NSW Plastic Nurses Association 2012Flaps and Grafts

Graft

VS

Flap

What is the

difference?

Reconstructive ladder

• Rung 1: Healing by secondary intention

• Rung 2: Primary closure• Rung 3: Delayed

primary closure• Rung 4: Split thickness

graft• Rung 5: FTSG • Rung 6: tissue

expansion • Rung 7: Random flap • Rung 8: Axial flap • Rung 9: Free Flap

Reconstructive Elevator

• Get off at the right level

Anatomy of Circulation

• The blood reaching the skin originates from deep vessels

• These then feed interconnecting perforator vessels which supply the vascular plexus

• Thus skin fundamentally perfused by musculocutaneous or septocutaneous perforators

Nahai-Mathes Classification

Anatomy of Circulation

• The vascular plexuses of the fascia, subcutaneous tissue and skin are divided into 6 layers

Anatomy of Circulation

1)Subfascial plexussmall plexus lying on the undersurface of the fascia

Anatomy of Circulation

2) Prefascial plexus-a larger plexus-particularly prominent on the limbs-fasciocutaneous vessels

Anatomy of Circulation

3)Subcutaneous Plexus-lies at the level of superficial fascia-Predominant on the torso-musculocutaneous vessels

Anatomy of Circulation

4)Subdermal Plexus-receives blood from underlying plexus-the main plexus supplying blood to the skin-represents the dermal bleed observed in incised skin

Anatomy of Circulation

5) Dermal Plexus-mainly arterioles-important in thermoregulation

Anatomy of Circulation

6)Subepidermal Plexus-contains small vessels without muscle in the walls-nutritive and thermoregulatory function

SKIN: Anatomy

SKIN: Anatomy

Skin Grafts: Classification

• Full thickness skin grafts:- epidermis & full thickness of dermis

• Split skin graft: - epidermis & a variable proportion of dermis- thin, intermediate or thick

Skin Grafts: SSG

SKIN: Anatomy

SKIN: Anatomy

Skin Grafts: “Process of Take”

• Vascularity of donor site• Tolerance to ischaemia• Metabolic activity of the graft

Skin Grafts: “Process of Take”

• 4 Phases:– Fibrin adhesion– Plasmatic imbibition– Revascularization: Inosculation & capillary

ingrowth– Remodelling: Revascularization & fibrous

attachment in restoring normal histological architecture

Skin Grafts: “Process of Take”

• Plasmatic Imbibition:– Initially graft ischaemic (24 – 48 hrs)– Fibrin adhesion– Imbibition allows the graft to survive this period– ? Important for nutrition of graft– ? Stops drying out

Skin Grafts: “Process of Take”

• Inosculation & capillary ingrowth:– At 48 hrs– Through fibrin layer– Capillary buds from recipient bed contact graft

vessels – Open channels (neo-vascularization) pink graft

Skin Grafts: “Process of Take”

• Revascularization & fibrous attachment:– Connection of graft & host vessels via anastomoses

(inosculation)– Formation of new vascular channels by invasion of graft

(neovascularisation)– Combination of old & new vessels (revascularisation)

Skin Graft Take: Dermis

• Appendages:- sweating dependent on no. of transplanted sweat glands & degree of sympathetic reinnervation; -will sweat like recipient site in FTSG only- sebaceous gland activity mostly in thicker grafts- SSG usually dry & shiny- hair grows from FTSG if well taken with no complications

Skin Graft Healing

• Initially white then pinkens with new blood supply

• Lymphatic drainage by day 6

• Collagen replacement from day 7 to week 6

• Vascular remodelling for months

Skin Graft Healing

Contraction:- shrinks immediately due to elastic recoil: – FTSG 40%; medium SSG 20%; thin SSG 10%.

- secondary contracture as heals: - FTSG remains same size after above shrinkage;

- SSG will contract as much as possible;- more dermis = less contraction- ? Due to myofibroblasts

Skin Graft Healing

• Reinnervation:– from margins to bed;– 4/52 to 2 years;– Depends on graft thickness and bed;– Uneventful healing leads to near normal 2PD;– Cold sensitivity can be a problem.

Skin Graft Survival

• Meticulous technique• Atraumatic graft handling• Well vascularized bed• Haemostasis• Immobilization• No proximal constricting bandages

Skin Graft Failure Haematoma Infection Seroma Mobility Inappropriate bed Dependency Arterial insufficiency Venous congestion Lymphatic stasis Technical – upside-down

Flaps

• 16th century Dutch word “flappe”“….something that hangs broad and loose , fastened only by one side..”

• A flap is a surgically developed segment of tissue that remains attached to a portion of its original blood supply

Methods of classification

• Composition– Skin +/- fascia– Muscle (+/- innervation)– Bone– Omentum / viscera– Composite

• Proximity to defect• Method of movement• Vascular anatomy

Methods of classification

• Composition– Skin +/- fascia

– Muscle (+/- innervation)

– Bone– Omentum / viscera– Composite

• Proximity to defect• Method of movement• Vascular anatomy

Methods of classification

• Composition– Skin +/- fascia– Muscle (+/- innervation)

– Bone– Omentum / viscera– Composite

• Proximity to defect• Method of movement• Vascular anatomy

Methods of classification

• Composition– Skin +/- fascia– Muscle (+/- innervation)– Bone

– Omentum / viscera

– Composite• Proximity to defect• Method of movement• Vascular anatomy

Methods of classification

• Composition– Skin +/- fascia– Muscle (+/- innervation)– Bone

– Omentum / viscera

– Composite• Proximity to defect• Method of movement• Vascular anatomy

Methods of classification

• Composition– Skin +/- fascia– Muscle (+/- innervation)– Bone– Omentum / viscera

– Composite• Proximity to defect• Method of movement• Vascular anatomy

Random flaps• Most common• Based on subdermal plexus• Unpredictable• Length:width of 3:1 or 4:1

Random flaps• 1989 Pasyk • Demonstrated a significantly greater capillary density in the papillary and

reticular dermis of the head, face, and neck than in the lower parts of the body.

• Because of this increased density, it is possible to design and transfer longer random-pattern skin flaps in the face and neck than elsewhere in the body

Flap survival

Length:Width increased width

of base would increase surviving length but feeding vessels have same perfusion pressure

Morton’s Pig Flap experiments ‘77

Axial flaps• Limited by available vessels• Based on direct cutaneous vessels• Random flap at distal tip• Examples

– nasolabial– midline forehead flaps

?Flap

?Flap

Forehead Flap

Ahuja modification (PRS 1989)

• template for rotation & transposition flaps

• past 180 degrees adds rotation to transposition

Limberg Flap

Limberg Flap

?Flap

Bilobed Flap

Advancement

• Glabella• VY flap• Monopedicled• Bipedicled• A-T flap

V-Y flap

A-T flap

• Bilateral advancement• triangular defect• Uses - hairline, brow, lip

?flap

Lip Switch

Lip Switch

Nasolabial Flap

• Superiorly based

Nasolabial Flap

• Inferiorly based