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Disclosures  
Acute  Physical  Therapy  Management   The  presenters  have  no  conflicts  of  interest.      
of  Skin  Gra:s  and  Flaps  

Brooke  Fontana,  PT,  DPT  

University  of  Kansas  Hospital  
Kansas  City,  Kansas  
 
Melanie  Parker,  PT,  DPT,  NCS  
Shepherd  Center  
Atlanta,  Georgia  
CSM  2014  Las  Vegas,  Nevada  

Learning  ObjecFves   Course  Outline  

•  Explain  the  procedure  for  skin  graQing  and  stages  of  healing.   •  Skin  Gra:s       •  Flaps      
•  Types  of  GraQs   •  Types  of  flaps  
•  Evaluate  the  evidence  regarding  mobilizaSon  aQer  skin  graQing.  
•  Phases  of  healing   •  Post-­‐operaSve  care  
•  DifferenSate  the  types  of  Sssue  flaps  and  understand  the   •  Reasons  for  failure   •  Clinical  signs  of  a  failing  flap  
physiological  response  to  these  procedures.   •  IdenSficaSon  of  healthy  and   •  Methods  for  monitoring  
•  Employ  proper  monitoring  techniques  when  mobilizing  paSents   non-­‐healing  graQs  using  photos   •  Review  of  evidence  related  to  
following  flap  reconstrucSon.     •  Post-­‐operaSve  care   mobilizaSon  
•  TradiSonal   •  Clinical  applicaFon  with  case  
•  Apply  evidence  based  knowledge  to  make  recommendaSons   •  Review  of  evidence   scenarios  and  discussion  
regarding  appropriate  acSvity  progression.   •  Proposed  pracSce  guidelines   •  Areas  that  need  further  research     CSM  
  2014  
•  Use  of  negaSve  pressure  wound  
therapy  

Evidence  is  changing  culture…   Vision  Statement:  

•  Clinical  trials  of  early  mobilizaSon  criScally  ill  paSents.    Kress  JP.    Crit  Care  Med.    2009  Oct;  37(10  
“Acute  care  physical  therapy  is  provided  by  physical  therapists  who:  
suppl):S442-­‐7.      
•  No  rest  for  the  wounded:  early  ambulaSon  aQer  hip  surgery  accelerates  recovery.    Oldmeadow  LB,  et  
al.  ANZ  Journal  of  Surgery,  2006  July;  76:  607–611.     • As  integral  members  of  the  health  care  team,  are  consulted  for  their  
•  EffecSveness  of  an  early  mobilizaSon  protocol  in  a  trauma  and  burns  intensive  care  unit:  a   experSse  in  paSent  management  and  clinical  decision  making  for  paSents  
retrospecSve  cohort  study.    Clark  DE  et  al.    Phys  Ther.  2013  Feb;  93(2):  186-­‐196.  
•  Move  to  improve:  the  feasibility  of  using  an  early  mobility  protocol  to  increase  ambulaSon  in  the   with  acute  health  care  needs.  
intensive  and  intermediate  care  seings.    Drolet  A,  et  al.  Phys  Ther.    2013  Feb;93(2):  197-­‐207.      
•  Mobilizing  outcomes:    implementaSon  of  a  nurse-­‐led  mulSdisciplinary  mobility  program.    Dammeyer  
• May  be  board-­‐cerSfied  specialists  in  acute  care  physical  therapy.  
JA,  et  al.    Crit  Care  Nurs  Q.  2013  Jan-­‐Mar;36(1):109-­‐19.   • May  be  assisted,  in  a  team  relaSonship,  by  physical  therapist  assistants,  
•  Physical  therapy  on  the  wards  aQer  early  physical  acSvity  and  mobility  in  the  intensive  care  unit.    
Hopkins  RO,  et  al.    Phys  Ther.    2012  Dec;    92(12):  1518-­‐23.       who  may  be  recognized  for  advanced  proficiency.  
•  Safety  and  feasibility  of  an  early  mobilizaSon  program  for  paSents  with  aneurysmal  subarachnoid  
hemorrhage.    Olkowski  BF,  et  al.  Phys  Ther.  2013  Feb;93(2):  208-­‐215.    
•  Early  mobility  of  paSents  postroke  in  the  neuroscience  intensive  care  unit.    Sprenkle  KJ,  et  al.    J  Acute   The  Acute  Care  SecSon  of  the  American  Physical  Therapy  AssociaSon  is  
Care  Phys  Ther.    2013;  4  (3):101-­‐109.  
•  Early  ambulaSon  and  length  of  stay  in  older  adults  hospitalized  for  acute  illness.    Fisher  SR,  et  al.  Arch  
recognized  as  the  expert  resource  for  the  provision  of  evidence-­‐based  acute  
Intern  Med.  2010  November  22;  170(21):  1942-­‐1943.       care  physical  therapy.”  
hmp://www.acutept.org  

