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SKIN GRAFT AND
SKIN FLAPPlastic surgery topic
Reviewed and present by
Mr. Patinya Yutchawit
Miss Kaewalin Thongsawangjang
...
William
Jennings
Bryan
Destiny is no matter
of chance. It is a
matter of choice. It
is not a thing to be
waited for, it is...
Content
• Skin graft
- Full thickness skin graft
- Partial thickness skin graft
• Skin flap
- local flap
- distant flap
• ...
SKIN GRAFT
Miss Tritraporn Sawantranon
Mr. Yotdanai Namuangchan
Mr. Jirarot Wongwijitsook
Miss Rattanaporn Sirirattanakul
Skin
EPIDERMIS
• Stratified squamous
epithelium composed
primarily of keratinocytes.
• No blood vessels.
• Relies on diffu...
Skin
DERMIS
• Composed of two “sub-layers”:
• superficial papillary
• deep reticular.
• The dermis contains collagen,
capi...
Definitions
Graft
A skin graft is a tissue of epidermis and varying amounts of dermis that
is detached from its own blood ...
FLAP
Any tissue used for
reconstruction or wound
closure that retains all or
part of its original blood
supply after the t...
Classification of Grafts
1. Autografts – A tissue transferred from one part of the body to
another.
2. Homografts/Allograf...
Types of Grafts
Grafts are typically described in terms of
thickness or depth.
Split Thickness(Partial): Contains 100% of ...
Type of Graft Advantages Disadvantages
Thin Split
Thickness
-Best Survival
-Heals Rapidly
-Least resembles original skin.
...
Indications for Grafts
• Extensive wounds.
• Burns.
• Specific surgeries that may require skin grafts for healing to
occur...
Split Thickness
Used when cosmetic appearance is not a primary issue or
when the size of the wound is too large to use a f...
Full Thickness
Indications for full thickness skin grafts include:
1. If adjacent tissue has premalignant or malignant
les...
Donor sites of skin graft
Skin Graft Donor Sites
• split-thickness skin grafts
• the original donor site may be used again for a subsequent
split-th...
Donor Site Selection
FTSG ( Full-Thickness Skin Grafts)
•Postauricular area
•Upper eyelid skin
•Groin area
Donor Site Selection (2)
STSG (Split-Thickness Skin Grafts)
•Scalp
•Thigh
•Buttocks
•Abdominal wall
FTSG & STSG
•Supraclav...
Healing Process of Skin Grafts
1) Plasmatic Imbibition :
- during the first 24-48 hrs.
- place skin graft  vascularizatio...
Healing Process of Skin Grafts
(2)
2) Inosculation :
- vessels in graft connect with those in recipient bed
3) Neovascular...
Condition for Take of Skin Grafts
Close contact:
- เพื่อให้เกิด Well vascularization
- Interrupted by tension, hematoma, s...
Condition for Take of Skin Grafts
(2)
 Good blood supply of recipient area:
• good blood supply & เกิด granulation tissue...
Recipient site preparation
• Clean site after excision
• Adequate hemostasis Graft
• Inadequate hemostasis Delayed graft
•...
Granulation tissue
Harvesting Dermatome
1. Split thickness skin graft
- Humby knife
- Padgette Drum-Type Dermatome
- Brown – Electrical Derma...
STSG dermatome
•Humby knife
• Padgett Drum-Type
Dermatome
• Brown – Electrical Dermatome
FTSG technique
Technical in Skin Grafts (1)
• การวางแบบใช้การกด (Pressure Method)
• การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing)
• ...
การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing)
• ใช้วัสดุการเย็บมาผูกกันบนผ้าก๊อซ,สาลี
• ปิดแผลไว้5 วัน
การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing)
การวางแบบใช้ผ้ายึดรัด (Elastic bandage)
• ใช้ในการวางผิวหนัง บริเวณแขนขาที่สามารถพันรอบได้
• บริเวณที่ไม่สามารถห้ามการเคลื...
