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Perforator free flaps, sural flaps are part of improved war and civilian amputee care
Perforator and sural flaps help solve problems related to resurfacing, soft tissue reconstruction.
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Orthopedic surgeons are looking to the past to create new soft tissue coverage techniques for soldiers and civilians with large wounds and amputations.
"The principals may be 80 years old, but the execution with modern microsurgical care and our understanding of vascular anatomy have improved the soft tissue reconstruction armamentarium. Understanding of new local flaps, such as the sural flap, may have applications in the field," said orthopedic and plastic surgeon L. Scott Levin, MD, FACS.
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New techniques include perforator flaps, which have been developed based on a better understanding of vascular anatomy.
Fillet flaps may be useful for patients with massive wounds similar to those seen in war-injured patients. "You have parts that may not be viable, but the most important thing is to preserve functional amputation levels," Levin said.
Microvascular free-tissue transfers can give surgeons another option for preserving extremities.
Single perforator
"Instead of taking muscles and skin, or so-called 'myocutaneous composite flaps,' now microsurgeons are harvesting tissue based on a single perforator," Levin said. Perforator flaps offer surgeons several advantages for treating these patients.
"They represent the next rung on the microsurgical reconstructive ladder that allows surgeons to take large skin flaps and avoid donor morbidity by not taking muscles," Levin said. Investigators are also conducting research in composite tissue allotransplantation. Levin said that surgeons from Kentucky have used the technique in three cases of arm transplants.
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Images: Levin LS |
Other injuries
"It's not only pertinent for the extremity war injured, but the facially injured as well," he said. "I think that basic science and the need to create a safe and effective immunomodulation needs to occur in the research laboratory before this becomes a reality for our soldiers."
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Along with the need for advances this field, interest in composite tissue allotransplantation is growing. "It is certainly [a] technology for the future," he said. He made his comments during his presentation at the American Academy of Orthopaedic Surgeons 74th Annual Meeting.
Civilian care
"One of the issues that our orthopedics and reconstructive surgeons face in the field is not only how to effectively care for our soldiers, but how to take care of the civilians," Levin said.
There is an increased interest in the use of local flaps for coverage due to the lack of operative microscopes in the field and the inability to evacuate civilians, he said.
"[The sural flap] is very effective for the distal-third injuries around the foot and ankle and can be used as an alternative to free-tissue transfer very, very effectively," Levin said.
While surgeons traditionally used a microscope and free flaps to treat these injuries, physicians now use loop magnification to resurface the area.
"This is a very effective new technology that has supplanted free-tissue transfer," Levin said. The technique can also be used for patients with heel injuries, he added.
For more information:
- L. Scott Levin, MD, FACS, division chief for plastic and reconstructive surgery, professor of orthopedic surgery, Duke University Medical Center, Box 3945, Durham, NC 27710; 919-681-5079; levin001@mc.duke.edu. He has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
- Levin LS. New developments in soft tissue coverage of massive wounds. Symposium: Orthopedic war injuries from combat casualty care to definitive treatment: A current review of the basic science, clinical advances and research opportunities (AAOS/ORSI). Presented at the 74th Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 14-17. 2007. San Diego.