Skin grafts and flaps.pptx

plastic surgeon at surgeon
Apr. 1, 2023

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Skin grafts and flaps.pptx

  2. INTRODUCTION • Skin grafts and flaps are two surgical techniques that are commonly utilized by surgeons when a defect cannot be closed by primary or secondary intention  SKIN GRAFT • Is a sheet of skin (epidermis & varying amounts of dermis) that is detached from its own blood supply and placed in a new area of the body. • Provide permanent skin replacement which is supple, sensate and durable. • Functions: biologic cover, thermoregulation, Identity & beauty. • Survival requires a vascularized wound recipient bed. • Graftable beds with adequate blood supply include healthy soft tissues, periosteum, perichondrium, paratenon, and bone surface that is perforated to encourage granulation tissue growth.
  3.  FLAPS • A flap consists of tissue that is moved from one part of the body to another with a vascular pedicle to maintain blood supply. • The vascular pedicle may be kept intact, or it can be transected for microvascular anastomosis of the flap vessels to vessels at another site.
  4. HISTORY • Description of replantation in Vedic times. • Sushruta Samhita, compiled in 600 BC Pedicle flaps in the face and forehead for nasal reconstruction. • 1817, Sir Astley Cooper grafted a FTS from a man's amputated thumb for stump coverage. • Ollier in 1872 importance of the dermis in skin grafts & in 1886 Thiersch used thin STS to cover large wounds.
  5. • Lawson, Le Fort, & Wolfe used FTSG to treat ectropion of the lower eyelid. Krause popularized the use of FTSG in 1893 Wolfe-Krause grafts. • In 1979, cultured human keratinocytes were grown to form an epithelial layer that was satisfactory for grafting wounds
  6. • 1597 Tagliacozzi - Nasal reconstruction by tubed pedicle flap from arm; described "delay" of pedicle flap • 1896 Tansini - Latissimus dorsi musculocutaneous flap for breast reconstruction (post- mastectomy) • 1965 Bakamjian - deltopectoral flap • 1972 Orticochea - musculocutaneous flap • 1981 Mathes and Nahai - Classification of muscle flaps based on vascular anatomy • 1981 Ponten - described fasciocutaneous flap
  7. Louis Ombrane- first muscle flap, describe the use of pectoralis minor flap for breast reconstruction
  8. Sir Harold Delf Gillies- consider Father of plastic surgery, Pioneer in fascial injury repairs.
  9. ANATOMY  Epidermis provides protective barrier against: • Mechanical damage • Microbe invasion • Water loss.  Dermis provides: • Mechanical strength (collagen & elastin) • Sensation (temp, pressure, proprioception) • Thermoregulation (vessels & sweat gland)
  10. BLOOD SUPPLY OF THE SKIN  The blood reaching the skin originate from two types of deep vessels. 1. Direct cutaneous and Septocutaneous • Arteries arising from segmental or musculocutaneous vessels travel with intermuscular fascial septa to supply the overlying skin 2. Indirect cutaneous vessels • AKA Musculocutaneous • Travel perpendicularly through muscle to the overlying skin.  Both these arteries divide at three levels- skin, subcutaneous tissue, and fascia.  At these three levels they form 6 recognizable vascular plexus.
  11. FASCIAL PLEXUS 1. SUBFASCIAL PLEXUS • Plexus lying on the under surface of the fascia • Relative minor plexus • Incapable of sustaining a fascial flap 2. PREFASCIAL PLEXUS • Dominant distribution system 3. SUBCUTANEOUS PLEXUS • Network of vessels which divide subcutaneous fat into deep and superfiscial layers. • More developed in torso than in extrimities • Supplies by both septocutaneous and musculocutaneos arteries.
  12. 4. SUBDERMAL PLEXUS • Primary blood supply to the skin • Primarily distribution function • Located at junction between reticular dermis and subcutaneous fat 5. DERMAL PLEXUS • Present at lower limit of dermal papillary ridge • Vessel present are arterioles and wall contain isolated muscular elements • Primarily thermoregulatory function 6. SUBEPIDERMAL PLEXUS • Located at the dermoepidermal junction • Contain mostly capillaries having no muscle in their wall • Therefore they serve to have primarily nutritive function.