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How  do  we  know…   Types  of  Gra:s  

•  When  a  paSent    should  get  up?  

Gra:   DescripFon
AutograQ PaSent’s  own  skin  taken  
 
Split-­‐thickness  skin  graQ AutograQ  consisSng  of  epidermis  and  a  porSon  of  the  dermis
•  If  he/she  should  walk?    Weight  bear?    Wear  compression?  
Full-­‐thickness  skin  graQ AutograQ  consisSng  of  epidermis  and  the  enSre  dermis
 
Mesh  graQ AutograQ  placed  through  a  mesher  to  provide  more  surface  area
•  What  the  appropriate  level  and  type  of  acSvity  is?                                                    
Sheet  graQ AutograQ  without  meshing

AllograQ GraQ  from  same  species

XenograQ Temporary  graQ  of  porcine  skin

…  and  who  decides?   Cultured  epidermal  autograQ  (CEA) AutograQ  of  unburned  epidermal  cells  cultured  in  the  lab

Skin  Gra:  
•  Consists  of  epidermis  and  dermis  
•  Split  thickness:  varying  amounts  of  dermis  
•  Full  thickness:  contains  enSre  dermis  
 
•  Is  devascularized  and  requires  re-­‐vascularizaSon  from  site  where  
it  is  placed  
 
•  Number  of  epithelial  appendages  depends  on  the  thickness  of  the  
graQ  

Phases  of  Skin  Gra:  Healing   Why  Gra:s  Fail…  

1.  ImbibiFon   • FormaSon  of  hematoma  or  seroma  
•  GraQ  survives  by  diffusion  of  nutrients  from  the   • InfecSon  
wound  bed   • Incomplete  excision  of  nonviable  Sssue  
•  Fibrin  deposiSon  
• Shearing  or  trauma  to  the  graQ  site    
2.  NeovascularizaFon  
•  New  vessels  invade  the  graQ  by  angiogenesis  
3.  MaturaFon  
•  New  collagen  bridges  form  between  the  wound  bed  
and  graQ  

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When  to  mobilize?   TradiFonal  Post-­‐operaFve  Care  

The  quesFon  of  WHEN  to  safely  mobilize  a:er  skin  gra:ing  has  been  asked  for  
MANY  years…   • ImmobilizaFon  for  5  days  
  • Bedrest  
There  have  been  studies  reaching  back  to  the  1970s  which  indicate  that  early  
ambulaFon  (within  24-­‐48  hours  post  op)  of  paFents  with  lower  extremity  skin  gra:s   • No  ROM  of  joints  which  new  graQ  crosses  
may  be  safe  
•  “The  early  ambula-on  of  pa-ents  with  lower  limb  gra7s”  (Bodenham  &  
• Bolster  dressing  that  is  removed  on  POD  3-­‐5  
Watson  1971)    
•  “A  technic  of  lower  extremity  mesh  gra7ing  with  early  ambula-on"  (Golden,  
Power,  &  Skinner,  et  al  1977)   • Resume  ROM  and  mobility  on  POD  5  
•  “The  immediate  mobilisa-on  of  pa-ents  with  lower  limb  skin  gra7s:  a  clinical  
report.”  (Sharpe,  Cardoso  &  BaheS  1983)  

However  more  robust  evidence  is  limited,  and  conservaFve  post  operaFve  protocols  
of  bedrest  and  delayed  mobilizaFon  remain  in  place  throughout  the  county  

