Plastic and reconstructive surgery aims to restore form and function through anatomical knowledge. It involves many areas including hands, aesthetics, microsurgery, burns, trauma, and oncology reconstruction. The document discusses skin anatomy, circulation, vascular territories (angiosomes), and various reconstructive techniques on a ladder from primary closure to flaps. It defines flaps as a unit of tissue transferred with an intact blood supply, and classifies them based on components, relationship to the defect, nature of blood supply, and movement.

2. PLASTIC AND RECONSTRUCTIVE
SURGERY
?

3. “….the application of
anatomical knowledge
to restore form and
function…”

4. ?
• Hands
• Aesthetics
• Microsurgery
• Craniomaxillofacial
• Burns
• Congenital
• Trauma and oncology reconstruction

5. 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

6. Anatomy of Circulation
• The vascular plexuses of the fascia, subcutaneous tissue and
skin are divided into 6 layers

8. 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

9. 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

11. 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)

12. 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)

13. Reconstructive ladder
• Primary closure

14. Simple closure
• Best result
• No tension
• Technique
dependent
• Sutures
• Staples, Tape,
Adhesive

16. Reconstructive ladder
• Primary closure
• Delayed primary closure

17. Reconstructive ladder
• Primary closure
• Delayed primary closure
• Secondary intention

18. Reconstructive ladder
• Primary closure
• Delayed primary closure
• Secondary intention
• Graft
– Transfer of tissue with no intrinsic blood supply

19. Graft
• Layers of the skin
• Split vs Full
• Other grafts
– Bone
– Tendon
– Nerve
– Composite

20. 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

22. Split skin graft

23. What is a Flap?
• 16th century Dutch word “flappe”
– ….something that hangs broad and loose ,
fastened only by one side..”

24. 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

25. Mathes&Nahai 1981
Muscle Flap Classification

26. 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

27. Nahai-Mathes Classification

28. 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

29. Flaps
• Simple or random patterned
– based on movement (advancement,
rotation, transposition
• Complex - named anatomic blood supply
• Local vs distant
• Pedicled vs Free (microvascular)