Flaps in orthopaedics


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Flaps in orthopaedics

  1. 1. Flaps in orthopaedics <ul><li>Zameer Ali </li></ul>
  2. 2. Diagrammatic representation of cross section skin
  3. 3. Skin grafting and classification
  4. 4. Classification on basis of thickness <ul><li>Split thickness skin grafting </li></ul><ul><li>Full thickness skin grafting </li></ul>
  5. 5. Diagramatic representation of skin
  6. 6. Species of origin <ul><li>Species of origin </li></ul><ul><li>1. Autologous (Auto) graft </li></ul><ul><li>2. Homologous (Homo, Allo) graft </li></ul><ul><li>3. Heterologous (Hetero. Xeno) graft </li></ul>
  7. 7. STSG (Thierish graft) <ul><li>It usually contains epidermis and part of dermis. </li></ul><ul><li>Thickness ranges from .01 (very thin) to .016 intermediate thickness) to .020 (thick graft) </li></ul>
  8. 8. Split thickness skin grafting <ul><li>STSG are useful for early resurfacing following burns ,immediate coverage of traumatic defects or surgical excision defect especially when area is too wide to use full thickness graft and replacement of defect caused by full thickness graft is quite large </li></ul>
  9. 9. STSG (Thierish graft) <ul><li>When vascularity of recipient area is doubtful STSG is more likely to take than full thickness graft </li></ul>
  10. 10. STSG (Thierish graft) <ul><li>Split thickness graft may be used as a definitive treatment in areas where durability of skin and function of underlying structures are not of prime consideration </li></ul><ul><li>Otherwise it must be used temporary to be later replaced by a more suitable type of graft </li></ul>
  11. 11. STSG <ul><li>STSG </li></ul>
  12. 12.
  13. 13. <ul><li>When free skin grafts are to be obtained, it is well to remember that &quot;the thinner the graft, the better the take,&quot; and yet when the graft is expected to be permanent, &quot;the thicker the graft, the better the function </li></ul>
  14. 14. <ul><li>.&quot; A thick graft is better able to withstand friction and constant use than a thin one and will contract only about 10%; a thin graft may contract 50% to 75%. </li></ul>
  15. 15. Sites from which to obtain full-thickness skin grafts. Groin or medial aspect of arm is preferable
  16. 16. STSG wolfe graft <ul><li>1) considerable secondary contraction </li></ul><ul><li>2) may develop pigmentation later on </li></ul><ul><li>3)Epidermis +partial dermis </li></ul><ul><li>4)No need to cover donor site </li></ul><ul><li>5) Quicker healing of donor site </li></ul><ul><li>Little contraction/shrinkage </li></ul><ul><li>usually Little /no pigmentation </li></ul><ul><li>Epidermis + whole of dermis </li></ul><ul><li>Donor site to be covered by STSG </li></ul><ul><li>Lesser healing of donor site </li></ul>
  17. 17. Factors affecting uptake of graft <ul><li>1. Recipient site capable for producing </li></ul><ul><li>capillary bud. </li></ul><ul><li>2. Approximation between the graft and </li></ul><ul><li>recipient site (: No hematomaor </li></ul><ul><li>infection) </li></ul>
  18. 18. <ul><li>3. Immobilisation during the phase of </li></ul><ul><li>grafting </li></ul><ul><li>6. Subsequent behavior of free graft </li></ul>
  19. 19. No take <ul><li>1. Compact bone </li></ul><ul><li>2. Bare cartilage </li></ul><ul><li>3. Bare tendon </li></ul><ul><li>4. Heavily irradiation of tissue </li></ul>
  20. 20. A. Take <ul><li>1. Fat, fascia. </li></ul><ul><li>2. Muscle, tendon sheath. </li></ul><ul><li>3. Periosteum. </li></ul><ul><li>Perichondrium, Cancellous bone tissue </li></ul>
  21. 21. Instruments for taking graft
  22. 22. Humby knife
  23. 23. Taking STSG
  24. 24. Graft taking with weck knife <ul><li>Technique of removing split-thickness skin graft from flexor surface above elbow with Weck knife. </li></ul>
  25. 25. Reese dermatome <ul><li>Large area of skin is removed by adhering to tape mounted on drum </li></ul><ul><li>Thickness is measured by shimmer that measures distance between drum and blade </li></ul>
  26. 26. Reese deramtome
  27. 27. Pneumatic dermatome
  28. 28. mesher
  29. 29.
  30. 30.
