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Reconstructive Procedures

Reconstructive Procedures

Reconstructive Procedures

Extremity Reconstruction

Extremity Reconstruction_2

Why do people need extremity reconstruction?

The extremities include both the upper limbs and the lower limbs.

Wounds of the extremities can occur due to multiple reasons including trauma, infection, and cancer excision. Patients with diabetes and peripheral vascular disease are also very prone to developing wounds of the extremities, particularly the feet.

The resultant defects vary in size, depth, and tissue involved, and can be debilitating and disfiguring, resulting in loss of function in the arm or the leg. Moreover, they often cannot be simply sutured closed, and if left open, will take a long time to heal and can be prone to infection.

Reconstructive surgery of the extremities aims to restore form and function to the patient by anatomical restoration of skin, muscle, and bone, with the goal of replacing like with like as much as possible and allowing the patient to return to normal activity early.


How is extremity reconstruction performed?

The extremity defect would first need to be assessed for size, shape, depth, and tissues involved. If it is a chronic or infected wound, adequate wound bed preparation must be performed to aid in successful reconstruction, and may involve wound debridement, special dressings such as negative pressure wound therapy, and antibiotic treatment [1].

Once the wound is ready, your plastic surgeon will utilize the armamentarium of the reconstructive elevator with the goals of functional as well as aesthetic reconstruction. This may involve the use of tissue expansion, grafts, or flaps. Grafts are performed when the wound bed has an adequate blood supply, while flaps are performed as local, perforator-based, pedicled or free flaps, depending on the extent of the defect and the complexity of surgery.

What happens before surgery?

Besides wound bed preparation, you may be required to undergo X-rays and other scans to help delineate the extent of the wound and/or plan for reconstruction. If there is a need to determine the blood supply to the extremity, an ultrasound or angiogram may be performed. This is especially pertinent if a microvascular-based reconstruction is planned. In a diabetic, chronic, or infected wound, tissue or pus may be sent for bacterial culture to determine the appropriate antibiotics to aid in a successful reconstruction. You may be started on broad-spectrum antibiotics in the meantime.

You may be required to see an anaesthetist, and blood tests and other investigations to determine your suitability for anaesthesia may be performed.

If your extremity reconstruction is performed in relation to cancer removal, you may require neo-adjuvant treatments such as radiotherapy or chemotherapy. Your cancer surgeon will discuss this with you.

During the procedure

Your reconstruction may be performed under local anaesthesia (LA), regional anaesthesia (RA), sedation, or general anaesthesia (GA). If there is a resection to be performed by another surgeon, the reconstruction can be performed concurrently. Complex reconstructions involving multiple tissues and microvascular work can take many hours to perform. During the procedure, you will be monitored closely by the surgeon and anaesthetist to ensure your well-being is kept at an optimal state, which may include blood transfusions if there is a significant amount of blood loss.

Post-operative care

After the reconstruction is performed, the wound, graft and/or flap will be monitored closely for a few days, with adjuncts such as immobilization and/or elevation of the involved extremity required. You may require a few days’ observation in the intensive care or high dependency unit right after the operation.

Once the reconstruction is stable at about 1 week after surgery, you will be started on dangling exercises and partial weight bearing with a pressure garment. This involved periodic lowering of the limb to enable training of the reconstruction to accept the effects of gravity. For both the upper and lower extremity, there will be a period of a few weeks where rehabilitation is required. Most patients can get back to full function/full weight bearing of the lower extremity at about 4 weeks after surgery.

If your extremity reconstruction is performed in relation to cancer removal, you may require adjuvant treatments such as radiotherapy or chemotherapy. Your cancer surgeon will discuss this with you.

Potential risks and complications

As with any surgery, general risks include pain, bleeding, and infection. Post-operative pain is usually well controlled after surgery with medication, and the risk of bleeding and infection leading to the need for another procedure is low. There is also the general anaesthetic risk, which will be explained to you by the anaesthetist, and is typically low especially if you are healthy. There is also a small risk that the reconstruction will not be successful or may have partial loss. These can be managed conservatively, or with further reconstruction. Specific to microvascular reconstruction, if there is any sign of problems with the blood supply to the transferred tissue, you may be brought back to the operating theatre expediently. Other known sequelae include scarring and numbness at the operative sites.

For the extremities, the reconstruction can be slightly bulky in the initial few months. This bulk can be managed with a small debulking procedure. This is especially pertinent to the lower extremity around the foot and ankle area, where footwear is concerned.
Extremity Reconstruction_1

Why choose Polaris Plastic Surgery?

At Polaris Plastic and Reconstructive Surgery, Dr Adrian has trained for many years in performing reconstruction for all types of extremity wounds. These include diabetic, traumatic and cancer related wounds. During his fellowship training, he specialized in reconstructive microsurgery, including reconstruction of the extremities and functional muscle reconstruction. Functional muscle reconstruction is highly complex and is especially important in cases where a large portion of the original muscle of the limb has been removed. He has published articles on lower extremity reconstruction and most importantly, has years of experience and works closely with other specialists and therapists involved in extremity reconstruction to achieve satisfactory outcomes.

Schedule a consultation with Dr Adrian to assess your needs and goals. He will communicate with you regarding your concerns, and in discussion with you, formulate a plan to perform the appropriate reconstructive procedure.

FAQ

Can extremity reconstruction be performed for diabetic patients?

Diabetic patients and those with peripheral vascular disease are more prone to developing wounds of the extremities, especially the lower extremity. This is due to reduced blood supply, along with loss of sensation to the toes, feet, and ankles. Left untreated, these wounds often get infected or turn gangrenous. Adequate early management along with diabetic control is key to prevention of complications. Established wounds can also be treated with a combination of debridement, special dressings, and potential reconstruction. This is a carefully mapped-out process which can involve multiple specialties including plastic surgeons, orthopaedic surgeons, vascular surgeons, and podiatrists. As the wound expert, the plastic surgeon is well placed to manage these wounds.

How soon can I get back to normal function after extremity reconstruction?

Return to function for extremity wounds is variable and depends on the extent and tissues involved. In a pure soft tissue wound, return to full weight bearing for the lower extremity can occur in about 3 to 4 weeks after surgery. If there is bony fracture fixation or reconstruction required, full weight bearing may take up to 2 to 3 months to occur, to allow for full healing of the bone.


References
1. Raju A, Ooi A, Ong YS, Tan BK. Traumatic lower limb injury and microsurgical free flap reconstruction with the use of negative pressure wound therapy: is timing crucial? J Reconstr Microsurg. 2014;30:427-30

2. AlMugaren, F. M., Pak, C. J., Suh, H. P. & Hong, J. P. Best Local Flaps for Lower Extremity Reconstruction. Plastic and reconstructive surgery. Global open 8, e2774-8 (2020).

3. Muramatsu K, Ihara K, Doi K, Yoshida K, Iwanaga R, Hashimoto T, Taguchi T. Functional neuro-vascularized muscle transfer for oncological reconstruction of extremity sarcoma. Surg Oncol. 2012 Dec;21(4):263-8.

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