Principle of Plastic Surgery, plastic surgery notes

PLASTIC SURGERY
Presented By Prof. Amin
@2023 Prof. Amin's Presentation 1

PLASTIC SURGERY
• Plastic surgery is a unique specialty that defies definition, has no organ
system of its own, is based on principles rather than specific procedures,
and, because of cosmetic surgery, is the darling of the media.
• What is plastic surgery? No complete definition exists. { Joe McCarthy }
defines it as the “PROBLEM-SOLVING SPECIALTY.”
• Some people call plastic surgeons the “FINISHERS” because they come in
when “the other surgeons have done all they can do and the operation
has to be finished.”
• An even more grandiose definition is the following from a plastic surgery
resident:
• “PLASTIC SURGERY is surgery of the skin and its contents.” There is no
way to define this specialty that has acquired “turf” through a
combination of tradition and innovation.
• What is the common denominator between craniofacial surgery and hand
surgery? Between pressure sore surgery and cosmetic surgery?
• Because plastic surgery has loose boundaries and no specific anatomic
region, it faces competition from regionally oriented specialties.

• No specialty receives the attention from the LAY PRESS that plastic
surgery receives.
• AT THE SAME TIME, NO SPECIALTY IS LESS WELL UNDERSTOOD.
• Although the public equates plastic surgery with cosmetic surgery, the
roots of plastic surgery lie in its reconstructive heritage.
• Cosmetic surgery, an important component of plastic surgery, is but one piece
of the plastic surgical puzzle.
• Plastic surgery consists of reconstructive surgery and cosmetic surgery but
the boundary between the two, like the boundary of plastic surgery itself,
is difficult to draw.
• The more one studies the specialty, the more the distinction between cosmetic surgery
and reconstructive surgery disappears.
• Even if one asks, as an insurance company does, about the functional importance of a
particular procedure, the answer often hinges on the realization that the function of the
face is to look like a face i.e., function = appearance.
• A cleft lip is repaired so the child will look, and therefore hopefully function, like other
children.

• A graft refers to total detachment of tissue from one
part of the body and transferal to another part,
where it must establish its own blood supply.
• Graft can be:
• AUTOGRAFT:
• Transferral within the same individual.
• ALLOGRAFT:
• Transferral between individuals of the same species.
• XENOGRAFT:
• Transferral between different species.

SKIN GRAFT TYPES
• Skin grafts are classified as either:
• SPLIT-THICKNESS
• FULL-THICKNESS,
• Depending on the amount of dermis included.
• Split-thickness skin grafts contain varying amounts of dermis,
• Whereas a full-thickness skin graft contains the entire dermis
• All skin grafts contract immediately after removal from the donor site and
again after revascularization in their final location.
• PRIMARY CONTRACTION is the immediate recoil of freshly harvested
grafts as a result of the elastin in the dermis.
• The more dermis the graft has, the more primary the contraction that will be
experienced.
• SECONDARY CONTRACTURE, the real nemesis, involves contraction of a
healed graft and is probably a result of myofibroblast activity.
• A full-thickness skin graft contracts more on initial harvest (primary
contraction) but less on healing (secondary contracture) than a split-
thickness skin graft.

SPLIT-
THICKNESS
FULL-THICKNESS

Contains The Entire Dermis
Secondary Contracture
Primary The Contraction
Full-thickness
Split-thickness
SKIN GRAFT

• The thinner the split-thickness skin graft, THE GREATER THE SECONDARY
CONTRACTURE.
• Granulating wounds left to heal secondarily, without any skin grafting,
demonstrate the greatest degree of contracture and are most prone to
hypertrophic scarring.
• The number of epithelial appendages transferred with a skin graft
depends on the thickness of the dermis present.
• The ability of grafted skin to sweat depends on the number of glands
transferred and the sympathetic reinnervation of these glands from the
recipient site.
• Skin grafts are reinnervated by ingrowth of nerve fibers from the
recipient bed and from the periphery.
• FULL-THICKNESS SKIN GRAFTS have the greatest sensory return because
of a greater availability of neurilemmal sheaths.
• Hair follicles are also transferred with a full-thickness

