Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1089 - файл
.pdf
248 J. P. Hong and A. Datli
Key Points
• Flap reconstruction for wounds are frequently considered in cases lacking
healing progress despite good wound care or complex wounds which timely
coverage will benefit the overall healing process
• Along with multidisciplinary approach and good principle of wounds care, the
repair and restoration strategies using flaps and microsurgery has widened the
possibilities for good aesthetic and functional results for complex wounds.
Introduction
Frequently considered chronic wounds for reconstruction are wounds lacking
healing progress despite good wound care. And those needing flaps or microsurgical reconstruction are wounds that are unable to close by skin grafts, wounds with
exposed vital structure such as tendon and bones, and wounds that has prolong
infections such as osteomyelitis and skin necrosis. These wounds have become a
major challenge to healthcare professionals all over the world. Reports show that in
the United States alone, these wounds affect an estimated 2.4–4.5 million people
(Brownrigg et al. 2013; Richmond et al. 2013). The acute wounds are often straight
forward involving good principle of wound care: debridement, infection control,
adequate vascularity and wound preparation for reconstruction followed by the
reconstruction itself (Hong and Hallock 2021). The big challenges involved in
wound healing is often chronic wounds especially in the lower extremity (Suh and
Hong 2019). Chronic leg and foot ulcers occur in many adults with vascular disease
or diabetes and are attributed to chronic venous insufficiency, arterial disease,
prolonged pressure, or neuropathy (Richmond et al. 2013; Frykberg and Banks
2015). Thus chronic wounds can be classified as vascular ulcers (venous and
arterial), diabetic ulcers, and pressure ulcers (Nunan et al. 2014). These ulcers last
on average 12 to 13 months, recur in up to 60 to 70% of patients, can lead to loss of
function and decreased quality of life, and are a significant cause of morbidity
(Richmond et al. 2013; Frykberg and Banks 2015). Moreover, care for such conditions has been reported to cost 2 to 3% of the healthcare budgets in developed
countries (Richmond et al. 2013; Frykberg and Banks 2015). From the patient
perspective the most frightening fact may be that these chronic ulcers when left
untreated or mistreated may lead to amputation (Hong and Oh 2012; Oh et al. 2013;
Suh et al. 2016a). Although inevitable amputations do occur, reconstructive options
may lead to limb salvage (Hong and Oh 2012; Oh et al. 2013).
Today, the reconstruction for soft tissue defects aim not only to provide just
coverage but also to restore function and acceptable form. Once the wound is
evaluated to have good or restored vascular supply, stable skeletal structures, and a
relatively clean wound after wound preparation, soft tissue reconstruction is then
considered (Suh and Hong 2019). The concept of a reconstructive ladder was
proposed to achieve wounds with adequate closure using a stepladder approach
Surgical Flaps in Wound Healing—An Update on Evidence-Based Management 249
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
from simple to complex procedures. Although still valued and widely taught, the
reconstructive ladder comes from the concept of the wound-closure ladder that
dates back beyond the era of modern reconstructive surgery (Gottlieb and Krieger
1994). A skin graft after granulation over the exposed anterior tibial bone can still
provide coverage but may end in inadequate coverage which can lead to complications such as additional soft-tissue loss, osteomyelitis, functional loss, increased
medical cost, unstable wounds and even, amputation. Using a well vascularized flap
whether it is a local or a free with adequate padding will provide superior results in
addition to coverage. In addition, other techniques including tissue expansion, skin
stretching, and negative pressure wound therapy have had new impact in
approaching reconstructive options (Janis et al. 2011). A simpler reconstructive
option may not necessarily produce optimal results especially for lower extremity
coverage. Thus to provide optimal form and function, we jump up and down the
rungs of the ladder like getting off the elevator at the ideal floor (Gottlieb and
Krieger 1994). Restoring the missing components such as muscle, bone, and skin
using a combined flap with microsurgery approach may provide an ideal solution to
complex defects. The reconstructive elevator requires creative thoughts and consideration of multiple variables to achieve the best form and function rather than a
sequential climb up the ladder (Fig. 1). This paradigm of thought does not eliminate
the concept of the reconstructive ladder but replaces it with a ladder of wound
closure that makes its mark in the field where a variety of advanced reconstructive
procedures and techniques is not readily available. Taking the lower extremity
wound for example, traditionally upper and middle one third of the lower leg can be
reconstructed with regional musc les like gastrocnemius and soleus muscle flaps or
by using perforator based local skin flaps also known as propeller flaps. However,
due to the scarcity of available tissues, the lower third of the leg and the foot may
require reconstruction using tissues distant from the defect when the defects are
Fig. 1 Reconstructive approach is shown comparing the classical reconstructive ladder to
reconstructive elevator. The reconstructive elevator requires creative thoughts and consideration of
multiple variables to achieve the best form and function rather than a sequential climb up the
ladder
250 J. P. Hong and A. Datli
moderate or large. It involves using microsurgery. Microsurgery is a surgical discipline that combines magni fication with advanced microscope, specialized precision tools and various operating techniques. These techniques are primarily used to
anastomose small blood vessels (arteries and veins) and to coapt nerves. A flap is a
piece of living tissue that carries its own blood supply and is moved from one area
of the body to another. When the blood supply is cut (pedicle) and transferred far
away from the original site, it becomes a free flap. By anastomosing the vessels
from the flap (pedicle) to the recipient vessels, it restores the vascular supply to the
flap and allows the distant flap to survive and provide adequate coverage. Flap
surgery can restore form and function to areas of the body that have lost skin, fat,
muscle movement, and/or skeletal support. Microsurgery will not only allow wound
coverage but can entail restoration of function and form.
