PLASTIC AND RECONSTRUCTIVE          SURGERY           ?
“….the application ofanatomical knowledge to restore form and      function…”
?•   Hands•   Aesthetics•   Microsurgery•   Craniomaxillofacial•   Burns•   Congenital•   Trauma and oncology reconstruction
Anatomy of Circulation• The blood reaching the skin originates from deep vessels• These then feed interconnecting perforat...
Anatomy of Circulation• The vascular plexuses of the fascia, subcutaneous tissue and  skin are divided into 6 layers
Angiosomes• Similar to a skin dermatome is a composite block of 3  dimensional tissue supplied by a named artery• Entire s...
Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br ...
SKIN: Physiology & Function• Epidermis:  – protective barrier (against mechanical damage,    microbe invasion, & water los...
SKIN: Physiology & Function• Dermis:  – mechanical strength (collagen & elastin)  – Barrier to microbe invasion  – Sensati...
Reconstructive ladder• Primary closure
Simple closure       • Best result       • No tension       • Technique         dependent       • Sutures       • Staples,...
Reconstructive ladder• Primary closure• Delayed primary closure
Reconstructive ladder• Primary closure• Delayed primary closure• Secondary intention
Reconstructive ladder•   Primary closure•   Delayed primary closure•   Secondary intention•   Graft    – Transfer of tissu...
Graft• Layers of the skin• Split vs Full• Other grafts  – Bone  – Tendon  – Nerve  – Composite
Skin Grafts: Classification• Full thickness skin grafts:- epidermis & full thickness of dermis• Split skin graft:   - epid...
Split skin graft
What is a Flap?• 16th century Dutch word “flappe”  – ….something that hangs broad and loose ,    fastened only by one side...
What is a Flap?• A flap is a unit of tissue that may be transferred from a  donor to a recipient site while maintaining it...
Mathes&Nahai 1981Muscle Flap Classification
Fasciocutaneous flaps    Cormack &Lamberty (BJPS 1984)• Type A – multiple perforators in the flap base  – no discrete orig...
Nahai-Mathes Classification
Reconstructive ladder•   Primary closure•   Delayed primary closure•   Secondary intention•   Graft    – Transfer of tissu...
Flaps• Simple or random patterned  – based on movement (advancement,    rotation, transposition• Complex - named anatomic ...
Intro to-plastics
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Intro to-plastics

  1. 1. PLASTIC AND RECONSTRUCTIVE SURGERY ?
  2. 2. “….the application ofanatomical knowledge to restore form and function…”
  3. 3. ?• Hands• Aesthetics• Microsurgery• Craniomaxillofacial• Burns• Congenital• Trauma and oncology reconstruction
  4. 4. 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
  5. 5. Anatomy of Circulation• The vascular plexuses of the fascia, subcutaneous tissue and skin are divided into 6 layers
  6. 6. Angiosomes• Similar to a skin dermatome is a composite block of 3 dimensional tissue supplied by a named artery• Entire skin surface of the body is therefore perfused by a multitude of angiosome units• First studied by Marchot 1889, expanded by Salmon 1930 and more recently by Ian Taylor
  7. 7. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113.• 3D composite of tissue supplied by an artery & draining vein• Direct perforators are more common in the limbs, whereas indirect perforators predominate in the torso
  8. 8. SKIN: Physiology & Function• Epidermis: – protective barrier (against mechanical damage, microbe invasion, & water loss) – high regenerative capacity – Producer of skin appendages (hair, nails, sweat & sebaceous glands)
  9. 9. SKIN: Physiology & Function• Dermis: – mechanical strength (collagen & elastin) – Barrier to microbe invasion – Sensation (point, temp, pressure, proprioception) – Thermoregulation (vasomotor activity of blood vessels and sweat gland activity)
  10. 10. Reconstructive ladder• Primary closure
  11. 11. Simple closure • Best result • No tension • Technique dependent • Sutures • Staples, Tape, Adhesive
  12. 12. Reconstructive ladder• Primary closure• Delayed primary closure
  13. 13. Reconstructive ladder• Primary closure• Delayed primary closure• Secondary intention
  14. 14. Reconstructive ladder• Primary closure• Delayed primary closure• Secondary intention• Graft – Transfer of tissue with no intrinsic blood supply
  15. 15. Graft• Layers of the skin• Split vs Full• Other grafts – Bone – Tendon – Nerve – Composite
  16. 16. 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
  17. 17. Split skin graft
  18. 18. What is a Flap?• 16th century Dutch word “flappe” – ….something that hangs broad and loose , fastened only by one side..”
  19. 19. What is a Flap?• A flap is a unit of tissue that may be transferred from a donor to a recipient site while maintaining its blood supply. – Flaps can be characterized by their component parts • cutaneous, musculocutaneous, osseocutaneous – Their relationship to the defect • local, regional, or distant – Nature of the blood supply • random versus axial – The movement placed on the flap • advancement, pivot, transposition, free, pedicled
  20. 20. Mathes&Nahai 1981Muscle Flap Classification
  21. 21. Fasciocutaneous flaps Cormack &Lamberty (BJPS 1984)• Type A – multiple perforators in the flap base – no discrete origin – may be combination of direct or indirect perforators• Type B – pedicle or free flap based on a single perforator• Type C – multiple segmental perforators from the same vessel
  22. 22. Nahai-Mathes Classification
  23. 23. Reconstructive ladder• Primary closure• Delayed primary closure• Secondary intention• Graft – Transfer of tissue with no intrinsic blood supply• Flap – Transfer of tissue with intact blood supply
  24. 24. Flaps• Simple or random patterned – based on movement (advancement, rotation, transposition• Complex - named anatomic blood supply• Local vs distant• Pedicled vs Free (microvascular)

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