• Mesh Instrument
• เจาะรูที่ผิวหนัง และขยายผิว
• เนื้อที่มากขึ้น
• เกิดช่องให้เลือด ซีรัม หรือ แบคทีเรียซึมออกมาจากใต้ผิว...
การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts)
การวางผิวหนังปลูกถ่ายโดยการตัดเป็นแว่นเล็กๆ (Punch Grafts)
• ใช้ปลูกผมที่หนังศรีษะ
• แต่ละแว่นจะมีเส้นผมประมาณ 10-15 เส้น
...
Healing of Donor area
1. Split-Thickness Skin Grafts
• preserve Skin Appendages
• Healing by Epithelialization
• Average 1...
2. Full-Thickness Skin Grafts
No spontaneous healing
• Primary closure
• Split thickness skin graft
Donor sites care
• Split-Thickness Skin Grafts
- Concepts : Close wound + Keep moisture
- Dressing with Tulle Gras, Gauze ...
Skin Graft Storage
• Used in Delayed Grafts / Skin Allografts
• Already cutted skin can be stored by
1. Place back into do...
Composite Grafts
• Small graft containing skin and underlying cartilage or other tissue
• Vascularization by Bridging phen...
SKIN FLAP
Miss Kaewalin Thongsawangjang
Miss Withunda Akaapimand
Mr. Patinya Yutchawit
§ vascularized block of tissue
§ mobilized from its donor site and transferred to
another location, adjacent or remote, fo...
1. Bare bone, bare tendon
2. Cover vessel or vital nerve
3. Avascular recipient site or poor perfusion of wound
4. Require...
1.Planning : type of flap and the method of its transfer
A. Choice of best donor area
B. A pattern of the defect
2.Size of...
Infection
Hematoma/seroma
Failure/necrosis
COMPLICATION
1. Color and texture are maintained
2. Durable cover over bony prominence
3. Continues to grow at the same rate
as body gr...
l. Due to blood supply
1. Random pattern flap
2. Axial pattern flap
ll. Due to site of flap
1. Local flap
2. Distant flap
1 Random pattern flaps
v Based on dermal & subdermal plexus
v Length:width of 2:1
Axial pattern flaps
v Based on direct cutaneous vessels
v Limited by available vessels
v Random flap at distal tip
v Peninsular flaps
v Island flaps
v Free flaps
l. Due to blood supply
1. Random pattern flap
2. Axial pattern flap
ll. Due to site of flap
1. Local flap
2. Distant flap
LOCAL FLAP
Definition, Rotational flap , Advancement flap
1. Flap rotating about a pivot
point
- Rotation
- Transposition :
- Z-plasty
- Rhomboid flap
- Interpolation
- Bilobed
2. ...
- Semicircular flap
- Commonly used for coverage of sacral
pressure sores
- Can cover wounds of various sizes
- Dog ear, B...
Y X
Z
- two triangular transposition skin flap
- Angle 60 องศา สามารถเพิ่มความยาว 75%
Central arm
A
B
C
D
Angle
3 arms
2 angle
1. เพิ่มความยาวของผิวหนัง เช่น scar contracture หรือ
Congenital finger web
2. การเปลี่ยนทิศทางของแผลเป็น
3. เปลี่ยนทิศทางอ...
• The pedicle of the flap must pass
above or beneath the tissue to reach
the recipient
• Beneath: Deepithelization No Cyst...
• Indicated when the tissue adjacent to a cutaneous defect is
insufficiently mobile to close the defect without causing ti...
Advancement flap
• 1 Single pedicle advancement flap
• 2 Bipedicle advancement flap
• 3 V-Y advancement flap
• 4 Y-V advan...
Burrow’s
triangle
Pantographic
expansion
DISTANT FLAP
Direct flap and tube flap
1. Direct flap (การโยกปิดโดยตรง)
2. Tube flap (การโยกปิดโดยการม้วนเป็นท่อ)
WRAP-UP!!
Mr. Patinya Yutchawit
To use
• When a deformity needs to be reconstructed,
either grafts or flaps can be employed to restore
normal function and...
