145d Coclia99 Grafts And Flaps


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  • 145d Coclia99 Grafts And Flaps

    1. 1. COCLIA 99: Grafts and Flaps in Head & Neck Surgery The images and text in this presentation were borrowed from multiple resources available on the internet without permission. This presentation is for education purposes only and should not be reproduced in any matter.
    2. 2. Skin Overview <ul><li>Epidermis </li></ul><ul><ul><li>stratified squamous epithelium </li></ul></ul><ul><ul><li>no blood vessels: receives nutrients by diffusion </li></ul></ul>
    3. 3. Skin Overview <ul><li>Dermis </li></ul><ul><ul><li>2 layers: papillary & reticular </li></ul></ul><ul><ul><li>reticular dermis: larger blood vessels, epidermal appendages </li></ul></ul><ul><ul><li>intradermal epithelial structures (sebaceous & sweat glands, hair follicles) are lined with epithelial cells with the potential for division and differentiation </li></ul></ul>
    4. 4. STSG vs. FTSG <ul><li>STSG </li></ul><ul><ul><li>Entire epidermis and a dermal component of variable thickness </li></ul></ul><ul><ul><ul><li>thin (0.005-0.012 inches) </li></ul></ul></ul><ul><ul><ul><li>intermediate (0.012-0.018 inches) </li></ul></ul></ul><ul><ul><ul><li>thick (0.018-0.030 inches) </li></ul></ul></ul><ul><ul><li>Thicker STSG requires more favorable conditions because of the greater amount of tissue requiring revascularization </li></ul></ul><ul><ul><li>Much broader range of application than FTSG </li></ul></ul><ul><li>FTSG </li></ul><ul><ul><li>Entire epidermis and dermis </li></ul></ul><ul><ul><li>Retains more characteristics of normal skin (color, texture, thickness) </li></ul></ul><ul><ul><li>Undergoes less contraction while healing </li></ul></ul><ul><ul><li>Limited to relatively small, uncontaminated, well-vascularized wounds </li></ul></ul>
    5. 5. <ul><li>Describe the three stages of survival for a STSG… </li></ul>
    6. 6. The Three Stages <ul><li>3 stages </li></ul><ul><ul><li>Imbibition (“to drink”): absorbs nutrients from underlying recipient bed; initial 2-3 days </li></ul></ul><ul><ul><li>Inosculation (“to kiss”): blood vessels in the skin graft grow to meet the blood vessels in the recipient bed; days 4-6 </li></ul></ul><ul><ul><li>Neovascularization: new blood vessels form bridging the graft to the recipient bed; days 6-7 </li></ul></ul>
    7. 7. <ul><li>What factors are important in graft survival? </li></ul>
    8. 8. Survival Factors <ul><li>Good </li></ul><ul><ul><li>Nutrition and oxygenation delivery </li></ul></ul><ul><ul><li>Removal of waste products </li></ul></ul><ul><li>Bad </li></ul><ul><ul><li>Mobility of graft </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Fluid collection beneath graft </li></ul></ul>
    9. 9. <ul><li>How are STSG and FTSG harvested? </li></ul>
    10. 10. STSG Harvesting <ul><li>Dermatome </li></ul><ul><ul><li>Uniform thickness (set width and thickness) </li></ul></ul><ul><ul><li>Fast </li></ul></ul><ul><ul><li>Must be familiar with equipment </li></ul></ul><ul><ul><li>15 blade scalpel simulates 0.015 inches </li></ul></ul><ul><li>Free hand with scalpel </li></ul><ul><ul><li>Variable thickness </li></ul></ul><ul><ul><li>Irregular edges </li></ul></ul>
    11. 11. FTSG Harvesting <ul><li>Free hand with scalpel </li></ul><ul><li>Enlarge by 3-5% </li></ul><ul><ul><li>Compensates for immediate primary contraction </li></ul></ul><ul><li>MUST trim off all residual adipose tissue </li></ul><ul><ul><li>Relatively avascular </li></ul></ul>
    12. 12. <ul><li>What is the point of meshing? </li></ul>
    13. 13. STSG Meshing <ul><li>Allows expansion up to 9 times the donor site </li></ul><ul><li>Purposes </li></ul><ul><ul><li>Cover large surface area </li></ul></ul><ul><ul><li>Recipient site is irregularly contoured </li></ul></ul><ul><li>The larger the size mesh the more fragile the graft </li></ul>
    14. 14. <ul><li>How is “pie-crusting” different from meshing? </li></ul>
    15. 15. Pie-Crusting <ul><li>Multiple stab wounds through the graft </li></ul><ul><ul><li>Made with scalpel or scissors </li></ul></ul><ul><li>Allows egress of wound fluid </li></ul><ul><li>Does not expand surface area </li></ul>
    16. 16. <ul><li>How can you manage the donor graft site (STSG and FTSG)? </li></ul>
