Plastic surgeons are now involved in treating diabetic foot patients to prevent limb amputation. About 50% of all limb amputations in the US are due to diabetes. New understanding of diabetes in the foot allows plastic and vascular surgeons to perform bypass procedures and reconstructive surgery to save limbs. The pathophysiology of diabetic foot ulcers involves peripheral neuropathy, peripheral vascular disease, hemorheologic abnormalities, and immune system impairment. Plastic surgeons work to reconstruct weight and non-weight bearing areas of the foot through various procedures to further prevent amputation.

1. Plastic Surgery
of the diabetic foot
a new challenge for the
reconstructive microsurgeon
Dr. Hussein S. Abulhassan
Professor of Plastic Surgery
Alexandria University

6.  Plastic surgeons have been recently
involved in the care of a new group of
patients’ population who were before
facing the ultimate fate of below or
above the knee limb amputation.
 This new group of patients are the
results of the excellent work of the
general and vascular surgeons along
with the refined work of diabetologists.
 It was estimated that out of all limb
amputations performed in USA 50 %
were in diabetic population.

7. New understanding of the
pathophysiology of diabetes in the
foot and lower extremity has
enabled the vascular surgeons and
the plastic surgeons to attack
these hopeless cases and perform
bypass procedures like
femorotibial or femeropedal
anastomoses.

8. Pathophysiology of diabetic ulceration
 In addition to the metabolic
consequences of diabetes and the
problems of the wound healing and
increased suscibtibility to infections.
 The pathophysiology of diabetic foot
ulcveration can be divided into
4 major areas:
Peripheral neuropathy
Peripheral vascular disease
Haemorreologic abnormalities
Immune system impairment

9. Peripheral neuropathy
Involvement of autonomic N.S.
Involvement of sensory nerves of
the foot.
Involvement of motor nerves of
small muscles of the foot.
Charcot’s bony changes.

10. Aetiology of peripheral
ulceropathy
Complex.
Autoimmune mechanism and
microvascular mechanism.
Segmental demyelination.
Role of double crush phenomenon.

11. Tarsal Tunnel Compression

12. Loss of ability to feel
pain or pressure
Abnormal pressure
points of the foot
Anhydrosis,
hyperkeratosis,
callus formation over
insesate areas
Hemorrhage
Fissures
Bacterial Localisation
Infection
Ulcer formation
 Hyperglycemia
 Low immune
modualtion
 Poor vision

13. Vascular Disease
 Two misconceptions in diabetic
foot:
1. Foot problems are due to
small-vessel disease.
2. Ischemic ulcers can occur in the
presence of normal pedal pulse.

14. Hemorheology
Alterations in blood flow 2ry to
serum viscosity and decreased
RBCs deformability.
Platelet aggregations, RBC
aggregations and increased
fibrinogen levels.

15. Immune Deficiency
Polymorphonuclear cell dysfunction.
Opsonization.
T-cell response, phagocytosis.

16. Management
Preoperative evaluation
Revascularization versus amputation.
Wound management.

17. Soft tissue reconstruction
Management of weight bearing
areas of foot.
Metatarsal heads
I- Weight Bearing Areas

21. Levels of foot amputations

22. Levels of toe amputations

26. Soft tissue reconstruction
Management of weight bearing
areas of foot.
The heel defects

35. II- Non-weight Bearing Areas
A. Forefoot
B. Instep region
C. Achilis region.

40. Adjuvant plastic surgery
procedures
Vascular reconstruction.
Tarsal tunnel release.
Bone management.
Tendon arrangement.

41. The Future