Management of Grafts and Flaps Handout - c.ymcdn.com · • Randomized&controlled&trial&of&60&paents&requiring&STSG&aer&burn&injury;& Randomized&into&two&groups:&Negave&pressure&closure,&Control&group&

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Fontana, Parker 2014 Not to be copied without permission 1

Acute Physical Therapy Management 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

Disclosures The presenters have no conflicts of interest.

Learning ObjecFves •  Explain the procedure for skin graQing and stages of healing. •  Evaluate the evidence regarding mobilizaSon aQer skin graQing.

• DifferenSate the types of Sssue flaps and understand the physiological response to these procedures.

•  Employ proper monitoring techniques when mobilizing paSents following flap reconstrucSon.

• Apply evidence based knowledge to make recommendaSons regarding appropriate acSvity progression.

Course Outline

•  Skin Gra:s •  Types of GraQs •  Phases of healing •  Reasons for failure •  IdenSficaSon of healthy and non-‐healing graQs using photos

•  Post-‐operaSve care •  TradiSonal •  Review of evidence •  Proposed pracSce guidelines

•  Use of negaSve pressure wound therapy

•  Flaps •  Types of flaps •  Post-‐operaSve care •  Clinical signs of a failing flap •  Methods for monitoring •  Review of evidence related to mobilizaSon

•  Clinical applicaFon with case scenarios and discussion

•  Areas that need further research CSM 2014

Evidence is changing culture…

•  Clinical trials of early mobilizaSon criScally ill paSents. Kress JP. Crit Care Med. 2009 Oct; 37(10 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.

•  EffecSveness of an early mobilizaSon protocol in a trauma and burns intensive care unit: a 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 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 JA, et al. Crit Care Nurs Q. 2013 Jan-‐Mar;36(1):109-‐19.

•  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.

•  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 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 Intern Med. 2010 November 22; 170(21): 1942-‐1943.

Vision Statement: “Acute care physical therapy is provided by physical therapists who:

• As integral members of the health care team, are consulted for their experSse in paSent management and clinical decision making for paSents with acute health care needs.

• May be board-‐cerSfied specialists in acute care physical therapy. • May be assisted, in a team relaSonship, by physical therapist assistants, who may be recognized for advanced proficiency.

The Acute Care SecSon of the American Physical Therapy AssociaSon is recognized as the expert resource for the provision of evidence-‐based acute care physical therapy.”

hmp://www.acutept.org

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How do we know…

• When a paSent should get up? •  If he/she should walk? Weight bear? Wear compression? • What the appropriate level and type of acSvity is?

… and who decides?

Types of Gra:s

Gra: DescripFon AutograQ PaSent’s own skin taken

Split-‐thickness skin graQ AutograQ consisSng of epidermis and a porSon of the dermis

Full-‐thickness skin graQ AutograQ consisSng of epidermis and the enSre dermis

Mesh graQ AutograQ placed through a mesher to provide more surface area

Sheet graQ AutograQ without meshing

AllograQ GraQ from same species

XenograQ Temporary graQ of porcine skin

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

1.   ImbibiFon • GraQ survives by diffusion of nutrients from the wound bed

•  Fibrin deposiSon 2.   NeovascularizaFon

• New vessels invade the graQ by angiogenesis 3.   MaturaFon

• New collagen bridges form between the wound bed and graQ

Why Gra:s Fail…

• FormaSon of hematoma or seroma • InfecSon • Incomplete excision of nonviable Sssue • Shearing or trauma to the graQ site

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When to mobilize? The quesFon of WHEN to safely mobilize a:er skin gra:ing has been asked for MANY years… 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 may be safe

•  “The early ambula-on of pa-ents with lower limb gra7s” (Bodenham & Watson 1971)

•  “A technic of lower extremity mesh gra7ing with early ambula-on" (Golden, Power, & Skinner, et al 1977)

•  “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

TradiFonal Post-‐operaFve Care

• ImmobilizaFon for 5 days • Bedrest • No ROM of joints which new graQ crosses • Bolster dressing that is removed on POD 3-‐5

