10/01/2020
(a day late)
I often hear that some areas, especially legs, are “too tight” to close after surgery.
It’s true, that many leg wounds after are left to heal by or granulation. I often offer this to our athletic patients with small defects they can’t commit to taking 2-3 weeks off from exercise. Stitches can pop with even light exercise.
However, for patients that prefer reconstruction, due to not wanting an open area, lack of wound care, or want it to heal faster, I offer closure.
Legs are notoriously tight, have thin tissue, poor vascularity for healing (far away from heart), poor return blood flow (spider veins), and have lots of gravitational pressure from standing.
Outside of my favorite flap for extremely tight legs or large defects to the fascia, muscle, or bone, is the Keystone Flap.
This flap is designed as moving a large base from the muscle (myocutaneous) in one direction. Then the edges are “sewn” out to even the tension forces or vectors. However, over time, I learned that using only top stitches and freeing tissue up in the deep fat allows much quicker closure for the patient, with less cutting, and sane aesthetic and functional outcome!
I teach my fellows and residents that if you want to close a large leg defect, proper planning and undermining of tissue will allow you to close almost any defect. If needed, a second Keystone flap from the opposite side can help close it.
Getting experience and comfort with these difficult defects allows a to be ready for any defect and give patients the most options!
.college
