OTORHINOLARYNGOLOGY 5.

1
COSMETIC AND RECONSTRUCTIVE SURGERY by Dr. Robie V. Zantua January 25, 2018

o Macrophages: directors of healing; sources of

interleukins.
WOUND HEALING o Oxygen tension ink at end of phase due to new
Divided into primary and secondary vessels
o Primary is when you suture o Inosculations – new vessels join existing vessels
o Secondary is when you leave the wound to let it scar o Increased O2 inhibits angiogenic factor release so
alone ends as an avascular scar
Multi-step process Oxygen is therefore important in preventing scar formation
Process that restores tissue integrity after injury and promoting early anastomosis of new vessels to old
vessels
Recreates the superficial epithelial barrier to water loss and bacterial invasion
Replaces deficits with new tissues and restores cutaneous tensile strength

A. Stages of Wound Healing

1. Primary Injury and Inflammatory Phase
o Primary injury: the incision or trauma that caused the wound
o Inflammatory phase divided into vascular phase and a
cellular phase
o Occurs during the 1st 3-4 days
o Hemostatic plug: composed of platelets and fibrin
(causing stoppage of the bleeding)
o Extrinsic and intrinsic coagulation pathway is activated
o PMNs predominate for 48 hours
o Monocytes: 48-96 hrs

*It is the collagen type IV and laminin that is important in would healing. Also, laminin is
important for plugging the bleeding vessel.
*Granulation tissue is actually a product of collagen deposition

3. Maturation phase *scar formation

Vast inflammatory process; vascular and cellular, plugging of the bleeding,
proliferation of the epithelial cells and now the maturation process...
o Can continue up to 2 years from the proliferative stage
o Collagen deposition
❖ Initially type III but macrophages produce
collagenase and proteases which degrade
type III collagen and make it a type four then the
mature scar is now a type I collagen
❖ Mature scar: Type I collagen
❖ 80% tensile strength when the scar matures
❖ Myofibroblasts provide contractive forces
necessary for wound contraction
RELATION OF ESSENTAIL FATTY ACIDS TO PROSTAGLANDIN ❖ It takes 7 days to form the mature type I collagen
thus at 7th day, you can remove now the sutures
because the wound has now adequate tensile
strength to prevent dehiscence of the wound

B. Physiology of Wound Healing

• Hemostasis
o VASOCONSTRICTION: EPINEPHRINE AND
NOREPINEPHRINE
o Prostaglandin F2A and thromboxane a2
o Then platelets adhere to collagen as plug
o Platelet aggregation release cytokines from alpha
granules of platelet
o Extrinsic Cascade clot formation by fibrin; vitronectin
and fibronectin attracts fibroblasts
• Inflammation
o 24 HRS Vasodilation
o PGE2 and prostacyclin release
o Histamine and serotonin released by mast cells Kinins
increased permeability, that’s why WBC get out of the
capillaries
o Inflammatory cells: B2 class of integrin and fibronectin
• Migratory Phase
2. Proliferative Phase *tissue regeneration o Fibroblast and mesenchymal cells
o 4-18 days after injury o Angiogenesis: 2-3 days
o Epithelial cells at the wound margins, fibroblasts and o Cytokines: EGF, FGF, TGFb, TGFa, TNFa, VEGF,
capillary endothelial cells activate metabolically to PD-ECGF
cover and fill the wound • Epithelialization
o Neovascularization – formation of new vessels o Starts 24HRS