What  the  evidence  says…   More  evidence…  

“Effect  of  early  and  late  mobilisaFon  on  split  skin  gra:  outcome”  
“Immediate  AmbulaFon  of  PaFents  with  Lower  Extremity  Gra:s”     •  RetrospecSve  study  of  various  populaSons  requiring  lower  extremity  graQs  
•  RetrospecSve  study     •  PaSents  straSfied  into  two  groups:  
•  Early  mobilisaSon  (0-­‐3  days  bedrest)  &  Late  mobilisaSon  (≥  4  days  bedrest)  
•  Splints  used  if  the  graQ  crossed  a  joint    
•  PaSents  encouraged  to  walk  once  recovered  from  the  anestheSc   •  No  significant  difference  in  the  healing  rate:  
  •  EM  had  88%  healing  rate  
•  LM  had  91%  healing  rate  
•  Average  skin  graQ  take:    96.4%   •  No  significant  difference  in  rates  of  gra:  loss,  infecFon,  hematoma,  hypergranulaFon  
•  Average  Sme  unSl  able  to  ambulate  30  feet  independently:  1.7  days    
•  Significantly  higher  rate  of  decondiFoning  in  LM  group  
•  Significantly  different  post-­‐op  length  of  stay:  
•  EM  3.92  days  
•  LM  7.96  days  
Burnsworth  B,  Drob  MJ,  Langer-­‐Schnepp  M.    Immediate  ambulaSon  of  paSents  with  lower-­‐
extremity  graQs.    J  Burn  Care  Rehabil.    1992;  13:  89-­‐92.   Luczak  B,  Ha  J,  Gurfinkel  R.    Effect  of  early  and  late  mobilisaSon  on  split  skin  graQ  outcome.    Australas  J  of  
Dermatol.    2012;    53:    19-­‐21.      

Conclusions   Proposed  PracFce  Guidelines  

“The  consistent  finding  in  the  literature  is  that  early  ambulaSon  can   •  “An  early  postoperaFve  ambulaFon  protocol  should  be  iniFated  
be  safely  iniSated  aQer  lower  extremity  skin  graQing  without   immediately,  or  as  soon  as  possible,  a:er  lower  extremity  
compromising  graQ  take  if  external  compression  is  applied”   gra:ing  unless  any  exclusion  criteria  are  encountered.”  
 
•  “External  compression  must  be  applied  before  ambulaFon.”  
“No  studies  of  any  paSent  populaSon  have  concluded  that  early  
ambulaSon  compromises  graQ  take”   •  “If  the  gra:  crosses  a  joint,  the  joint  should  be  immobilized  
 
conFnuously  unFl  the  first  dressing  change.”  

Nedelee  B,  Serghiou  BM,  Niszczak  J,  et  al.    PracSce  guidelines  for  early  ambulaSon  of  burn   Nedelee  B,  Serghiou  BM,  Niszczak  J,  et  al.    PracSce  guidelines  for  early  ambulaSon  of  burn  
survivors  aQer  lower  extremity  graQs.    J  Burn  Care  Res.  2012;33:319-­‐329   survivors  aQer  lower  extremity  graQs.    J  Burn  Care  Res.  2012;33:319-­‐329  

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NegaFve  Pressure  Wound  Therapy  

PracFce  Guidelines  for  Early  
AmbulaFon  of  Burn  Survivors  a:er  
Lower  Extremity  Gra:s.  
•  Foam  dressing  conforms  to  the  wound  by  addiSon  of  negaSve  
Nedelec,  Bernademe;  Serghiou,   pressure  
Michael;    OTR,  MBA;  Niszczak,  
Jonathan;  MS,  OTR;  McMahon,  
Margaret;  Healey,  Tanja  
•  Promotes  skin  graQ  adherence  by  removal  of  exudate  
 
Journal  of  Burn  Care  &  Research.  
33(3):319-­‐329,  May/June  2012.  
DOI:  10.1097/BCR.
0b013e31823359d9  

Nedelee  B,  Serghiou  BM,  Niszczak  J,  et  al.    PracSce  

guidelines  for  early  ambulaSon  of  burn  survivors  
aQer  lower  extremity  graQs.    J  Burn  Care  
2   Res.  
2012;33:319-­‐329  
Figure 1 . Algorithm for early ambulation of lower extremity grafts.

