Lecture 1- Pinciples, Grafts & Flaps

PRINCIPLES OF PLASTIC SURGERY

SKIN GRAFTS AND FLAPS OSCAR V.A. TAGULINAO, M.D., FPCS, FPAPS SECTION OF PLASTIC SURGERY, DEPARTMENT OF SURGERY UNIVERSITY OF SANTO TOMAS CARDINAL SANTOS MEDICAL CENTER

LINES OF LANGERS Animation Gravity Inconspicuous scar

WOUND HEALING 1. INFLAMMATORY PHASE Humoral phase Cellular phase 2. EPITHELIALIZATION 3. COLLAGEN FORMATION 4. SCAR MATURATION

INFLAMMATION PHASE • HUMORAL PHASE – Histamine from mast cells, granulocytes & platelets – vasodilatation & permeability – Kinins & prostaglandins

• CELLULAR PHASE – Polymorphonuclears, monocytes, fibrinous material

EPITHELIALIZATION

EPITHELIALIZATION is complete after 48 hrs in a sutured wound

CORRECT

WRONG

COLLAGEN FORMATION • 3rd day – spindle-shaped cells

HEALING BY SECONDARY INTENTION

WOUND CONTRACTION

WOUND CONTRACTION • Centripetal advance of wound edge • Myofibroblasts, Marjolin’s Ulcer

SCAR CONTRACTURE Hypertrophic Keloid

HOW TO MINIMIZE SCARRING

• Debride all devitalized tissues • Remove foreign bodies • Close primarily • Handle tissues gently • Prevent infection

KINDS OF GRAFTS Split thickness graft thin thick

epidermis & upper third of dermis epidermis & upper half of dermis

Full thickness graft epidermis & entire dermis

CHARACTERISTICS OF GRAFTS 1.thin grafts contract more 2.thin grafts may change color 3.thick grafts will grow hair 4.sensation follows recipient

GRAFT REQUIREMENTS 1.vascular recipient bed 2.contact between graft & recipient 3.immobilization of graft 4.free from infection

SPLIT THICKNESS GRAFTS

FULL THICKNESS GRAFTS

PROBLEMS WITH GRAFT Lacks tissue bulk

PROBLEMS WITH GRAFT contracts

may grow hair

Grafts will not survive on avascular recipient sites

KINDS OF FLAPS 1.Skin flaps 2.Muscle flap 3.Compound flap •Fasciocutaneous flap •Musculocutaneous flap •Osseocutaneous

KINDS OF SKIN FLAPS: BLOOD SUPPLY Random flaps Subdermal plexus of capillaries

Arterialized flaps Artery runs along the length of flap

KINDS OF SKIN FLAPS: FLAP SOURCE Local flaps Advancement flaps, rotation flaps, interpolation flaps

Distant flaps Crane flaps, waltzing flaps, free flaps

CHARACTERISTICS OF FLAP 1. has own blood supply 2. thick and has bulk 3. contracts less than grafts 4. retains characteristics of donor area 5. maybe used in avascular recipient sites

RANDOM FLAPS

ARTERIALIZED FLAPS

ARTERIALIZED FLAPS

LOCAL FLAPS Advancement flap

LOCAL FLAP Rotation flap

LOCAL FLAP Interpolation flap

V-Y advancement flap brings tissue to defect

Z-plasty rearranges tissues to add length or fill in a depressed area.

A

A

B B

A

A

B B

Multiple Z-plasties add more length and change the direction of the scars.

Zplasty

Zplasty

DISTANT FLAPS Groin flap

DISTANT

FLAPS

MUSCLE FLAPS Soleus muscle skin graft

MUSCULOCUTANEOUS FLAPS • skin, subcutaneous tissue and muscle • perforating arteries from the muscle • maybe used as free flap with vascular pedicle

MUSCULOCUTANEOUS FLAP Latissimus dorsii

MC FLAP Biceps femoris

MC FLAP Free flap

GRAFTS AND FLAPS