Thus in whet her acute or chronic wounds where a wound is stalling, complex and
challenging, using the flaps with or without microsurgery in conjunction with multidisciplinary approach can provide adequate and timely coverage. In this chapter will
focus on patient selection, mutidisciplanary approach, wound preparation, surgical
techniques and outcomes regarding reconstruction using local and free flaps.
Patient Selection, Multidisciplinary Approach
and the Wound Preparation
The wounds that are considered for recons tructive surgery using flaps (flap
reconstruction) may occur from various causes such as acute trauma, diabetic foot
ulcers with or without ischemia and infection, pressure sores, radiation wounds,
chronic osteomyelitis, unstable scar, and poorly managed complex traumatic
wounds. Table 1 shows our experience that needed microsurgical reconstruction for
Table 1 Wounds that
underwent microsurgical
reconstruction
Diagnosis N %
Burger’s disease 5 0.9
COM 140 24.2
Diabetic foot 269 46.7
Exposed femoral artery graft 2 0.3
Exposed hardware 9 1.6
Foreign body 4 0.7
Hidradenitis suppurative 7 1.2
Pressure sore 22 3.8
Post traumatic/burn scar contracture 18 3.1
Pyoderma gangrenosum 2 0.3
Radiation ulcer 13 2.6
Unstable scar 86 14.9
Total 577 100.00
Surgical Flaps in Wound Healing—An Update on Evidence-Based Management 251
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
wounds excluding the acute trauma and cancer reconstruction (Suh and Hong
2019). If the wound is small enough with good regional vascular supply such as
pressure sores for ankle region or a small neuropathic diabetic foot ulcers, local
flaps may be enough to reconstruct the defect. However, for large and complex
wounds, microsurgical approach can provide an efficient solution. In addition to the
wound, the patient has to be ambulating prior to reconstruction, will likely be able
to ambulate after reconstruction, have reasonable systemic condition to overcome
the challenges of multiple surgeries, psychologically motivated and have good
family support (Fitzgerald O’Connor et al. 2011).
When considering these patients for flap reconstruction, holistic/
multidisciplinary approach for the patient must commence concurrently with
wound management (Hong and Oh 2012; Brocco et al. 2018; Wraight et al. 2005).
Without controlling the underlying factors especially in chronic wounds, it will
have higher chance for complications. For example, diabetic patients will need to
address the issues to control their hyperglycemia, renal insufficiency, nutrition, and
other associated medical comorbidities that may adversely affect the healing
requiring close collaboration with endocrinologist (Endara et al. 2013; Patel 2005).
Vascular interventionist or vascular surgeons needs to be involved to evaluate and
improve the vascular status. One must maximize the circulation of the leg for
reconstruction (Hong and Oh 2012; Dillingham et al. 2002; Darling et al. 2017 ) The
exact roles of endovascular and open bypass procedures are still evolving, but are
primarily determined by arterial anatomy, wound severity, and patient comorbidities (Darling et al. 2017; Bradbury et al. 2010). Whate ver the method, it is
imperative to restore as much blood flow as possible to the foot so it can be
adequately used as a recipient vessel (Suh et al. 2016a, 2016b). It is crucial when
considering flap reconstruction, that adequate vascular supply not only to the defect
region but to the flap is confirmed (Power et al. 2022; Hong et al. 2021; Hong and
Koshima 2010; Song et al. 2019). The orthopedic surgeons or podiatrists needs to
be involved to evaluate the skeletal status of the lower leg or foot when indicated.