Graft vs. Flap
Graft
Does not maintain
original blood supply.
Flap
Maintains original blood
supply.
Graft (Skin graft)
• Thickness (Full/Split/Dermatome-freehand)
• Donor site
• Recipient site
• Survival (Plasma imbibition...
Full VS Split thickness skin graft
Full Split
Donor - Require 2nd closure from
redundancy site
- A knife
- Repopulate and ...
Survival
24-48hr
Plastma
imbibition
Byday3
Inosculation
Byday5
Angiogenesis
Fail (Unable to revascularized)
• Poor wound bed (Poorly vascularized/radiated)
• Sheer
• Hematoma/Seroma
• Infection
Skin Flap
• Classification (By composition/By location/By vascular pattern)
• Survival
Survival
A. The success of a flap depends not only on its survival but also its
ability to achieve the goals of reconstruc...
References
• Grabb and Smith's Plastic Surgery Grabb's Plastic Surgery 9e
• Essentials for Students for plastic surgery; A...
The end
Any question ?
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
Skin graft and skin flap
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Skin graft and skin flap

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Skin graft and skin flap

  1. 1. SKIN GRAFT AND SKIN FLAPPlastic surgery topic Reviewed and present by Mr. Patinya Yutchawit Miss Kaewalin Thongsawangjang Miss Withunda Akaapimand Miss Rattanaporn Sirirattanakul Miss Tritraporn Sawantranon Mr. Yotdanai Namuangchan Mr. Jirarot Wongwijitsook
  2. 2. William Jennings Bryan Destiny is no matter of chance. It is a matter of choice. It is not a thing to be waited for, it is a thing to be achieved.
  3. 3. Content • Skin graft - Full thickness skin graft - Partial thickness skin graft • Skin flap - local flap - distant flap • Wrap-up!!
  4. 4. SKIN GRAFT Miss Tritraporn Sawantranon Mr. Yotdanai Namuangchan Mr. Jirarot Wongwijitsook Miss Rattanaporn Sirirattanakul
  5. 5. Skin EPIDERMIS • Stratified squamous epithelium composed primarily of keratinocytes. • No blood vessels. • Relies on diffusion from underlying tissues. • Separated from the dermis by a basement membrane.
  6. 6. Skin DERMIS • Composed of two “sub-layers”: • superficial papillary • deep reticular. • The dermis contains collagen, capillaries, elastic fibers, fibroblasts, nerve endings, etc.
  7. 7. Definitions Graft A skin graft is a tissue of epidermis and varying amounts of dermis that is detached from its own blood supply and placed in a new area with a new blood supply. Graft Does not maintain original blood supply.
  8. 8. FLAP Any tissue used for reconstruction or wound closure that retains all or part of its original blood supply after the tissue has been moved to the recipient location. Flap : Maintains original blood supply.
  9. 9. Classification of Grafts 1. Autografts – A tissue transferred from one part of the body to another. 2. Homografts/Allograft – tissue transferred from a genetically different individual of the same species. 3. Xenografts – a graft transferred from an individual of one species to an individual of another species.
  10. 10. Types of Grafts Grafts are typically described in terms of thickness or depth. Split Thickness(Partial): Contains 100% of the epidermis and a portion of the dermis. Split thickness grafts are further classified as thin or thick. Full Thickness: Contains 100% of the epidermis and dermis.
  11. 11. Type of Graft Advantages Disadvantages Thin Split Thickness -Best Survival -Heals Rapidly -Least resembles original skin. -Least resistance to trauma. -Poor Sensation -Maximal Secondary Contraction Thick Split Thickness -More qualities of normal skin. -Less Contraction -Looks better -Fair Sensation -Lower graft survival -Slower healing. Full Thickness -Most resembles normal skin. -Minimal Secondary contraction -Resistant to trauma -Good Sensation -Aesthetically pleasing -Poorest survival. -Donor site must be closed surgically. -Donor sites are limited.
  12. 12. Indications for Grafts • Extensive wounds. • Burns. • Specific surgeries that may require skin grafts for healing to occur. • Areas of prior infection with extensive skin loss. • Cosmetic reasons in reconstructive surgeries.
