Plastic surgery principles aim to optimize wound healing through adequate debridement and resection while ensuring good blood supply. Scars should be placed carefully along lines of minimal tension and defects replaced with similar tissue. Meticulous surgical technique and consideration of donor site costs are important. The skin has two layers - the epidermis which acts as a protective barrier and the dermis which provides strength and sensation. Grafts do not maintain their original blood supply while flaps do, allowing flaps to bring their own vascularity to the recipient site. Careful technique and consideration of various factors influence graft and flap survival.

1. Plastic Surgery

2. Plastic surgery principles.
 Optimise wound by adequate debridement or
resection
 Wound or flap must have a good blood supply to
heal
 Place scars carefully – ‘lines of election’a
 Replace defect with similar tissue – ‘like with like’b
 Observe meticulous surgical technique
 Remember donor site ‘cost’
 a:Lines of election – analogous to Langer’s lines of minimal skin tension.
 b: Millard DR. Principalization of plastic surgery. Boston: Little & Brown, 1986

3. Skin
EPIDERMIS
 No blood vessels.
 Relies on diffusion from underlying
tissues.
 Stratified squamous epithelium
composed primarily of
keratinocytes.
 Separated from the dermis by a
basement membrane.
 protective barrier (against
mechanical damage, microbe
invasion, & water loss)
 high regenerative capacity
 Producer of skin appendages
(hair, nails, sweat & sebaceous
glands)

4. Skin
DERMIS
 Composed of two “sub-layers”:
superficial papillary & deep
reticular.
 The dermis contains collagen,
capillaries, elastic fibers,
fibroblasts, nerve endings, etc.
 mechanical strength (collagen &
elastin)
 Barrier to microbe invasion
 Sensation (point, temp, pressure,
proprioception)
 Thermoregulation (vasomotor
activity of blood vessels and sweat
gland activity)

5. Schematic showing two neighbouring angiosomes. Note the choke vessels within
the muscle spanning the two cutaneous territories of angiosome A and B – two
common examples of myocutaneous flaps which utilise this physiology include
the rectus abdominus and the latisimus dorsi flaps.

6. SKIN: Anatomy

7. SKIN: Anatomy

9. Definitions
Graft
A skin graft is a tissue of epidermis and varying amounts
of dermis that is detached from its own blood supply and
placed in a new area with a new blood supply.
 “Grafts are tissues that are transferred without their blood
supply, which therefore have to revascularise once they
are in a new site.”
Flap
Any tissue used for reconstruction or wound closure that
retains all or part of its original blood supply after the
tissue has been moved to the recipient location.
 “Flaps are tissues that are transferred with a blood
supply. They therefore have the advantage of bringing
vascularity to the new area”

10. Graft vs. Flap
Graft
Does not maintain
original blood supply.
Flap
Maintains original blood
supply.

11. Classification of Grafts
1. Autografts – A tissue transferred from one part of
the body to another.
2. Homografts/Allograft – tissue transferred from a
genetically different individual of the same
species.
3. Xenografts – a graft transferred from an individual
of one species to an individual of another species.

12. Cla ssifica tion :
•According to their donor sites &
thickness:
Thin intermediate. Thick
Xenograft AllograftAllograft

13. Types of Grafts
Grafts are typically described in terms of thickness or
depth.
Split Thickness(Partial): Contains 100% of the
epidermis and a portion of the dermis. Split thickness
grafts are further classified as thin or thick.
Full Thickness: Contains 100% of the epidermis and
dermis.

14. Different type of skin graft
depending on the thickness of graft

16. Type of Graft Advantages Disadvantages
Thin Split
Thickness
-Best Survival
-Heals Rapidly
-Least resembles original skin.
-Least resistance to trauma.
-Poor Sensation
-Maximal Secondary
Contraction
Thick Split
Thickness
-More qualities of normal
skin.
-Less Contraction
-Looks better
-Fair Sensation
-Lower graft survival
-Slower healing.
Full
Thickness
-Most resembles normal
skin.
-Minimal Secondary
contraction
-Resistant to trauma
-Good Sensation
-Aesthetically pleasing
-Poorest survival.
-Donor site must be closed
surgically.
-Donor sites are limited.

