5th Annual GWEP Wound Care Workshop Dr. Bodor

1. Richard M. Bodor, MD
Section Chief, VA San Diego Medical Center, 2006-2012
Wound Care Medical Director, VA Department of Surgery
Health Sciences, Associate Clinical Professor, UCSD
Plastic Surgery, non-salaried

2. Each Anatomic Region Has Special
Clinical Considerations to Consider
 Common Factors, and Unique Factors, as well, to each
Anatomic Region
 Reconstructive Demands Change for Each Region,
with the Impact of Wounds Being Unique at Each Site
 Impact of Salvage Must Be Reviewed for Each Region
 Unique Reconstructions by Region – Yet We Still Must
Optimize Basic Wound Healing Factors for Success

3. Optimize the Wound and Patient…

4. The “Reconstructive Ladder”:
A Stepwise Approach to Coverage:
 Highest – Free flap (free tissue transfer, etc.). This is the
transplant of tissue using microsurgery approaches
 Higher – Regional flaps (rectus muscle TRAM flap breast
reconstruction, etc.)
 High – Local flaps (Z-Plasty, advancement flaps, etc.)
 Medium – Skin Grafts
 Lower – Primary Local closure, surgically (ex. like
lacerations), also known as (primary intention closure)
 Lower still – On-lay of wound matrix, biosynthetics
 Lowest – Do ‘nothing’ except optimize local care
(=secondary intention closure)

5. Definitions
 Grafts – have no blood flow. They depend on good
wound bed’s blood supply (lives by: graft
imbibition(diffusion), inoscolation(microvessle
ingrowth), final revascularization). Early grafts
must be protected….“grafts: like a postage stamp”
 Flaps: Surgically developed segment of mobile
PERFUSED tissue that remains attached to a
portion of its original blood supply. “Flaps have
flow” that they bring into the wound…

6. Skin Grafting Procedure

7. Advancement Flaps
Bi-pedicle
 Linear defect of
the extremity

8. Groin Wounds: “Tiger Country”
 Common Causes:
 Vascular Reconstruction Sites (Infected Bypass Grafts, etc.),
Post Complex Hernia Reconstruction with Exposed Mesh,
Trauma, etc.
 Special Considerations:
 Dangerous Anatomy: “What is below this wound?”
 Vascular “blowouts” – they do happen, and be ready!
 Examples - having just minutes to live…..
 Concurrent Cases – Multi-Team approach
 Staged debridements, together!
 Both Teams view the wound, decide when to cover the wound
 Other Specialists (nutrition, ID Teams, physical therapy, RN)

9. Groin Wounds:
 Assess Collaborating Teams:
 Will Hernia or Trauma, or Vascular team replace their
underlying Mesh or Grafts?
 Discuss impact of this - on the success of the reconstruction,
hospital duration, etc.
 Do all teams recognize the relative risks – what to watch for
(immediate blowouts, sentinel bleeds, etc.)
 Optimize Underlying Factors:
 Nutrition (Prealbumin, Albumin, etc.)
 Positioning restrictions (discuss with RN, PT)
 Clearance of Infection (debridement, cultures, ABX, etc.)
 Medical Optimization is crucial… (T&C, blood pressure, etc.)

10. Groin Reconstructions:
 Can Be Complex:
 Especially difficult if Local Tissues are Obliterated
(Trauma, multiple surgeries and previous attempted
flaps, etc.)
 Reconstructive Ladder (start low level, if possible)
 Surgeon: Must know all “back-up” flaps, anatomy, etc. in
the region, including
 Sartorius Muscle (multiple ways, re-advancements, etc.)
 Rectus Abdominus Muscle flaps
 Tensor Fascia Lata Myocutaneous flaps, skin grafts, etc.
 Anatomic salvage options needed…

11. Groin Reconstructions: Special
Post – Operative Considerations
 Follow and treat all infection, and underlying issues
 Cultures (standard and quantitative, etc.)
 Duration of Abx (discuss with ID, all teams, etc.)
 Look for: early failing reconstruction signs (lack of adherence, flap tip
viability, bulging pulsing mass, etc.).
 Remember: we must be “surgical nutritionists” when salvaging these:
 Keofeed, Peg, or “ten cans or cartons a day” may be needed.
 List by the Bedside: in view of patient, nurses, etc.
 Ask about Milk intolerance, etc. as well; diabetic options; renal options, etc.
 Explain to patient: and RNs, residents, etc. the reasons that missing a
looming groin reconstruction failure is “not an option”…risks are great!
 Wounds: defend your reconstruction until proven to be stable
 VAC – if cleared by all teams
 Splinting, Log-rolling, minimize early excessive bathing beyond basics
 Slow Recovery of Hip Use (with specialist PT well versed in plan)