Trans: Lameda
Edited by: Lexi :)
TOPIC: WOUND HEALING

o Cytokines: EGF, FGF2, PDGF, TGFb, TGFa, KGF,

IGF
• Proliferative Phase and Collagen Synthesis A. Planning
o Starts 5 days Requires knowledge on the biomechanics, know the cause of the injury..
o Cytokines: EGF, FGF2, PDGF, TGFb, IL1 TNFa • History
• Wound Contraction o PVD/CAD, collagen vascular dz, DM, XRT
o Myofibroblast • Social habits
o Cytokines: FGF2, TGFb o Cigarettes?
• Late Phase: Scar Remodelling • Medications
o 3weeks o ASA, NSAIDs, anticoagulants, herbal medicines (more
o Cytokines: EGF, PDGF, TGFb, IL-1, TNFa bleeding)
• Cause of defect
C. Factors that Affect Wound Healing o Recurrence?
• Intrinsic • Physical Exam
o Nutrition o Defect
❖ Protein undernutrition ❖ Size, placement
Proteins are raw materials for enzymes and cell o Surrounding skin
proliferation ❖ Lesions, laxity, color match, scars
❖ Vit C Def Does the color match?
❖ Vit A def o Fascial structures
❖ Functional concerns, lip, lid
o Diabetes Mellitus – delayed wound healing Consider lines of tension, creases and anesthetic
o Age the older you are, the less efficient is wound healing units
• Extrinsic o Incision placement
o Infection ❖ RSTLs, BAUs
o Smoking • Template
o Corticosteroids – will affect prostaglandin • Draw options/measure
o Ionizing Radiation • Undermine
o Surgical Technique – designed according to Langers • Review options/remeasure
Line (creases of the skin) • Incise
❖ Tension *suture wound with tension = wound • Rotate vs. advance vs. transpose
would dehisce • Key stitches
❖ Crushing of tissues • Excise cones
❖ Dressing • Close
• Local:
o Infection, Hypoxia, Smoking, Irradiation LOCAL SKIN FLAP
• Systemic: • Facial Defects common
o Malnutrition, Cancer, Diabetes, Uremia, Alcoholism, o Trauma
Steroids, Immunosuppression, Chemo, Jaundice and o Skin malignancies
liver failure • For better survival of skin flaps *
• Treatment
SKIN o Primary Closure
• Stretch o Secondary Healing
Meaning you remove the malignancy and let it heal by itself or
o Elasticity you can use:
❖ Elastin ❖ Skin graft
❖ Collagen ❖ Local flaps
As you grow older, you lose elasticity
o Tension vs. Blood supply
• ZONES OF PERFUSION
❖ The success of the flap depends on the
• Zone 1
tension vs the blood supply.
• Macrocirculatory system
❖ By putting tension you will decrease the
• Zone 2
perfusion
• Capillary system small to bigger vessel
• Biomechanics
• Zone 3
o Creep
• Interstitial system
❖ Extrusion of fluid in dermis
• Zone 4
❖ Breakdown of dermal framework
• Cellular System
o Stress relaxation
❖ Increased cellularity
Consider creases as your alignment
o Characteristics
❖ RSTLs
❖ LMEs

Example of zones of perfusion: I, II, III, IV

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TOPIC: WOUND HEALING

*zone 3 and 4 = interstitial perfusion meaning blood is important because it brings your a. Rotation
enzymes in your cells o Pivotal flap
A. Local Flaps Classification o Curvilinear
• BLOOD SUPPLY o Standing cone results
1. Random – without specific blood supply o Two borders
So when you talk about the skin, there is segmental arteries, o Broad based
perforating branches, direct cutaneous vessels and subdermal o Uses- cheek, forehead
plexus. This is referring now to your random kind of a flap.
In a random flap, you have a subdermal vessel but the actual
zone 2, you have the perforating muscular artery and
perforating subcutaneous. But beyond that, there is no actual
vessel that will perfuse. So when you take a portion of the
skin, it will be a random flap because there is no vessel that
goes with the flap. Therefore it is unpredictabl
❖ Most common
❖ Based on subdermal plexus
❖ Unpredictable outcome bec of blood supply
❖ Length:width of 3:1 or 4:1 this is the maximum;
they are only based on the subdermal plexus.
“SUB-DER-MAL subcutaneous arteries okay?”
❖ No blood supply; meaning, we mentioned zone 1
zone 2 and the rest are interstitially perfused.
That’s the meaning of random. There’s no blood
supply

Get a tissue inside the defect and rotate it. Of course you have to take the burrows triangle
because it will fold as you rotate the skin

b. Advancement
o Sliding movement
o Adequate undermining
o Standing cones created
o Uses- forehead, brow
o Types
❖ Monopedicle
▪ Forehead, Brow
▪ 3:1 ration
▪ Burow’s triangles remove it

