Chapter 8: Plastic Surgery

Skin Grafting Local Cutaneous Flaps Local Muscle and Myocuteneous Flaps Fasciocutaneous Flaps Microsurgery and Free Flaps Diagrams of Skin Flaps

When considering soft tissue reconstruction one always needs to go through a decision tree in evaluating options from the simplest to most complex reconstructive technique depending upon the patient's health, resultant changed biomechanics, and soft tissue defects location: 1. Allow the soft tissue defect to heal by secondary intention 2. Close the wound primarily 3. Apply a split thickness or full thickness skin graft 4. Use a local fascial, fasciocutaneous, muscle or musclocutaneous flap 5. Use a microvascular free flap transfer

Skin Grafting
1. Definitions: a. Consists of harvesting epidermis with a varying thickness of accompanying dermis and placing it on a recipient base., b. Split thickness: Includes epidermis and a portion of dermis (the more dermis included, the thicker the graft) c. Intermediate split thickness: contain more dermis d. Thick split thickness grafts: contains most dermis f. Full thickness grafts: contain all the epidermis and dermis, no fascia or fat but has the sweat and sebaceous glands g. Grafts can be autografts (same individual), allografts (same species), isografts (twins), and xenografts (different species) h. A free skin graft is completely detached from the body during its transfer from the donor site 2. Anatomy of skin: a. The epidermis represents 95% of the skin thickness and dermis 5% b. The dermis contains sebaceous glands, except in the palms and soles c. The dermis is principally made up of collagen and elastin d. The subcutaneous tissue contains the sweat glands and hair follicles (except in the palms and soles that lack hair) e. The blood supply arises out of a vascular network that lies on top of fascia and sends vertical branches up through the subcutaneous tissue and dermis. The vessels arborize along the way and terminate as capillary buds between the dermal papillae (the thinner the graft, the more vessels are transected) 3. Preparation of the recipient site: a. Must have no infection for a successful graft (a bacterial count of less than 100,000/gram of tissue) To sterilize a wound: i. Surgical debridement ii. Topical Sylvadine for 4-5 days plus IV antibiotics: or iii. Biological dressings (pig skin or amnionic membranes) plus IV antibiotics

b. Must be well vascularized for a successful graft (pH at 7.4, Tcp 02> 40 mm Hg and epithelialization at the border) c. If the wound is fresh then you can graft onto dermis, fat, fascia, paratenon, or periosteum d. You cannot graft onto cortical bone or tendon e. Granulation tissue contains bacteria and must be removed at the time of grafting f. Hemorrhage must be controlled g. Thorough irrigation 4. Split thickness skin graft: a. The thinner the graft the higher the chances of a successful take, due to in part to the higher number of transected blood vessels through which primary revascularization can be established b. The thinner graft will shrink more at it heals (about 50-70% of its size) because the decreased amount of dermis is less effective in inhibiting secondary contraction c. The thinner the graft the greater the chance for hyperpigmentation d. The thinner the graft, the more susceptible it is to trauma, because of the absence of rete pegs and the loss of lubricating sebaceous glands e. A thin skin graft is usually .012-.013 inches thick f. Donor site bleeding minimized with topical thrombin or dilute concentration of epinephrine and dressed with Xeroform or Scarlett Red, Opsite or Tegaderm, and/or Biobrane (semipermeable dressing) g. Recipient site bleeding must be controlled (topical thrombin or dilute epinephrine) and if not place the skin graft back onto the donor site and return to the OR in 24-48 hours h. Graft cut with a BrownAire or Zimmer air driven dermatome are reliable (can be cut by a Humby or Goulian knife by hand but is difficult). For power: i. Set desired width by using a width guard (either 5 cm, 8 cm, 10 cm) ii. Set thickness by turning knob (usually .012-.013") and introduce a #15 scapel blade between the cutting blade and base to check thickness NOTE* A # 15 scapel blade is the proper thickness of the graft, so by placing this blade into the dermatome, provides a double-check

i. Meshing the donor graft allows for removal of hematomas or seromas and increases its size (do not mesh at a ratio greater than 1 1 /2 to 1) j. Inset the graft using a Stent tie-over dressing (or a bolster dressing). The bolster is built by first placing Xeroform® on the wound then normal saline soaked cotton in the center. The nylon suture used at the wound's periphery are then crossed over and tied to each other, forcing out the water in the cotton. This allows the graft to conform exactly to the recipient site h. The foot and leg should then be placed in a posterior splint to eliminate movement/shearing i. Dressing changed in 5-7 days if meshed, and if unmeshed at 48

