SURGERY III

DR. ANGELO MICHAEL SINGCO

TOPIC: PLASTIC AND RECONSTRUCTIVE SURGERY
DATE: September 30,2022

OUTLINE PAGE
Historical Background 1
General Principles 1
Skin Incisions 1
➢ The Z-plasty technique 1
➢ The W-plasty technique 1
➢ Schematic of the Z-plasty technique 1
Wound Healing 2 • these are some of the lines referred to as relaxed skin tension
➢ Preoperative 2 lines. We usually follow these lines to have a good healing.
➢ Intraoperative 2 • Relaxed skin tension lines may be exploited to create incisions
➢ Postoperative 2 that minimize anatomic distortion and improve cosmesis.
Skin Grafts and Skin Substitutes 2
• In general, incisions are placed perpendicular to the action
➢ Splint-Thickness Graft 2
of the joint
➢ Full-Thickness Graft 2
• The principles of proper incision placement can be combined
➢ Composite Grafts 2
with simple surgical techniques to reorient the scar and lessen
➢ Graft Take 3
the deformity
➢ Plasmatic Inhibition 3
➢ Inosculation 3
THE Z-PLASTY TECHNIQUE
➢ Revascularization 3
Flaps 3 • Uses the transposition of random skin flaps both to break up a
➢ Random Pattern Flaps 3 linear scar and to release a scar contracture through lengthening
➢ Fasciocutaneous and Mycocutaneous Flaps 4
THE W-PLASTY TECHNIQUE
HISTORICAL BACKGROUND • Scar excision and reconstruction in zigzag fashion to
camouflage the resulting scar
• The word plastic is derived from the Greek plastikos meaning “to
mold”
SCHEMATIC OF THE Z- PLASTY TECHNIQUE
• John Staige Davis who established the name of the specialty
with the 1919 publication Plastic Surgery—its Principles and
Practice
• Plastic Surgery is the field of surgery that addresses congenital
and acquired defects, striving to return form and function

GENERAL PRINCIPLES
SKIN INCISIONS
- most often times we follow the lines of Langer
• Human skin exists in a state of tension created by internal and
external factors Top: Simple Z- Plasty (To mobilize the scar)
• Externally, skin and underlying subcutaneous tissue are acted Middle: Four- Flap Z- Plasty
on by gravity and clothing Bottom: Five- Flap Z- Plasty
• Internally, skin is subjected to forces generated by underlying
muscles, joint extension and flexion, and tethering of fibrous Tissue lengthening with Z- plasty
tissues from zones of adherence
• Carl Langer, an anatomist from Vienna, first fully described these Type of Z- Plasty Increase in length of central limb
tension lines in the mid-1800s based on his studies of fresh
Simple 45⁰ 50
cadavers
• A.F. Borges described another set of skin lines that is different
Simple 60⁰ 75
from Langer’s Lines, reflect the vectors of relaxed skin tension
• The term Langer’s Lines often is used interchangeably with the Simple 90⁰ 100
term relaxed skin tension lines
• The former lines describe skin tension vectors observed in the Four- flap with 60⁰ angles 150
stretched integument of cadavers exhibiting rigor mortis,
whereas the latter lines lay perpendicular to and more accurately Double opening 75
reflect the action of underlying muscle.
Five Flap 125

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 WOUND HEALING CLASSIFICATION OF SKIN GRAFTS (**try to memo)
• The fundamentals of plastic surgery are based on wound healing
TYPE DESCRIPTION THICKNESS
physiology
(IN)
• Wound repair consists of an exquisitely regulated symphony of
molecular and cellular instruments that act in concert to restore Split thickness Thin (Thiersch-Ollier) 0.006-0.012
the local tissue environment to prewound conditions
• Tissue injury disrupts the tissue microenvironment and sets into
Intermediate (Blair-Brown) 0.012-0.018
motion a cascade of events that combine to reestablish the
environmental status quo
• Preoperative, intraoperative, and postoperative interventions Thick (Padgett) 0.018-0.024
may be taken by the surgeon to minimize infection and optimize
wound healing. Full thickness Entire dermis (Wolfe-Krause) Variable

