What is "orthoplastic" surgery?

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John M. Felder, MD, FACS, Plastic Surgeon, Royal Oak, Michigan

If you or a loved one has been told their leg or arm must be amputated - plastic surgery is definitely not a term that first springs to mind.  However, you may be shocked to know that plastic surgeons prevent amputations.  When amputations are being considered because of severe wounds, plastic surgeons may be the only surgeons capable of saving the limb.  Take the following case.  Here's an x-ray.  What kind of surgeon are you thinking should treat this?  It looks like an orthopedic surgery case, right??

Well, wait a minute.  Here's where it becomes plastic surgery - a case for The Reconstructive Surgeon!

Sometimes even in the best of hands, orthopedic surgeries will have problems like this.  It is almost never the surgeon's fault.  Frequently factors such as the severity of trauma may cause a wound to separate after a plate and screws are put into a fracture.  Even more frequently, there are underlying diseases in the patient that contribute. This patient was a smoker.  Smoking drastically impacts wound healing potential, particularly in the leg and foot, and is a frequent cause of wound dehiscence like you see here.  

You can see at this point that the broken bone is no longer the main concern.  The problem that will lead to the patient losing his leg is the soft tissue (skin) wound.  Without skin to cover the hardware, the hardware and bone will become infected.  

Once a bone is infected, it leads to a high risk of amputation.  Why? Think of it like a cavity in your tooth.  Sometimes, the cavity can be drilled out and filled.  But if the infection in the tooth is bad enough, it has destroyed the structural part of the tooth and the bacteria are "lodged" to the point where the only way to get rid of the cavity is to pull the tooth. 

It's the same thing in bones.  Once bacteria get on hardware, like the plate and screws that you see here, it's also a big problem.  Even though they can't eat or destroy the metal, bacteria form a layer of slime on the metal called biofilm.  The bacteria protect themselves with a snot-like layer that your body's immune cells can't break through.  Antibiotics also can not get through the slime.  Think of it like algae or moss on a boulder in a stream. 

Water can rush over the boulders with force, but they will not remove the moss, which has attached itself to the rock.  

You can scrape the moss off the rock (remove the biofilm off of the bone), but without getting the wound closed, there is no hope to save the leg because with the bone exposed to the outside environment, the bacteria will immediately reaccumulate.  

But getting the wound closed is not simple.  As you can see, we are already missing too much skin to close the wound.  There is no way to pull the skin together over the plate. 

This is where plastic surgeons get involved!  We sometimes call this type of surgery "orthoplastic surgery," because orthopedic surgeons and plastic surgeons work together closely to address this type of problem.  I am a specialist in orthoplastic surgery and it is one of my favorite parts of my job because it allows me to work closely with my talented colleagues in another specialty.  The orthopedic surgeons take care of the bone and hardware.  The plastic surgeon contributes to saving the leg by closing the wound. By working as a team, we can tackle a complex problem easily. 

But how in the world are we going to close this wound???  For that, you need a "free flap" and some "microsurgery." Lucky for this leg, The Reconstructive Surgeon is also a "microsurgeon." In other posts, I will speak in detail about what flaps are.  But think of a free flap as a piece of tissue, usually skin or muscle, that we disconnect from one part of the body where there is extra tissue, and transplant it to the part of the body that needs it.  In this case, skin from the thigh will be transplanted to the ankle.  To keep this skin alive, it needs blood flow in and out.  So we connect the blood vessels from the skin of the thigh to the blood vessels to the skin of the ankle.  This is called "microsurgery" because the blood vessels are small - usually between 1-3 millimeters in diameter, and we suture them together under a microscope.  Here's the basic idea:

Let's look at how we use a free flap for "limb salvage," or "limb preservation" in this patient's case.  Here we are using the anterolateral thigh free flap.  For short, the ALT flap.  The flap is harvested from the thigh.  We are going to cut out the skin (and underlying subcutaneous tissue) in the oval - that's the flap!  The dots are where we can hear blood vessels entering the skin paddle with our doppler microphone.

Ever wondered what it looks like under the skin of your thigh?  Here it is:

You can see we have cut through the skin and dissected down between the muscles.  You can see small blood vessels entering the rectus femoris muscle.  The forceps are pointing to a larger blood vessel (the descending branch of the lateral femoral circumflex artery) that ends up going into the skin flap. Now look at this:

Can you tell what's going on in this photo?

Crossing the blue rubber mat (blue background), large blood vessels encased in a fatty sheath are headed towards the skin flap to bring blood in and out of the flap, keeping it alive.  

Can't tell they are blood vessels?  Check out the pulsations in this video...

Now, can you tell what's going on in the next photo?

Here, the skin flap is folded over so you can see its underside.  In the green circle, the blood vessels are penetrating the underside of the flap, and will then go up through the subcutaneous tissue to perfuse the skin.  We call blood vessels like this perforators.  The vessel is perforating or piercing through the deeper tissues to go up to the skin.  And so this is a perforator flap.  Because we are going to detach it from the body and reattach it to the ankle, it is a perforator free flap.

Now - Here is where the magic happens.

....just connect some tiny arteries and veins under a microscope, giving the flap new blood flow from the leg... and it lives down at the ankle just like it used to live up in the thigh!  And in one elegant surgery....

Voila!

The wound is immediately healed, and the patient keeps his leg.

Now THAT - is "real plastic surgery!"

I hope you now understand how plastic surgeons actually help prevent amputations.  I hope this also highlights the reconstructive nature of true plastic surgery, and helps you understand that the "plastic surgery" you see on Instagram and Tik Tok is about 1% of what our specialty is capable of when we dedicate our skillset to helping the unfortunate.  Keep following future blog posts to learn more about the incredible and unique surgeries that plastic surgeons can do!  Perhaps one day you will have a friend or loved one that doesn't know where to turn when facing a difficult reconstructive problem, and you can help guide them using what you've learned here.  

If you enjoyed or learned something from this post, please share it to your social media app - It might help someone find the treatment they need! By raising awareness, you can play a part in helping to prevent unnecessary amputations as well.

All photographs are used with patient consent