  13. 13. Split Thickness Used when cosmetic appearance is not a primary issue or when the size of the wound is too large to use a full thickness graft. 1. Chronic Ulcers 2. Temporary coverage 3. Correction of pigmentation disorders 4. Burns
  14. 14. Full Thickness Indications for full thickness skin grafts include: 1. If adjacent tissue has premalignant or malignant lesions and precludes the use of a flap. 2. Specific locations that lend themselves well to FTSGs include the nasal tip, helical rim, forehead, eyelids, medial canthus, concha, and digits.
  15. 15. Donor sites of skin graft
  16. 16. Skin Graft Donor Sites • split-thickness skin grafts • the original donor site may be used again for a subsequent split-thickness skin graft harvest. • Full-thickness skin graft donor sites • must be closed primarily because there are no remaining epithelial structures to provide re-epithelialization.
  17. 17. Donor Site Selection FTSG ( Full-Thickness Skin Grafts) •Postauricular area •Upper eyelid skin •Groin area
  18. 18. Donor Site Selection (2) STSG (Split-Thickness Skin Grafts) •Scalp •Thigh •Buttocks •Abdominal wall FTSG & STSG •Supraclavicular area
  19. 19. Healing Process of Skin Grafts 1) Plasmatic Imbibition : - during the first 24-48 hrs. - place skin graft  vascularization - temporary ischemia - diffusion of nutrients by capillary action from the recipient bed (plasma + RBC)
  20. 20. Healing Process of Skin Grafts (2) 2) Inosculation : - vessels in graft connect with those in recipient bed 3) Neovascular ingrowth : - graft revascularized by ingrowth of new vessels into bed - complete within 3-5 days
  21. 21. Condition for Take of Skin Grafts Close contact: - เพื่อให้เกิด Well vascularization - Interrupted by tension, hematoma, seroma, pus - แก้ไข : delayed graft, เจาะช่องที่ skin ของ donor Immobilization : -Tie-Over Bolus Dressing  5 days
  22. 22. Condition for Take of Skin Grafts (2)  Good blood supply of recipient area: • good blood supply & เกิด granulation tissue ได้ : muscle, periosteum, perichondrium, paratendon • poor blood supply & ไม่เกิด granulation tissue : bone (ยกเว้น maxilla&orbit), cartilage, tendon • “Bridging Phenomenon” Infection - bacteria > 105 / tissue 1 g  จะไม่รับการปลูกถ่าย
  23. 23. Recipient site preparation • Clean site after excision • Adequate hemostasis Graft • Inadequate hemostasis Delayed graft • Open wound with granulation tissue – Suspected Infection Vascular supply – Should be removed before do a new graft
  24. 24. Granulation tissue
  25. 25. Harvesting Dermatome 1. Split thickness skin graft - Humby knife - Padgette Drum-Type Dermatome - Brown – Electrical Dermatome 2. Full thickness skin graft
  26. 26. STSG dermatome •Humby knife
  27. 27. • Padgett Drum-Type Dermatome
  28. 28. • Brown – Electrical Dermatome
  29. 29. FTSG technique
  30. 30. Technical in Skin Grafts (1) • การวางแบบใช้การกด (Pressure Method) • การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing) • การวางแบบใช้ผ้ายึดรัด (Elastic bandage) • การวางแบบเปิด (Exposed Grafts) • การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts) • การวางผิวหนังปลูกถ่ายโดยการตัดเป็นแว่นเล็กๆ (Punch Grafts)
