Wel comprehensive presentation on skin graft and flap Ethiopian presentation by Dr Dagmawi Geremew

1. General Principles of Skin Graft and
Flaps
Presenter;Dr Dagmawi.Geremew,SR2
Moderator;DrYigeremu Kebede(Consultant
General Surgeon,Plastic & Reconstructive Surgeon)
Nov10,2021

2. Outlines
Anatomic Review
Principles of Skin Grafting
 Introduction
 Classifications & Types
 Indications and Contraindications
 Operative Techniques
 Complications
Prnciples of Flap Surgery
 Introduction
 Applications
 Classification
 Principles
 Complications
Summary

3. Skin Anatomy
• The largest organ in the human body
• It serves Many functions
Three properties essential for
understanding reconstruction :
• Elasticity
• Extensibility
• Resilience
• Two layers

4. Blood Supply
“Plastic surgery is a constant battle between
blood supply and beauty.”
Sir Harold Delf Gillies

5. Angiosome

6. Principles of Skin Grafting

7. Introduction
• Graft is something that is removed from the
body, is completely devascularized, and
replaced in another location.
• originated among the Tilemaker caste in India
approximately 3000 years ago.
• a standard option for closing defects that
cannot be closed primarily

8. Classfication
Autografts
Isograft / Syn graft
Allograft
Xenografts
Composite Grafts

9. Indications
• Coverage of a skin defect due to many causes
• To cover chronic wounds
• As an adjunct to tissue flap reconstructive techniques.
Contraindications
• Wounds with avascular bed, Infection
• Wounds with deep spaces and exposed structures

10. Types

11. Characterstics

12. Comparison

13. Graft Take
Phase 1 -Plasmatic / serum imbibition
• Lasts for 24 to 48 hours
• Immediate post graft survival
• A fibrin layer forms
• Diffusion is the route
• Edematous and in anaerobic metabolism
• Adding to pre-graft weight

14. Phase 2 –Revascularization
• Lasts 2-7days
1Theory of inosculation
2Theory of vascular ingrowth from recipient bed
3Theory of formation of acellular vascular channels
• Signs of perfusion
• Risky period affected by Factors
• The dressing is critical

15. Phase 3;Maturation
• graft and surrounding tissues remodel and
contract
• 1 year to complete maturation
• Disappearance of immature vessels

16. Graft contracture
Primary contraction
Secondary contraction

17. Choice of Selection
The size of the defect to cover,
The anatomic area to reconstruct,
The availability of donor sites and
The anticipated wound contraction
The Degree of Take
Colour Match
Texture

18. Operative Techniques
• Pre-operative preparation
• Patient optimization
• Treatement of any systemic infection, anemia
and nutritional support
• Treatement of co morbid medical illnesses if
any

19. Donor site selection

20. Recipient site preparation
Well vascularized
Free of all necrotic / ischemic tissue,
cellulitis, purulent drainage and
significant edema.
Hemostasis
Low bacterial count
Trimming
Irrigation

21. Procedure ; Graft harvesting – STSG

22. Graft harvesting – FTSG
• Scalpel
• marking.
• tumescent technique
• Incision & elevation
• Defatting
• Close donor site

23. Meshing skin graft
• Expansion
• Prevention
 Graft mesher
 Pie crusting

24. Graft inset
-STSG
• transferred dermis side down
• Then long bolster sutures are tied
FTSG -Fit
• Immobility

25. Post – operative Recipient site care
Immobilization
Why
Prevent shearing of the graft
Prevent accumulation of fluid
 Facilitates take phases
How
Compression
Splints or casts
A bolster dressing
Sealants
When First dressing change?

26. Post – operative Donor site care
more painful
Infection Monitoring
Average 7-10 days to heal
• Wet phase
• Dry phase
• Primary dressings should remain

27. Functional Recovery
• STSGs remain without glandular function or
hair growth
• hair regrowth 2–3 months after FTSG
• sensitivity of the grafted area after 1 year
• Sensory complaints
• sweat glands reactivate up to 3 months
;Moisturizers

28. Graft failure
Causes
• Collection
• Instability
• Infection
• Nontake
• Minimized by careful
preparation and early
inspection
Signs
• Persistently white
graft
• Dry black graft
• Mobile
• Loss;partial vs
complete

29. The Reconstructive Ladder
• A systematic approach
that facilitates decision
making when
reconstructing a defect.
• Progresses from simple
to complex choices
• Reconstructive
“elevator”
• The best solution to a
reconstructive dilemma

30. Principles of Flap surgery

31. Introduction
• A unit of tissue transferred from a donor to a
recipient site while maintaining its blood
supply independent of the injured area
• The term flap originated from the Dutch word
“flappe”
• Sushruta Samita, 600 BC
• Vary greatly in complexity

32. Applications
● When Grafting not amenable
● Replace tissue loss
● restore form and function
● Provide skin coverage through which surgery can be
carried on latter
● Provide padding over bony prominences
● Bring in better blood supply to poorly vascularized bed
● Improve sensation to an area
● Bring in specialized tissue for reconstruction such as
bone or functioning muscle

33. Classification

34. complete classification of flaps
■ Circulation: medial
circumflex femoral artery
■ Constituents: gracilis
muscle
■ Contiguity: free flap
■ Construction: antegrade
flow
■ Conditioning: none
■ Conformation: muscle
only