12. Example: Groin Reconstructions

13. Knee Region Wounds:
“No Man’s Land”
 Mobile Region, with common pathology being often from
Trauma (exposed hardware, Fractures, orthopedic
reconstructions, etc.).
 Other etiologies include: osteomyolitis, cancer, burns, etc.
 Complete “Reconstructive Ladder” approach is necessary
here as well
 Occasionally skin graft adequate after VAC, but often
 Regional Flaps (Medial Gastrocnemius – if taken as extended
islanded flap.) can often reach up to the patella), etc.
 Occasionally : free flaps may be needed.
 In any case: Know the anatomy (deep popliteal fossa,
Vascular Loop staged free flaps may be needed, etc.)

14. Knee Region Wounds:
Special considerations
 Reconfirm Vascular Adequacy - for wound healing
 Optimize Nutrition (albumin, prealbumin, etc.)
 Debridement - to adequate clean wound (VAC, etc.)
 Post Flap / Graft - Defend your reconstruction!
 Splinting , knee immobilizers, padding
 Elevated Wheelchairs
 Avoid “equinous deformity” complications: don’t
forget the ankle (splinting , +/-ROM), during recovery.

15. Knee Region Wound: Examples

16. MEDIAL GASTROC FLAP: Chronic
Chronic Draining Sinus, Joint
Infected, EARLY POST-OP
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17. MEDIAL GASTROC FLAP FLEXION

18. Leg Wounds: “A Tale of Three
Cities” (measurement by 1/3rds):
 Upper 1/3 Region:
 Here, if the reconstructive ladder approach fails early, salvage
to cover bone usually available with local muscle flaps
(Gastrocnemius), bi-pedicle flaps, etc.
 Middle 1/3 Region:
 Here, there if Reconstructive ladder approach fails early, there
is salvage to cover bone usually available with local muscle
flaps (Sartorius muscle flaps), bi-pedicle flaps, etc.
 Lower 1/3 Region:
 Here salvage is much more difficult; all is more distant,
without large muscle flaps regionally. Classic teaching: is that
major distal wounds need amputations vs. free flaps*
 * or very creative flaps in select patients

19. Leg Wound: Examples

20. Lower 1/3: Another Key
“Limb Threatened Zone”
 Don’t ignore this key anatomic region (lower 1/3 and areas distal
from there). Amputation becomes a genuine consideration, if
the “Reconstructive Ladder” fails early in this course.
 Limited Soft Tissue Reconstruction options: Never ignore these!
 Free flap (classic) – typically consider 8-12 hours of major surgery
 Much time to heal (ex. one year until weight bearing on some infected fx)
 vs. Amputation – often a better treatment choice, even for “ambulators”
 Less morbid, less risk for surgery
 More rapid “ambulation” for many
 Costs vs. benefits to the patient’s lifestyle must be considered:
 Energy requirements (BKA, AKA, etc.)
 Age (Surgical Risk Comorbidities)
 Ambulation status (ask this in detail)
 Psychological issues
 So: TAKE THESE LOWER 1/3 LEG WOUNDS VERY SERIOUSLY!

21. Lower 1/3: Special Considerations
 Surgeon: must know all the complex anatomy with little
room for error. There is limited muscle coverage or local
flap options so adding insult to the injury by ignoring high
level consultations, can do great harm...
 Unique surgical anatomic considerations: great amounts of
nerves (for sensory and motor funtions), very distant
vessles (respect and optimize inflow and outflow, and
lymphatics), vital perforators (for defending local
fasciocutaneous options), very distal weightbearing bone
(for vital fracture healing), and other key issues here. All
must recognize these impact wound healing.

22. Lower 1/3: Special Considerations
Impacting Wound Healing…
 Arterial blood flow – very distal (may need a work-up, a bypass
or an angioplasty, or consultations); check all pulses (palpable
pulses, not just by doppler reviews…).
 Venous Stasis, Lymph edema considerations -(may need extra
elevation, and other interventions, or consultations)
 Infection – Consider Osteomyolitis (especially if underlying
hardware, or chronic exposed bone or tendons distally); may
need consultation, work-up, multiple debridements, etc.
 Chronic Wound – may need to consider other underlying issues
(Marjolin’s ulcer – bad SCCA), consider biopsy in all chronic
wounds
 Neuropathy – a major component of many distal wounds
(especially in Diabetics…but examine baseline in all patients).
 Ex. Thumbtack in Shoe….went to amputation of purulent limb