hours to check for fluid accumulation (if accumulation occurs, it should be aspirated with a needle j. The graft on the extremity should be kept elevated for 7-10 days, until venous circulation is fully established 5. Physiologic phases in skin graft take: a. Plasmatic imbibation phase during first 48 hours (graft is ischemic at this time) b. Inosculatory and capillary growth phase phase starts after 48 hours when capillary budding from the recipient bed makes contact with the graft. c. Circulation occurs between the 4th and 7th day 6. Full thickness skin graft: a. Best donor site for full thickness grafts are the flexor surfaces such as the groin, anticubital fossa, and popliteal fossa, and then closed primarily, leaving a linear scar. b. The length to width ratio of the donor graft should be at least 3-1 c. The donor graft is then sewn into the recipient site d. Perforations should be made into the donor graft to allow for seroma removal e. Revascularization is more tenuous with a full thickness graft than with a split thickness graft f. Full thickness graft usually takes primarily, there is no contraction of the wound, lubrication of the skin is normal, and there is no change in skin color or texture g. Neurotization occurs in the following order: pain, light touch, then temperature h. Sensory recovery starts at 4 weeks and can take up to 1-2 years 7. Reasons for graft failure: a. Lack of compression of the graft to the recipient site b. Movement/shearing c. Infection (second most common cause) d. Seroma e. Hematoma (most common cause) NOTE* It is important that the pressure on the graft does not exceed 30 mm Hg or else blood flow to the graft will be compromised

Local Cutaneous Flaps 1. Anatomic principles of skin flaps: a. It is not the length to width ratio but rather the presence of an artery at the base of a flap that determines its success. Therefore the preoperative use of a doppler enables one to determine whether the flow to a particular area of the foot is antegrade or retrograde (the flow can be redirected due to an occlusion of either the anterior tibial or posterior tibial artery) b. A defined area of skin receives blood from 3 sources

i. Cutaneous artery: direct cutaneous arteries run in subcutaneous fat parallel to the skin, and are usually accompanied by two venae commitantes (veins that drain the area supplied by the cutaneous artery) ii. Musculocutaneous artery iii. Fasciocutaneous arteries c. The flaps that have a direct blood supply (direct cutaneous artery flaps) have a larger length to width ratio, than traditional random flaps and can be used as: i. Axial pattern flaps (traditional name) and can be used as a pedicle flaps (a flap dissected free at its base, of most of the tissue surrounding the artery and veins thus giving the flap added mobility) ii. An island flap: where the vascular pedicle is dissected completely free for a certain length and the flap is transferred to a local site separate from the donor site while the pedicle is buried under intervening tissue iii. A free flap: where the pedicle is totally detached and then hooked up by microsurgery to recipient vessels anywhere in the body d. Musculocutaneous flaps consist of muscle, subcutaneous fat and skin, with the muscle receiving its blood supply according to one of 5 patterns NOTE* In the foot it is preferable to harvest the muscle without the overlying skin paddle as skin graft over the muscle, as the blood supply to the overlying skin has a very narrow range and can cause significant donor defects if harvested as a unit

e. The fasciocutaneous system is the chief source of blood supply to the skin. It arises from a major regional artery as perforators that pass along the fascia between muscle bellies and then fan out at the level of the deep fascia (an example is along the long axis of the 3 arteries, posterior tibial, anterior tibial, and peroneal i. Example of a faciocutaneous flap of the foot is the medial plantar flap NOTE* A random flap with is obligate 1:1 length to width ratio in the foot is a flap based on unknown vascular anatomy. Axial pattern flaps have an identifiable blood flow at their base and have a length to width ratio that depends upon the angiotome which the artery serves. These flaps must be preplanned, and can be extended beyond their angigtomes using delay principles

2. Local flaps: a. Local flaps are adjacent to the defect and are either rotated on a pivot point or are advanced forward from their base to cover a defect. They include a minimum of the epidermis, dermis and subcutaneous tissue. The donor site is either closed primarily or skin grafted b. Flaps that rotate about a pivot point

