OSCAR V.A. TAGULINAO, M.D., FPCS, FPAPS SECTION OF PLASTIC SURGERY, DEPARTMENT OF SURGERY

UNIVERSITY OF SANTO TOMAS CARDINAL SANTOS MEDICAL CENTER

PRINCIPLES OF PLASTIC SURGERY

SKIN GRAFTS AND FLAPS

PRINCIPLES OF PLASTIC SURGERY

SKIN GRAFTS AND FLAPS

LINES OF LANGERS

Animation

Gravity

Inconspicuous scar

1. INFLAMMATORY PHASE

Humoral phase

Cellular phase

2. EPITHELIALIZATION

3. COLLAGEN FORMATION

4. SCAR MATURATION

WOUND HEALING

INFLAMMATION PHASE

• HUMORAL PHASE– Histamine from mast cells,

granulocytes & platelets – vasodilatation & permeability

– Kinins & prostaglandins

• CELLULAR PHASE– Polymorphonuclears, monocytes,

fibrinous material

EPITHELIALIZATION

EPITHELIALIZATION is complete after 48 hrs in a sutured wound

CORRECT WRONG

COLLAGEN FORMATION

• 3rd day – spindle-shaped cells

HEALING BY SECONDARY INTENTION

WOUND CONTRACTION

• Centripetal advance of wound edge

WOUND CONTRACTION

• Myofibroblasts, Marjolin’s Ulcer

Hypertrophic Keloid

SCAR CONTRACTURE

HOW TO MINIMIZE SCARRING• Debride all devitalized tissues

• Remove foreign bodies

• Close primarily

• Handle tissues gently

• Prevent infection

Split thickness graft

thin

thick

KINDS OF GRAFTS

epidermis & upper third of dermis

epidermis & upper half of dermis

Full thickness graftepidermis & entire dermis

1.thin grafts contract more

2.thin grafts may change color

3.thick grafts will grow hair

4.sensation follows recipient

CHARACTERISTICS OF GRAFTS

1.vascular recipient bed

2.contact between graft & recipient

3.immobilization of graft

4.free from infection

GRAFT REQUIREMENTS

SPLIT THICKNESS GRAFTS

FULL THICKNESS GRAFTS

PROBLEMS WITH GRAFTLacks tissue bulk

PROBLEMS WITH GRAFTcontracts may grow hair

Grafts will not survive on avascular recipient sites

1.Skin flaps

2.Muscle flap

3.Compound flap

•Fasciocutaneous flap

•Musculocutaneous flap

•Osseocutaneous

KINDS OF FLAPS

KINDS OF SKIN FLAPS:BLOOD SUPPLY

Random flaps

Arterialized flaps

Subdermal plexus of capillaries

Artery runs along the length of flap

KINDS OF SKIN FLAPS: FLAP SOURCE

Local flaps

Distant flaps

Advancement flaps, rotation flaps, interpolation flaps

Crane flaps, waltzing flaps, free flaps

1. has own blood supply

2. thick and has bulk

3. contracts less than grafts

4. retains characteristics of donor area

5. maybe used in avascular recipient sites

CHARACTERISTICS OF FLAP

RANDOM FLAPS

ARTERIALIZED FLAPS

ARTERIALIZED FLAPS

LOCAL FLAPS

Advancement flap

LOCAL FLAP

Rotation flap

LOCAL FLAP

Interpolation flap

V-Y advancement flap brings tissue to defect

Z-plasty rearranges tissues to add length or fill in a depressed area.

A

B

A

B

A B A

B

Multiple Z-plasties add more length and change the direction of the scars.

Z-plasty

Z-plasty

DISTANT FLAPSGroin flap

DISTANT

FLAPS

MUSCLE FLAPS

Soleus muscle

skin graft

• skin, subcutaneous tissue and muscle

• perforating arteries from the muscle

• maybe used as free flap with vascular pedicle

MUSCULOCUTANEOUS FLAPS

MUSCULOCUTANEOUS FLAPLatissimus dorsii

MC FLAP

Biceps femoris

MC FLAP

Free flap

GRAFTS AND FLAPS