Evidence     More  Evidence…  

“RetrospecFve  evaluaFon  of  clinical  outcomes  in  subjects  with  split-­‐ “EffecFveness  of  NegaFve  Pressure  Closure  in  the  IntegraFon  of  
thickness  skin  gra::  comparing  V.A.C.  therapy  and  convenFonal   Split  Thickness  Skin  Gra:s”  
therapy…”   •  Randomized  controlled  trial  of  60  paSents  requiring  STSG  aQer  burn  injury;  
•  RetrospecSve  review  of  142  paSents  who  underwent  LE  STSG;  either   Randomized  into  two  groups:  NegaSve  pressure  closure,  Control  group  
convenSonal  dressings  (CT)  or  V.A.C.  therapy  (NPWT)  used  post  operaSvely  
   
•  Significantly  greater  percentage  of  gra:  take  at  first  follow-­‐up,  maximal  gra:   •  Significantly  less  gra:  loss  (median)  in  the  NPC  group:  
take,  and  gra:  acceptance  for  the  NPWT  group   •  0.0  cm²,  0.0%  in  NPC  group  
•  95  ±  9%,  96  ±  9%,  97%  for  NPWT  respecSvely   •  4.5  cm²,  12.8%  in  the  control  group  
•  86  ±  23%  ,  83  ±  33%,  84%    for  CT  respecSvely  
•  Significantly  fewer  repeated  STSGs  required  for  the  NPWT  group   •  Significantly  shorter  length  of  hospital  stay  (median)  in  the  NPC  group:  
•  3.5%  for  NPWT   •  13.5  days  in  NPC  group  
•  15%  for  CT   •  17  days  in  control  group  

Blume  PA,  Key  JJ,  Thakor  P,  Thakor    S,  Sumprio  B.    RetrospecSve  evaluaSon  of  clinical  outcomes  in  subjects  with  split-­‐thickness  skin   Llanos  S,  Danilla  S,  Barraza  C,  et  al.    EffecSveness  of  negaSve  pressure  closure  in  the  integraSon  of  split  thickness  skin  
graQ:  comparing  V.A.C.  therapy  and  convenSonal  therapy  in  foot  and  ankle  reconstrucSve  surgeries.  Int  Wound  J.  2010;7:  480-­‐487.   graQs.    Ann  Surg.  2006;244:  700-­‐705.  

Clinical  Take-­‐Aways  for  Skin  Gra:s   Flaps  

•  Shearing  of  the  skin  gra:  should  be  avoided   A  flap  is  a  unit  of  skin,  underlying  Sssue,  and  blood  supply  
•  No  ROM  if  a  graQ  crosses  a  joint  unSl  POD  5  
 
transferred  from  a  donor  to  a  recipient  site.  
 
•  Edema  puts  a  gra:  at  risk  poor  adherence    
•  Elevate  extremiSes  at  rest  
•  Use  compression  
Can  be  classified  by:  
 
•  Evidence  supports  early  ambulaFon  with  skin  gra:ing   •  Component  parts   •  The  movement  placed  on  the  
  •  Fasciocutaneous   flap  
•  Use  of  a  wound  VAC  over  a  gra:  helps  prevent  shearing  and   •  Musculocutaneous   •  Advancement  
promotes  adherence  of  the  skin  gra:   •  Osseocutaneous   •  Pivot  
•  Facilitates  mobility     •  TransposiSon  
•  SplinSng  should  sSll  be  considered  
  •  Nature  of  the  blood  supply    
•  Collaborate  with  surgical  team  to  advocate  for  a  mobility  plan   •  Random   •  RelaFonship  to  the  defect   CSM  
with  which  all  parFes  agree   •  Axial   •  Local   2014  
•  Regional  
  •  Distant  

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Distant  Flaps   Gastrocnemius  Muscle  Flap  

Can  be  transferred  over  a  great  distance  as  a  pedicled  flap  or  free  
flap  
 
•  Pedicled  flap:    vascular  supply  remains  anatomically  connected  
•  Free  flaps:    vascular  supply  is  disconnected  and  microsurgically  
reconnected  to  a  new  artery  and  new  vein  near  the  recipient  site  

CSM  
2014  

www.microsurgeon.org/gastroc  

LaFssimus  Dorsi  Muscle  Flap  

hmp://www.thedenverclinic.com/services/mangled/early-­‐soQ-­‐Sssue-­‐coverage/71-­‐examples-­‐of-­‐soQ-­‐Ssse-­‐flaps.html   hmp://www.microsurgeon.org/laSssimus  