PREOPERATIVE MANAGEMENT Composite Full-thickness skin with

• Assess and optimize cardiopulmonary function; correct
hypertension
• Treat vasoconstriction: attend to blood volume, thermoregulatory
vasoconstriction, pain, and anxiety
• Assess recent nutrition and provide treatment as appropriate
• Treat existing infection
• Assess wound risk using the SENIC index
• Start administration of vitamin A in patients taking
glucocorticoids
• Maintain right blood glucose control
INTRAOPERATIVE MANAGEMENT
• Administer appropriate prophylactic antibiotics at start of
procedure. Keep antibiotic levels high during long operations.
• Keep patient warm.
• Maintain gentle surgical technique with minimal use of ties and
cautery
• Keep wounds moist.
• Perform irrigation in cases of contamination
• Elevate tissue oxygen tension by increasing the level of inspired
oxygen.
• Delay closure of heavily contaminated wounds.
• Use appropriate sutures (and skin tapes).
• Use appropriate designs.
POST OPERATIVE MANAGEMENT
• Keep patient warm.
• Provide analgesia to keep patient comfortable, if not pain free.
• Keep up with third-space losses. Remember that fever increases
fluid losses.
• Assess perfusion and react to abnormalities.
• Avoid diuresis until pain is gone and patient is warm.
• Assess losses (including thermal losses) if wound is open.
• Assess need for parenteral/enteral nutrition and respond.
• Continue to control hypertension and hyperglycemia.
SKIN GRAFTS AND SKIN SUBSTITUTES
• Skin is comprised of 5% epidermis and 95% dermis
• Skin grafting techniques date back >3000 years to India
• Modern skin grafting methods include split-thickness grafts, full-
thickness grafts, and composite tissue grafts
• Selection of a particular technique depends on the requirements
of the defect to be reconstructed, the quality of the recipient bed,
and the availability of donor site tissue
tissue additional tissue (subcutaneous
fat, cartilage, muscle)
SPLIT-THICKNESS GRAFTS
• simplest method of superficial reconstruction in plastic surgery.
• Have low primary contraction, high secondary contraction, and
high reliability of graft take
• Tend to heal with abnormal pigmentation and poor durability
• Meshed to expand the surface area that can be covered
• Useful when a large area must be resurfaced, as in major burns
• The major drawbacks of meshed grafts are poor cosmetic
appearance and high secondary contraction
FULL-THICKNESS GRAFTS
• Include the epidermis and the complete layer of dermis
• Subcutaneous tissue is carefully removed from the deep
surface of the dermis to maximize the potential for engraftment
• Least secondary contraction upon healing, the best cosmetic
appearance, and the highest durability
• Frequently used in reconstructing superficial wounds of the
face and the hands
• These grafts require pristine, we; -vascularized recipient beds
without bacterial colonization, previous irradiation, or atrophic
wound tissue
COMPOSITE GRAFTS
• Donor tissue containing more than just epidermis and dermis
• Commonly include subcutaneous fat, cartilage and
perichondrium, and muscle
• Useful in select cases of nasal reconstruction
• Excision of the skin of the nasal lobule may create too deep a
defect to reconstruct with a full-thickness skin graft
Figure 45-3. Composite graft reconstruction of nasal lobule. A.
Scarred lobule from previous lesion excision. B. Scar excision
markings. C. Insetting of composite ear lobe skin and subcutaneous
fat graft. D. Postoperative day 3; note the pink hue of revascularization.
E. Appearance at 5 weeks postoperatively. F. Donor site at 5 weeks
postoperatively.