i. Rotation flap: is designed when a pie shaped triangle defect is created to remove a lesion or preexistent defect. The flap includes skin and subcutaneous tissue ii. Transposition flap: are rectangular in shape with rounded edges and can be rotated 900 iii. Limberg flap: is a type of transposition flap that depends on the looseness of the adjacent tissue, and is used when the defect has a rhomboid shape (angles of 60° and 1200) iv. Z-plasty is a type of rotation flap that is used to lengthen an existing scar and to reorient them along lines of minimal tension. The Z-plasty consists of 3 limbs of equal length on the shape of a Z, and the angles between the limbs can vary from 30° to 900, and the wider the angle the more the theoretical gain in length NOTE* Clinically, 60° has been found to be the most useful and yields a theoretical 75% gain in length, however, the actual gain in length is anywhere from 28% to 45% less than calculated. The length of the center of the limb also determines the amount of length gained, and the longer it is, the larger the gain v. Interpolation flap: has a soft tissue pedicle with a distal skin island which is rotated into a defect that is close to but not adjacent to the donor site vi. Island flap: is a specialized interpolation flap where the only link between the cutaneous flap and its bed is the neurovascular bundle. This can be very useful in the foot, as the results are aesthetic, sensate, and very functional c. Advancement flaps: i. Advancement flaps: are moved directly forward to fill a defect without rotation or lateral movement. A rectangular incision of skin dissected out and advanced into the defect thereby creating a folding of tissue at both ends of its base (burrow's triangles), which are removed so that the skin can be sutured together ii. V-Y flap: is a V shaped flap whose sides are advanced creating a Y when the incisions are closed. Can also use a double V to Y flaps when a defect is to large for one (defects 3-4 cm wide) Local Muscle and Myocutaneous Flaps One can transfer simple muscle or muscle with overlying skin to cover a soft tissue defect. It is critical to know the anatomic blood supply of the muscle and skin 1. Abductor digiti minimi flap: Is a muscle flap used to fill defects of the lateral ankle joint or skin 2. Abductor hallucis brevis muscle flap: The medial counterpart of the abductor digiti minimi. If more bulk is needed it can be harvested with the medial half of the flexor hallucis brevis muscle 3. Flexor digitorum brevis muscle flap: can only be considered in the well

vascularized non-diabetic foot, as its harvesting may lead to charcot changes by weaking the midfoot arch Fasciocutaneous Flaps These flaps are thin, pliable, and reliable, however, are not as useful as muscle in treating osteomyelitis because the blood flow per centimeter2 is 3-5 times less 1. Dorsalis pedis flap (direct cutaneous blood supply): Is a direct skin flap in the foot, can be used as a free flap, its advantage is that it is thin and can be used as a sensory flap if the superficial nerve is incorporated a. The potential flap territory overlies the artery b. It is mandatory to know when using this flap whether the arterial flow is antegrade or retrograde, which vascular system supplies the first dorsal metatarsal artery, and whether the anterior branch of the peroneal artery is dominant (if the distal portion of the flap is supplied by the vascular blood supply from the sole of the foot, then a delay of that portion of the flap should be done to avoid distal flap necrosis) c. Should be only used in well vascularized patients as a 2nd resort because of donor site morbidity 2. Filet of toe flap (direct cutaneous blood supply): Similar characteristics as that of the sole of the foot (it is filling and sensate), a toe has to be sacrificed. It can be rotated locally, or carried with its neurovascular bundle for more proximal placement 3. Lateral calcaneal artery fasciocutaneous flap (direct cutaneous blood supply): Derives its blood supply from the calcaneal branch of the peroneal artery. In order to dissect this flap, it is critical to doppler out the artery along its full length, and the artery should lie along the mid axis of the flap which allows for a 8x4cm vertical flap to be harvested. If the viability is questionable, dissection is stopped and the flap delayed for 5-7 days. It is best to start with a lateral incision down to the periosteum, and dissect up in a retrograde fashion 4. Plantar flaps: The blood supply to the sole of the foot is supplied by the medial and lateral branches of the tibialis posterior artery. a. Lateral plantar artery flap b. Medial plantar artery flap: better than the lateral artery flap because it is based on the less important medial plantar artery and is designed over a nonweight-bearing portion of the sole, and can include the abductor hallucis ms. to give the flap extra bulk Microsurgery and Free Flaps This has revolutionized the ability to cover soft tissue defects. Can include fasciocutaneous, musculocutaneous, osteocutaneous, and osteomusculocutaneous flaps 1. Donor site does not include the foot, and donor site morbidity is minimal

2. The free flap has to have adequate inflow through one of the three distal arteries (preferably the distal posterior tibial or dorsalis pedis). If adequate flow does not exist, then revascularization via in-situ by-pass graft is mandatory first 3. Free flap anastamosis, whenever possible, should always be done end to side so that the distal flow is not compromised 4. For the dorsum of the foot a fasciocutaneous free flap from either the parascapular area, the radial forearm, the lateral arm or the temporalis fascia with STSG (the advantage are that these flaps are thin, have minimum donor morbidity, and have reliable vascular pedicles 5. The muscle flap for the sole of the foot comes from either the serratus anterior or gracilis muscle 6. If metatarsals and skin need to be replaced then a osteocutaneous flap from the contralateral fibula is used, or parascapular osteocutaneous flap NOTE* The advantage of using vascularized bone is that the risk of infection is diminished and the bony union is more rapid

Diagrams of Skin Flaps

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