With multiple department s being involved, the clinical nurse specialist plays a
central role in maintaining clear communication and efficient treatment solution in
the front line of management. An algorithm to consider wounds for flap reconstruction is shown in Fig. 2. Improving vascularity by intervention angioplasty or
bypass surgery usually reflects the extremity but other pharmacological methods
can be also considered for other parts of the body (Park et al. 2022; Hong et al.
2001; Jin et al. 2019).
Controlling infection is also an important factor to address. Poorly controlled
infection may cause late stage flap failures often leading to flap failure (Suh and
Hong 2019; Wax and Rosenthal 2007; Bild et al. 1989; Armstrong et al.
1998).
When skin tissue is not clearly demarcated, the use of hyperbaric oxygen therapy
can be helpful to achieve demarcation between the necrotic and viabl e tissue. In
cases where bone infection is suspected, complete excision of the bone at the time
of coverage is essential followed by antibiotic use (Aragon-Sanchez and Lipsky
2018; Allahabadi et al. 2016). Bone gaps can be filled by temporary cement mixed
with antibiotics to occupy the space and the flap coverage performed. After the
252 J. P. Hong and A. Datli
Fig. 2 Algorithm for reconstruction is presented
eradication of the infected bone, the cement can be removed during the second
stage surgery replacing it with bone grafts or flaps. When considered for flap
reconstruction, the wound preparation process may easily be overlooked. However,
preparing the wound adequately addressing vascularity, infection, dead space,
stability of the skeletal structure will lead to a better outcome (Hong et al. 2017;
Knox et al. 2007).
Surgical Techniques
The first surgical step of treatment for any wound is to evaluate, debride and treat
infection (Atti nger and Bulan 2001). Optimal management of chronic wound and
especially diabetic foot infection can potentially reduce incidence of major limb
amputations and other related morbidities. All nonviable and infected soft tissue
and bone should be excised during debridement. In diabetic foot, milking along the
proximal tendon can be helpful to identify and limit ascending infection especially
for diabetic foot wounds. Tissue culture should be sent and antibiotics used
accordingly. Sufficient irrigation should follow after debridement to reduce bacterial count (Badia et al. 1996). The use of hydros urgery system may allow to
efficiently debride large extensive wounds by preserving viable tissues and irrigating simultaneously (Granick et al. 2006). The understanding of vascular distribution of the foot, angiosome, helps to plan not only reconstruction but
debridement especially in legs with limited vascularity (Suh et al. 2016b; Clemens
and Attinger 2010). Performing debridement according to the angiosome territory,
Surgical Flaps in Wound Healing—An Update on Evidence-Based Management 253
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
one may enhance flap survival by increasing the chance for marginal vascularization from healthy surrounding angiosome territory (Suh et al. 2016b). Repetitive
debridement should be performed as part of wound preparation for reconstruction
while monitoring c-reactive protein for possible hidden infections and using it as an
index for possible infection after reconstruction. In chronic wounds, thorough
debridement may lead to what it seems like an irreparable wound that may warrant
amputation. Microsurgical procedures, including soft tissue and bone flaps, and
vessel and nerve grafting, can be used to reconsider such problems as defects with
replaceable parts.
Once adequate debridement and reason able vascular perfusion is achieved, for
extensive and complex defects, flap reconstruction is considered. The biggest
challenge in flap surgery especially diabetic foot is finding an adequate recipient
vessel for free flaps and an adequate pedicle for local flaps. No must consider
atherosclerosis can hinder the vascular supply leading to the flap. One should check
the perfusion and the velocity of the flow when local flaps are considered especially
in wounds with calcified vessels. Using a handheld Doppler or especially a duplex
ultrasound can provide you with real-time flow velocity information increasing the
reliability of the local flap (Cho et al. 2020; Hong 2022; Hong et al. 2022a, 2022b).
When performing the free flap, when a named artery will be used as recipient, one
must try to find a small segment spared from calcification (Hong and Oh 2012).
One must remember, especially for the ischemic limb, that it was the initial poor
vascular supply that caused the wound formation and thus all efforts should be
made to preserve the distal flow to the foot. Microsurgical techniques such as
end-to-side anastomos is, T-style flow through or end-to-end on a branch of a major
artery will minimize steal phenomenon where flow may be diverted to low resistance vascular bed of the new flap (Rainer et al. 2003; Sonntag et al. 1995). Another
challenge for chronic conditions with inflammation like chronic osteomyelitis or
radiation wounds is the scarring of the tissues. It can make the dissection for the
recipient vessels very difficult. Thus searching the recipient vessel out of the zone of
injury or inflammation may make the search easier and reliable.