  13. Pathway of the various known cutaneous perforator that pierce the deep fascia to supply the fascial plexus Refrence sabiston
  14. RECONSTRUCTIVE LADDER • Is the set of levels of increasingly complex management of wounds in reconstructive surgery. • The surgeon should start on the lowest rung and move up until a suitable technique is reached.
  15. CLASSIFICATION OF GRAFTS  Autografts - A tissue transferred from one part of the body to another.  Homograft/Allograft - tissue transferred from a genetically different individual of the same species.  Xenografts - a graft transferred from an individual of one species to an individual of another species.
  16. Type Of Graft Advantages Disadvantages Thin split thickness (0.15 to 0.3mm) • Best survival • Heals rapidly • Least resemblance to original skin • Least resistance to trauma • Poor sensation • Maximal secondary contraction Thick split thickness • Intermediate- 0.3 to 0.45 mm • Thick- 0.45 to 0.6mm • More qualities of normal skin • Less contraction • Looks better • Fair sensation • Lower graft survival • Slower healing Full thickness • Most resemblance to normal skin • Minimal secondary contraction • Resistance to trauma • Good sensation • Aesthetically pleasing • Poorest survival • Donor site must be closed surgically • Donor sites are limited • Cannot cover larger wound size
  17. STSG FTSG Thickness Epidermis+/- dermis • Epidermis+dermis+ appendages Instrument required • Humby/dermatome • Scalpel/scissor Donor area • Thigh, leg, upper arms, trunk, buttock, scalp • Post auricular area, supraclavicular area, flexor aspect of joint Graft contraction • Primary less • Secondary more • Primary more • Secondary less Colour change • Hyperpigmented • Retains colour Resistance to trauma • Poor tolerance • Better tolerance Hair growth • None • Grows after a long time
  18. INDICATIONS 1-Skin loss: • Post-traumatic • Post surgical • Pathological process e.g venous ulcer • Extensive burn 2- Mucosal loss: • After excision of leukopakic patch in oral cavity • Vaginal agenesis
  19. CONTRAINDICATIONS  Absolute contraindications: • Wounds with an active infection of streptococcus (100000 bacteria/ gram of tissue), active bleeding, and known cancer. • Wounds with exposed bone, tendon, nerve, or blood vessel without appropriate vascular layer.  Relative contraindications: • Wounds over joints or key anatomic landmarks in which contraction would reduce mobility and/or aesthetics (i.e., wrist, elbow, eyelid) • Previously irradiated wounds. • Infection with pseudomonas
  20. PHYSIOLOGY OF GRAFT UPTAKE 3 phases: • Plasmatic imbibition • Revascularization - Vascular inosculation & Neovascularization • Organization
  21. PLASMATIC IMBIBITION • Plasmatic circulation, also called serum imbibition, during the first 48 hours nourishes the graft with plasma exudate from host bed capillaries. • Imbibition allows the graft to survive this period
  22. REVASCULARIZATION  Starts after 48 hours and include two process • The primary is neovascularization in which blood vessels grow from the recipient bed into the graft. • Secondary is inosculation in which graft and host vessels form anastomoses.
  23. ORGANIZATION • Begins immediately after grafting with a fibrin layer at the graft-bed interface, holding the graft in place. • This is replaced on post graft day 7 with fibroblastin • Grafts are securely adherent to the bed by days 10 to 14.
  24.  Lymphatic circulation • Parallels restoration of blood supply over the first week Completed • At the end of first week graft begins to lose weight.  Epidermal proliferation • Start on 4th and 8th day post transplant • Persists for several weeks  Nerve • Reinnervation and return sensory function : 4-5weeks to months or years • Full sensation may never completely return • Pain returns first, with light touch and temperature returning later.
  25.  Appendages 1. Sweating • Dependent on no. of transplanted sweat glands & degree of sympathetic reinnervation • Better in thicker STSG and FTSG only 2. Sebaceous & eccrine glands • Degenerate initially • Subsequent glandular regeneration • Sebaceous gland activity mostly in thicker graft SSG 3. Hair grows from FTSG if well taken with no complications  Collagen replacement from day 7 to week 6
  26. SKIN GRAFT CONTRACTURE  All skin grafts undergo primary and secondary contractures. 1. Primary contracture • Is the immediate reduction in the size of skin graft after it has been harvested, caused by passive recoil of elastin fibers in the dermis. • As FTSGs have a greater amount of dermis, primary contracture is more significant in FTSG than STSG. (FTSG 40%, Intermediate thickness SSG- 20%, Thin SSG 10%) 2. Secondary contracture • Is the shrinkage of the skin graft in the wound bed over time, caused by myofibroblasts. • Secondary contracture is greater for STSGs than FTSGs, as the additional dermis in FTSGs is resistant to the pull of myofibroblasts. • Clinically, STSG placement should not be in aesthetically sensitive areas that could become deformed with contractures such as around the eyelids, face, and mouth.