Post-­‐operaFve  Care  
•  Maintaining  arterial  inflow  and  venous  ouylow  is  imperaSve  
•  Venous  insufficiency  is  more  common  than  arterial  
•  Majority  of  compromise  occurs  within  the  first  72  hours  aQer  surgery  
•  May  require  emergent  exploraSon  to  restore  circulaSon  
•  Close  monitoring  is  essenSal  

Salgado  CJ,  Moran  SL,  Mardini  S.    Flap  monitoring  and  paSent  management.    Plast  Reconstr  Surg.    2009;124:295-­‐302.  
hmp://www.thedenverclinic.com/services/mangled/early-­‐soQ-­‐Sssue-­‐coverage/71-­‐examples-­‐of-­‐soQ-­‐Ssse-­‐flaps.html  

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Clinical  Signs  of  a  Failing  Flap  

Signs  of  arterial  insufficiency   Signs  of  venous  insufficiency  
•  Pale  or  momled  flap  color   •  Purple,  blue,  or  dusky  
discoloraSon  
•  ReducSon  in  flap  temperature  
•  CongesSon  
•  Loss  of  capillary    refill    (>2  sec)  
•  Swelling  
•  Loss  of  flap  turgor  
•  Rapid  capillary  refill,  followed  
by  eventual  loss  of  capillary  
refill  
•  Dark  bleeding  at  the  edges  
•  Eventual  loss  of  arterial  inflow   31   Koul  AR,  Nahar  S,  Prabhu  J,  Kale  SM,  Praveen  Kumar  H  P.  Free  Boomerang-­‐shaped  Extended  Rectus  Abdominis  
Myocutaneous  flap:  The  longest  possible  skin/myocutaneous  free  flap  for  soQ  Sssue  reconstrucSon  of  extremiSes.  
Indian  J  Plast  Surg  [serial  online]  2011  [cited  2014  Jan  23];44:396-­‐404.  Available  from:  
hmp://www.ijps.org/text.asp?2011/44/3/396/90808    

Methods  for  Monitoring  the  Flap   Hand-­‐held  Doppler  Probe  

•  Clinical  observaSon  
•  Pinprick  tesSng   •  Most  common  method  of  
•  Surface  temperature  monitoring  
monitoring  
•  Hand-­‐held  Doppler  ultrasonography  
•  Implantable  Doppler   •  Must  be  sure  to  detect  the  
•  Pulse  oximetry   flap’s  vascular  pedicle  rather  
•  Laser  Doppler   than  the  recipient  vessel.  
•  Tissue  pH  
•  Photography  

CSM  
2014  
Salgado  CJ,  Moran  SL,  Mardini  S.    Flap  monitoring  and  paSent  management.    Plast  Reconstr  Surg.     Salgado  CJ,  Moran  SL,  Mardini  S.    Flap  monitoring  and  paSent  management.    Plast  Reconstr  Surg.    
2009;124:295-­‐302.   2009;124:295-­‐302.  

Implantable  Doppler  Monitoring   Doppler  Video  

hmp://www.microsurgeon.org/monitoring  
hmp://www.cookmedical.com  

hmp://www.youtube.com/watch?v=9QlHRUojvQk  

Fontana,  Parker  2014  Not  to  be  copied  

without  permission   6  
 2/5/14  

ViopFx  Monitoring   Blood  Supply    

•  Noninvasive   •  MacrocirculaSon  
•  MicrocirculaSon  
•  Measures  the  scamering  and  
•  Arterial  inflow  supplies  nutrients  and  oxygen  to  Sssue  
absorpSon  of  near-­‐infrared  light  
•  Venous  ouylow  removes  carbon  dioxide  and  waste  
•  The  raSo  of  oxyhemoglobin  and   •  Systemic  regulaSon  of  blood  flow  is  mediated  by:  
deoxyhemoglobin  provides  real  Sme  
•  Neural  receptors  
measurement  of  the  Sssue’s  
•  α-­‐adrenergic,  β-­‐adrenergic,  serotonergic  
oxygenaSon.  
•  Humoral  substances  
•  SensiSvity  is  also  displayed   •  Norepinephrine,  epinephrine,  serotonin,  histamine,  prostaglandins  
CSM  
2014  
Daniel  RK,  Kerrigan  CL.  Principles  and  physiology  of  skin  flap  surgery.    In  McCarthy  JG,  ed.  PlasSc  Surgery.  Philadelphia,  PA:    WB  Saunders;  
1990:  275-­‐328.       38  
hmp://www.viopSx.com/docs/applicaSons/plasSc_surgery.asp  