• Resume ROM and mobility on POD 5

What the evidence says… “Immediate AmbulaFon of PaFents with Lower Extremity Gra:s”

•  RetrospecSve study •  Splints used if the graQ crossed a joint •  PaSents encouraged to walk once recovered from the anestheSc •  Average skin graQ take: 96.4% •  Average Sme unSl able to ambulate 30 feet independently: 1.7 days

Burnsworth B, Drob MJ, Langer-‐Schnepp M. Immediate ambulaSon of paSents with lower-‐extremity graQs. J Burn Care Rehabil. 1992; 13: 89-‐92.

More evidence… “Effect of early and late mobilisaFon on split skin gra: outcome”

•  RetrospecSve study of various populaSons requiring lower extremity graQs •  PaSents straSfied into two groups:

•  Early mobilisaSon (0-‐3 days bedrest) & Late mobilisaSon (≥ 4 days bedrest)

•  No significant difference in the healing rate: •  EM had 88% healing rate •  LM had 91% healing rate

•  No significant difference in rates of gra: loss, infecFon, hematoma, hypergranulaFon •  Significantly higher rate of decondiFoning in LM group •  Significantly different post-‐op length of stay:

•  EM 3.92 days •  LM 7.96 days

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 “The consistent finding in the literature is that early ambulaSon can be safely iniSated aQer lower extremity skin graQing without compromising graQ take if external compression is applied”

“No studies of any paSent populaSon have concluded that early ambulaSon compromises graQ take”

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

Proposed PracFce Guidelines •  “An early postoperaFve ambulaFon protocol should be iniFated immediately, or as soon as possible, a:er lower extremity gra:ing unless any exclusion criteria are encountered.”

•  “External compression must be applied before ambulaFon.”

•  “If the gra: crosses a joint, the joint should be immobilized conFnuously unFl the first dressing change.”


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2

PracFce Guidelines for Early AmbulaFon of Burn Survivors a:er Lower Extremity Gra:s. Nedelec, Bernademe; Serghiou, Michael; OTR, MBA; Niszczak, Jonathan; MS, OTR; McMahon, Margaret; Healey, Tanja Journal of Burn Care & Research. 33(3):319-‐329, May/June 2012. DOI: 10.1097/BCR.0b013e31823359d9

Figure 1 . Algorithm for early ambulation of lower extremity grafts.


NegaFve Pressure Wound Therapy •  Foam dressing conforms to the wound by addiSon of negaSve pressure

• Promotes skin graQ adherence by removal of exudate

Evidence “RetrospecFve evaluaFon of clinical outcomes in subjects with split-‐thickness skin gra:: comparing V.A.C. therapy and convenFonal therapy…”

•  RetrospecSve review of 142 paSents who underwent LE STSG; either convenSonal dressings (CT) or V.A.C. therapy (NPWT) used post operaSvely

•  Significantly greater percentage of gra: take at first follow-‐up, maximal gra: take, and gra: acceptance for the NPWT group •  95 ± 9%, 96 ± 9%, 97% for NPWT respecSvely •  86 ± 23% , 83 ± 33%, 84% for CT respecSvely

•  Significantly fewer repeated STSGs required for the NPWT group •  3.5% for NPWT •  15% for CT

Blume PA, Key JJ, Thakor P, Thakor S, Sumprio B. RetrospecSve evaluaSon of clinical outcomes 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.

More Evidence… “EffecFveness of NegaFve Pressure Closure in the IntegraFon of Split Thickness Skin Gra:s”

•  Randomized controlled trial of 60 paSents requiring STSG aQer burn injury; Randomized into two groups: NegaSve pressure closure, Control group

•  Significantly less gra: loss (median) in the NPC group:

•  0.0 cm², 0.0% in NPC group •  4.5 cm², 12.8% in the control group

•  Significantly shorter length of hospital stay (median) in the NPC group: •  13.5 days in NPC group •  17 days in control group

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.