Require well vasculazed bed
Shrink considerable Less shrinkage
FULL-THICKNESS
SKIN GRAFT
Match can be achieved
Few Adenexal structures maintained
Adenexal structures maintained
SPLIT-THICKNESS

REQUIREMENTS FOR SURVIVAL OF A SKIN GRAFT
• The success of skin grafting, or “take,” depends on the ability of the
graft to receive nutrients and, subsequently, vascular ingrowth from the
recipient bed.

SKIN GRAFT REVASCULARIZATION OR “TAKE” OCCURS IN THREE
PHASES.
a. The first phase involves a PROCESS OF SERUM IMBIBITION and lasts for
24 to 48 hours.
• Initially, a fibrin layer forms when the graft is placed on the recipient bed, binding the graft
to the bed.
• Absorption of nutrients into the graft occurs by capillary action from the recipient bed.
b. The second phase is an INOSCULATORY PHASE in which recipient and
donor end capillaries are aligned.
c. In the third phase, the graft is REVASCULARIZED through these “Kissing”
capillaries.
• Because the full-thickness skin graft is thicker, survival of the graft is more precarious,
demanding a well-vascularized bed.

The FIRST PHASE begins with placement of
the graft on the recipient bed, to which the
graft adheres because of fibrin deposition.
This lasts approximately 72 hours.
The SECOND PHASE involves
ingrowth of fibrous tissue
and vessels into the graft.

• To optimize take of a skin graft, the recipient site must be
prepared.
• Skin grafts require a vascular bed for that reason
• Exposed cortical bone,
• Bare tendons
• Cartilage
• There are exceptions, however, as skin grafts are frequently
successful inside the orbit or on the temporal bone, despite removal
of the periosteum.

• CLOSE CONTACT BETWEEN THE SKIN GRAFT AND ITS
RECIPIENT BED IS ESSENTIAL.
• HEMATOMAS AND SEROMAS under the skin graft will
compromise its survival, and IMMOBILIZATION of the graft
is essential.

A DIAGRAMMATIC REPRESENTATION OF THE PROCESS OF TAKE OF A FREE
SKIN GRAFT.
• The initial adhesion of the graft to the bed by fibrin,
• The growth of capillaries from the bed into the fibrin layer to link up with
the capillaries in the graft, and
• The growth of fibroblasts into the fibrin clot to convert the initial fibrin
adhesion into a fibrous tissue attachment

F L A P

FLAPS….
• A flap refers to tissue transferred to an adjacent or
distal site while retaining a functional vascular
attachment.
• Flaps transferred to a local site while maintaining their original
arterial and venous connections are known as Pedicled flaps.
• Flaps transferred to a distant site with microvascular anastomosis
of their native arterial and venous connections to vessels in the
recipient bed are known as Free flaps.

BLOOD SUPPLY OF THE SKIN:
☘ In the last 25 years, the ‘ANGIOSOME MODEL’ has furthered our
understanding of the anatomical blood supply of skin and therefore the
ability to reconstruct soft tissue defects using vascularised flaps of
various tissue compositions.
☘ With respect to its blood supply, the body can be envisaged as three-
dimensional segments of tissue called angiosomes, each with an arterial
supply and a venous drainage
! Blood equilibrates and flows between neighbouring angiosomes via
‘choke’ vessels, which tend to be situated within muscles.
! Cutaneous arteries, direct branches of segmental arteries (concentrated
at the dorsoventral axes and intermuscular septae), perforate the
underlying muscles or run directly within fascial layers to the skin from
the deep tissues…

o The blood supply to the skin anastomoses in subfascial,
fascial, subdermal, dermal and subepidermal plexi.
o The epidermis contains no blood vessels so cells
there derive nourishment by diffusion.
o The venous drainage of the skin is via both valved and un
valved veins.
o The unvalved veins allow an oscillating flow between
cutaneous territories within the subdermal plexus –
equilibrating flow and pressure.
o The valved cutaneous veins drain via plexi to the deep veins.