Blood  Flow  with  ElevaFon   Mobilizing  A:er  a  Flap  

•  With  elevaSon,  sympatheSc  nerves  and  inflow   •  Gravity  contributes  to  increased  capillary  
vessels  are  divided.   pressure  and  increased  fluid  leaking  into  the  
intersSSum  
•  Blood  blow  is  only  20%  of  normal  in  the  distal  end  
•  Edema  can  lead  to  increased  venous  
of  a  pedicled  flap  within  6-­‐12  hours.   congesSon  of  the  flap  
•  In  1-­‐2  weeks,  75%  of  normal  flow  is  recovered.   •  Distal  flap  necrosis  is  due  to  venous  stasis  
•  In  3-­‐4  weeks,  flow  returns  to  100%.    
•  NeovascularizaSon  can  sustain  a  flap  from  days  3-­‐10   •  Venous  drainage  is  imperaSve  to  flap  survival  
post  operaSvely,  even  aQer  arterial  occlusion    
 

 
CSM    
2014    

Rohde  C,  Howell  BW,  Buncke  GM,  et  al.    A  Recommended  protocol  for  the  immediatepostoperaSve  care   Rohde  C,  Howell  BW,  Buncke  GM,  et  al.    A  Recommended  protocol  for  the  immediatepostoperaSve  
of  lower  extremity  free-­‐flap  reconstrucSons.    J  Reconstr  Microsurg.    2009;25:15-­‐20.   care  of  lower  extremity  free-­‐flap  reconstrucSons.    J  Reconstr  Microsurg.    2009;25:15-­‐20.  

RecommendaFons  for  PostoperaFve  Care    

by  Rohde,  et  al  
• Any  personnel  with  specific  training  may  start  
dangling  
• Start  dangling  protocol  at  POD  14  
• Start  dangling  for  5  minutes  twice  daily;  increase    by  5  
minutes  per  session  per  day  or  add  an  addiSonal  
session  

CSM  
2014   Rohde  C,  Howell  BW,  Buncke  GM,  et  al.    A  Recommended  protocol  for  the  immediate  postoperaSve  care  
of  lower  extremity  free-­‐flap  reconstrucSons.    J  Reconstr  Microsurg.    2009;25:15-­‐20.  

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without  permission   7  
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RecommendaFons,  conFnued   RecommendaFons,  conFnued  

• Two  approaches  for  compression  are  proposed:   • Assess  flap  before  and  aQer  dangling/wrapping    
 
• Weight  bearing  
•  The  extremity  should  be  wrapped  with  each  dangling  
•  Per  orthopedics  if  there  is  a  fracture  
     OR   •  If  no  fracture,  begin  weight  bearing  when  wound  is  mature  and  paSent  
•  Compressive  wrap  should  not  be  placed  unSl  the  wound  is   tolerates  dangling  30  minutes  6  Smes  per  day  
mature  and  the  paSent  is  toleraSng  dangling  
• Discharge  paSent  when  paSent  tolerates  dangling  with  a  
 
good  understanding  of  flap  assessment  (2-­‐3  weeks)  

Rohde  C,  Howell  BW,  Buncke  GM,  et  al.    A  Recommended  protocol  for  the  immediate  postoperaSve  care  of  lower   Rohde  C,  Howell  BW,  Buncke  GM,  et  al.    A  Recommended  protocol  for  the  immediate  postoperaSve  care  of  lower  
extremity  free-­‐flap  reconstrucSons.    J  Reconstr  Microsurg.    2009;25:15-­‐20.   extremity  free-­‐flap  reconstrucSons.    J  Reconstr  Microsurg.    2009;25:15-­‐20.  
 
