A Closer Look At Plastic Surgery Techniques

Clinical Editor: Lawrence Karlock, DPM

Q: What plastic surgery techniques do you commonly use to treat the neuropathic foot?
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. 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?
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.

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