    17. 17. STSG Donor Site <ul><li>Options </li></ul><ul><ul><li>Semi-occlusive dressings (Op-Site, Tegaderm) </li></ul></ul><ul><ul><ul><li>Shown to be superior: transparent, sterile, moist </li></ul></ul></ul><ul><ul><li>Semi-open dressings (Vaseline gauze, Xeroform) </li></ul></ul><ul><ul><ul><li>Might damage new fragile epithelial layer when removed </li></ul></ul></ul><ul><ul><li>No dressing </li></ul></ul><ul><li>Healing </li></ul><ul><ul><li>begins within 24 hours of harvesting </li></ul></ul><ul><ul><li>directly proportional to the number of epithelial appendages </li></ul></ul><ul><ul><li>inversely proportional to the thickness of graft </li></ul></ul>
    18. 18. FTSG Donor Site <ul><li>Usually closed primarily </li></ul><ul><li>Can cover with STSG (rarely done) </li></ul>
    19. 19. Flap Classification <ul><li>by arrangement of their blood supply </li></ul><ul><ul><li>random, arterial </li></ul></ul><ul><li>by the method of transfer </li></ul><ul><ul><li>advancement, pivotal , hinged </li></ul></ul><ul><li>by configuration </li></ul><ul><ul><li>rhomboid, bilobed </li></ul></ul><ul><li>by location </li></ul><ul><ul><li>local, regional , distant </li></ul></ul>
    20. 20. <ul><li>What is the difference between random and axial pattern flaps? </li></ul><ul><li>Give examples of each type </li></ul>
    21. 21. Random Pattern Flaps <ul><li>Do not have named arterial or venous vessels </li></ul><ul><li>Rely on blood flow through dermal and subdermal plexus </li></ul><ul><li>Eventually connects with perforating vessels (neovascularization) </li></ul><ul><li>Limited in length and width </li></ul>
    22. 22. Random Pattern Flaps <ul><li>Advancement flap </li></ul><ul><li>Rotation advancement flap </li></ul><ul><li>Rhomboid flap </li></ul>
    23. 23. Axial Pattern Flaps <ul><li>Rely on blood supply from named direct cutaneous arteries and veins </li></ul><ul><ul><li>Runs along longitudinal flap axis </li></ul></ul><ul><ul><li>Runs in subcutaneous tissue superficial to muscle </li></ul></ul><ul><li>Flap blood supply secure for at least length of blood vessels </li></ul><ul><li>Can further lengthen flap with tacking on random pattern flap at distal end </li></ul>
    24. 24. Axial Pattern Flaps <ul><li>Nasolabial flap </li></ul><ul><ul><li>angular </li></ul></ul><ul><li>Median or paramedian forehead flaps </li></ul><ul><ul><li>supratrochlear </li></ul></ul><ul><li>Lateral forehead flap </li></ul><ul><ul><li>superficial temporal </li></ul></ul>
    25. 25. <ul><li>What is a Burow’s triangle? </li></ul>
    26. 26. Burow’s Triangle <ul><li>A triangle of skin can be excised from the base of a flap to aid in closure </li></ul><ul><li>Effective for correcting dog ears </li></ul>
    27. 27. Flap Classification <ul><li>by arrangement of their blood supply </li></ul><ul><ul><li>random, arterial </li></ul></ul><ul><li>by the method of transfer </li></ul><ul><ul><li>advancement, pivotal , hinged </li></ul></ul><ul><li>by configuration </li></ul><ul><ul><li>rhomboid, bilobed </li></ul></ul><ul><li>by location </li></ul><ul><ul><li>local, regional , distant </li></ul></ul>
    28. 28. <ul><li>Discuss these flaps: </li></ul><ul><ul><li>advancement </li></ul></ul><ul><ul><li>transposition </li></ul></ul><ul><ul><li>rotation </li></ul></ul><ul><ul><li>interpolation </li></ul></ul>
    29. 29. Advancement Flap <ul><li>The flap’s leading edge moves into the defect </li></ul><ul><li>Flap movement is longitudinal rather than rotational </li></ul><ul><li>Burow’s triangles can be excised from the base of the flap to aid in closure </li></ul>
    30. 30. Transposition Flap <ul><li>Movement of adjacent skin from an area of excess to the area of deficiency </li></ul><ul><li>Moves laterally about a pivot point into an adjacent defect </li></ul><ul><li>Usually rectangular configuration </li></ul><ul><li>Donor site can be closed primarily </li></ul><ul><li>Examples: rhomboid flap, Z-plasty </li></ul>
    31. 31. Rotation Flap <ul><li>Moves adjacent tissue rotated in an arc around a pivot point </li></ul><ul><li>Relies on perforators that course superficially to supply the dermal and subdermal plexuses </li></ul><ul><li>Length of the flap's perimeter should be at least 4 times the width of the defect </li></ul>
    32. 32. Interpolation Flaps <ul><li>Rotates about a pivot point into a nearby but not adjacent defect </li></ul><ul><li>Usually linear configuration </li></ul><ul><li>Pedicle passes above or below a skin bridge </li></ul><ul><li>Base is located at some distance from the defect </li></ul><ul><li>Flap is subsequently detached in a second surgical procedure </li></ul>