  31. 31. การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing) • ใช้วัสดุการเย็บมาผูกกันบนผ้าก๊อซ,สาลี • ปิดแผลไว้5 วัน
  32. 32. การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing)
  33. 33. การวางแบบใช้ผ้ายึดรัด (Elastic bandage) • ใช้ในการวางผิวหนัง บริเวณแขนขาที่สามารถพันรอบได้ • บริเวณที่ไม่สามารถห้ามการเคลื่อนไหวได้เช่น ขาหนีบ ลาคอ การวางแบบเปิด (Exposure Grafts)
  34. 34. • Mesh Instrument • เจาะรูที่ผิวหนัง และขยายผิว • เนื้อที่มากขึ้น • เกิดช่องให้เลือด ซีรัม หรือ แบคทีเรียซึมออกมาจากใต้ผิวหนัง • บริเวณที่รับกว้าง ที่ให้จากัด การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts)
  35. 35. การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts)
  36. 36. การวางผิวหนังปลูกถ่ายโดยการตัดเป็นแว่นเล็กๆ (Punch Grafts) • ใช้ปลูกผมที่หนังศรีษะ • แต่ละแว่นจะมีเส้นผมประมาณ 10-15 เส้น • ต้องเตรียมบริเวณที่จะวางด้วยการตัดหนังออกเป็นแว่นเล็กๆ ห่าง 5 มม. • เย็บบริเวณที่เอามา • Micrografts (2-3เส้น)
  37. 37. Healing of Donor area 1. Split-Thickness Skin Grafts • preserve Skin Appendages • Healing by Epithelialization • Average 10 – 14 days • Thin STSG (7-9 days) • Pilosebaceous apparatus and sweat gland • Thick STSG (14 days) • Sweat gland
  38. 38. 2. Full-Thickness Skin Grafts No spontaneous healing • Primary closure • Split thickness skin graft
  39. 39. Donor sites care • Split-Thickness Skin Grafts - Concepts : Close wound + Keep moisture - Dressing with Tulle Gras, Gauze and Bandage - Alternative : Opsite, Duoderm, Cutinova - Open dressing after 2 weeks for complete epithelialization except suspected infection
  40. 40. Skin Graft Storage • Used in Delayed Grafts / Skin Allografts • Already cutted skin can be stored by 1. Place back into donor site (10 days) 2. Wrap in NSS guaze and store in 4 °C (21 days) 3. Frozen and store in Skin Bank (5 years)
  41. 41. Composite Grafts • Small graft containing skin and underlying cartilage or other tissue • Vascularization by Bridging phenomenon • Distant between wound rim and graft < 0.5cm • Example : • ear skin and cartilage to reconstruct nasal alar rim defects • Chondromucosal grafts from Nasal Septum to reconstruct lower inner eyelid
  42. 42. SKIN FLAP Miss Kaewalin Thongsawangjang Miss Withunda Akaapimand Mr. Patinya Yutchawit
  43. 43. § vascularized block of tissue § mobilized from its donor site and transferred to another location, adjacent or remote, for reconstructive purposes GRAFT VS FLAP ??? SKIN FLAPS
  44. 44. 1. Bare bone, bare tendon 2. Cover vessel or vital nerve 3. Avascular recipient site or poor perfusion of wound 4. Require thickness or strength of wound 5. Wound at pressure site 6. Cosmetic better than skin graft (color, elasticity) 7. Require a plenty of layer (from huge excision) INDICATION
  45. 45. 1.Planning : type of flap and the method of its transfer A. Choice of best donor area B. A pattern of the defect 2.Size of the flap 3.Closure of donor area 4.Prevention of flap failure A. Tension B. Venous congestion C. Hematoma Principle of flap repair
  46. 46. Infection Hematoma/seroma Failure/necrosis COMPLICATION
  47. 47. 1. Color and texture are maintained 2. Durable cover over bony prominence 3. Continues to grow at the same rate as body growth Successful Flaps???
