A Closer Look At Plastic Surgery Techniques

Clinical Editor: Lawrence Karlock, DPM
Storm also emphasizes durable soft tissue coverage since these patients are very prone to develop another ulceration. He says soft tissue flaps can provide tissue coverage that is adjacent to the defect and have a better chance of surviving. Dr. Storm adds that some flaps are designed to allow further rotation down the road if necessary. Dr. Blume maintains that it is extremely important to address the Achilles tendon equinus with an Achilles tenotomy or tendon lengthening in addition to a fusion. “We do typically utilize external fixation with mid-foot arthrodesis in conjunction with a rotational flap and split-thickness skin grafting to the arch region, which is nonweightbearing,” notes Dr. Blume. Q: How do you approach the pressure-induced heel ulceration? A: Dr. Blume says the most complex foot wounds involve the heel region. He points out that many of these ulcerations occur with bedridden patients who have undergone a variety of procedures including coronary artery bypass grafting and hip open reduction internal fixation procedure. He adds that many of these patients have underlying vascular disease and diabetes. “Tissue loss in the heel (for these patients) is extremely devastating and can lead to a major amputation,” emphasizes Dr. Blume. Dr. Blume says patients with pressure-induced heel ulcerations commonly have “islands of ischemia” throughout the heel, and these ulcers are difficult to convert into granulating wounds. Dr. Storm notes the pressure prevents blood perfusion to the skin and the ischemia results in pain. In the neuropathic or comatose patient, there is no protective reflex and the ischemia turns into necrosis, according to Dr. Storm. As far as treatment goes, Dr. Storm says the first step is to relieve the pressure and allow devitalized tissue to demarcate itself. He notes you would then proceed to remove all obviously necrotic tissue and address any infection. At this point, Dr. Storm says you should initiate good wound care and consider surgical intervention. If you’re looking at an ulceration of partial thickness, Dr. Blume recommends appropriate debridement and use of VAC therapy, and following up with split-thickness skin grafting to the nonweightbearing posterior, lateral and medial apex. If the ulceration is to the plantar apex of the heel, Dr. Blume says rotation flaps and often free tissue transfers are required. When treating a large heel ulcer of a bedridden patient, Dr. Storm says split-thickness skin grafts can provide immediate coverage and have relatively low risk, but cautions that these grafts are not very durable and will need to be protected indefinitely. For large tissue defects from the heel ulceration that extend into the Achilles tendon, Dr. Blume emphasizes broad dissection and resection with myocutaneous free tissue transfers, although he cautions that they have high morbidity and mortality rates. Dr. Karlock says he treats heel defects with judicious bone resection and emphasizes appropriate soft tissue coverage in order to save a functional limb. Q: What are your thoughts about new bioengineered skin equivalents? How do these compare with split thickness and full-thickness skin grafting in managing neuropathic ulcers? A: Dr. Karlock notes he commonly uses Apligraf and has been pleased with the results. He says Apligraf is user-friendly, applicable in an office setting and you don’t have to worry about the lack of a donor site. While bioengineered skin equivalents like Apligraf and Dermagraft can help facilitate a healthy granulating wound bed for further skin grafting, Dr. Blume says these products are not the true equivalent of a skin graft. Dr. Storm agrees. When these products are used appropriately, Dr. Storm says they provide instant biological coverage and speed ulcer closure by providing needed wound healing substrates. However, he says they do not provide the “rapid” take of a graft. In regard to neuropathic ulcers, Dr. Storm says he rarely uses skin grafts since these ulcers are usually on weightbearing surfaces and the graft will commonly fail when the patient begins walking. While Dr. Storm says he has not used skin equivalents for these ulcers, he would consider doing so if the patient is not a surgical candidate. He adds that his experience with the skin equivalents is limited to venous stasis ulcers, and does feel that they heal the ulcers faster than dressings alone. However, Drs.

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