Plastic and reconstructive surgery presentation

1. Plastic and reconstructive
surgery
Dr. Shubhanshu

2. Outline
• Anatomy and physiology
• Various type
• Principle of flap
• How to manage difficult and complex tissue
loss

3. Trauma
• Soft-tissue loss (skin, tendons, nerves, muscle)
• Upper and lower limb injury

4. Anatomy

5. Plastic surgery principles
• Adequate debridement or resection
• Wound or flap must have a good blood supply to
heal
• Gentle handling of tissue
• Minimal skin tension
• Replace defect with similar tissue – ‘like with like’
• Optimum Surgical technique
• Remember donor site ‘cost’

6. How does a skin graft survive?
• Imbibition plasma from the wound bed
• Inosculation of blood by after 48 hours fine
anastomotic connections
• Capillary ingrowths
• Granulation will support a graft
• Contraindicated to cover exposed
tendon/cartilage/cortical bone

7. Grafts
• Without their blood supply
– Split-thickness skin grafts (varying thickness)
• Thiersch grafts
• Cover all size of wound
• Contract
– Full-thickness skin grafts
– Wolfe grafts
– For Smaller area, not contract, Used in fingers

8. Grafts
– Composite skin grafts
• usually skin and fat, or skin and cartilage
• Rebuilding missing element like finger tip
– Nerve grafts
– Tendon grafts

9. Flap
• Transferred with a blood supply
– Random flaps-length to breadth ratio within 1.5:1
– Axial flaps
– Pedicled flaps
– Free flaps
• Composite flaps - osseocutaneous or myocutaneous
flaps
– Perforator flaps

11. Initial assessment
• Adequate removal of devitalized tissue
• vital structures reconstruction immediately or
better reconstructed later
• Degree of contamination require debridement
further
• Definitive soft-tissue cover of the wound

12. In Orthopedics
• Skin grafts – Split thickness, Full thickness
• Rotational flap
• Cross leg flap
• Biceps femoris flap
• Gastrocnemius flap
• Soleus flap
• Sural flap
• Peroneous flap

14. Concern
• Contracture
• Venous congestions
• Flap ischemia
• Loss of sensation

15. Skin graft
Grab skin so become tense
cut graft with humpley knife
Dress donar with calcium
alginate redress after 10 days
Apply graft directly over
wound
Apply dressing redress after
5 days

16. Rotational Flap
Draw Isosceles triangle around
defect apex towards centre of arc
rotation of flap
Draw arc
Raise skin subcutaneous tissue
Place flap over wound
• For Sacral pressure sore

17. Cross Leg flap
• cover open fractures of the tibia and fibula
with extensive soft tissue loss.
• Cross-arm flaps and cross-thigh flaps can be
created using the same principle.

18. Cross Leg Flap
Preplan 24 hr before
Preserve long saphenous
vein
Length breadth ration
upto 1:1
Elevate the planned flap from the opposite leg, raising the deep fascia with
the flap
Take a split skin graft from the thigh of the recipient leg and dress the donor
Ensure that there is no tension or torsion on the flap area

19. • Perform a ‘delay’ procedure after 2 week
• Partially dividing the base and then re-
suturing this wound.
• At 3 week divide the flap completely
• Suture the flap into place avoiding tension &
proximal portion to its donor site.

20. For Ischial pressure sores
BICEPS FEMORIS FLAP
Prone position
Excise whole lining to ischial pressure sore and
reduce ischial tuberosity by osteotome
Draw line from ischial tuberosity to head of fibula
Mark elliptical flap 8-10cm extending proximal to defect and
distally within 5 cm of crease of knee joint
Incise along line to biceps femoris
Divide origins of biceps femoris, semitendinosus and semimembranosus muscles at the ischial tuberosity
Divide biceps femoris tendon at distal margin of flap
Divide semimembranosus and semitendinosus distally to provide greater mobility of flap
Suture for at least 3 weeks

21. GASTROCNEMIUS FLAP
• Both heads of the gastrocnemius muscle can be used
separately
• M/C Medial Head
• Used as simple muscle flaps or as myocutaneous flaps.
– Anterior upper third of tibia
– Exposed knee joint
– Exposed metal prosthesis
• The muscle flap alone is more malleable and versatile
than myocutaneous flap.
• Do not use both heads simultaneously.

22. GASTROCNEMIUS FLAP
Take incision identify both bellies and their attachment
Separate fascia incise tendon just distal to muscle attachment
Elevate the muscle belly proximally by dissecting laterally and medially
Free the muscle belly to the level of the popliteal fossa, preserving vascular pedicle
passing into it
Create a subcutaneous tunnel from the base of the muscle belly to defect and enlarge
to accommodate muscle flap
Pass the muscle belly through this tunnel into the defect
Take a thick split skin graft from the thigh and apply it to the exposed muscle in the
defect
Allow weight-bearing at 10 days & mobilize progressively
Fit an elastic support stocking to cover the graft overlying the muscle(for 3 month)

25. Soleus Flap
An incision is made on the medial aspect of the leg commencing approx 10
cm below the popliteal fossa extending to the achilles tendon
Soleus and gastrocnemius muscles are identified and separated.
Hemisoleus is then divided from its insertion at the achilles tendon and
dissected cephalad to allow for a sufficient arc of rotation to cover the defect
Two sets of perforating vessels are divided to achieve this
Hemisoleus is then inset into the defect and sutured in place
split-thickness skin grafts (STSG) to cover the muscle

28. • Most common usage of this flap is for the distal-third defects of the
leg.
• The reverse sural flap permits the soft tissue reconstruction without
the need for microsurgery.
Sural Flap
flap is marked on the skin in the form of an ellipse centered on the raphe between the two
gastrocnemius muscle bodies, whose projection is visible on the posterior aspect of the leg
The incision starts on the lateral and superior borders of the flap and continues in the
subfascial plane until the sural nerve is identified in the median raphe
Then the incision goes on the other boundaries of the flap and the subfascial dissection
continues with the ligation of all the perforators from the gastrocnemius belly
The sural nerve is attached to the fascia at the superior border of the flap.

33. Peroneous Brevis flap
• Lower 1/3 leg wound
• Distal leg ankle
• Lateral Malleolous,
• Proximal calcaneus
• Achilles
• Medial malleolous
• Ankle joint
Intact peroneal artery perforators

34. Peroneous Brevis Flap
Identify peroneous brevis separate in distal to proximal
Preserve peroneous lie posterior surface close to posterior septum
Proximal connection of muscle to fibula was detached and muscle was dissected off
fibula in a proximal to distal direction leaving a thin layer of muscle attached to fibula
Preserve the superficial peroneal nerve, anterior tibial vessels to augment the
vascularity during harvest of flap
Covered with a split thickness skin graft

36. THANKYOU