Innovations in diabetic foot reconstruction using supermicrosurgery

Abstract

The treatment of diabetic foot ulceration is complex with multiple factors involved, and it may often lead to limb amputation. Hence, a multidisciplinary approach is warranted to cover the spectrum of treatment for diabetic foot, but in complex wounds, surgical treatment is inevitable. Surgery may involve the decision to preserve the limb by reconstruction or to amputate it. Reconstruction involves preserving the limb with secure coverage. Local flaps usually are able to provide sufficient coverage for small or moderate sized wound, but for larger wounds, soft tissue coverage involves flaps that are distantly located from the wound. Reconstruction of distant flap usually involves microsurgery, and now, further innovative methods such as supermicrosurgery have further given complex wounds a better chance to be reconstructed and limbs salvaged. This article reviews the microsurgery involved in reconstruction and introduces the new method of supermicrosurgery.

Reconstruction Using Free Flaps for Diabetic Heel Defects: Outcomes and Risk Factor Analysis

“…This is rather low compared with our previous series of diabetic foot reconstruction looking at the foot as a whole which had flap success rate around 90%. 1,2,6,16 The biggest factor behind increased failure can be due to the anatomic paucity of arterial supply in the heal region along with the deterioration of flow frequently found in diabetic foot with progression of calcification of the arteries. The heel being supplied by two branches, one from posterior tibial and the other from peroneal artery; lack of perfusion can form a watershed region of the heal leading to breakdown of skin and ulceration.…”

The role of reconstructive microsurgery in treating lower‐extremity chronic wounds

“…The exact roles of endovascular and open bypass procedures are still evolving, but are primarily determined by arterial anatomy, wound severity, and patient comorbidities . Whatever the method, it is imperative to restore as much blood flow as possible to the foot so it can be adequately used as a recipient vessel . The orthopaedic surgeons or podiatrists need to be involved to evaluate the skeletal status of the lower leg or foot when indicated.…”

“…One of the basic elements of plastic surgery is to replace like with like. Thus for defects with skin defects, we are shifting towards using perforator flaps such as anterolateral thigh (ALT) perforator flap, thoracodarsal artery perforator (TDAP) flap, and superficial circumflex iliac perforator (SCIP) flap as it provides, a thin flap to minimise shearing, can take only the superficial fat to imitate the fibrous septa of the sole to adhere tightly, enhance neovascularisation of the subdermal plexus with adjacent tissue, and provide adequate blood supply to fight infection . The elevation technique of each individual flap is described in detail in the referenced articles.…”

“…Nylon 9‐0 or 10‐0 sutures can be used to anastomose vessels of 1 to 2 mm diameters. Recently, a new technique called supermicrosurgery is being used to anastomose vessels at a perforator level . The concept of supermicrosurgery introduced by Koshima et al has increased the popularity of perforator flaps and lymphatic surgery anastomosing vessels ranging from 0.3 to 0.8 mm in diameter .…”

Úlceras del pie diabético: importancia del manejo multidisciplinario y salvataje microquirúrgico de la extremidad

“…Además, se evita la necesidad de disección de largos pedículos y, por lo tanto, disminuye la morbilidad de la zona dadora. Desempeña un papel alternativo en la reconstrucción del pie diabético ya que permite que la anastomosis a un pequeño vaso del angiosoma adyacente bien vascularizado proporcione suficiente perfusión para permitir que un colgajo libre cubra el territorio isquémico y otorgue una adecuada irrigación 36 . Actualmente, el abordaje propuesto en la reconstrucción de las úlceras del pie diabético consiste en utilizar el concepto de angiosomas y supermicrocirugía free style 37 .…”