2. Axial
Whereas axial flaps are provided with a specific artery and
veins. And therefore this is more viable when you use it to
repair. Kasi when you repair, you use a normal skin to rotate
or advance or repair the defect in the face. So if it fails, do
again a second operation and that will be hard to explain to
the patient. And so you have to make a proper plan and
choose the proper flaps
❖ There is a specific blood vessel. Ex. Pectoralis
flap: thoracoacromial artery and vein are ❖ Bipedicle
preserved to make the pedicle or flap viable ▪ Forehead, brow
❖ Limited by available vessels ▪ Disadvantage long suture line
❖ Definite blood supply and vein 2 undermined flaps to cover the defect
❖ Based on direct cutaneous vessels
*kaya axial flaps are better than random flaps
❖ Random flap at distal tip
❖ Examples
▪ Nasolabial flap
▪ Midline forehead flaps for repairing the
nose

❖ V- Y Flap
Remove a V and produce a Y :)

• TISSUE MOVEMENT
When you try to repair a defect in the face or cheek, you can use a flap that you
can rotate or advance or transpose.

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TOPIC: WOUND HEALING

In this type of flap, you need a linear axis and degree of rotation;
geometry is important!
o Measure, remeasure
o Linear axis
o Rotated over intact skin
o Pivot point
o Versatile
o Geometry
o Not concrete, variations exist

❖ A-T Flap
▪ Bilateral advancement 1. Rhomboid
▪ Triangular dfect ✓ 60 & 120 degree angle
▪ Uses: hairline, brow, lip
Lips - philtrum; remove the basal cell CA then
close is as a T

❖ Cheek Advancement – If you have a defect

in the cheek. You transpose the whole skin
of the cheek 2. Dufourmental
▪ Some rotation ✓ 60 to 90 degree angles
▪ Uses- medial cheek, nasolabial ✓ Triangular
sulcus
▪ Prevent complications (ectropion)
Scars are hidden kasi andun ssiya sa
lines of creases and tension lines (there
will be no tension)

3. Bilobes
❖ Double transposition flaps
❖ Original description
▪ 90 degree arcs
▪ Final 180 degree arc
If you have something big like this one, a cheek ❖ Arcs of 90 to 110 degrees preferable
advancement flap was done to cover the defect. The ❖ Uses- lower third of nose
whole cheek (only the skin) was rotated. See it There is 2 flaps
follows the lines of tension and crease of the face so
the scars will not be visible and you have a good
cosmetic repair after 1 year.

❖ Nasolabial flap
▪ Axial pattern
▪ Used in the lower 2/3 of the nose, upper
lip
▪ It is inferiorly based to correct the defect
in the nose or lip
▪ A superiorly based will be something like
this

❖ Midforehead flap
▪ Indian rhinoplasty
▪ Median, paramedian forehead flap
▪ Axial pattern- Supertrochlear artery
at medial brow, 2 cm from midline
▪ Pedicle can be as little as 1.2 cm
▪ Thin distal tip appropriately
▪ Disadvantage long scar, limited
length, revision
You use the middle forehead to repair the
dorsum of the nose
❖ Paramedian Forehead Flap
Make use of the superior orbital artery
then you rotate it under the skin
c. Transposition
Additional info from recordings: (doc describing pictures pero di na yata nakuhaan ng pic
yung ibang slides ni doc)
✓ SCC – wide excision; what was used here was the temporalis fascia to cover
the buccinator defect
✓ Abeslander (?) flap – a rotation flap; if there is more than 1/3 you need to repair.
So you rotate that to repair the defect
o There is a modified where in you extend the excision
✓ The most difficult is when you repair the angle
✓ When you deal with malignancies, there will always be a defect that you always
have to repair. We use a trapezius flap for large defects sa oral cavity, cheeks
✓ Temple defect: basal cell cancer, so this was repaired with an advancement
flap and you have to undermine the temporalis skin so that you can pull the flap
to close the defect
✓ BCC – this was repaired with a rhomboid flap, covering now the defect
✓ Multiple BCC – you remove it and correct it again with an advancement flap;
what you advance is the forehead