Clinical Take-‐Aways for Skin Gra:s

•  Shearing of the skin gra: should be avoided •  No ROM if a graQ crosses a joint unSl POD 5

•  Edema puts a gra: at risk poor adherence •  Elevate extremiSes at rest •  Use compression

•  Evidence supports early ambulaFon with skin gra:ing •  Use of a wound VAC over a gra: helps prevent shearing and promotes adherence of the skin gra: •  Facilitates mobility •  SplinSng should sSll be considered

•  Collaborate with surgical team to advocate for a mobility plan with which all parFes agree

Flaps

• Component parts •  Fasciocutaneous •  Musculocutaneous •  Osseocutaneous

• Nature of the blood supply •  Random •  Axial

•  The movement placed on the flap •  Advancement •  Pivot •  TransposiSon

• RelaFonship to the defect •  Local •  Regional •  Distant

A flap is a unit of skin, underlying Sssue, and blood supply transferred from a donor to a recipient site.

Can be classified by:

CSM 2014

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Distant Flaps 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

Gastrocnemius Muscle Flap

www.microsurgeon.org/gastroc

CSM 2014

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

LaFssimus Dorsi Muscle Flap

hmp://www.microsurgeon.org/laSssimus

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

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.

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Clinical Signs of a Failing Flap

Signs of arterial insufficiency

•  Pale or momled flap color •  ReducSon in flap temperature •  Loss of capillary refill (>2 sec) •  Loss of flap turgor

Signs of venous insufficiency •  Purple, blue, or dusky discoloraSon

•  CongesSon •  Swelling •  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 •  Clinical observaSon •  Pinprick tesSng •  Surface temperature monitoring •  Hand-‐held Doppler ultrasonography •  Implantable Doppler •  Pulse oximetry •  Laser Doppler •  Tissue pH •  Photography


Hand-‐held Doppler Probe

• Most common method of monitoring

• Must be sure to detect the flap’s vascular pedicle rather than the recipient vessel.


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Implantable Doppler Monitoring

hmp://www.microsurgeon.org/monitoring

hmp://www.cookmedical.com

Doppler Video

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

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ViopFx Monitoring

• Noninvasive • Measures the scamering and absorpSon of near-‐infrared light

•  The raSo of oxyhemoglobin and deoxyhemoglobin provides real Sme measurement of the Sssue’s oxygenaSon.

•  SensiSvity is also displayed

hmp://www.viopSx.com/docs/applicaSons/plasSc_surgery.asp

CSM 2014

Blood Supply •  MacrocirculaSon •  MicrocirculaSon

•  Arterial inflow supplies nutrients and oxygen to Sssue •  Venous ouylow removes carbon dioxide and waste

•  Systemic regulaSon of blood flow is mediated by: •  Neural receptors

•  α-‐adrenergic, β-‐adrenergic, serotonergic •  Humoral substances

•  Norepinephrine, epinephrine, serotonin, histamine, prostaglandins

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

Blood Flow with ElevaFon • With elevaSon, sympatheSc nerves and inflow vessels are divided.

• Blood blow is only 20% of normal in the distal end of a pedicled flap within 6-‐12 hours.

•  In 1-‐2 weeks, 75% of normal flow is recovered. •  In 3-‐4 weeks, flow returns to 100%. • NeovascularizaSon can sustain a flap from days 3-‐10 post operaSvely, even aQer arterial occlusion

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

CSM 2014

Mobilizing A:er a Flap

• Gravity contributes to increased capillary pressure and increased fluid leaking into the intersSSum

•  Edema can lead to increased venous congesSon of the flap

• Distal flap necrosis is due to venous stasis • Venous drainage is imperaSve to flap survival

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

CSM 2014

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

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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RecommendaFons, conFnued

• Two approaches for compression are proposed:

•  The extremity should be wrapped with each dangling

OR

•  Compressive wrap should not be placed unSl the wound is mature and the paSent is toleraSng dangling


RecommendaFons, conFnued

• Assess flap before and aQer dangling/wrapping • Weight bearing

•  Per orthopedics if there is a fracture •  If no fracture, begin weight bearing when wound is mature and paSent tolerates dangling 30 minutes 6 Smes per day

• Discharge paSent when paSent tolerates dangling with a good understanding of flap assessment (2-‐3 weeks)


Tissue OxygenaFon with Free Flap Dangling

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.