17. Skin Grafts: “Process of Take”
 Plasmatic Imbibition:
 Initially graft ischaemic (24 – 48 hrs)
 Fibrin adhesion
 Imbibition allows the graft to survive this period
 ? Important for nutrition of graft
 ? Stops drying out

18. Skin Grafts: “Process of Take”
 Inosculation & capillary ingrowth:
 At 48 hrs
 Through fibrin layer
 Capillary buds from recipient bed contact graft vessels
 Open channels (neo-vascularization)
 pink graft

19. Skin Grafts: “Process of Take”
 Revascularization & fibrous attachment:
 Connection of graft & host vessels via anastomoses
(inosculation)
 Formation of new vascular channels by invasion of graft
(neovascularisation)
 Combination of old & new vessels (revascularisation)
 Fibroblast proliferation: conversion of fibrin adhesion 
fibrous tissue attachment (anchorage within 4 days)

20. Skin Grafts: “Process of Take”

21. Skin Graft Take
 Appendages:
- sweating dependent on no. of transplanted sweat
glands & degree of sympathetic reinnervation; will
sweat like recipient site in FTSG only
- sebaceous gland activity mostly in thicker grafts:
SSG usually dry & shiny
- hair grows from FTSG if well taken with no
complications

22. Skin Graft Healing
 Initially white then pinkens with new blood supply
 Lymphatic drainage by day 6
 Collagen replacement from day 7 to week 6
 Vascular remodelling for months

23. Skin Graft Healing
 Contraction:
- shrinks immediately due to elastic
recoil: – FTSG 40%; medium SSG 20%; thin
SSG 10%.
- secondary contracture as heals:
- FTSG remains same size after above
shrinkage;
- SSG will contract as much as possible;
- more dermis = less contraction
- ? Due to myofibroblasts

24. Skin Graft Healing
 Reinnervation:
 from margins to bed;
 Depends on graft thickness and bed;
 Uneventful healing leads to near normal;
 Cold sensitivity can be a problem

25. Skin Graft Expansion
 Based on principle that wounds reepithelialized from
the periphery
 Expansion provides larger areas from which
epithelium can grow
 Larger areas can be covered with less skin

26. Skin Graft Expansion
 Meshing
- covers large area
- easier to contour
- fluid can drain through holes
- cosmetic results less than ideal
- various mesh ratio

27. Meshed graft or sheet graft :
Advantages
Lager area
Contours irregular surface
Drain blood & exudates
Increase edges_______reepithilialization
Disadvantages
Much of wound heal 2*______contracture
Cobble stone appearance
Sheet Graft
Joint
Hands
face

28. Skin Graft Survival
 Meticulous technique
 Atraumatic graft handling
 Well vascularized bed
 Haemostasis
 Immobilization
 No proximal constricting bandages

29. Other Factors that Contribute to
Graft Failure
 Systemic Factors
 Malnutrition
 Sepsis
 Medical Conditions (Diabetes)
 Medications
 Steroids
 Antineoplastic agents
 Vasonconstrictors (e.g. nicotine)

30.  INDICATIONS OF SKIN GRAFT:
 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 a genesis

31.  Contraindications:
 1- Avascular recipient areas :
 - Cortical bone without periosteum
 - Cartilage without perichondrim
 - Tendon without paratenon
2- Infection :
 a- heavily infected wound with copious
discharge(100 000 bact./ gram of tissue).
 b- Infection by Beta haemolytic streptococcus

32. Donor Sites
The ideal donor site would provide skin that is
identical to the skin surrounding the recipient area.
Unfortunately, skin varies dramatically from one
anatomic site to another in terms of:
- Colour
- Thickness
- Hair
- Texture

33. Donor Sites

34. Donor site for FTG
 Post auricular skin
 Upper eyelid skin
 Supraclavicular skin
 Flexural skin
 Thigh and abdominal skin
 FTG should be clear of fat
 FTG sutured edge to edge while STG overlaps the
defect.
 Use quilting / tie over

35. Harvesting Tools
 Razor Blades
 Grafting Knives (Blair, Ferris, Smith, Humbly, Goulian)
 Manual Drum Dermatomes (Padgett, Reese)
 **Electric/Air Powered Dermatomes (Brown, Padgett,
Hall)
Electric & Air Powered tools are most commonly used.

