Nsw plastic-nurses

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Nsw plastic-nurses

  1. 1. NSW Plastic Nurses Association 2012 Flaps and Grafts
  2. 2. Graft VS FlapWhat is the difference?
  3. 3. Reconstructive ladder
  4. 4. • 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
  5. 5. Reconstructive Elevator• Get off at the right level
  6. 6. 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
  7. 7. Nahai-Mathes Classification
  8. 8. Anatomy of Circulation• The vascular plexuses of the fascia, subcutaneous tissue and skin are divided into 6 layers
  9. 9. Anatomy of Circulation1)Subfascial plexus small plexus lying on the undersurface of the fascia
  10. 10. Anatomy of Circulation2) Prefascial plexus -a larger plexus -particularly prominent on the limbs -fasciocutaneous vessels
  11. 11. Anatomy of Circulation3)Subcutaneous Plexus -lies at the level of superficial fascia -Predominant on the torso -musculocutaneous vessels
  12. 12. Anatomy of Circulation4)Subdermal Plexus-receives blood fromunderlying plexus-the main plexussupplying blood to theskin-represents thedermal bleedobserved in incisedskin
  13. 13. Anatomy of Circulation5) Dermal Plexus-mainly arterioles-important inthermoregulation
  14. 14. Anatomy of Circulation6)Subepidermal Plexus -contains small vessels without muscle in the walls -nutritive and thermoregulatory function
  15. 15. SKIN: Anatomy
  16. 16. SKIN: Anatomy
  17. 17. 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
  18. 18. Skin Grafts: SSG
  19. 19. SKIN: Anatomy
  20. 20. SKIN: Anatomy
  21. 21. Skin Grafts: “Process of Take”• Vascularity of donor site• Tolerance to ischaemia• Metabolic activity of the graft
  22. 22. Skin Grafts: “Process of Take”• 4 Phases: – Fibrin adhesion – Plasmatic imbibition – Revascularization: Inosculation & capillary ingrowth – Remodelling: Revascularization & fibrous attachment in restoring normal histological architecture
  23. 23. 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
  24. 24. 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
  25. 25. 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)
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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.
  30. 30. Skin Graft Survival• Meticulous technique• Atraumatic graft handling• Well vascularized bed• Haemostasis• Immobilization• No proximal constricting bandages
  31. 31. Skin Graft Failure Haematoma Infection Seroma Mobility Inappropriate bed Dependency Arterial insufficiency Venous congestion Lymphatic stasis Technical – upside-down
  32. 32. 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
  33. 33. Methods of classification• Composition – Skin +/- fascia – Muscle (+/- innervation) – Bone – Omentum / viscera – Composite• Proximity to defect• Method of movement• Vascular anatomy
  34. 34. Methods of classification• Composition – Skin +/- fascia – Muscle (+/- innervation) – Bone – Omentum / viscera – Composite• Proximity to defect• Method of movement• Vascular anatomy
  35. 35. Methods of classification• Composition – Skin +/- fascia – Muscle (+/- innervation) – Bone – Omentum / viscera – Composite• Proximity to defect• Method of movement• Vascular anatomy
  36. 36. Methods of classification• Composition – Skin +/- fascia – Muscle (+/- innervation) – Bone – Omentum / viscera – Composite• Proximity to defect• Method of movement• Vascular anatomy
  37. 37. Methods of classification• Composition – Skin +/- fascia – Muscle (+/- innervation) – Bone – Omentum / viscera – Composite• Proximity to defect• Method of movement• Vascular anatomy
  38. 38. Methods of classification• Composition – Skin +/- fascia – Muscle (+/- innervation) – Bone – Omentum / viscera – Composite• Proximity to defect• Method of movement• Vascular anatomy
  39. 39. Random flaps• Most common• Based on subdermal plexus• Unpredictable• Length:width of 3:1 or 4:1
  40. 40. 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
  41. 41. Flap survival Length:Width  increased width of base would increase surviving length but feeding vessels have same perfusion pressure
  42. 42. Morton’s Pig Flap experiments ‘77
  43. 43. Axial flaps• Limited by available vessels• Based on direct cutaneous vessels• Random flap at distal tip• Examples – nasolabial – midline forehead flaps
  44. 44. ?Flap
  45. 45. ?Flap
  46. 46. Forehead Flap
  47. 47. Ahuja modification (PRS 1989)• template for rotation & transposition flaps• past 180 degrees adds rotation to transposition
  48. 48. Limberg Flap
  49. 49. Limberg Flap
  50. 50. ?Flap
  51. 51. Bilobed Flap
  52. 52. Advancement• Glabella• VY flap• Monopedicled• Bipedicled• A-T flap
  53. 53. V-Y flap
  54. 54. A-T flap• Bilateral advancement• triangular defect• Uses - hairline, brow, lip
  55. 55. ?flap
  56. 56. Lip Switch
  57. 57. Lip Switch
  58. 58. Nasolabial Flap• Superiorly based
  59. 59. Nasolabial Flap• Inferiorly based

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