  27. DONOR SITES  Donor site considerations include color, texture, thickness, amount of skin required, and scar visibility. 1. STSG: • The donor site should be chosen based on the amount of skin graft needed, surgical positioning of the patient, ease of donor site harvest, and aesthetics. • Broad, flat regions like the anterolateral thighs, back, trunk, lateral arm/forearm, lateral lower leg serve as the easiest donor sites when using a mechanical dermatome because they are firm surfaces against which the dermatome operator can push. • Aesthetically, donor sites that will be routinely covered by clothing are typically chosen, such as the thighs. • In large wounds or burns, donor sites are subject to limitation by the location of remaining healthy skin.
  28. • The original donor site may be used again for a subsequent split-thickness skin graft harvest. • Thin STSG - Average 2-3 week • Thick STSG – 3-4 weeks • Donor site should be cover with paraffin, Gauze and Bandage and primary to kept in situ for 2 weeks, except in cases of suspected infection. 2. FTSGs • are taken from areas at which the skin is thin and can be spared without deformity, such as the upper eyelids, postauricular crease, supraclavicular area, hairless groin, or elbow crease. • donor sites must be closed primarily because there are no remaining epithelial structures to provide re-epithelialization.
  29. “Modified graft cutting razor” described by Humby in 1936 Braithwaite's skin grafting knife, stainless-steel, by Allen and Hanbury, 1955. Watson's skin grafting knife prototype made following his instructions by Allen and Hanbury Cobbet's modification of braith waite design
  30. (A) Humeca Battery operated dermatome. (B) Padgett Dermatome. (C) Zimmer air dermatome. A C
  31. Split-thickness skin grafts can be meshed • To increase the overall size of the graft • Meshing can occur in various ratios such as 3/8 to 1, 1 to 1, 2 to 1, 3 to 1, and even 6 to 1 • Prevent fluid, blood, or seroma build-up between the recipient wound bed and skin graft
  32. • A tie over bolster of petroleum-infused gauze, cotton balls, and non-dissolvable suture is frequently placed on smaller STSG recipient sites. • A negative pressure wound vacuum is another viable option for areas that are difficult to bolster. • In cases of large volume STSGs, petroleum- infused gauze and bulky gauze/kerlix are placed over the grafts. • The grafts should not be left open to the air.
  33. GRAFT FAILURE • Inadequate recipient bed (poor vascularity) • Hematoma(MC), seroma • Inadequate graft fixation and graft shearing • Infection (in particular Streptococcus, which can “eat up” a graft within 24 hours) • Technical errors (too thick or too thin graft, upside-down graft) • Systemic health problems and nutritional status.
  35. TERMINOLOGY • Flap base- proximal part when the whole flap insert into the defect • FLAP pedicle – proximal part when the only distal part of flap inserted into defect • Flap bridge – central part when the only distal part of flap inserted into defect • Pennisular flap – flap passes in whole into the defect • Island flap – pedicel is deepithelised and tunneled to reach defect
  36. • Delayed flap - delaying of the flap by incising outline but not elevating the flap • Expanded flap – delaying of the flap by tissue expander inserted under the flap • The crane principle – temporary flap for a short period and than returned to its location, leaving behind a layer of tissue at the recipient site for a skin graft
  37. PRINCIPLE FOR FLAP SURGERY PRINCIPLE I • Replace Like With Like • Ralph Millard once said, "when a part of one's person is lost, it should be replaced in kind, bone for bone, muscle for muscle, hairless skin for hairless skin, an eye for an eye, a tooth for a tooth.“ • If this cannot be accomplished, use the next most similar tissue substitute.