A flap consists of tissue that is mobilized on the basis of its vascular anatomy.
Flaps can be composed of skin (including subcutaneous fat), skin and fascia, skin
and muscle, or skin, muscle and bone, or various compositions of tissues. Because
the circulation to the tissue to be mobilized is crucial for flap survival, the development of flap techniques has depended on defining the vascular anatomy of the
skin and underlying soft tissue (Neligan 2018) The flap for reconstruction of
chronic wounds has to provide a well vascularized tissue to control infection, allow
adequate contour for footwear, be durable, and provide solid anchorage to resist
shearing forces especially in the plantar surface. In cases with large dead spaces, a
flap should be selected to provide obliteration of the dead space as well. Common
local flaps based on the subdermal plexus or the underlying vascular source without
identification include the bipedicle flap, advancement flaps (i.e., V–Y), and rotation
or transposition flaps (Neligan 2018). Today these techniques are still widely used
254 J. P. Hong and A. Datli
for small or medium-sized defects that can be reconstructed with regional skin.
A similar concept used for larger wounds on the trunk and extremities is the
keystone flap. Described by Behan, the keystone flap is a curvilinear-shaped
trapezoidal-design flap, essentially being two V–Y advancement flaps along the
long axis of the flap (Behan 2003). One can also identify the pedicle by using a
handheld Doppler or Duplex ultrasound and base the island flap on a perforator and
rotate as a local flap as shown in case example 1 (Song et al. 2019; Park et al. 2015;
Oh et al. 2012 ).
A free flap is a piece of tissue that is disconnected from its’ original blood
supply, and is moved a significant distance to be reconne cted to a new blood supply
around or within the wound or a defect. Various tissues may be used as a free flap
as long as it has its own blood supply that can used to connect. The artery that
comes with the flap is sewn under the surgical microscope to the artery near the
defect to bring the blood in, and the vein is sutured to a vein near the defect to
reestablish the blood flow. Free flaps are more reserved for larger defects or defects
that needs composite tissues for reconstruction. An example would be a composite
flap with muscle, skin and bone together. Using a free flap will be technically
demanding as it requires microsurgery skills.
Controversy still remains which flap, whether muscle flaps with skin grafts,
fasciocutanous flaps and recently added perforator flaps, offers the optimal solution
to reconstruct the wound. But as long as the large defect is covered with any well
vascularized tissue, it will provide an independent and well-nourished vascular
supply to eradicate infection, increase local oxygen tension, enhancing antibiotics
activity, and neovascularization to the adjacent ischemic tissue (Hong and Oh 2012;
Shestak et al. 1990; Chang and Mathes 1982; Datli et al. 2017; Kedar et al. 2020).
One of the basic elements of plastic surgery is to replace like with like. Thus for
defects with skin defects, we are shifting toward using perforator flaps (skin and
subcutaneous fat composite flap) such as ALT (anterolateral thigh) perforator flap,
TDAP (thoracodarsal artery perforator) flap and SCIP (superficial circumflex iliac
perforator) flap as it provides, a thin flap to minimize shearing, can take only the
superfi
cial fat to imitate the fibrous septa of the sole to adhere tightly, enhance
neovascularization of the subdermal plexus with adjacent tissue, and provide adequate blood supply to fight infection (Hong and Oh 2012; Oh et al. 2013; Suh et al.
2016a, 2016b; Hong et al. 2017; Hong 2006; Abdelfattah et al. 2019). Elevation
technique of each individual flaps are described in detail in the referenced papers.
Vigilant postoperative care is needed after flap reconstruction as flows to the flap
can be suddenly impaired due to multiple reasons including mechanical compression to the pedicle, faulty anastomosis, and low systolic blood pressure to name a
few. However, usually after 2 days of uneventful monitoring, one can expect a
relatively good outcome as most of thrombosis occurs within the first 2 days (Kroll
et al. 1996; Chen et al. 2007).