  31. 31. Skin flaps <ul><li>Skin flaps are composed of skin and subcutaneous tissue temporarily attached by vascularized pedicle to donor site </li></ul>
  32. 32. Filletted graft from injured finger
  33. 33. Classification <ul><li>l. Due to blood supply </li></ul><ul><li>1. Random pattern flap </li></ul><ul><li>2. Axial pattern flap </li></ul>
  34. 34. Types of skin flaps <ul><li>Random pattern flaps </li></ul><ul><li>Axial flaps </li></ul><ul><li>Island flaps </li></ul>
  35. 35. Axial flap <ul><li>Limited by available vessels </li></ul><ul><li>Based on direct cutaneous vessels </li></ul><ul><li>Random flap at distal tip </li></ul>
  36. 36. Axial flap <ul><li>Axial pattern flaps allow a safe length-to-width ratio of at least 3:1, the possibility of covering either the dorsal or palmar surface, and a sufficiently long pedicle to allow arm and hand movement. Because such flaps usually do not require a delay in detachment of one end, they are useful for coverage of acute hand injuries. </li></ul>
  37. 37. Random pattern flap <ul><li>Most common </li></ul><ul><li>Based on subdermal plexus </li></ul><ul><li>Unpredictable </li></ul><ul><li>Length:width of 3:1 or 4:1 </li></ul>
  38. 38. Random pattern flap <ul><li>A randomn pattern flap is one perfused by musculocutaneous arteries located in pedicle of flap and connected to dermal and subdermal plexus </li></ul>
  39. 39. Due to site of flap <ul><li>1. Local flap </li></ul><ul><li>2. Distant flap </li></ul>
  40. 40. <ul><li>Flap coverage can be used in the primary closure of a hand wound or in a secondary procedure to replace scars, skin of poor quality, or necrotic skin. </li></ul>
  41. 41. <ul><li>flap can be obtained locally or from a distant part. If the area to be covered is small, a local flap may be indicated, </li></ul>
  42. 42. Local flap (thenar flap)
  43. 43. Tests for flap circulation <ul><li>Blanch test (Capillary circulation returns within 4 seconds after blanching if more time is consumed suggestive of vascular insufficiency </li></ul><ul><li>However above test gives no clue about venous drainage </li></ul>
  44. 44. Flourescein test <ul><li>The flourscein test is accurate method of evaluating skin flap circulation </li></ul>
  45. 45. Flap survival <ul><ul><li>increased width of </li></ul></ul><ul><ul><li>base would increase </li></ul></ul><ul><ul><li>surviving length but </li></ul></ul><ul><ul><li>feeding vessels have </li></ul></ul><ul><ul><li>same perfusion pressure </li></ul></ul>
  46. 46. Principles of skin flap surgery <ul><li>1) The recipient and donor area must be brought in position and an over sized pattern is applied </li></ul>
  47. 47. <ul><li>2 ) local flaps are preferred because they provide similar texture and cololr charecteristics </li></ul>
  48. 48. <ul><li>3) Axial pattern flaps based on specific arterio venous system are better than random pattern flaps </li></ul>
  49. 49. <ul><li>4) elderely patients are not good candidates for large flaps because of arteriosclerotic changes </li></ul><ul><li>5) the flap should not be subjected to kinking or pressure ( dressing over flap should be avoided ) </li></ul>
  50. 50. <ul><li>6) Hematoma formation jeoparadizes flap </li></ul><ul><li>Complette haemostasis ,use of suction drainage and delay of flap transfer when haemostasis is doubtful will reduce hematoma formation </li></ul>
  51. 51. <ul><li>7) transfer should be delayed when adequate vascularity of flap is doubtful </li></ul><ul><li>When transfering a flap from distance raw area produced by raising flap must be eleminated this is achieved by </li></ul>
  52. 52. <ul><li>A) bringing donor area and recipient area close </li></ul><ul><li>B) immediate application of STSG </li></ul><ul><li>C) forming hinge flap adjacent to recipient area . </li></ul>
  53. 53. <ul><li>Flap separation should be delayed till 21 st day once vascularization of flap at recipient area is doubtful. </li></ul>
  54. 54. <ul><li>Flaps should not be in tension </li></ul>
  55. 55. Delay of flaps <ul><li>Instead of raising and immediately transferring flaps , </li></ul><ul><li>flaps may be partially divided in stages before transferring </li></ul><ul><li>This will increase vascularity and ensure survival of flap </li></ul>
  56. 56. <ul><li>Local flaps may be designated as </li></ul><ul><li>1 advancement, </li></ul><ul><li>2 rotation </li></ul><ul><li>3 translation </li></ul><ul><li>4 transposition types. </li></ul>
  57. 57.
