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
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