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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!