Three types of artery supply blood to the skin.
• DIRECT CUTANEOUS ARTERIES and veins emerge from deeper vessels.
Many of these arise in the axillae and groin (e.g. superficial thoracic artery,
superficial epigastric artery) but also at other sites, such as the anterior
chest wall.
MUSCULOCUTANEOUS PERFORATING ARTERIES emerge from the surface of
muscles.
Generally, these muscles are broad and flat ones that largely exist on the
trunk.
FASCIOCUTANEOUS PERFORATING ARTERIES pass along an intermuscular or
intercompartmental fascia septum.
Generally, these vessels are found on the limbs.
The vessels ascend and anastomose at all levels to form horizontal plexuses that
run in the skin subcutaneous tissue and fascia.
The three-dimensional area of tissue supplied by a single vessel and its venae
commitantes is known as an angiosome.

• The major flap types are largely named according to the tissue
transferred.
• A flap which consists of skin and superficial facia is referred to
as a SKIN FLAP,
• When the investing layer of deep fascia is included, the flap
becomes FASCIOCUTANEOUS FALP
• Flap my also consist of muscle usually detached at one end, and
moved to cover a surface: MUSCLE FLAP.
• A flap is transferred to reconstruct a primary defect and is inset
into this defect,
• the transfer usually leaves a secondary defect which is most
instances is closed by direct suture or covered with a free skin
graft

• The classification of flaps can be simplified by understanding that
there are a number of methods of classification.
• Cars can be classified according to engine size, colour, body, shape
or fuel requirements.
• FLAPS CAN BE CLASSIFIED according to:
1. Congruity,
2. Configuration,
3. Components,
4. Circulation or
5. Conditioning (the ‘five cs’).
• A description of the vast array of flaps available is beyond the scope
of this chapter.

• Flap surgery is mainly in the domain of the reconstructive
specialist, but general surgeons should understand the
principles on which they are based.
• Surgeons should also be aware of the poten- tial role of
flaps in their subspecialty, and may wish to master some
simple flap techniques that are relevant to their surgical
practice.
• For example, a colorectal surgeon may wish to use a gluteal
musculocutaneous rotation flap to close a perineal wound at
the end of an abdominoperineal resection, and a
fasciocutaneous rhomboid Limberg flap is commonly employed
in the treatment of pilonidal disease (see Chapter 24).

V–Y advancement flap on a subcutaneous pedicle.

A cheek rotation flap.
(a) A large flap is necessary even when the defect is small.
(b) A ‘back cut’ can be used to reduce tension

Transposition flap from a nasolabial fold to a defect in the upper lip.

Z-plasty to release a contracture on the neck

Full-thickness skin cover is essential for
the palm of the hand.
A simple direct flap technique, which
may still be of value when more
sophisticated reconstruction is not
available.

Direct pedicle grafts from one leg
to another.
The disadvantages of several
weeks of immobilisation
And these flaps have been
virtually replaced by more
advanced reconstructive
procedures.

CROSS-FINGER FLAP.
The flap has been raised from the dorsum of the middle phalanx of the
middle finger to cover a defect on the tip of the index finger.
(A split-skin graft will have adequate durability on the donor site.)
After 3 weeks the pedicle of the flap is divided.