  38. PRINCIPLE II • Think of Reconstruction in Terms of Units • According to Millard, human beings may be divided into 7 main parts: the head, neck, body, and extremities. Each of these body parts can be further subdivided into units. The head, for example, is composed of several regional units: scalp, face, and ears. • Consider that each of these units has its own unique features, and each feature has, in turn, multiple subunits with their own special shapes. All of these different units and subunits must be considered and reproduced during reconstruction
  39. PRINCIPLE III • Always Have a Pattern and a Back-up plan • Once a plan has been determined, rehearse it • Surgeon should ask him or herself "what do I do next if this fails?" • Proceed to the operating room only after answering this question definitively. • Once in the operating room, keep an open mind and be ready to adjust the surgical plan as the situation dictates.
  40. PRINCIPLE IV • Steal From Peter to Pay Paul • “Steal from Peter to pay Paul, but only when Peter can afford it." Using what the body has to reconstruct a deficit is essentially "robbing the bank’’ • The goal to achieve is ultimate efficiency, or, according to Millard, "getting something for almost nothing • Do not make the naive mistake of merely advancing tissue to the deficient area unless this can be accomplished completely without tension.
  41. PRINCIPLE V • Never Forget the Donor Area • If reconstruction of the primary defect is too costly in terms of resultant deformity or disability, reevaluate and use another reconstructive option.
  42. PHYSIOLOGY Changes of a flap and the recipient site after elevation and transfer:  After 10-24 hours – • Decreased arterial supply • Congestion and edema • Dilation of arterioles and capillaries  After 1-3 days - • Increased number and quality of Anastomoses between flap and recipient bed • Increased number of small vessels in pedicle
  43.  After 3-7 days • Reorientation of vessels along the long axis of the flap; anastomoses created at 1-3 days now functionally significant  After 1 week • Circulation well established between flap and recipient bed  After 2 weeks • Continuous maturation of anastomoses  After 3 weeks • Flap achieves 90% of its final circulation
  44. INDICATIONS • When primary repair is unobtainable (To cover wider and deeper defects ) • The wound bed is not amenable ot grafting(such as those with exposed bone or tendon) • The aesthetic are unfavorable for grafting • Covering vital structure • To cover bone, tendon and cartilage • If graft repeatedly fails
  45. CLASSIFICATIONS OF FLAPS  Skin-bearing flaps are classified according to three basic characteristics 1. Composition 2. Method of movement 3. Blood supply
  46. COMPOSITION REFERS TO THE TISSUE CONTAINED WITHIN THE FLAP 1. Cutaneous 2. Musculocutaneous 3. Fasciocutaneous 4. Osseocutaneous 5. Adipofascial 6. Sensory flaps
  47. THE METHOD OF MOVEMENT 1. Local transfer as with advancement or rotation flaps 2. Distant transfer as with pedicle flaps from the abdomen to the perineum 3. Microvascular free flaps
  48. WITH REGARD TO BLOOD SUPPLY 1. RANDOM PATTERN- which means that it derives its blood supply from the dermal and subdermal vascular plexus of vessels supplied by perforating arteries. 2. AXIAL FLAP - designed to include a named vessel running longitudinally along the axis of the flap to penetrate the overlying cutaneous circulation at multiple points along the course of the flap’s length to provide greater length and reliability.
  49. LOCAL FLAPS  Local flaps contain tissue lying adjacent to the defect that usually matches the skin at the recipient site in color, texture, hair, and thickness.  Should be the same size and thickness as the defect and be designed to avoid distortion of local anatomic landmarks, such as the eyebrow or hairline.  Planned so that the donor site can be closed directly but In some cases, the site from which the flap is raised is closed with a skin graft.  Rely on the inherent elasticity of skin and are most useful in the older patient.
  50.  Commonly used Local flaps include- • Rotation flaps • Transposition flaps • Advancement flaps
  51. ROTATION FLAPS  Are semicircular flap of skin and subcutaneous tissue  Revolve in a and arc around a pivot point to shift in a circle  Provide the ability to mobilize large area of tissue with a wide vascular base for recontstruction.
  52. TRANSPOSITION FLAPS  Are rectangular or square and turn laterally to reach the defect  Donor site can be closed primarily.