 

Tissue  OxygenaFon  with  Free  Flap  Dangling   A  “Dangle  Protocol”  

Surgeon-­‐specific  and  paSent-­‐specific    
•  Usually  begins  ~post-­‐op  day  7  
•  Usually  allowed  5  minutes,  three  Smes  daily  
•  Compression  depends  on  the  surgeon  
 
•  Flap  should  be  assessed  before,  during  and  
aQer:  
•  Color  (pale,  momled,  bluish,  cyanoSc,  dusky)  
•  Swelling    
•  Temperature  
•  Doppler  
 

Ridgway  EB,  Kutz  RH,  Cooper  JS,  Guo  L.    New  insight  into  an  old  paradigm:  wrapping  and  dangling  with  lower-­‐
extremity  free  flaps.    J  Reconstr  Microsurg.  2010;26:559-­‐566.      

Clinical  Take-­‐Aways  for  Flaps   Case  Scenario  1  

•  Familiarize  yourself  with  the  surgical  procedure  and  what  structures  were   52  year  old  female  sustained  deep  parSal  thickness  burn  to  R  anterior  lower  
involved.   leg,  dorsum  of  foot  and  toes  while  lighSng  a  wood  burning  stove  
•  Consider  the  implicaSon  of  acSvity  on    the  viability  of    the  flap  and  advocate    
for  the  appropriate  progression.   •  Burn  is  <  5%  TBSA  
•  Be  sure  to  monitor  the  flap,  communicate  with  the  team,  and  document!   •  No  inhalaSon  Injury  
•  Weightbearing  is  usually  less  of  an  issue  than  limb  dependency  is.   •  Underwent  mulSple  surgeries  for  debridement  of  LE  
•  Avoid  exercise  or  acSvity  that  will  shunt  blood  away  from  the  flap  for   •  UlSmately  underwent  meshed  STSG  to  the  anterior  lower  leg  and  dorsum  of  
prolonged  periods.   foot  
 
 

http://acrazykindoffaith.blogspot.com/

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without  permission   8  
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Case  Scenario  1   Case  Scenario  2  

•  What  needs  to  be  considered  in  this  case  prior  to  iniSaSng  mobilizaSon?   48  year  old  male  s/p  fall  from  a  ladder  in  which  he  sustained  a  comminuted  
distal  Sb/  fib  fracture.      
•  When  would  it  be  appropriate  for  her  to  mobilize?   •  Hospital  day  1:    To    OR  for  I&D,  wound  vac  placement,  and  external  fixaSon  
on  day  of  injury.  
•  Hospital  day  3:    Repeat  I&D;  vac  change  
•  What  kind  of  weight  bearing  would  be  appropriate?  
•  Hospital  day  4:    PT  evaluaSon  

What  precauSons  would  you  anScipate?  

What  would  his  iniSal  mobility  goals  include?  

Case  2,  conFnued   Case  2,  conFnued    

•  Hospital  day  7:    Returned  to  OR  for  I&D,  removal  of  ex  fix,  ORIF,  anterolateral   •  Actual  post-­‐operaSve  instrucSons:  
thigh  free  flap  to  leQ  ankle    NWB  L  LE  
•  Hospital  day  8:      Returned  to  OR  for  failing  free  flap.    Underwent  redo  of  the    Dangle  x5  minutes,  three  Smes  daily  
arterial  anastomosis  and  venous  ouylow  reestablished  with  bypass  using    Ace  wrap  lower  leg  and  foot  prior  to  dangle  and  remove  aQer  
contralateral  saphenous  vein.  
 Monitor  cook  signal,  foot  color,  DP,  PT  pulse  with  dangle  
•  Hospital  day  14:  Returned  to  OR  for  re-­‐inset  of  flap  and  STSG.  
•  Goals  
•  Hospital  day  19:    PT  reevaluaSon  
•  Progression  of  dangling  
 
  •  ConsideraSons  for  discharge  planning  
 
What  precauSons  would  you  anScipate?  
How  should  his  physical  therapy  goals  be  updated?  

