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