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)