Case  Scenario  3       Case  3,  conFnued  

63  year  old  male  with  history  of  craniotomy  for  oligodendroglioma  in  1999.     •  Hospital  day  4:    Returned  to  OR  for  debridement  for  failed  laSssimus  dorsi  
•  Developed  infecSon  and  exposed  hardware  and  underwent  mulSple   muscle  flap/  I&D,  free  rectus  myocutaneous  microvascular  free  flap  and  
surgeries,  followed  by  management  with  a  wound  vac.       STSG.      
•  Underwent  cranioplasty  with  removal  of  infected  Stanium  mesh  and   •  Hospital  day  10:    PT  re-­‐consulted  
reconstrucSon  with  new  Stanium  mesh,  screws,  and  coverage  with  a  free   •  Purulent  drainage  noted  with  mobilizaSon  
laSssimus  dorsi  flap  and  split  thickness  skin  graQ.       •  Returned  to  OR  for  removal  of  mesh  cranioplasty  from  R  parietal  region,  
•  Hospital  day  2:  PT  consult   I&D,  Vac  placement  
•  Dark  red  bloody  drainage  noted  with  mobilizaSon   •  Hospital  day  12:  Returned  to  OR  for  vac  change,  debridement  of  muscle  flap,  
  and  closure  of  anterior  scalp  wound.    
 
What  precauSons  should  be  followed?  
Special  consideraSons  for  monitoring?  
 

Fontana,  Parker  2014  Not  to  be  copied  

without  permission   9  
 2/5/14  

Areas  for  Further  Research…   QuesFons  and  comments….  

Melanie_Parker@shepherd.org  
•  Use  of  assisSve  device  aQer  graQing  
 
•  MobilizaSon  with  the  use  of  a  wound  VAC  over  graQs   bfontana@kumc.edu  
•  Early  vs.  late  compression  aQer  flap      
•  OpSmal  type  and  amount  of  compression    
•  When  to  begin  dangling  aQer  flap    
•  OpSmal  progression  of  Sme  limb  is  dependent  
 
•  Impact  of  cardiovascular  exercise  on  flap  survival    

References  
Burnsworth  B,  Drob  MJ,  Langer-­‐Schnepp  M.    Immediate  ambulaSon  of  paSents  with  lower-­‐extremity  graQs.    J  Burn  Care  
Rehabil.    1992;  13:  89-­‐92.    
Luczak  B,  Ha  J,  Gurfinkel  R.    Effect  of  early  and  late  mobilisaSon  on  split  skin  graQ  outcome.    Australas  J  of  Dermatol.    
2012;    53:    19-­‐21.    
Blume  PA,  Key  JJ,  Thakor  P,  Thakor    S,  Sumprio  B.    RetrospecSve  evaluaSon  of  clinicaloutcomes  in  subjects  with  split-­‐
thickness  skin  graQ:  comparing  V.A.C.  therapy  and  convenSonal  therapy  in  foot  and  ankle  reconstrucSve  surgeries.    Int  
Wound  J.2010;7:  480-­‐487.  
Llanos  S,  Danilla  S,  Barraza  C,  et  al.    EffecSveness  of  negaSve  pressure  closure  in  the  integraSon  of  split  thickness  skin  
graQs.    Ann  Surg.  2006;244:  700-­‐705.  
Mathes  SJ,  Levine  J.    Muscle  flaps  and  their  blood  supply.    Grabb  and  Smith’s  Plas-c  Surgery,  6th  Edi-on.    2007  
Nedelee  B,  Serghiou  BM,  Niszczak  J,  et  al.    PracSce  guidelines  for  early  ambulaSon  of  burn  survivors  aQer  lower  
extremity  graQs.    J  Burn  Care  Res.  2012;33:319-­‐329.  
Talbot  SG,  Pribaz  JJ.    First  aid  for  failing  flaps.    J  Reconstr  Microsurg.  2010;26:513-­‐516.  
Ridgway  EB,  Kutz  RH,  Cooper  JS,  Guo  L.    New  insight  into  an  old  paradigm:  wrapping  and  danling  with  lower-­‐extremity  
free  flaps.    J  Reconstr  Microsurg.  2010;26:559-­‐566.      
Salgado  CJ,  Moran  SL,  Mardini  S.    Flap  monitoring  and  paSent  management.    Plast  Reconstr  Surg.    2009;124:295-­‐302.  
Rohde  C,  Howell  BW,  Buncke  GM,  et  al.    A  Recommended  protocol  for  the  immediate  postoperaSve  care  of  lower  
extremity  free-­‐flap  reconstrucSons.    J  Reconstr  Microsurg.    2009;25:15-­‐20.  
 
 

 
 
 
 
 
 
 
 

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