  48. 48. l. Due to blood supply 1. Random pattern flap 2. Axial pattern flap ll. Due to site of flap 1. Local flap 2. Distant flap
  49. 49. 1 Random pattern flaps v Based on dermal & subdermal plexus v Length:width of 2:1
  50. 50. Axial pattern flaps v Based on direct cutaneous vessels v Limited by available vessels v Random flap at distal tip
  51. 51. v Peninsular flaps v Island flaps v Free flaps
  52. 52. l. Due to blood supply 1. Random pattern flap 2. Axial pattern flap ll. Due to site of flap 1. Local flap 2. Distant flap
  53. 53. LOCAL FLAP Definition, Rotational flap , Advancement flap
  54. 54. 1. Flap rotating about a pivot point - Rotation - Transposition : - Z-plasty - Rhomboid flap - Interpolation - Bilobed 2. Advancement skin flap - Single pedicle flap - Bipedicle flap - V-Y advancement flap - Y-V advancement flap
  55. 55. - Semicircular flap - Commonly used for coverage of sacral pressure sores - Can cover wounds of various sizes - Dog ear, Backcut, Burrow’s triangle
  56. 56. Y X Z
  57. 57. - two triangular transposition skin flap - Angle 60 องศา สามารถเพิ่มความยาว 75%
  58. 58. Central arm A B C D Angle 3 arms 2 angle
  59. 59. 1. เพิ่มความยาวของผิวหนัง เช่น scar contracture หรือ Congenital finger web 2. การเปลี่ยนทิศทางของแผลเป็น 3. เปลี่ยนทิศทางองผิวหนัง
  60. 60. • The pedicle of the flap must pass above or beneath the tissue to reach the recipient • Beneath: Deepithelization No Cyst • Donor site: primary closure, skin graft
  61. 61. • Indicated when the tissue adjacent to a cutaneous defect is insufficiently mobile to close the defect without causing tissue distortion. • commonly used in reconstruction of facial skin defects (nasal tip, temporal forehead) • Concept: • 2 lobe (90องศา), 1 pivot • 1st lobe: near wound size • 2nd lobe: a half of the 1st • 2nd defect: primary suture
  62. 62. Advancement flap • 1 Single pedicle advancement flap • 2 Bipedicle advancement flap • 3 V-Y advancement flap • 4 Y-V advancement flap
  63. 63. Burrow’s triangle Pantographic expansion
  64. 64. DISTANT FLAP Direct flap and tube flap
  65. 65. 1. Direct flap (การโยกปิดโดยตรง)
  66. 66. 2. Tube flap (การโยกปิดโดยการม้วนเป็นท่อ)
  67. 67. WRAP-UP!! Mr. Patinya Yutchawit
  68. 68. To use • When a deformity needs to be reconstructed, either grafts or flaps can be employed to restore normal function and/or anatomy
  69. 69. Graft vs. Flap Graft Does not maintain original blood supply. Flap Maintains original blood supply.
  70. 70. Graft (Skin graft) • Thickness (Full/Split/Dermatome-freehand) • Donor site • Recipient site • Survival (Plasma imbibition>Inosculation>Angiogenesis)
  71. 71. Full VS Split thickness skin graft Full Split Donor - Require 2nd closure from redundancy site - A knife - Repopulate and resurface from remaining skin appendages - Special blade/dermatome Recipient - For smaller defect - Better consistency and texture - undergoes less secondary contraction - For larger defect - undergo secondary contraction as it heals
  72. 72. Survival 24-48hr Plastma imbibition Byday3 Inosculation Byday5 Angiogenesis
  73. 73. Fail (Unable to revascularized) • Poor wound bed (Poorly vascularized/radiated) • Sheer • Hematoma/Seroma • Infection
  74. 74. Skin Flap • Classification (By composition/By location/By vascular pattern) • Survival
  75. 75. Survival A. The success of a flap depends not only on its survival but also its ability to achieve the goals of reconstruction. B. The failure of a flap results ultimately from vascular compromise or the inability to achieve the goals of reconstruction. 1. Tension 2. Kinking 3. Compression 4. Vascular thrombosis 5. Infection
  76. 76. References • Grabb and Smith's Plastic Surgery Grabb's Plastic Surgery 9e • Essentials for Students for plastic surgery; AMERICAN SOCIETY OF PLASTIC SURGEONS 8e • Schwartz's Principles of Surgery, 9e • Practical plastic surgery e-book • http://oralmaxillo-facialsurgery.blogspot.com/
  77. 77. The end Any question ?

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