    33. 33. Flap Classification <ul><li>by arrangement of their blood supply </li></ul><ul><ul><li>random, arterial </li></ul></ul><ul><li>by the method of transfer </li></ul><ul><ul><li>advancement, pivotal , hinged </li></ul></ul><ul><li>by configuration </li></ul><ul><ul><li>rhomboid, bilobed </li></ul></ul><ul><li>by location </li></ul><ul><ul><li>local, regional , distant </li></ul></ul>
    34. 34. Rhomboid Flap <ul><li>Pedicle width controls the amount of circulation within the dermal-subdermal plexus </li></ul><ul><li>Closed with a choice of 4 different flaps </li></ul><ul><li>Line of tension is greatest at donor site </li></ul><ul><li>Point of greatest tension is at “C” </li></ul>
    35. 35. Rhomboid Flap
    36. 36. Bilobed Flap <ul><li>Each lobe of the flap is tethered to a cutaneous pedicle </li></ul><ul><li>Two important variables: flap length, flap angle </li></ul><ul><li>1 st lobe is designed to be equal to the width of the original defect </li></ul><ul><li>2 nd lobe is constructed with an elliptical tip to facilitate side-to-side closure of the tertiary defect </li></ul>
    37. 39. <ul><li>What is the safe length-to-width ratio of a flap? </li></ul>
    38. 40. Length-to-Width Ratio <ul><li>3:1 used as a rough guideline only </li></ul><ul><li>Face is very vascular </li></ul><ul><li>Random pattern pedicled flap blood supply originates from nearest cutaneous arterial perforator at the base </li></ul><ul><li>Surviving length: determined by the perfusion pressure of the feeding vessels and the intravascular resistance </li></ul><ul><li>Increasing the width of a flap’s base does not increase the survivng length of the flap </li></ul>
    39. 41. Flap Classification <ul><li>by arrangement of their blood supply </li></ul><ul><ul><li>random, arterial </li></ul></ul><ul><li>by the method of transfer </li></ul><ul><ul><li>advancement, pivotal , hinged </li></ul></ul><ul><li>by configuration </li></ul><ul><ul><li>rhomboid, bilobed </li></ul></ul><ul><li>by location </li></ul><ul><ul><li>local, regional , distant </li></ul></ul>
    40. 42. <ul><li>Describe some common regional flaps used in head and neck reconstruction </li></ul><ul><li>Give the blood supply for each </li></ul>
    41. 43. Common Regional Flaps <ul><li>Pectoralis major </li></ul><ul><li>Deltopectoral </li></ul><ul><li>Latissimus dorsi </li></ul>
    42. 44. Pectoralis Major <ul><li>Myocutaneous flap </li></ul><ul><li>Pectoral branch of the thoracoacromial artery </li></ul><ul><li>Advantages: bulk, reliability, one-stage procedure </li></ul><ul><li>Disadvantages: bulk, insensate, tend to tether adjacent mobile structures </li></ul><ul><li>Can reach as high as the nasopharynx </li></ul>
    43. 45. Deltopectoral <ul><li>Faciocutaneous flap </li></ul><ul><li>Perforating branches of mainly the first four intercostal arteries </li></ul><ul><li>Skin graft is needed to reconstruct part of the donor site </li></ul>
    44. 46. Latissimus Dorsi <ul><li>Thoracodorsal artery </li></ul><ul><li>Useful to line large defects (sizable, bulk) </li></ul><ul><li>Disadvantage: potential for kinking of the feeding vessels at the shoulder </li></ul>
    45. 47. Nasolabial Fold Reconstruction <ul><li>Maintain nasolabial crease </li></ul><ul><li>Do not distort lip or nasal alae </li></ul><ul><li>Rhomboid flap </li></ul><ul><li>Bilobed flap </li></ul><ul><li>Advancement flap </li></ul>
    46. 48. Nasolabial Flap <ul><li>Medial cheek tissue located lateral to the nasolabial crease </li></ul><ul><li>Random blood supply from branches of the facial artery </li></ul><ul><li>Based either superiorly or inferiorly </li></ul><ul><li>Superiorly based: lower two thirds of the nose (nasal dorsum, alae, tip) </li></ul><ul><li>Inferiorly based: upper lip, floor of nose, columella </li></ul>
    47. 49. Medial Canthus Reconstruction <ul><li>Rhomboid flap </li></ul><ul><li>Bilobed flap </li></ul><ul><li>Modified glabellar flap </li></ul><ul><li>Eyelid myocutaneous flap </li></ul>
    48. 50. Indian Forehead Flap <ul><li>Midline forehead flap </li></ul><ul><li>Blood supply: paired supratrochlear vessels </li></ul><ul><li>Incision: hairline to nasofrontal angle, penetrated to periosteum </li></ul><ul><li>3 weeks: pedicle divided </li></ul>