23. Lower 1/3: Special Considerations
Impacting Wound Healing.
 Diabetes – recognize the special microvascular, neuropathic,
immunological, counselling, and visual issues in Diabetics
 Smoking – rule this out in all; many will answer “I am not a
smoker” (but quit last week after 35 years). Some providers
measure blood levels in unreliable historians before flaps, etc.
 Functional Considerations: Tailor to the specific patient
 Ex. Does this debilitated, or SCI patient ambulate? Do they
transfer?
 What level to amputate those? Special considerations
 Ex. Does this blind diabetic patient need this final limb (don’t make
assumptions….review all in detail with the patient)
 Consider all other factors, and optimize (classic: optimize local
care, VAC, onlay mesh biosynthetics, grafts, etc.); a “last shot”!
 Other: Consider creative alternatives, staged surgeries…

24. Gracilis Free Flap Diagrams

25. Limb Salvage-Distal 1/3

26. Limb Salvage-Distal 1/3
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27. Limb Salvage-Distal 1/3
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28. Limb Salvage-Distal 1/3
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29. Limb Salvage-Free flap, Distal 1/3
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30. Free Flap – Long Term Photo
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31. Foot Wounds: “Way Distal 1/3…”
 Foot: anatomic place where creative foot salvage can occur, must optimize all
wound healing factors (perfusion, nutrition, local care – as in distal 1/3), etc.
 Surgeon’s full knowledge of all issues for Medical Optimization, Sensory Limb
Anatomy, Vascular anatomy, Bone anatomy, etc. is vital for successful Salvage:
 Creative Foot or Toe Filet Flaps, vs.
 Creative Amputations to optimize to best Amputation Level (classic levels)
 Understand: the impact of amputation (freely consult foot Ortho specialist to
minimize post TMA deformities with pre-emptive tendon releases, etc.)
 “Never throw anything away downstream….you may need it upstream” (ex.
instead of standard amputation, consider at each level: whether a Toe Filet, Foot
Filet, or Leg Filet is a better consideration…i.e. always consider future needs).
 Creative Splinting (and shoe) vital for initial (and also durable) wound healing:
 “Off-weighting starts with the brain”, however (teach patient, caretakers, etc.).
 At best: 6 weeks for incisions to be only “half strong” (!).
 Teach the patient: wound never remains healed at full strength without care…
 Foot Wounds: Like Distal 1/3, but has above unique considerations

32. Foot Wounds: Examples

33. Special “Creative Flaps…”.
 Free flap – The Classic Reconstruction for salvage of the
distal Leg and Foot Wound
 Typically Subspecialty Trained – Fellowships in microsurgery
beyond Plastic Surgery
 Higher years of experience, better published results (i.e. a
learning curve over the early years of experience).
 Complex for the surgeon, and the patient
 vs. “Creative flaps” – When classic flaps unavailable.
Fasciocutaneous flaps, perforator flaps, Filet flaps, cross
leg flaps, etc.
 Reversed Sural Artery Flaps – Insensate (standard type), or
even sensate type (more risk; and more meticulous
dissection required)…

34. Examples of Creative Limb Salvage
Distal Flaps…
 When Standard Flap Options Not Feasible…

35. Reversed Sural Artery Flap (Sensate
and Non-Sensate Options):

36. Limb Salvage-Distal 1/3
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37. Limb Salvage-Distal 1/3
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38. Limb Salvage-Distal 1/3
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39. Limb Salvage-Distal 1/3
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40. Limb Salvage-Distal 1/3
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41. Conclusions: Considerations for
Limb Salvage by Anatomic Region
 We must optimize all Medical Issues typically ignored:
 The Limb Salvage Reconstructive Surgeon must be the:
 Surgical “Nutritionist” (keofeed, prealbumin, etc.)
 Surgical “Physical Therapist” (offweighting, splinting)
 Surgical “Psychiatrist” (home situation, amputation impact)
 Surgical “Anatomist” (technical sub-specialization, knowing free
flaps and other creative anatomic procedures complex regions)
 Surgical “quarterback” (multi-disclipinary approach needed)
 Surgical “Wound Specialist” (reconstructive ladder, grafts, matrix
biosynthetics, etc.)
 Surgical “Primary Provider” (needing continued care of underlying
issues for durable healing success –diabetes, smoking, pressure, etc.)
 Not the usual career path of a typical Plastic Surgeon….

42. Limb Salvage- Special Considerations in
Key Anatomic Sites
 Thank you for your time
 Stay tuned for more SCAN Rounds
 Don’t forget your CME and CEU credits!
 Richard M. Bodor, MD
 Section Chief, VA Plastic Surgery 2006-2012
 Medical Director, Wound Care, VA Department of Surgery
 Health Sciences, Associate Clinical Professor, non-salaried,
UCSD Plastic Surgery Division, San Diego, CA