  53. RHOMBOID FLAPS  One of the example of traansposition flap  Useful for repairing defects of the medial and lateral canthi, cheeks, and lateral upper two- thirds of the nose.  It relies on the loosness of adjacent skin to transfer a rhomboid shape flap into a defect that has been converted into similar rhomboid shape
  54. Figure 2: Flap with sinus excised.
  55. Figure 3: Fasciocutaneous flap raised. Figure 4: Flap stitched.
  56. Z plasty  One of the example of transposition flap  It involve transposition of two inter-digitating triangular flaps without trnsion to use lateral skin to produce a gain in length.  There is change in direction as well as gain in length of the common limb of Z  Most important factors are angle size and length of the limb  Used in contracture release like dupuytren’s contracture, release of burn contracture, pilonidal sinus.
  57. BILOBED FLAP  Consist of two lobes of skin and subcutaneous tissue based on a common pedicle  Design • Primary flap is smaller than the defect • Secondary flap is more triangular in shape • Optimal angle between the two flaps is 90 degree, can vary between 45 to 180 degree, • Greater tha angle, larger the dog ear
  58. • Zitelli modification • Primary flap is oriented to 45 degree, and secondary flap is oriented to 90 degree- emilinared dog ear • Convert the defect to a “tear drop” shape by the excision of a triangle on the sides of pedical base.
  59. ADVANCEMENT FLAP  Advancement flap move directly forward and rely on skin elasticity tp stretch and to fill a defect  No rotation or lateral movement is applied  It is of 3 types • Single pedicle advancement flap • Bipedicle advancement flap • V-Y advancement flap
  60. Single pedicle advancement flap
  61. Bipedicle advancement flap
  62. V-Y advancement flap  Advancement skin on each side of a V- shaped incision to close the wound with Y shaped closure  V-Y pedicle plasty technique allow most patients to regain sensation and two point discrimation in the fingertip
  63. MUSCLE AND MUSCULOCUTANEOUS FLAPS  Consideration of a muscle as a potential flap is possible because muscles have an independent, intrinsic blood supply.  Compared with skin flaps, muscle flaps have more robust blood supply and demonstrate superiority in wounds compromised by irradiation or infection  A major consideration with muscle flaps is whether the loss of function is acceptable.  If some portion of the muscle chosen as the flap is left innervated and attached at its insertion and origin, function is preserved after the transfer of the remainder of the muscle.
  64.  This can be done by splitting the muscle into segments, provided each is supplied by a different dominant pedicle  MUSCULOCUTANEOUS FLAP • Also called a myocutaneous flap, is a muscle flap designed with an attached skin paddle. • Each superficial skeletal muscle carries blood supply to the skin lying directly over it through musculocutaneous or septocutaneous perforators
  65. Type I: Single pedicle (e.g., gastrocnemius, tensor fascia lata) Type II: Dominant pedicle with minor pedicles (e.g., gracilis, trapezius) Type III: Dual dominant pedicles (e.g., gluteus maximus, serratus anterior) Type IV: Segmental pedicles (e.g., sartorius, tibialis anterior) Type V: Dominant pedicle, with secondary segmental pedicles (e.g., latissimus dorsi)
  66.  In terms of reliability of the vascular anatomy and usefulness as a flap, large muscles with a recognized dominant pedicle supplying most of a flap (types I, III, and V) are most useful.  The territory of the pedicles in type II muscles may vary  type IV muscles are useful only when smaller flaps are needed
  67. TENSOR FASCIA LATA • Application – coverage of lower abdominal wall, perineum, ischium and sacrum • Vascular anatomy: ascending branch of lateral circumflex femoral (off profunda femoris)
  68. • The flap is outlined using an anterior edge axis of the antero-superior iliac spine to lateral patella (yellow line) and the axis of the femur (green line). • The anterior axis of the flap is the former, and the posterior axis is the latter. • The level of entry of the perforator into the TFL is approximately the level of the junction of the proximal and middle third of the ASIS- lateral patella axis. • The distal flap is incised and the deep aspect of the flap is raised distal to proximal. • The perforator to the muscle is large and easily identified. • It is surrounded on all sides and the pedicle is traced to the lateral circumflex femoral vessels.
