in Dallas, TX
Plastic surgeons, Dr. Duffy and Dr. McKane of Dallas, have the unique ability to address chronic and acute wounds, congenital problems, and acquired problems such as burns, traumatic injuries, or defects following cancer. Open wounds or defects from a cancer operation or radiation therapy are challenges that plastic surgeons are specially trained to deal with. We strive to utilize the simplest approach possible, but sometimes that approach, by necessity, is very complicated and requires extensive surgery. Often, the surgery required is done in multiple stages. Sometimes plastic surgeons are involved before the defect is present, such as when a woman is scheduled to undergo a mastectomy and wants immediate breast reconstruction. In other situations, in which they were already consulted, wounds were already present following radiation treatment, underlying bone infection, or trauma.
The unique challenge to plastic surgeons is to get these wounds covered in a stable and durable fashion. Plastic surgery involvement often results in the preservation of limbs, function, and occasionally, even the patient’s life. Since each wound and patient are different, there are many techniques that are used to address these varied situations. The approach that is needed is a function of what has caused the wound, where the wound is, and the overall health status of the patient.
Skin grafts are used extensively in the reconstruction of burns and may be split thickness or full thickness. The donor site will heal on its own when a split thickness graft is taken since this procedure includes using the epidermis and part of the dermis. When a full thickness graft is taken, the donor site must be closed at the time of surgery since the epidermis and the entire thickness of the dermis are used. The type of graft taken is a function of where the wound is located and how large it is. In the majority of cases, skin grafts are successful and heal well. In rare instances, healing doesn’t occur properly and a grafting procedure might have to be repeated. It’s important to follow the surgeon’s post-care instructions to ensure a successful surgery.
Tissue expansion is a procedure that allows for the body to grow extra skin by stretching the adjacent skin. A balloon-like device, called an expander, is inserted near the defect or lesion that will need to be excised and then the expander is gradually expanded with salt water over the course of multiple office visits. In the last stage of the procedure, the expander is removed and the stretched skin is used to cover the defect. Tissue expansion offers distinct advantages such as:
- The new skin will almost perfectly match the surrounding skin’s color and texture.
- Since the skin is still connected to the same blood and nerve supply, there is less of a possibility of it being rejected and dying off.
- Since tissue expansion doesn’t involve moving skin from one site to another, scars are significantly less visible.
However, tissue expansion can be a lengthy process since it takes a significant amount of time to grow new skin. In some cases, the process can take up to 4 months or longer.
Skin or Muscle Flaps
If there is underlying bone, nerve, or tendon exposed, then a skin graft will be inadequate and skin or muscle flaps may be needed to reconstruct this wound. Skin flaps or muscle flaps allow for more durable reconstruction. A “flap” is typically a combination of muscle, fat, and skin tissues that are taken from the patient’s own body. These flaps are typically used when there is exposed bone following orthopedic procedures or infections following heart bypass surgery. Rotation of a muscle into a wound results in better healing and the ability of antibiotics to bathe the exposed bone if it is infected. Since the tissues come from the patient, the procedure is safer and more reliable, as compared to using foreign materials.
Microsurgery allows transplantation of tissues from one part of the body to another to address complex defects such as exposed bones, tendons, or nerves. Dr. Duffy and Dr. McKane use microsurgery to reconstruct the breast, wounds of the lower extremities, the head and neck, and following burns or other types of injuries such as radiation skin damage. This type of surgery is complicated and lengthy and is usually a last resort in treating these difficult wounds. Specialized microscopes and precision instruments are used to perform detailed and meticulous operations on small parts of the body. Most plastic surgeons do not do microsurgery on a regular basis, but Dr. Duffy and Dr. McKane do a very high volume and it is a significant part of their practice.
Perforator flaps are a new approach that have been developed in microsurgery over the last 5 – 10 years. These flaps use the arteries and veins that run through the underlying muscles to get to the skin and fat that are the main building block of a complicated reconstruction. Perforator flaps allow for the reconstruction of many body parts without the harvest of underlying muscle, thereby minimizing postoperative pain and loss of function. A large part of Dr. Duffy’s and Dr. McKane’s practice involves microsurgery and perforator flaps. These flaps offer a significant improvement in donor site complications when microsurgery is needed and have greatly changed the way microsurgery is practiced.
Flaps for Myelomeningoceles
Myelomeningoceles are congenital neural tube defects that result in an open spinal cord, paraplegia, and wound healing problems of the lower back in newborns. The backbone and spinal canal don’t fully close prior to birth. Immediately after birth, pediatric neurosurgeons close the neural tube defect and if the skin defect is large, a plastic surgeon is called in to assist with the closing of this defect. Dallas plastic surgeon, Dr. Duffy, has recently developed a new approach to close up large myelomeningocele skin defects.
Dr. Duffy has utilized an approach of removing a flap of tissue from the child’s buttocks region to rotate into the defect. This island of tissue is supplied by perforating arteries from the gluteus maximus muscle. Little or no muscle is taken with the flap, thereby maintaining function of the gluteus maximus muscle, which might be important in the future for getting out of a wheelchair or preventing hip dislocations.
Six patients have been operated on to date with complete survival of the flaps in each patient and successful closure of the defect in each patient. This approach may lead to decreased problems with unstable scarring in the area, as well as diminished rates of infection in these children who often need to have shunts in place to treat underlying hydrocephalus.
This is an exciting new approach to a difficult problem and Dr. Duffy and his pediatric neurosurgical colleagues will be publishing their results over the next year or so. Once these results are published, that publication will be noted on the website. Additional information about the procedure, in the meantime, can be obtained by contacting Dr. Duffy’s office or emailing him at: [email protected].
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A large part of Dr. Duffy’s and Dr. McKane’s practice is reconstructive surgery. They operate on a wide variety of patients of different ages and problems and this variety is one of the wonderful things about plastic surgery that they love. They are often asked to evaluate chronic or difficult wounds and derive a great deal of satisfaction from getting these wounds closed definitively. There are a number of techniques and approaches that may be used that these surgeons utilize for better results. Since each patient is different, the initial consultation for a wound will require the surgeon to get to know the patient, their overall health, conditions that might impact their ability to heal, what the wound is like, where it is located, and what the patient’s own individual goals are. Please contact our office today to schedule a consultation.Contact Us