A: Dr. Karlock says he commonly uses the “filet toe flap” to cover large forefoot defects. Dr. Blume points out that patients who experience Charcot osteoarthropathy typically have loss of continuity within the mid tarsus and Lisfranc’s joint. You’ll commonly see wounds along the cuboid lateral column and talonavicular joint medial column, notes Dr. Blume. He says you’ll also see these wounds along the medial talus when patients have ankle dislocations and Charcot ankle deformities. As far as plastic surgery techniques, Dr. Blume says the most appropriate reconstructive option for these patients is the rotational suprafascial flap, which you may rotate from medial to lateral in order to reconstruct the plantar aspect of the foot. In the neuropathic foot, Dr.

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