  58. 58. <ul><li>Skin to be used for a local flap should not be damaged, since necrosis may occur. Developing a local skin flap requires undermining and minimal tension on the flap. </li></ul>
  59. 59. Advancement flap <ul><li>Use of an advancement flap involves mobilizing a small flap of skin to cover an adjacent defect without using a skin graft for the donor defect. </li></ul>
  60. 60. <ul><li>These are used to cover fingertip amputations. </li></ul><ul><li>Rotation flaps are raised on a curved radius with undermining of the flap and closed under modest tension without a skin-grafted donor defect </li></ul>
  61. 61. Translation flaps <ul><li>Translation flaps usually are rectangular and are used to close an adjacent defect. The flap is moved around a pedicle base and is closed without tension. Translation flaps require a skin graft for the donor site </li></ul>
  62. 62. Translation flaps
  63. 63. Translation flaps <ul><li>Translation flap raised from skin in continuity with area of skin loss. Donor area is covered by graft. </li></ul>
  64. 64. Transposition flaps <ul><li>Transposition flaps usually are moved across an adjacent area of normal skin to close an adjacent defect without tension. Skin grafting at the donor site is necessary ... </li></ul>
  65. 65. <ul><li>The advantages of a local flap over one from a distant part are that the involved part is not tied to the distant donor and that in many instances finger motions may continue </li></ul>
  66. 66.
  67. 67. Flag flap <ul><li>&quot;Flag flap.&quot; A, Skin can be moved over distance to palmar surface or to neighboring digit. B, &quot;Flagstaff&quot; contains the pedicle consisting of dorsal vein, dorsal branch of digital artery, and dorsal branch of digital nerve </li></ul>
  68. 68. dorsoulnar thumb flap <ul><li>The circulation to the dorsoulnar side of the hand and thumb has been further elucidated by Brunelli et al., leading to the development of the dorsoulnar thumb flap </li></ul>
  69. 69. dorsoulnar thumb flap <ul><li>Dorsoulnar flap harvested from inner side of thumb metacarpophalangeal area reaches distal area of thumb </li></ul>
  70. 70. CROSS-FINGER FLAPS <ul><li> CROSS-FINGER FLAPS useful for covering a defect of the skin and other soft tissues on the volar surface of the finger when tendons and neurovascular structures are exposed and a small amount of subcutaneous fat is needed. </li></ul>
  71. 71. CROSS-FINGER FLAPS <ul><li>They also are useful for some amputations of the thumb These grafts are best avoided in patients over 50 years of age, in hands with arthritic changes or a tendency to finger stiffness for some other reason, or if local infection is present </li></ul>
  72. 72. Cross-finger flap.
  73. 73. Cross-finger flap. <ul><li>Cross-finger flap. Laterally based pedicle flap has been raised from middle finger and has been applied to distal pad of index. donor finger and bridge between two fingers have been covered with split-thickness skin graft </li></ul>
  74. 74. Principles of three types of local flaps <ul><li>. In each type, defect to be covered is converted into triangular one. Flap may be rotated </li></ul><ul><li>or transposed or both. </li></ul><ul><li>Defect created by transposing flap must be covered with split-thickness graft. </li></ul>
  75. 75. <ul><li>Flap rotating about a pivot point </li></ul><ul><li>- Rotation </li></ul><ul><li>- Transposition : Rhomboid flap </li></ul><ul><li>- Z-Plasty </li></ul>
  76. 76. <ul><li>Skin coverage by pedicle method provides a well vascularized cover for underlying vital structures with minimum scaring relaxing all tissues within the part and improving local blood supply and nutrition </li></ul>
  77. 77. <ul><li>Flaps withstand wear and tear of rough usage as soon as nerve supply returns to them </li></ul><ul><li>A skin flap is best method of resurfacing palm of hand and volar surface of fingers </li></ul>
  78. 78. Axial pattern flap <ul><li>An axial pattern flap (arterial flap ) contains at least one specific direct cutaneous artery within its longitudinal axis </li></ul><ul><li>Artery lies in subcutaneous layer just superficial to muscular fascia therefore flap thickness should include subcutaneous fat and deep fascia </li></ul>
  79. 79. Axial pattern flaps <ul><li>Examples </li></ul><ul><li>Deltopectoral flap </li></ul><ul><li>Hypo gastric flap </li></ul><ul><li>Superficial inferior epigastric flap </li></ul><ul><li>Groin flap </li></ul><ul><li>Superficial circumflex iliac artery flap </li></ul>
  80. 80. Abdominal flaps <ul><li>Traditionally, flaps from the abdomen have been used as tubed pedicle flaps or as direct flaps. </li></ul>
  81. 81. Axial pattern abdominal flaps <ul><li>The tubed pedicle technique requires the formation of a bipedicle tube and 6 weeks of maturation followed by detachment of one end of the tube to be applied to the hand, followed by another 3 to 6 weeks before the flap is completely detached and &quot;inset&quot; into the defect. </li></ul>