  69. Residual left inguinal lymph nodal mass (postradiotherapy) Defect created after inguinal block dissection Flap after dissecting all around
  70. The free end of the flap was rotated upward and medially to the defect Primary and donor site approximated without tension
  71. GASTROCNEMIUS MUSCLE FLAP • Application – Reconstruct defects of the proximal tibia and knee. • Vascular anatomy: Each head of gastrocnemius is supplied by the sural artery, which is branch of the popliteal artery;
  72. • The sural nerve and lesser saphenous vein are encountered while dissecting to the muscular fascia. • The deep fascia is divided and the popliteal space is entered. • By identifying the popliteal vessels, the branches to the gastrocnemius can easily be identified.
  73. The branch to the medial gastrocolic artery can be traced under the muscle and the entrance of the pedicle into the muscle can be identified. The origin of the muscle is divided.
  74. The distal muscle is divided and the flap is isolated on the pedicle.
  75. Gastrocnemus muscle flap
  76. TRAPEZIUS • Application- Skull, head and neck, oral cavity, shoulder, mandible fascial reanimation • Vascular anatomy: Transverse cervical artery
  77. Patient slightly tilted away from the side of the flap to expose the upper back, just beyond thoracic spinal processes Start by identifying the anterior edge of the trapezius muscle
  78. Anteriorly the transverse cervical vessels are encountered Flap rotated into position
  79. Primary closure of door site
  80. TRAPEZIUS FLAP FOR COVERAGE OF THE RIGHT SHOULDER. A) Cutaneous metastasis of breast cancer at the right shoulder. B) Status after resection C) Preparation of the myocutaneous trapezius muscle from caudal to cephalic. D) Identification of the deep branch of the cervical artery and vein.
  81. E. Transposition of the myocutaneous flap. F. Intraoperative insert of the flap. G,H. Postoperative result
  82. GRACILIS FLAP • Application- Gracilis flap involves transfer of a fresh gracilis muscle for a deficit or defect involving major muscle loss or atrophy, utilizing microvascular anastomoses for muscle revascularization and reinnervation, to allow the transferred gracilis muscle to become a functional muscle. • Vascular anatomy:  Gracilis vessels from the medial femoral circumflex system  Vein(s): Two venae, one usually slightly larger than the artery
  83. The gracilis vessels take origin from the medial femoral circumflex system, a branch of the profundda femoral vessels. The incision is marked over the axis of the muscle, two to three finger breadths below the easily palpable adductor longus muscle.
  84. • The pedicle is identified by incising the muscular fascia over the gracilis muscle and retracting the space between the gracilis and adductor longus. • The pedicle is traced back to its origin by exposing it between the planes of adductor longus and magnus. • After exposing the pedicle, the proximal and distal insertions need only be detached and the minor pedicles divided.
  85. a. Pelvic floor defect after pelvic exenteration and design of gracilis flaps on the inner side of both thighs. b. The flap is freed with the proximal end of the muscle as a pedicle. c. The skin was removed, and the muscle and subcutaneous tissues of the fascia were retained to prepare the gracilis adipofascial flap. The flap was rotated at 180° into the pelvic floor defect through the subcutaneous tunnel. d. The pelvic floor defect was repaired with the gracilis adipofascial flap. e. The recipient and donor sites were sutured. f. 8 months postoperatively.
  86. GLUTEUS MAXIMUS FLAP  Application- Sacrum, ischium, trochanter, breast reconstruction  Vascular anatomy: • Dominant – superior gluteal artery, inferior gluteal artery • Minor- first perforator of profunda femoris, intermuscular branches of lateral circumflex femoral artery.
  87. • The orientation and position of the flap is marked. • It begins medial two or three finger breadths below the upper aspect of the gluteal crease. • It then angles superiorly and laterally as depicted. • The flap is elevated from superior and lateral to medial, deep to the muscular fascia. • The exit of the dominant perforator from the gluteus must be identified. • When the dominant perforator(s) is found, it is traced through the muscle and between the piriformis and gluteus medius.
  88. Gluteus maximus flap. (A)Large defect in the sacral region. (B) Myocutaneous gluteus maximus flap before transposition. (B) (C) Operative situs after skin closure. (D) Postoperative result.
  89. SARTORIUS MUSCLE FLAP  Application- Coverage, reconstruction  Vascular anatomy: • This muscle derives its segmental blood supply from the superficial femoral artery (SFA). • The sartorius muscle flap is performed by mobilizing the muscle along its lateral edge to preserve the medially based blood supply.
