When nerve or arteries are injured or tissue is moved from one area of the body to another area of the body (free tissue transfer), microsurgical techniques are necessary. Meticulous technique is required to sew 1-2 mm diameter arteries together. When performed effectively, a breast can be reconstructed from your own tissue or a wound can be covered with healthy tissue from another area of the body initiating the wound healing process.
Luke Gutwein, MD
Plastic & Reconstructive Surgeon
St. Augustine's Medical Services
American Board of Surgery Certified
Professor of Anatomy
St. George's University
Grenada, West Indies
Microsurgery is highly technical and exclusive to the few surgeons trained to perform it. Suture is as thin as your hair and anything except meticulous technique is met with failure
Wound Soft Tissue Coverage for Limb Preservation
Acute and chronic wounds can threaten a limb by exposure of critical structures (bone, artery, nerve, and tendon). If the wound fails to heal by the normal wound healing process, limb dysfunction and infection may ensue progressing to limb loss. Reconstructive surgery allows movement of tissue from other areas of the body (free tissue transfer) in order to cover these critical structures preserving function. An example, would be to take thigh tissue and cover critical structures at the ankle area to prevent a below knee amputation.
A fall resulted in a fractured ankle complicated with an infected wound. The first thing to do is to cut away dead tissue and remove foreign bodies such as internal hardware (plates & screws placed in the first attempt for fracture repair) in order to allow the healing process to start fresh again. An external fixator holds the bones in place to allow the fracture to heal. A 7 centimeter wound defect remains at the foot-lower leg junction with critical structures exposed (bone & tendon)
The plan is to move thigh tissue (skin & fat) to cover the wound defect. This is an anterolateral thigh flap or ALT flap, a very common flap used in reconstructive surgery. Anatomical landmarks include the lateral patella (knee cap) and anterior superior iliac spine (ASIS). On this axis, the skin paddle is designed based on perforating vessels (A,B,C). Movement of tissue such as this requires a microsurgical skill set.
The postoperative result with a healed wound and no below knee amputation. The tissue flap may be thinned after 6 months to give a normal contour to the lower leg.
Burn Wound Management & Reconstruction
A burn wound can happen in an instant whether you are in the kitchen with children or around a campfire (accidents do happen but please take appropriate precautions). A burn wound can lead to a long healing phase and abnormal scarring (hypertrophic scars). Early burn wound excision and skin grafting can speed up this healing process and decrease scarring. Not all burn wounds need excision and skin grafting, therefore, it is important to see a plastic surgeon or burn surgeon for evaluation.
Scald burn from hot water when child tried to remove contents from a microwave
Child with scald burn to hands
Complex lacerations can occur at any time and if not cared for and repaired in an efficient and appropriate manner negative long-term sequelae may develop such as an enlarged scar, painful neuroma, infection, or loss of function. Tissue should be washed out with nonviable tissue and foreign debris removed. Tissue edges should be approximated in a layered closure. At the time of closure, critical structures are identified and repaired (muscle, nerves, arteries, and tendons)
Hand & Facial Fracture Repair
Muscles insert onto bones and if a bone breaks it can be displaced (pulled on by the muscle) and surgical correction is necessary for proper healing. This commonly occurs in the hand and mandible. Proper bone alignment is essential for the wear surfaces of the teeth to fit together in a normal fashion. The same principles hold true in the hand to restore proper function after injury.
Realignment of bone fragments with plate
Midface fractures that need operative repair
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