  82. 82. Abdominal flaps <ul><li>The direct abdominal flaps typically are limited in their length-to-width ratio because of the random circulation. It rarely is safe to use such a flap with a length-to-width ratio that varies significantly from 1:1. </li></ul>
  83. 83. A random pattern abdominal flap <ul><li>A random pattern abdominal flap to be applied to the hand should have its base either distal, toward the superficial epigastric vessels, usually on the same side as the affected hand, or proximal, above the umbilicus toward the thoracoepigastric vessels, usually on the opposite side </li></ul>
  84. 84. A random pattern abdominal flap <ul><li>The flaps above the umbilicus should not be used in a patient with a &quot;barrel chest&quot; with chronic lung disease.. </li></ul>
  85. 85. A random pattern abdominal flap
  86. 86. A random pattern abdominal flap <ul><li>Lower abdominal flap may be made narrower in relation to its length if it contains superficial circumflex iliac artery and vein (lower right) or superficial epigastric artery and vein.  </li></ul>
  87. 87. A random pattern abdominal flap <ul><li>Abdominal flaps obtained from areas above the umbilicus usually avoid the fat &quot;storage areas.&quot; If the flap is obtained from the infraumbilical area, the recipient grafted area usually increases in bulk, since the infraumbilical area skin adds fat </li></ul>
  88. 88. AFTERTREATMENT <ul><li>The flap should be inspected almost hourly during the first 48 hours for circulatory compromise produced by tension or torsion or for the development of a hematoma. </li></ul>
  89. 89. AFTERTREATMENT <ul><li>Sutures that appear to be too tight should be removed because the pressure they apply on the flap may be sufficient to produce ischemia. </li></ul>
  90. 90. AFTERTREATMENT <ul><li>If an area becomes necrotic, it should be excised and covered with a split skin graft. Gross infection from necrosis or hematoma usually results in failure. </li></ul>
  91. 91. AFTERTREATMENT <ul><li>The area should be redressed frequently to avoid offensive odor and reduce the chance of infection. Usually the flap can be safely detached after 3 weeks. In children this can be reduced to 2 weeks. </li></ul>
  92. 92. Groin Pedicle Flap <ul><li>the iliofemoral (groin) flap, popularized by McGregor, was widely used in reparative and reconstructive surgery of the upper extremity. </li></ul>
  93. 93. Groin Pedicle Flap
  94. 94. Groin Pedicle Flap <ul><li>Advantages of the groin flap include (1) its location in an area sparse in hair, (2) minimal donor site morbidity, (3) multiple arteriovenous supply, (4) potential for incorporating bone with the overlying skin flap even when used as a pedicle flap, and (5) potentially large size. </li></ul>
  95. 95. Groin Pedicle Flap <ul><li>Disadvantages include (1) problems with color matching, (2) possibility of damage to vessels from previous inguinal surgery, and (3) thickness of the flap in obese patients </li></ul>
  96. 96. Groin Pedicle Flap <ul><li>The groin pedicle flap usually receives its arterial supply from the superficial circumflex iliac branch of the femoral artery. Its venous drainage is through the superficial inferior epigastric and superficial circumflex iliac veins. </li></ul>
  97. 97. Hypogastric (Superficial Epigastric) Flap <ul><li>it has proved extremely useful for coverage of the hand and forearm. Its arteriovenous pedicle consists of the superficial epigastric artery and vein The axis of the flap usually is oriented in a superolateral direction, with the base near the inguinal ligament centered at about the midpoint of the ligament. </li></ul>
  98. 98. Hypogastric (Superficial Epigastric) Flap
  99. 99. Hypogastric (Superficial Epigastric) Flap <ul><li>Flaps measuring up to 18 cm long × 7 cm wide have been used. Its advantages and disadvantages are similar to those described for the groin pedicle flap . </li></ul>
  100. 100. Hypogastric (Superficial Epigastric) Flap <ul><li>Usually a bone graft cannot be incorporated into the skin flap. During preoperative planning it is important to examine the abdomen on the affected side for the presence of previous surgical or traumatic scars that might have damaged the arterial supply. </li></ul>
  101. 101. Island flap <ul><li>The island flap has pedicle devoid of skin and consists of nutrient artery and vein </li></ul>
  102. 102. filleted graft <ul><li>A filleted graft is a flap of tissue fashioned from a nearby part, usually a finger, from which the bone has been removed but in which one or more neurovascular bundles have been retained. </li></ul>
  103. 103. filleted graft <ul><li>In the hand such a graft is indicated only when deep tissues such as tendons, nerves, and joints are exposed and when a nearby damaged finger is to be sacrificed because it is not salvageable; it is never used at the expense of a salvageable, useful part. </li></ul>
  104. 104. <ul><li>Thank you…….. </li></ul>