41. Mesh grafting

43. Contraction of the graft

44. LINEAR CLOSURE
SKIN GRAFT
SKIN FLAPS
FREE FLAPS
MYOCUTANEOUS
/FASCIOCUTANEOUS
FLAPS

45.  Flaps – a partially or completely isolated segment of
tissue perfused with its own blood supply.
 A vascularized block of tissue mobilized from its
donor site and transferred to another location,
adjacent or remote for reconstructive purposes.
 May consist of skin, subcutaneous tissue, fascia,
muscle, bone or viscera (e.g.. Omentum)
 Reconstructive option of choice when padded and
durable cover needed
 Vary greatly in complexity…
from simple skin flap to microvascular free flap

46. History of Flaps
 Origin in India -2500-1500 BC
 Sushruta 800BC –forehead flap
 Charak Samhita
 Al-Zahrawi 10th century scholar
 Branca family of Italy
 Sir Harold Gillies – work on facial injuries, modern
plastic surgery

52. Flaps Uses
1. Replace tissue loss due to trauma or surgical
excision
2. Provide skin coverage
3. Provide padding over bony prominences
4. Bring in better blood supply to poorly vascularized
bed
5. Improve sensation to an area (sensate flap)
6. Bring in specialized tissue for reconstruction such
as bone or functioning muscle

53. Classification of Flaps
 Can be based on (five ‘C’ s)
1. Congruity
2. Configuration
3. Components
4. Circulation
5. Conditioning

54. Congruity
 Local – immediately adjacent to defect
 Regional – moved from adjacent region
 Distant – moved from remote anatomic area
 Pedicled – moved with intact tissue bridge for
support
 Islanded – no intact skin but moved under the skin
for non contiguous defects.

55. Configuration
 By design and method of transfer
1. Advancement
2. Rotation
3. Transposition
4. Interpolation
5. Pedicled

56. Components
 Skin flaps
 Containing purely another component than skin e.g.
muscle ,fascia ,bone ,bowel ,omentum etc.
 Myocutaneous
 Fasciocutaneous
 Osteocutaneous

57. Circulation
 Random pattern flaps
 Axial pattern flaps
1. Island axial pattern flaps
2. Free flaps

58. Conditioning
 Increasing flap safety – by enhancing its axiality
 Used in older days
 Invoking delay phenomenon
 Classically done by cutting down on either sides of flap to be
raised
 It opens up choke vessels
 Flap transferred 2-3 weeks later
 Particularly useful in higher risk patients
 e.g. Pedicled TRAM flap

62. SKIN FLAPS
 Use : 1.recipent bed with poor vascularity
2.coverage of vital structures ( to operate later
)
3.reconstructing full thickness structures e.g.
eyelid ,cheek, nose, lip, ear etc.
4.padding bony prominences
 Disadvantage : it can’t sustain over contaminated
(infected ) bed.
 Types : 1.those rotating around a pivot point
a)rotation b) transposition c)interpolation
2.advancement flaps
a)single pedicled advancement b) V-Y
advancement c)bipedicled advancement

65. Muscle and Myocutaneous flaps
Mathes and Nahai classification
 One vascular pedicle (eg, tensor fascia lata)
 Dominant pedicle(s) and minor pedicle(s) (eg, gracilis)
 Two dominant pedicles (eg, gluteus maximus)
 Segmental vascular pedicles (eg, sartorius)
 One dominant pedicle and secondary segmental pedicles (eg,
latissimus dorsi)

66. According to mode of innervation (Taylor)
Type I – single unbranched nerve enters muscle.
Type II- Single nerve, branches prior to entering.
Type III – Multiple branches from same nerve trunk.
Type IV – Multiple branches from different nerve trunks.
Affects suitability for functioning muscle transfer

67.  Uses of muscle and myocutaneous flaps :
1. Functional muscle flap for motor reconstruction
2. Sensate Myocutaneous flap for sensate
reconstruction
3. Coverage of complex wounds
4. Chronic vascular insufficiency
5. Chronic radiation wounds
6. Exposed or infected prosthesis

68. Local Flaps

70. Local flaps
Advantages
 Best local cosmetic tissue match
 Often a simple procedure
 Local or regional anaesthesia option
Disadvantages
 Possible local tissue shortage
 Scarring may exacerbate the condition
 Surgeon may compromise local resection

71. Rotation Flap
 Movement is in the direction of an arc around a fixed
point and primarily in one plane.
 This is a semi-circular flap.

