Plastic and reconstructive surgery involves restoring form and function to damaged tissues using techniques to move skin and tissue. Key principles include optimizing blood supply to flaps and grafts, placing scars carefully, and replacing defects with similar tissue. Common flap types are local flaps which are moved a short distance on a blood supply, and free flaps which are completely detached and reattached microsurgically. Surgical techniques like elliptical excision, advancement flaps, and Z-plasties are used to close wounds and redirect scars. Care must be taken to ensure good blood supply and prevent tension on moved flaps.

2. PLASTIC & RECONSTRUCTIVE SURGERY
• The Plastic is derived from the greek word ‘PLASSEIN’ – means Mould or
Shape
• Reconstructive plastic surgery involves restoring the form and function to the
damaged body tissues (Trauma, Cancer, Congenital) using various techniques.
• ‘Sushruta’ (Father of Modern Surgery) in 600 BC used Forehead flaps to
reconstruct nose (Rhinoplasty) on the criminals who had their noses
amputated as a punishment
• Modern techniques were developed after First World War, especially with Sir
Harold Gillies work on reconstructing facial injuries which was enabled by new
safe anaesthetic intubation

3. 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’
• Replace defect with similar tissue
• Observe meticulous surgical technique
• Remember donor site ‘cost’

4. GRAFTS & FLAPS
• Grafts are tissues that are
transferred without their blood
supply, which therefore have to
revascularise once they are in a
new site.
• Flaps are tissues that are
transferred with a blood supply.
They therefore have the
advantage of bringing vascularity
to the new area.

5. FLAPS
• LOCAL | COMPOSITE LOCAL | DISTANT
• Random flaps. Three sides of a rectangle, bearing no specific relationship to where the blood
supply enters; thus training the blood supply from a single border of the rectangle.
• Axial Flaps. Much longer flaps, based on known blood vessels supplying the skin
• Pedicled / Islanded Flaps. The axial blood supply of these flaps means that they can be swung
round on a stalk or even fully ‘islanded’ so that the working end of the skin being transferred
can have the pedicle buried
• Free Flaps. The blood supply has been isolated, disconnected and then reconnected using
microsurgery at the new site
• Composite flaps. Various tissues are transferred together, often skin with bone or muscle
(osseo-cutaneous or myo-cutaneous flaps, respectively).

7. TECHNIQUES
• FUSIFORM (ELLIPTICAL) EXCISION
• ADVANCEMENT FLAP
• ROTATIONAL FLAP
• Z – PLASTY
• RHOMBOID FLAP
• BILOBED FLAP
• V - Y ADVANCEMENT

8. INTRODUCTION
• A piece of skin that has been excised/removed leaves a hole in the remaining skin.
• This hole can be closed by a skin flap so that healing can occur by primary intention.
• Skin flaps optimally close the defect without tension
• Care is taken to stay in the subcutaneous plane during excision of the lesion.
• Counter traction is helpful during incision and excision
• Scissors can be used to undermine as well as cut the deep layers of the soft tissues
• Incisions should be made perpendicular to the skin edges with a sharp knife

9. FUSIFORM (ELLIPTICAL) EXCISION
• An elliptical incision is made around the lesion, the length of
which is 1.5 to 3 times the width of the lesion.
• If the width-to-length ratio is any closer to 1:1, then
puckering at the edges will result
• The skin to be excised can be held with a forceps and excised
with sharp dissection using knife/scissors
• Undermining is done using scissors (tips of the scissors are
best kept upwards) / by using blade
• Initially, deep suture is placed in the mid portion of the
insicion according to the principle of halving and a Surgeon’s
knot is used to approximate the wound edges
• Then the skin skin sutures are placed according to the
principle of halving.

10. ADVANCEMENT FLAP
• Rectangular with a 2 to 3 length to width ratio
• After excision of the lesion, two sides of the flap are
incised and the entire flap is undermined in the layer
between the skin and deeper subcutaneous tissues.
• Skin adjacent to the long edges of the incision is also
undermined for 1-2 cm to allow for increased flap
mobility and wound closure without tension
• The First suture is placed in the center of the flap and
is tied with a hand tie and a Surgeon’s knot. By keeping
constant tension one can prevent tying an air knot.
• Corner stitches are placed next as there is increased
tension in this flap design
• By the principle of halving, the wound is closed

11. • If the edge is closed in an uneven manner, it results in a
“dog ear” or “standing cone deformity”
• A standing cone excision is done this site.
• First a back cut is made.
• Excision is always done away from the flap pedicle to the
point of the triangle
• Undermining is done and the skin is moved with a forceps
and the excess skin is trimmed and excised appropriately
and the flap inset to give a good fit.
• The flap is then sutured into place and the standing cone
deformity is resolved.

12. ROTATION FLAP
• The rotation flap is utilised to close triangular defects
• It follows a smooth curve from the site of the defect.
• It then gets rotated into place. Typically, the limb of
rotation is 2-4 times longer than the axis of the defect
• This is a flap with a wide vascular pedicle and extremely
useful in facial reconstruction.
• After the lesion is excised, the flap is incised with a knife
and broadly undermined.
• The point of maximal rotation is the point of maximal
tension in this flap and it is inset first with a suture
• The flap edge is then closed to the longer skin edge with
the principle of halving.

14. Z - PLASTY
• Z – Plasty is useful in lengthening contracted scars as well
as reorienting the direction of scars
• The limbs are the same length and both come off at the
same angle from the central limb.
• Sharper angle results in risk of necrosis in the tip of the
flap. Broader angle results in difficult rotation
• Broad undermining is done under both flaps, as well as
under the entire incised region, to allow ease of flap
elevation and rotation
• Each flap is then grasped with a forceps and transposed
across so that the central limb totally reorients by 90°.
• The corner stitches are placed into each flap first to
transpose them
• Finally the Width of the defect is increased.

16. RHOMBOID FLAP
• Limbs of the flap are in equal length
• The angles are 60° and 120° , that’s how the flap is
fashioned
• Then the flap and the edges of the lesion are
widely undermined
• Now the flap is rotated into the position without
any extreme tension
• First suture is placed at the site of maximal tension
, then at all the apices
• Finally the wound is closed according to the
principle of halving

18. BILOBED FLAP
• It is used in case of circular lesions
• Circular lesion is excised
• First flap is marked which is ¾ to the diameter of the
lesion. Second flap is of ½ to ¾ to the diameter of the
lesion and incised
• Flaps and the edges of the lesion are undermined
widely.
• Now the excess triangular portion of the the lesion is
removed
• First flap is rotated into the area of lesion and sutured
at the apex.
• Second flap is rotated to the position and sutured at
the point of tension
• Other sites of the flap are sutured accored to the
principle of halving

20. CARE OF FLAPS
• After a flap has been moved, it should be observed for tissue colour, warmth and turgor, and be
pressed to assess blanching and capillary refill time.
• Loss of arterial inflow results in pale, cold, flaccid tissue
• Loss of venous outflow results in blue congestion, increased turgor, rapid capillary refill and initially a
warm flap
• In a pedicled flap, such venous congestion may be relieved by releasing suture tension; applying
leeches to suck out excess venous blood is a last resort when no other means of restoring venous
drainage can be obtained.
• Patient should be well hydrated with a hyperdynamic circulation, a very warm body temperature and
well-controlled analgesia to reduce catecholamine output (Wet, Warm, Comfortable)

21. MOST COMMON 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 septicemic patient
• The dressing applied too tightly around the pedicle
• Microsurgical failure in free flap surgery (usually caused by problems with
surgical technique)
• Tobacco smoking by patient.

22. THANK YOU