Orthoplastic surgery is a multidisciplinary approach that combines orthopedic and plastic surgery principles to treat complex musculoskeletal problems. An example of this is limb salvage, where both soft tissue and bone are involved. Here are some examples for which Orthoplastic Surgery may be needed:
Mohs Reconstruction
After MOHS surgery to remove skin cancers, a soft tissue defect results. The reconstruction is sometimes performed by the dermatologist performing the MOHS surgery. Alternatively, depending on location and complexity of the defect, a plastic surgeon may be asked to help with the reconstruction.
Dr. Sammy’s sister, Dr. Emmilia Dowlatshahi, is a fellowship trained MOHS surgeon in Amsterdam, in the Netherlands. They often will discuss reconstructive options and nuances of the procedures, to improve the overall functional and aesthetic appeal of the final result.
As a microsurgeon, Dr. Sammy is particularly interested in MOHS reconstruction since it requires a certain degree of creativity, thorough pre-surgical planning, and atraumatic surgical technique to achieve a satisfactory result.
Skin cancer, including melanoma as well as non-melanoma (SCC, Squamous Cell Carcinoma, BCC Basal Cell Carcinoma).
These skin cancers can be indolent meaning they don't cause any significant pain or discomfort which is why getting regular skin checks by a dermatologist is critical in detecting these skin cancers early. After the MOHS procedure, where the skin cancer is removed, the resulting wound or defect can be variable, depending on the location of the skin cancer.
Visual examination of the resulting defect allows Dr. Dowlatshahi to formulate a surgical plan for reconstruction. Physical examination, with a particular regard for the pliability of the surrounding skin, will provide important information as to the reconstructive techniques that will be feasible.
Reconstructive Microsurgery
Reconstructive microsurgery is a dedicated surgical discipline which uses precision instruments, atraumatic surgical technique and a dedicated operating microscope to repair and reconstruct tissues from head to toe. Microsurgery is one of the main pillars of plastic surgery but is now gaining traction in other surgical disciplines as well. Every plastic surgeon undergoes microsurgical training during residency, but some surgeons choose to undergo additional training in microsurgery during a dedicated fellowship.
Microsurgical reconstruction is one of the most powerful tools in reconstructive surgery since it allows surgeons for the first time to truly replace “like with like” by transplanting tissues from one body part to another. This is done by dissecting out blocks of tissue (which can include skin, fat, nerve, muscle, tendon, bone, lymphatics, fascia), moving them to another body part, and individually reattaching the structures, including the artery and veins that provide blood flow to the transplanted part.
The field of kidney transplantation was pioneered by a plastic surgeon, Dr. Murray, who was awarded the Nobel Prize. Few are aware that the entire field of organ transplantation owes credit to this remarkable plastic surgeon who was applying microsurgical techniques to a then unsolved problem.
Today, microsurgery is used by many plastic surgeons to perform free tissue transfer (called “free flap” in surgical jargon) for reconstruction of:
-head and neck cancers
-congenital anomalies
-trauma reconstruction of the extremities
-nerve repair
-reattachment of body parts (replantation)
-breast reconstruction
-wound reconstruction
-toe to hand transfer
-vascularized bone transfer for bone nonunions or defects around the body.
Problems that require microsurgical reconstruction span from head to toe and can be associated with pain, open wounds, areas of numbness, segmental bone loss, skeletal instability, unstable scar, and lack of tissue.
In preparation for a microsurgical procedure, a thorough physical examination of the diseased body part is carried out to define exactly what tissues are required, but also of potential tissue donor areas that will be used to take the tissues that are needed to complete the reconstruction.
Dr. Dowlatshahi routinely uses ultrasound technology to guide this aspect of the physical examination, especially to locate blood vessels and nerves and measure blood flow to nake the operation more expedient and predictable. Furthermore, xrays and CT scans are necessary if bony reconstruction is required. MRI can help obtain more detailed information regarding the soft tissues at the donor or recipient site. On occasion, angiograms (which are blood vessel studies) are necessary to map out the blood vessel anatomy and can be done with CT or MRI technology, but also the conventional way which is by injecting contrast dye into the blood vessels and taking pictures with xray. Dr. Dowlatshahi collaborates with radiologists, interventional radiologists and cardiologists, as well as vascular surgeons to obtain the necessary information required to complete the reconstruction successfully.
Vascularized Bone Grafts
Vascularized bone grafts are when we take a segment of bone from one part of the body and transfer it to another, while maintaining the blood supply (artery and vein).
Bone loss can be due to infection, trauma, radiation, cancer, avascular necrosis, or various types of fracture nonunions. The bone involved can be as small as the lunate in the wrist, to the large pelvic bones, or long bones such as the humerus, femur or tibia.
In the case of a non-healing fracture (“nonunion”) there can be pain, swelling and instability. Cases of avascular necrosis often present with swelling, pain and restricted motion at the affected joint. In the setting of infection, a draining wound or sinus can be present.
Physical examination is important to assess the surrounding soft tissues, their pliability, associated wounds, radiation damage, presence of infection. If the involved body part is an extremity, a thorough pulse exam is essential. The sensation of the affected extremity will help guide the decision making as well. Xrays are part of the basic evaluation. Advanced imaging such as MRI and CT scan are often required to better understand the skeletal anatomy and soft tissue envelope.
Wound Complications After Achilles Tendon Repair
Due to the lack of blood supply in this area and the thin soft tissues covering the achilles tendon, wound complications in this area are common after procedures on the achilles tendon, especially if large permanent braided sutures are utilized. Dr. Dowlatshahi is frequently asked to see patients with wound issues after achilles repairs or reconstructions.
Risk factors are age, diabetes, smoking status, and immunocompromised patients. A breach in sterile technique, or incision breakdown can lead to colonization of the braided suture material and subsequent infection. Clearing infection from this suture material is very difficult, even with strong antibiotics and good wound care.
Continued drainage and swelling, as well as pain and discomfort at the achilles tendon repair site. The incision is often open, with one or more draining sinuses. Repeated bouts of drainage and infection often occur, requiring antibiotic treatment.
When a wound complication occurs, it is important to assess the soft tissues carefully and understand what the original injury was, and the specifics of how it was treated. If bone anchors are used, the patient must be assessed for signs for bone infection called osteomyelitis. An MRI or CT scan can be helpful.
