Lower Extremity Reconstruction & Amputation Care

Complex lower extremity wounds — from traumatic injuries and failed prior surgeries to chronic non-healing wounds and cancer resections — require a surgeon with expertise in microsurgery and reconstructive planning. Dr. Lakhiani provides the full spectrum of lower extremity reconstruction, from limb salvage to amputation optimization.

Free Tissue Transfer (Free Flap Reconstruction)

Free tissue transfer — also called free flap surgery — is the cornerstone of complex lower extremity reconstruction. It involves transplanting tissue (skin, muscle, fat, bone, or a combination) from one part of the body to the wound site, reconnecting the blood vessels using microsurgical technique under a surgical microscope.

Common free flap options for lower extremity reconstruction include:

• Anterolateral thigh (ALT) flap: A versatile flap that provides skin and soft tissue for coverage of large defects, particularly around the knee and proximal leg
• Gracilis muscle flap: A small, reliable muscle that can fill dead space and provide well-vascularized tissue for wound healing, especially useful for smaller defects
• Latissimus dorsi flap: A large muscle flap for coverage of very extensive wounds, often used with a skin graft
• Fibula free flap: Provides vascularized bone for segmental bone defects, combined with skin for soft tissue coverage
• Medial sural artery perforator (MSAP) flap: A thin, pliable option for moderate-sized defects, particularly useful around the ankle and foot

Limb Salvage

Limb salvage is the attempt to preserve a limb that might otherwise require amputation. Dr. Lakhiani approaches limb salvage as a collaborative effort with orthopedic surgeons, vascular surgeons, and infectious disease specialists. Indications include:

• Open fractures: Gustilo type IIIB and IIIC fractures with significant soft tissue loss
• Chronic non-healing wounds: Wounds that have failed conservative treatment, including diabetic foot ulcers with exposed bone or hardware
• Post-traumatic bone defects: Segmental bone loss requiring vascularized bone transfer
• Infected hardware: Wounds with exposed orthopedic hardware that require soft tissue coverage after debridement
• Oncologic defects: Soft tissue and bone defects after tumor resection in the lower extremity

Limb Salvage vs. Amputation Decision-Making

The decision between limb salvage and amputation is one of the most consequential in orthoplastic surgery. Dr. Lakhiani believes this decision should be made collaboratively with the patient, weighing:

• The realistic functional outcome of salvage — will the limb be weight-bearing and useful?
• The number of additional surgeries required for salvage
• The patient's overall health and ability to tolerate prolonged reconstruction
• The potential quality of life with a well-optimized amputation and modern prosthetics
• The patient's personal goals, occupation, and preferences

In some cases, a well-performed amputation with TMR and a modern prosthesis provides a better functional outcome and quality of life than a salvaged but painful, stiff, or nonfunctional limb.

Amputation Care & Stump Revision

For patients who undergo amputation — or those with existing amputations experiencing complications — Dr. Lakhiani provides comprehensive amputation care:

Stump Revision

Patients with painful, poorly fitting, or non-functional stumps may benefit from revision surgery. Common indications include:

• Painful neuromas at the stump end
• Bony overgrowth or prominent bone causing skin breakdown
• Inadequate soft tissue padding
• Unstable soft tissue coverage (recurrent skin breakdown)
• Prosthetic fitting difficulties due to stump shape or soft tissue problems

Targeted Muscle Reinnervation (TMR)

TMR is a surgical technique that transfers the severed nerves in an amputated limb to nearby motor nerve branches and their target muscles. This serves two critical purposes:

• Neuroma prevention and treatment: By providing the cut nerve with a target to regenerate into, TMR dramatically reduces the incidence of painful neuromas — one of the most common and debilitating complications of amputation
• Improved prosthetic control: The reinnervated muscles generate EMG signals that can be used to control advanced myoelectric prostheses, enabling more intuitive and natural prosthetic movement

TMR can be performed at the time of initial amputation (when possible) or as a secondary procedure for patients with established neuromas or who wish to improve prosthetic control.

Regenerative Peripheral Nerve Interface (RPNI)

RPNI is a complementary technique to TMR in which a small piece of muscle graft is wrapped around the end of a severed nerve. The nerve regenerates into this muscle graft, which serves as a biological target to prevent neuroma formation. Key advantages of RPNI include:

• Can be performed on multiple nerves simultaneously
• Does not require sacrifice of a motor nerve branch (unlike TMR)
• Can be combined with TMR for a comprehensive neuroma prevention strategy
• Each RPNI can serve as an independent signal source for advanced prosthetic control

Prosthetic Optimization

The goal of modern amputation surgery is not just wound healing — it is creating a residual limb that interfaces optimally with a prosthesis for the best possible function. Dr. Lakhiani works closely with prosthetists and rehabilitation specialists to ensure that surgical decisions support long-term prosthetic success. This includes attention to:

• Appropriate bone length and contouring
• Adequate and durable soft tissue padding
• Neuroma prevention (TMR/RPNI)
• Myodesis (muscle attachment to bone) for stable, functional muscle
• Skin coverage that can tolerate the mechanical demands of a prosthetic socket

The Lower Extremity Salvage & Amputee Clinic

Dr. Lakhiani directs the Lower Extremity Salvage & Amputee Clinic, a multidisciplinary program that brings together all the specialists needed for comprehensive limb reconstruction and amputation care under one roof:

• Plastic/reconstructive surgery — free flap reconstruction, stump revision, TMR, RPNI
• Orthopedic surgery — fracture management, bone reconstruction, joint salvage
• Prosthetics — custom prosthetic fitting, advanced myoelectric devices
• Physical therapy & rehabilitation — gait training, strengthening, functional recovery
• Pain management — addressing phantom limb pain, residual limb pain, and neuroma pain

This collaborative approach ensures that patients receive coordinated care from the initial injury or decision point through full functional recovery.