AN HISTORICAL ILLUSTRATION.
The long abdominal or groin skin flap was raised and its pedicle ‘tubed’ to protect the raw surfaces.
The end of the flap was implanted into the wrist.
Once safely established on the wrist, the pedicle was divided and carried on its new blood supply to cover
a defect on the face or neck.
More sophisticated reconstructive procedures have replaced this INGENIOUS technique

SKIN FLAPS
Random Pattern Flaps
• These local flaps have no SPECIFICALLY IDENTIFIED VESSELS and rely on
vessels in the subdermal and dermal plexuses.
• Because of the random nature of their pedicles, the distal circulation of these skin
flaps is unreliable and they can only be safely raised using a length to width ratio of
2 : 1.
• These flaps are commonly used for small defects and are categorized
according to their direction of movement (advancement, rotation,
transposition).
• A Z plasty is an example of a transposition flap.
Axial Pattern Flaps:
• These flaps have a defined single vascular PEDICLE RUNNING
LONGITUDINALLY WITHIN THEM.
• This axial arrangement allows a flap to be raised with a length to
breadth ratio greater than 2:1.
• Examples of this type of flap include:
• Groin flap based on the superficial circumflex artery,
• Deltopectoral flap based on the internal mammary branches.
• Median forehead flap based on the supratrochlear artery.

Muscle flaps
• Muscle can be transferred either on its own as a muscle flap, usually
covered with a split-thickness skin graft, or with a paddle of
subcutaneous tissue and skin as a myocutaneous flap.
• Muscles are classified according to the nature of their vascular
pedicle(s).
• They can be transposed locally (e.g. gastrocnemius flap in lower-limb reconstruction)
or completely detached from their origins and insertions and transferred as free flaps
(e.g. free transverse rectus abdominis flap in breast reconstruction).
Fascial flaps
• Fascia can also be transferred alone or with its overlying subcutaneous
tissue and skin as a fasciocutaneous flap.
• These flaps are less bulky and avoid the need to sacrifice underlying
muscle.
• A facial plexus exists and these flaps can either be transposed locally in
random pattern or elevated on identifiable perforators.

Wound healing and
Management

Relaxed skin tension lines.

WOUND HEALING AND MANAGEMENT
Normal wound healing
• This can be considered in four distinct stages, which are not
mutually exclusive and show considerable overlap.
1. COAGULATION (IMMEDIATE).
• Following wounding, the clotting cascade is initiated, local
vasoconstriction occurs and a platelet clot forms.
• Platelet-derived growth factor (PDGF) is released.
2. INFLAMMATION (0-4 DAYS).
• Vasodilation then ensues and inflammatory cells are attracted to the
site of injury, initially neutrophils then macrophages, which remove
tissue debris.
• Lymphocytes are recruited later and persist in chronic inflammation.

3. FIBROPLASIA (4 DAYS TO 3 WEEKS).
• Fibroblasts are attracted by PDGF and leukocyte growth factors.
• They lay down type III collagen and ground substance.
• Vascular buds appear and this neovascularized tissue is known as
granulation tissue.
4. REMODELLING (3 WEEKS TO 18 MONTHS).
• Fibroblasts differentiate into myofibroblasts, which are responsible for
wound contraction.
• Type III collagen is replaced by type I collagen and blood vessels
atrophy.
• These processes result in wound healing by an epithelialized white scar.
• Maximal wound tensile strength is achieved at about day 60, when it is
80% of normal.

The inflammatory phase of wound healing begins immediately following tissue injury and
serves to obtain hemostasis, remove devitalized tissues, and prevent invasive infection by
microbial pathogens.

The proliferative phase of wound healing occurs from days 4 to 21 after wounding.
During this phase, GRANULATION TISSUE FILLS the wound and keratinocytes migrate to
restore epithelial continuity.

The remodeling phase of wound healing is the longest phase and lasts from
21 days to 1 year.

o AIMS INCLUDE:

1. Age
2. Ischemia
3. Reperfusion injury
4. Infection or bacterial burden
5. Malnutrition- Global
6. Nutrient-specific
7. Foreign bodies
8. Diabetes
9. Steroids
10. Uremia
11. Jaundice
12. Cancer
13. Genetic causes (e.g., Ehlers-Danlos, Werner syndromes)
14. Irradiation
15. Chemotherapy
16. Tobacco use
17. Alcohol use
18. Edema
19. Pressure

Principle of Plastic Surgery, plastic surgery notes

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Principle of Plastic Surgery, plastic surgery notes