  90. Both skin incisions are made with a skin bridge of at least 5–7 cm to preserve skin viability. A. Quadriceps defect with patella exposed B. Sartorius muscle is harvested with preserved vascular pedicle • The sartorius tendon is prepared. Sutures are passed through the predrilled patellar tunnels to secure the transferred muscle to the superior pole of the patella. • Tighten the attachment with reinforcement proximally and distally.
  91. PECTORAL MAJOR MYOCUTANEOUS FLAP  Application- Coverage, reconstruction, functional, free flap  Vascular anatomy: • Dominant – pectoral branch of thoracoacromial artery • Minor- pectoral branch of lateral thoracic, minor segmental internal mammary perforators artery.
  92. LATTISMUS DORSI FLAP • For reconstructing large defects of the head, neck, and chest, whenever a defect requires broad soft-tissue coverage • Based on the thoracodorsal artery which is a terminal branch of the subscapular artery
  93. FASCIAAND FASCIOCUTANEOUS FLAPS  Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous tissue and the underlying fascia.  If raised without skin referred to as fascial flaps.  Provide coverage when a skin graft is insufficient for coverage. eg, in coverage over tendon or bones.  Less bulky, fasciocutaneous flaps are indicated when thinner flaps are required  Are not as resistant to infection as muscle flaps.  Monitoring flap failure occasionally can be difficult
  94. MATHES AND NAHAI CLASSIFICATION OF FASCIOCUTANEOUS FLAP (1997) Type A– Flap with direct cutaneous pedicle to the fascia. Eg. H&N: Scalp, paramedian forehead and temporoparietal fascial flaps; Upper limb: Flaps based on digital and dorsal metacarpal arteries; Trunk: Groin and hypogastric flaps; Superficial external pudendal artery; Lower limb: Gluteal-thigh, pudendal-thigh flaps, sural artery, saphenous flaps and toes for transfer. Type B– Flap with a septocutaneous perforator. Eg. Trunk: Supraclavicular, scapular and parascapular flaps; Upper limb: Lateral and medial arm, Antecubital, Radial forearm, Radial and ulnar recurrent, PIA (posterior interosseous) flaps; Lower limb: ALT (Antero-lateral-thigh, ATA, Dorsalis pedis, PTA, Peroneal artery, Medial and lateral plantar artery flaps. Type C– Flap with perforators from a musculocutaneous source. Eg. Median forehead, Nasolabial, Deltopectoral (DP), Thoracoepigastric (transverse abdominal), Transverse back flaps, ALT flaps.
  95. FOREHEAD FLAP • Draws its blood supply from supratrochlear artery.
  96. TEMPOROPARIETAL FASCIAL FLAP Draws its blood supply from the superficial temporal artery
  97. The incision is in the preauricular area and is fashioned in a "Y" shape in the scalp, to allow for exposure of the fascia.
  98. • The skin flaps are elevated just deep to the hair follicles, with care being taken not to amputate the follicles. • The dissection is usually done sharply with a knife, while the assistant follows with bipolar electrocautery. When the skin flaps are elevated, the superior aspect of the STF flap is incised down to the deep temporal fascia.
  99. Elevation at this level is quite quick, where an areolar plane separates the deep temporal fascia from the superficial temporal fascia. The flap is isolated on the vascular pedicle.
  100. A. Right orbital and facial defect after exenteration for basal cell carcinoma. B. Drawing showing approximate position of the superficial temporal vessels. C. Temporoparietal fascial flap brought into the orbital defect. D. Intraoperative appearance after skin graft. E. Appearance 7 months postoperatively.
  101. REVERSE SURAL FLAP • The reverse flow sural artery flap draws its blood supply from the perforators that communicate between the peroneal artery and median sural artery around the ankle joint. • The most consistent perforators are at a distance of 4–7 cm from the lateral malleolus. • The flap also derives its blood supply through the vasa vasorum of the short saphenous vein (venocutaneous perforators) and the vasa nervorum of the sural nerve. • As the blood flows from distal end to the proximal end of the flap, it is named as “reverse” sural artery flap.