35. 1,Circulation
• Random cutaneous flaps
• Are based on random, nondominant contributions from the
dermal and subdermal plexus.
• L:W ratio of flap is critical for flap survival, & limits their
ability to reliably cover large defects.
• The ratio had to be 1:1, maximum of 1:1.5 for the flap to
survive.
• Even though the source artery is not known, if the ratio is
1:1 the flap survives.
• Reliable first choices for coverage of smaller defects
throughout the body

36. Axial flaps
• Based on a reliable and anatomically defined vascular
territory,
• Longitudinally oriented within the flap that extends
beyond the base of the flap.
• Preferred for coverage of moderate to large defects.
• Delay procedures are often unnecessary - Axially oriented
circulation
• limitation - limited topographic arc of rotation when
pedicled
• Overcome by microvascular free tissue transfer

37. 2,Composition
 Perforator flap
 Fasciocutaneous flap
 Musculocutaneous flap
 Osseous flap
 Osteomyocutaneous flap

38. perforator flap
• isolated perforator(s).
• A muscle perforator.
• A septal perforator.
• muscle perforator flap.
DIEP
• septal perforator flap.
RAP

39. Myocutaneous Flaps
Uses
Functional muscle flap
Sensate Myocutaneous flap
Coverage of complex wounds
Chronic vascular insufficiency
Chronic radiation wounds
Exposed or infected
prosthesis
The disadvantages
39

40. Arc of Roatation
may prevent successful
flap transposition
Depends on
•The No of Pedicles
•location of the
dominant vascular
pedicle
Safe standard arc of
rotation
Reverse arc of rotation

41. Fasciocutaneous Flaps

42. 3,Contiguity
• Proximity to the defect
Local Flaps
Regional flaps
Distant flaps

43. Local Flaps
classified by their mov’t to resurface the defect
Advancement Flaps
● Moved primarily in a straight line from the
donor site to the recipient site.
● No rotational or lateral movement is applied.
● Can be:
○ Single pedicle
○ Bipedicle
○ V-Y/Y-V advancement

44. Rotational flap
● Semi-circular flap that rotate around a fixed pivot point
● The donor site is closed by sutures or with a skin graft.
● Rotation is facilitated by:
○ back-cutting or
○ excising a Burow’s triangle

45. Transposition flaps
● square or rectangular flaps which rotated about a pivot
point into an immediately adjacent defect.
● The more the flap is rotated, the shorter the it
becomes.
● Most commonly used in head and neck
● Variations:
○ Rhomboid
○ Z- plasty

46. Interpolation Flap
● Similar to transposition flap except the
pedicle pass over or under the intervening
tissue
● Pedicle will be divided after revascularization
● Used for large or deep defect where adjacent
local tissue are insufficient

47. Regional Flaps
Utilized to cover large
defects which require
bulk
1. PMMF 2. DPF
47

48. Distant Flaps
● Outside the anatomic
region of the defect
● Two types:
○ Direct
○ Free flaps
48

49. 4,Construction (flow)
• Unipedicle
• Bipedicle
• Antegrade
• Retrograde
• Turbocharged
• Supercharged
• Arterialized venous

50. 5,Conditioning
Delayed Flap
Prelaminated Flap
Prefabricated Flap
Sensory Flap
Functional Flap
Tissue Expansion

51. The Delay phenomenon
A Two Staged procedure to increase survival &
Territory
Important for selected flaps
Standard Delay vs Strategic Delay
Stage 1;Incision or Ligation
Stage 2;Transfer

52. Mechanism
• Metabolic Changes,Acclimatization
• Depletetion ofvasoconstriction and
prothrombotic substances in the skin flap
• vascular territory expansion by opening
existing choke arteries
• Induction of angiogenesis
• sympatholytic state

53. 6,Conformation

54. Post operative care
• Pivotal
• Analgesics,Antibiotics,Anticoagulation
• Avoid Pressure,Elevation
• Avoid Motion,Splints but not Circuar Casts
• Avoid weight bearing
• Drains
• Multi disceplinary

55. Post operative Flap Monitoring
• Mandatory.
• clinical observation.
• Tissue color, warmth & turgor, capillary refill
time
• Doppler ultrasound and tissue oximetry
should also be used when available

56. 56
Principles of Flap
Surgery

57. Flap Selection
● Discussion
● Step-wise approach
● Size and location of flap
● Accurate Evaluation of the defect
● Angiosome Adherence
● Location
● Evaluation of surrounding defect
● Size of defect
● Functional and aesthetic consideration
57

58. Flap complicationS
Flap necrosis;Total vs partial
Intrinsic and Extrinsic Cause,Patient factors
Vascular compromise
Complications specific to the donor site
Hematoma,Seroma,SSI

59. Prevention
1,Judgment
Inadequate
preparation
Inadequate flap
design
Inadequate
knowledge of
anatomy.
2,Technique, and
3,patient management

60. 60
Skin Grafts Vs Flaps

61. Summary
• Vascular Anatomy is the core Prerequiste for
Reconstruction
• Skin Graft is the Simplest tool
• Flap Is Vascularized Unlike Graft
• Post operative care of Reconstruction sites is
of equivalence with the initial Reconstructive
Process
• Prevention is the best tool to avoid Failure

62. References
1. Neligan Plastic Surgery 4th Edition Volume 1
2. Grabb and Smith’s Plastic Surgery Eighth Edition
3. Selected Reading In Plastic and Reconstructive
Surgery
4. Handbook Of Plastic Surgery 3rd Edition
5. Arterial Anatomy Of Skin Flaps by George C. Cormack
and B . George H. Lamberty 2nd edition
6. Schwartz’s Principles of Surgery 11th Edition
7. Uptodate 2021 62

63. Thank You!