|Sole of the Foot
Thick tissue defects on the weight-bearing sole of the foot need repair with similarly thick and resilient tissue. This can usually be done by shifting sole tissues from areas which bear little or no weight to those which must withstand the full force of walking.
This patient had a melanoma right in the center of the heel. Removal of this tumor would require the sacrifice of the entire heel area.
This is the surgical plan for the resection and a flap of tissue from the sole.
Here is shown the flap raised and ready for rotation into the heel defect. (This surgery is done under tourniquet control; hence the lack of bleeding).
The flap is now in position, and a skin graft has been added to the area from which it was taken. This area of the foot bears to weight.
This is the healed reconstruction.
Top of Foot
Areas over the lower shin and top of the foot are difficult to repair with local tissues. In the majority of cases, if bone of other vital tissues are exposed, flap transfer from a distance will be required employing microsurgical techniques.
This patient's injury lead to death of the skin and soft tissues on the dorsum of the foot right down to the bone.Skin grafting right on the bone will not usually work.
This is a flap of tough, well vascularized tissue known as "fascia" taken from beneath the patient's scalp in preparation for transfer to the foot. It will be connected to blood vessels at the ankle and will support an overlying skin graft.
This shows the foot after flap transfer and the placement of a skin graft on its surface.
This is the healed wound on the foot and in the donor area of the scalp.
Reconstruction of the lower extremity is required in a great variety of circumstances.Trauma may lead to bone and soft tissue loss. In these instances, the orthopedist may be assisted by the plastic surgeon. Proper soft tissue cover for a repaired skeleton is critical to the healing of the latter.
When tumors invade the long bones, resections may be prodigious. If bone replacement in kind is sought, large defects will dictate the use of vascularized bone ("free flap") transfers. If the orthopedist chooses to replace bone with prosthetic materials, these will often need soft tissue investment moved by the plastic surgeon.
This is a scan showing tumor destroying this boy's tibia, or "shin bone" in the knee area. Resection will require sacrifice of the joint.
Here the bone has been removed and a metal tibia and knee joint placed by the orthopedist. This will never heal with skin investment alone, dictating the need for transfer of muscle for cover.
Muscles are "flapped" to cover the prosthesis.
This is the healing leg postoperatively.