  102. GROIN FLAP • The groin flap is a vascularized axial flap based on the superficial circumflex iliac artery arising from the femoral artery just below the inguinal ligament. • It is used regularly by many reconstructive surgeons for covering soft tissue defects of the hand
  103. • The axis of the flap is a finger breadth below the inguinal ligament. • A Doppler can be used to define the distal course of the artery.
  104. • When the fascia over sartorius muscle is identified, it is incised and entered. • The dissection proceeds medially deep to this fascial layer, elevating the pedicle from lateral to medial. • When the origin of the artery and vein are identified, the flap is isolated on the vascular pedicle.
  105. Regional abdominal flap for fasciocutanous axial
  106. THE ANTEROLATERAL THIGH (ALT) FLAP • Blood supply: Descending branch of lateral femoral circumflex artery.
  107. • The maximum width of the flap is judge with a pinch test. • Donor sites that can not be primarily closed are skin grafted. • The anterior flap is raised and perforators are identified to the flap and spared. • The posterior flap is elevated and the perforators to the flap are surrounded. • The dominant perforator(s) is chosen.
  108. • The perforators usually travel through muscle and must be dissected free. A bipolar cautery can be used. • The pedicle can be traced to the origin to gain length.
  109. Anterolateral thigh – free flap
  110. POSTERIOR TIBIALARTERY FLAP • Coverage defects in the lower limb, particularly in the leg, are quite a challenge due to the particulars of the anatomy in said area, such as the presence of bony prominences, soft tissue shortage and limited skin elasticity
  111. Identification of perforating artery through the fascia.
  112. Perforator flap- based on posterior tibial artery
  113. Perforator flap – posterior tibial artery +transposition
  114. MICROVASCULAR FREE TISSUE TRANSFER/FREE FLAP  Transplants distant tissue with its arterial and venous supply from another part of the body to be anastomosed to vessels at the recipient site.  The transferred tissue may be skin, fat, muscle, cartilage, fascia, bone, nerves, bowel, or omentum as needed to reconstruct a given defect.  Selection of tissue for transfer depends on the size, composition, and functional capabilities of the tissue needed; technical considerations, such as vessel size and pedicle length; and donor site deformity that will be created with regard to function and aesthetic appearance.
  115.  Muscle does not tolerate warm ischemia for longer than 2 hours; skin and fasciocutaneous flaps can tolerate ischemia times of 4 to 6 hours.  Planning is the most important factor to minimize the effects of ischemia, and all structures at the recipient site should be ready for the tissue transfer when the donor pedicle is divided.  Vein grafts have been shown to reduce the success rate and are not a primary choice but may be needed if the pedicle is short or the vessels in the field are damaged.  Both end-to-end and end-to-side arterial anastomoses have similar patency rates, although end-to-side anastomosis is preferred if there is vessel size or wall thickness discrepancy or the continuity of the recipient vessel must be preserved
  116.  Most free flap thromboses occur in the first 48 hours after surgery, and With reexploration, salvage rates have been seen to vary from 54% to 100% in different series.  Tissue survival rates for free tissue transfers exceed 98%.  Reexploration rates range from 6% to 25%,
  117. TRANSVERSE RECTUS ABDOMINIS FLAP • It is either superior pedicle based on the superior epigastric vessels or inferior pedicle based on the inferior epigastric • Superior pedicle based is used to cover postmastectomy area or chest wall defect. • Inferior pedicle flap is used to cover the defect in groin and thigh.
  118. Osteofasciocutaneous free fibula flap
  119. Free Lattismus dorsi flap
  120. LOCAL FLAPS  Advantages: • Best local cosmetic tissue match. Often a simple procedure. • Local or regional anesthesia option.  Disadvantages: • Possible local tissue shortage • Scarring may exacerbate the condition.
  121. DISTANT FLAPS  Advantages: • Good blood supply and good take up. • Gives bulk, texture and colour to the area  Disadvantages: • Lone term hospitalization • Infection • Kinking, rotation and flap necrosis • Staged procedure.
  122. GRAFT FLAP Limited to transplant of skin Can carry other tissue Depends on recipient site on nutrition As its own blood supply Cosmetic- may discolor or contract Better color take and less likely to contract Less adaptable to wight bearing Mist adaptable to weight bearing Less able to survive on a bed with questionable nutrition Can be used on a bed with questionable nutrition Requires pressure dressing Does not requires pressure dressing Cannot bridge defect Can bridge defect.