Surgical Flaps in Wound Healing—An Update on Evidence-Based Management 255
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
AB C
DEF
Fig. 3 An example of a local flap is shown in this 56-year-old female patient visited the clinic
with hidradenitis suppurativa hurley stage 3 on the left axiila. Multiple interconnected sinus tracts,
abscesses and rope like elevation of the skin can be noted (A). Excision margins, the design of the
flap (5 13 cm) and preoperatively traced perforators can be seen (B). The entire armpit was
completely excised, including hair-bearing skin and underlying soft tissue (C). The propeller flap
(local flap) was elevated based on a perforator near the chronic lesion and rotated 180 degrees to
cover the defect (D). Flap was trimmed according to the size of the defect and both axillary wound
and donor site was closed primarily (E). During 26 months of follow up no recurrence was noted
in the axilla (F)
Case Examples
Case 1
An example of a local flap is shown. The goal in using a well vascularized local flap
was to eradicate infection, provide adequate coverage over the defect without
compromising the aesthetic outcome. A 56 year old female patient visited the clinic
with hidradenitis suppurativa hurley stage 3 on the left axii la (Fig. 3). Multiple
interconnected sinus tracts, abscesses and rope like elevation of the skin can be
noted (Fig. 3A). Excision margins, the design of the flap (5 13 cm) and preoperatively traced perforators can be seen (Fig. 3B). The entire armpit was completely excised, including hair-bearing skin and underlying soft tissue (Fig. 3C).
The propeller flap (local flap) was elevated based on a perforator near the chronic
lesion and rotated 180 degrees to cover the defect (Fig. 3D). Flap was trimmed
according to the size of the defect and both axillary wound and donor site was
closed primarily (Fig. 3E). During 26 months of follow up no recurrence was noted
in the axilla (Fig. 3F).
256 J. P. Hong and A. Datli
AB C
DE
Fig. 4 A 53 year-old-male patient is shown with an exposed plate on the back after debridement
and use of antibiotics (A). The wound started to develop after few months with an initial swelling
and ultimately draining purulent discharge. After debridement and cleaning the wound, an
18 8 cm propeller flap (local flap based on a perforator) was designed and rotated after
de-epithelization to obliterate the dead space (B– D). At postoperative 12 months, the wound was
completely healed without any signs of recurrence (E)
Case 2
An example of a local flap is shown in Fig. 4. The goal in using a wel l vascularized
local flap was to achieve eradication of infection, obliteration of dead space and
adequate wound healing. A 53 year-old-male patient is shown with an exposed
plate on the back after debridement and use of antibiotics (Fig. 4A). The wound
started to develop after few months with an initial swelling and ultimately draining
purulent discharge. After debridement and cleaning the wound, an 18 8cm
propeller flap (local flap based on a perforator) was designed and rotated after
de-epithelization to obliterate the dead space (Fig. 4B–D). At postoperative
12 months, the wound was completely healed without any signs of recurrence
(Fig. 4E).
Case 3
An example of free flap using the superficial circumflex iliac artery perforator
(SCIP) flap is shown in Fig. 5. The goal of using free flap was to provide adequate
coverage using a well vascularized tissue and to prevent high level amputation.
A 65-year-old patient with wounds from diabetic ulcer is noted after transmetatarsal
open amputation (Fig. 5A and B). After multiple debridements and using NPWT,
Surgical Flaps in Wound Healing—An Update on Evidence-Based Management 257
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A B C
D E
Fig. 5 A 65-year-old patient with wounds from diabetic ulcer is noted after transmetatarsal open
amputation (A and B). After multiple debridement and using NPWT, wound was ready for flap
coverage and SCIP flap was used as a free flap and the pedicle was connected to the dorsalis pedis
artery and vein (5). The flap after 18 months of surgery shows good contour with no further
ulceration and the patient exhibits good functional gait (D and E)
wound was ready for flap coverage and SCIP flap was used as a free flap and the
pedicle was connected to the dorsalis pedis artery and vein (Fig. 5C). The flap after
18 months of surgery shows good contour with no further ulceration and the patient
exhibits good functional gait (Fig. 5D and E).
Outcomes
The spectrum of treatment for chronic wounds can be wide: Addressing systemic
issues like blood sugar control and nutrition, family support, good standard of care,
providing advanced care such as NPWT, hyperbaric oxygen, cell therapy, to surgical options. Without the ability to have reconstruction in the treatment options,
the spectrum of care is not optimal. Conversely, without a team with multidisciplinary offerings, the care would not be complete. No one service can provide the
care that is needed which are all interconnected. With the introduction of multidisciplinary approach, the goal and trend of management has shifted away from
major amputation towards limb salvage for complex chronic wounds (Wraight et al.
2005). Addressing the issues of perfusion, infection, wound treatment, skeletal
stability and biomechanics, now we are able to increase the salvage rate. Examples
of such multidisciplinary approaches have shown to reduce major amputation at 3
to 4% in diabetic foot as we have seen at our center (Krishnan and Becker 2005;
Holstein et al. 2000 ). We must have good clinical judgement whether to amputate
Соседние файлы в папке @xirurgi_2025