microvasculartechniques for limb salvage plastic ......microvasculartechniques for limb salvage...
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MicroVascular Techniquesfor Limb Salvage
Charles K Lee, MD, FACSChief of Plastic Surgery & Microsurgery,St.Mary’s Medical Center, San FranciscoAssistant Clinical Professor of Surgery,
University of California, San Francisco (UCSF)
Plastic & Reconstructive MicroSurgery�Angiosomes� Ian Taylor, MD� San Francisco (Harry
Buncke, MD, Stephen Mathes, MD)
� Perforator Flaps� Local Fascial Flaps� Local Propellar Flaps� Arterial Flow Through Free
Flap� Venous Flow Through Free
Flap
4/20/2013Ian Taylor, MD, Plastic Surgery, Australia, 1987
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Angiosome Map
Multiple Perforators throughout BodySeptalIntraMuscular� Flap Harvest (Soft Tissue + Artery and Vein) Expanded the Repetoire of Free Tissue Transfer
Lower Extremity Reconstruction with Local Perforator Fascial Flaps and Skin Graft
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4 weeks postop
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Propellar Flaps based on Perforators
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ALT Perforator Flap� AnteroLateral Thigh Perforator Flap (Arterial Flow Through Flap)
� 1984—Song, et al; Br. Jo. of Plastic Surgery
� “Thin” and pliable� Patient population differs
� Reliable anatomy� Long pedicle (20cm)� Large surface area (40X20cm)� Sensate (Lateral femoral cutaneous nerve)
� Chimeric/composite
� Easy harvest
� Minimal Donor Site
� Ideal Soft Tissue Flap
� Medial Dissection first� Septocutaneous perforator
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� Lateral circumflex femoral� Lateral descending branch
� Vastus Lateralis
� Rectus Femoris� 80% muscular perforators (Wei 2002)� 20% septocutaneous perforators� Perforator can be wrapped around branches of femoral nerve to Vastus
ALT Perforator Flap
� Advantages:� Workhorse flap� Consistent Anatomy-septocutaneous,
musculocutaneous� Long pedicle (20cm), Large surface area
(20X40cm)� Contoured/thinned� Neurotized (sensate)� Composite/Chimeric� Donor Site—Primary Closure (<8cm)
� Disadvantages:� Tedious dissection if muscular perforator� Not always thin (female vs. male)� Technical considerations insetting� Pedicle orientation and pressure� Unsitely donor site if not closed primarily
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Venous Flow Through Flap� Cephalic Vein/ Saphenous Vein
Calcaneal Wound, CLI� Flow through flap
Skin Replacement - Flap Skin Replacement - Flap
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Venous Flow Through Free Flap� Flow through flap
Skin Replacement - Flap
Skin Replacement - Flap Skin Replacement - Flap� Flow through flap
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Expanding Role of Microsurgery & Vascular Surgery
�Angiosome Concept� Perforator LOCAL Flaps� Perforator FREE Flaps� Arterial Flow Through� Venous Flow Through FREE Flaps� --Simultaneous Soft Tissue and Vascular
Reconstruction
�Thank you!