72. Transposition flap
 The rectangular flap is rotated on a pivot point.
 The more the flap is rotated, the shorter the flap
becomes.
 Most commnly used in head and neck

73. Z plasty
 Creation of 2 triangular transposition flaps
 Length of both limbs must be same
 Angle may vary
 Uses :
1. Lengthning of scar
2. Changing direction of scar into more favorable one
3. Interrupt scar linearity

75. Rhombic flaps
 Specially designed transposition flaps for rhombic
shaped defects
 Defect must have 60 and 120 angles

77. Bilobed flaps
 Another variation of transposition flap
 2 transposition flaps sharing common pedicle
 First flap used to reconstruct defect ;second used for
donor site defect

78. Interpolation flaps
 Similar to transposition flap
 Difference is..pedicle rest over intervening tissue
 Pedicle divided and inset at second stage after
revascularization
 E.g. median forehead flap, thenar flap

79. Advancement flaps
 Moved primarily in a straight line from the donor site
to the recipient site.
 No rotational or lateral movement is applied.
 E.g. rectangular advancement, V-Y advancement
etc.

81. V-Y advancement flap
 Create a triangular-shaped flap with the base of the flap
at the cut edge of the skin where the amputation
occurred. It should be as wide as the greatest width of
the amputation
 Skin incisions are made through the full thickness of the
skin.
 Advance the flap over the defected area and suture it to
the nail bed.
 Place corner stitches to avoid interference with the blood
supply to the corners. Convert the V-shaped defect into a
final Y-shaped wound
 The V-Y pedicle plasty technique allows most patients to
regain sensation and two-point discrimination in the
fingertip.
 The cosmetic results are usually excellent, with good
contour and fingertip padding is preserved

83. Combined local flaps
 In some circumstances, such as burn contracture
release, local flaps can usefully be combined to
import surplus tissue from a wide area adjacent to a
scar or defect that needs removal.
 Examples are the W-plasty and the multiple Y-to-V
plasty, which is a very versatile means of releasing
an isolated band scar contracture over a flexion
crease

84. REGIONAL FLAPS
 As the distance of required flap transposition
increases, the incorporation of a defined blood
supply becomes critical.
 Classified as axial, however most flaps have random
pattern at their distal ends
 Utilized to cover large defects which require bulk
 Examples : 1. PMMF 2. DPF 3. Trapezius flap

96. Distant flaps

97. Pedicled flaps
 Distant flaps can be moved on long pedicles that contain the blood supply.
 The pedicle may be buried beneath the skin to create an island flap or left
above the skin and formed into a tube.
 Moving flaps long distances while still attached are with a long muscular
pedicle that contains a dominant blood supply (a myocutaneous flap) or
with a long fascial layer that likewise contains a major septal blood supply
(a fasciocutaneous flap)

98. Free flaps
 With fine instruments and materials it has become commonplace to be
able to disconnect the blood supply of the flap from its donor site and
reconnect it in a distant place using the operating microscope.
 The free tissue transfer is now the best means of reconstructing major
composite loss of tissue in the face, jaws, lower limb and many other body
sites, as long as resources allow it.
 Free muscle transfers should be reanastomosed within 1–2 hours.

99. Advantages
 Being able to select exactly the best tissue to move
 Only takes what is necessary
 Minimises donor site morbidity
Disadvantages
 More complex surgical technique
 Failure involves total loss of all transferred tissue
 Usually takes more time unless the surgeon is
experienced

100. Free-tissue donor sites

101. Principles
of flap
surgery
Principle I:
Replace Like
With Like
Principle II:
Think of
Reconstructio
n in Terms of
Units
Principle III:
Always Have a
Pattern and a
Back-up Plan
Principle IV:
Steal From
Peter to Pay
Paul
Principle V:
Never Forget
the Donor
Area

102. Monitoring of the flap
Tissue colour
warmth and turgor
assess blanching
capillary refill time.

103. Complications

104. Causes of flap
failure
poor anatomical knowledge when raising the flap
(such that the blood supply is deficient from the
start)
flap inset with too much tension
local sepsis or a septicaemic patient
the dressing applied too tightly around the
pedicle;