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GRAFT TAKE
• Skin graft take occurs in three phases: imbibition, inosculation,
and revascularization

PLASMATIC IMBIBITION
• Refers to the first 24 to 48 hours after skin grafting, during which
time a thin film of fibrin and plasma separates the graft from the
underlying wound bed

INOSCULATION
Figure 45-5. Random pattern transposition flap
• After 48 hours, a fine vascular network begins to form within the
fibrin layer. These new capillary buds interfere with the deep
surface of the dermis and allow for transfer of some nutrients and
oxygen

REVASCULARIZATION
• The process by which new blood vessels either directly invade
the graft or anastosome to open dermal vascular channels and
restore the pink hue of skin
• These phases are generally complete by 4 to 5 after graft
placement
• During these initial few days, the graft is most susceptible to
interference in engraftment caused by infection, mechanical Figure 45-6. A and B. Random pattern transposition flap, the
shear forces, and hematoma or seroma rhomboid flap

FLAPS
• Vascularized block of tissues that is mobilized from its donor site
and transferred to another location, adjacent or remote, for
reconstructive purposes
• The difference between a graft and a flap
o A graft brings no vascular pedicle and derives its blood flow
from recipient site vascularization
o A flap arrives with its blood supply intact

RANDOM PATTERN FLAPS

• Have a blood supply based on tiny blood vessels in the dermal-
subdermal plexus, as opposed to the discrete, well-described
vessels of axial pattern flaps Figure 45-7. Random pattern rotational flap.
• A transition flap is rotated about a pivot point into an adjacent • With the defect, you do an incision backwards. Then undermine
defect and pull it to close the wound.
• A Z-plasty is a type of transposition flapping which two flaps are
rotated, each into the donor site of the other, to achieve central
limb lenghtnening
• The rhomboid (Limberg) flap
• Rotational flaps are similar to transposition flaps but differ in that
they are semicircular
• Advancement flaps slide forward or backward along the flap’s
long axis. Two common variants include the rectangular
advancement flap and the V-Y advancement flap

Figure 45-8. Random pattern advancement flap.

A. Rectangular advancement flap with Burrow’s triangle excision. B.
V-Y advancement flap.

• Same as this one, the Burrow’s Triangle and the V-Y

advancement flap. These are some of the basic flaps used on
small wounds.
Figure 45-4. Random pattern flap architecture

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FASCIOCUTANEOUS AND MYOCUTANEOUS FLAPS EXAMPLE OF MYOCUTANEOUS FLAP
• The composition of a flap describes its tissue components FREE TISSUE TRANSFER
• A fasciocutaneous flap contains skin and fascia • an autogenous transplantation of vascularized tissues
• A adipofascial flap contains subcutaneous fat and fascia without • involves three main steps:
overlying skin (a) Complete detachment of the flap, with devascularization, from the
• A muscle flap contains muscle only donor site
• A myocutaneous flap also contains overlying skin and (b) Revascularization of the flap with anastomoses to blood vessels in
intervening tissues the recipient site
• An osseous flap contains vascularized bone only (c) An intervening period of flap ischemia
• A osteomyocutaneous flap contains, in addition, muscle, skin, • Flap circulation must be restored within a tolerable ischemia
and subcutaneous tissues time.
• The contiguity of a flap describes its position related to its source
• Local flaps are transferred from a position adjacent to the defect
• Regional flaps are from the same anatomic region of the body
as the defect
• Distant flaps are transferred from a different anatomic region to
the defect (pedicled flaps)
• May be transferred as free flaps by microsurgery
• Skeletonization – to allow any tortuosity of the supplying blood
vessel to be released in order to maximize their reach towards a
given defect
• The contiguity of a flap describes its position related to its source
• Local flaps are transferred from a position adjacent to the defect
• Regional flaps are from the same anatomic region of the body
as the defect This is how you get blood supply to your flap area.
• Distant flaps are transferred from a different anatomic region to
the defect (pedicled flaps)
• may be transferred as free flaps by microsurgery
• Skeletonization
o to allow any tortuosity of the supplying blood vessels to be
released in order to maximize their reach toward a given
defect

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