NSW Plastic Nurses Association 2012 Flap and Graft Differences

NSW Plastic Nurses Association
2012
Flaps and Grafts

Graft VS Flap
What is the difference?

• Rung 1: Healing by
secondary intention
• Rung 2: Primary closure
• Rung 3: Delayed primary
closure
• Rung 4: Split thickness
graft
• Rung 5: FTSG
• Rung 6: tissue expansion
• Rung 7: Random flap
• Rung 8: Axial flap
• Rung 9: Free Flap

Reconstructive Elevator
• Get off at the right level

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


• The vascular plexuses of the fascia,
subcutaneous tissue and skin are divided into
6 layers

1)Subfascial plexus
small plexus lying on
the undersurface of
the fascia

2) Prefascial plexus
-a larger plexus
-particularly
prominent on the
limbs
-fasciocutaneous
vessels

3)Subcutaneous
Plexus
-lies at the level of
superficial fascia
-Predominant on the
torso
-musculocutaneous
vessels

4)Subdermal Plexus
-receives blood from
underlying plexus
-the main plexus
supplying blood to the
skin
-represents the
dermal bleed
observed in incised
skin

5) Dermal Plexus
-mainly arterioles
-important in
thermoregulation

6)Subepidermal
Plexus
-contains small
vessels without
muscle in the walls
-nutritive and
thermoregulatory
function

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

Skin Grafts: “Process of Take”
• Vascularity of donor site
• Tolerance to ischaemia
• Metabolic activity of the graft

• 4 Phases:
– Fibrin adhesion
– Plasmatic imbibition
– Revascularization: Inosculation & capillary
ingrowth
– Remodelling: Revascularization & fibrous
attachment in restoring normal histological
architecture

• 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

• Inosculation & capillary ingrowth:
– At 48 hrs
– Through fibrin layer
– Capillary buds from recipient bed contact graft
vessels
– Open channels (neo-vascularization)
 pink graft

• 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)

Skin Graft Take: Dermis
• 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

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

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

Skin Graft Healing
• Reinnervation:
– from margins to bed;
– 4/52 to 2 years;
– Depends on graft thickness and bed;
– Uneventful healing leads to near normal 2PD;
– Cold sensitivity can be a problem.

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

Skin Graft Failure
 Haematoma
 Infection
 Seroma
 Mobility
 Inappropriate bed
 Dependency
 Arterial insufficiency
 Venous congestion
 Lymphatic stasis
 Technical – upside-down

Flaps
• 16th century Dutch word “flappe”
“….something that hangs broad and loose ,
fastened only by one side..”

• A flap is a surgically developed segment of
tissue that remains attached to a portion of its
original blood supply

Methods of classification
• Composition
– Skin +/- fascia
– Muscle (+/- innervation)
– Bone
– Omentum / viscera
– Composite
• Proximity to defect
• Method of movement
• Vascular anatomy

• Composition
– Skin +/- fascia
– Muscle (+/-
innervation)
– Bone
– Omentum / viscera
– Composite

• Composition
– Skin +/- fascia
– Muscle (+/- innervation)
– Bone
– Omentum /
viscera
– Composite

Random flaps
• Most common
• Based on subdermal plexus
• Unpredictable
• Length:width of 3:1 or 4:1

Random flaps
• 1989 Pasyk
• Demonstrated a significantly greater capillary density in the papillary and
reticular dermis of the head, face, and neck than in the lower parts of the
body.
• Because of this increased density, it is possible to design and transfer longer
random-pattern skin flaps in the face and neck than elsewhere in the body

Flap survival
 Length:Width
 increased width
of base would
increase
surviving length
but feeding
vessels have
same perfusion
pressure

Morton’s Pig Flap experiments ‘77

Axial flaps
• Limited by available vessels
• Based on direct cutaneous vessels
• Random flap at distal tip
• Examples
– nasolabial
– midline forehead flaps

Ahuja modification (PRS 1989)

• template for rotation
& transposition flaps
• past 180 degrees adds
rotation to
transposition

Advancement
• Glabella
• VY flap
• Monopedicled
• Bipedicled
• A-T flap

A-T flap

• Bilateral advancement
• triangular defect
• Uses - hairline, brow, lip

Nasolabial Flap

• Superiorly based

Nasolabial Flap

• Inferiorly based

NSW Plastic Nurses Association 2012 Flap and Graft Differences

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (20)

Similaire à NSW Plastic Nurses Association 2012 Flap and Graft Differences

Similaire à NSW Plastic Nurses Association 2012 Flap and Graft Differences (20)

Plus de drpouriamoradi

Plus de drpouriamoradi (13)

NSW Plastic Nurses Association 2012 Flap and Graft Differences