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

Clinical Take-‐Aways for Flaps •  Familiarize yourself with the surgical procedure and what structures were involved.

•  Consider the implicaSon of acSvity on the viability of the flap and advocate for the appropriate progression.

•  Be sure to monitor the flap, communicate with the team, and document!

• Weightbearing is usually less of an issue than limb dependency is.

•  Avoid exercise or acSvity that will shunt blood away from the flap for prolonged periods.

http://acrazykindoffaith.blogspot.com/

Case Scenario 1 52 year old female sustained deep parSal thickness burn to R anterior lower leg, dorsum of foot and toes while lighSng a wood burning stove •  Burn is < 5% TBSA •  No inhalaSon Injury •  Underwent mulSple surgeries for debridement of LE •  UlSmately underwent meshed STSG to the anterior lower leg and dorsum of foot

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Case Scenario 1 • What needs to be considered in this case prior to iniSaSng mobilizaSon?

• When would it be appropriate for her to mobilize?

• What kind of weight bearing would be appropriate?

Case Scenario 2 48 year old male s/p fall from a ladder in which he sustained a comminuted distal Sb/ fib fracture. •  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 •  Hospital day 4: PT evaluaSon

What precauSons would you anScipate? What would his iniSal mobility goals include?

Case 2, conFnued •  Hospital day 7: Returned to OR for I&D, removal of ex fix, ORIF, anterolateral thigh free flap to leQ ankle

•  Hospital day 8: Returned to OR for failing free flap. Underwent redo of the arterial anastomosis and venous ouylow reestablished with bypass using contralateral saphenous vein.

•  Hospital day 14: Returned to OR for re-‐inset of flap and STSG. •  Hospital day 19: PT reevaluaSon

What precauSons would you anScipate? How should his physical therapy goals be updated?

Case 2, conFnued •  Actual post-‐operaSve instrucSons:

NWB L LE Dangle x5 minutes, three Smes daily Ace wrap lower leg and foot prior to dangle and remove aQer Monitor cook signal, foot color, DP, PT pulse with dangle

•  Goals •  Progression of dangling •  ConsideraSons for discharge planning

Case Scenario 3 63 year old male with history of craniotomy for oligodendroglioma in 1999. •  Developed infecSon and exposed hardware and underwent mulSple surgeries, followed by management with a wound vac.

•  Underwent cranioplasty with removal of infected Stanium mesh and reconstrucSon with new Stanium mesh, screws, and coverage with a free laSssimus dorsi flap and split thickness skin graQ. •  Hospital day 2: PT consult

•  Dark red bloody drainage noted with mobilizaSon

What precauSons should be followed? Special consideraSons for monitoring?

Case 3, conFnued •  Hospital day 4: Returned to OR for debridement for failed laSssimus dorsi muscle flap/ I&D, free rectus myocutaneous microvascular free flap and STSG.

•  Hospital day 10: PT re-‐consulted •  Purulent drainage noted with mobilizaSon •  Returned to OR for removal of mesh cranioplasty from R parietal region, I&D, Vac placement

•  Hospital day 12: Returned to OR for vac change, debridement of muscle flap, and closure of anterior scalp wound.

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Areas for Further Research…

•  Use of assisSve device aQer graQing •  MobilizaSon with the use of a wound VAC over graQs •  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

QuesFons and comments…. [email protected]

[email protected]

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.

Documents

Management of Grafts and Flaps Handout - c.ymcdn.com · • Randomized&controlled&trial&of&60&paents&requiring&STSG&aer&burn&injury;& Randomized&into&two&groups:&Negave&pressure&closure,&Control&group&