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TOPIC: WOUND HEALING

✓ If big defect, this one usually is not only BCC but can also be SCC, we have
mentioned the forehead flap but we can also use the nasolabial flap. But they
used here a free flap from the tragus / cartilage of the ear. They used that to
maintain the ala and used a nasolabial flap then after 6 mos, you can repair it
✓ If you have something like this, 2 defects, this was repaired by advancement
flap, from the hairline you advance.
✓ If you have a small lesion like that, you can repair it with a bilobe flap
✓ If you have something big like this one, a cheek advancement flap was done to
cover the defect. The whole cheek (only the skin) was rotated. See it follows the
lines of tension and crease of the face so the scars will not be visible and you
have a good cosmetic repair after 1 year.
✓ See this big defect: rhomboid; this time we now use the scalp to advance and
repair the defect

B. Flap Survival ❖ Dec blood viscosity to inc blood flow –

• Length: Width (ratio) meaning venous fluid needs bigger caliber
o Increased width of base would increase surviving of vessels
length but feeding vessels have same perfusion ❖ Hemodilution
pressure ❖ Increased viscosity = less flow
• Perfusion Pressure ❖ Determine viscosity
• Blood Supply ❖ Determined by protime
o Supply exceeds requirements 5. Inflammation
o Changes ❖ give NSAIDs
❖ Temperature 6. Antioxidants (will enhance oxygenation and produce H202)
❖ Autonomics (sympathetic or ❖ allopurinol
parasympathetic) trauma ❖ superoxide dismutase, Vit C, Vit A, Vit E
o Arteriovenous Shunts ❖ increased reperfusion when you use these
❖ Sympathetic control antioxidants
❖ Fully opened shunt bypasses capillary bed
• Flaps can survive up to 13hrs of complete avascularity

*How do you increase the viability of a flap if it is already in the periphery?

1. Design the flap – zone 1 and 2 will increase
So you design the flap that you will have more capillaries or vessels
perfusing the tissue or the skin. One vessel will be less viable than a
three vessel; identify the vessel that will supply that portion of that
skin

This is what we do in AV shunt, this is the dermis, and this is the epidermis. There is a
shunt between the artery and the vein at the capillary level.

C. Delay Phenomenon
So what do you do when you delay?
2. Delay • Incise and undermine
Or you delay the flap if you have a deltopectoral flap to repair a • 10 to 21 day delay – most common
defect in the head and neck. You can delay the transfer of the graft. o Only at this time you can transfer the flap
You incise it first and then you wait for 3-5 days (that’s what you call • No benefit at 3 weeks to 3 months
delaying the flap. This: • Improved blood supply
❖ Improves the blood flow; will neovascularize o AV shunt closure
tissues o Conditioning to ischemia
❖ Conditions the skin to ischemia o Alignment of vessels
❖ Hyperadrenergic state in accurately raised Because there is revascularization, new vessel reconnect with
flaps old vessels (wound healing)
*When you increase the adrenergic state, you
increase the perfusion although the vessels D. Postoperative Care
constrict
3. Vasodilators – to promote good perfusion • Pain reliever
❖ Phenoxybenzamine • Wound care
❖ Nitroglycerine o Hydrogen peroxide, antibiotic ointment
❖ Isoflurane over nitrous oxide • Sutures removed at 5 to 7 days
Isoflurane has greater effects in vasodilation o To avoid scars
4. Rheology • Direct sunlight avoided for 2 – 3 months
❖ Poisseulle’s Equation: • Dermabrasion 6-12 weeks there is scar
• Revision / irregularization – after 6 months

E. Complications
• Infection
• Hematoma/seroma
• Cyanosis because of the tension
• Failure/ necrosis, dehiscence
Factors in wound healing: age, endocrine function problem, drug therapy, under
chemotherapy, sepsis, obesity and malignant diseased can be a factor in

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TOPIC: WOUND HEALING

wound healing. In this patients, they are high risk. Beware and inform the
patients of the possible complications

BASIC PRINCIPLES OF FREE FLAPS

You remove the tissue then you re-anastomose the artery and the vein to the recipient site.
Example is a forearm flap. If you have a defect like this one, you can repair that with a free
flap with the skin taken from the forearm. Preparation of the flap includes measuring. This
is how you get the skin from the flap including the fascia because the artery will be the
radial artery and the vein will be the cephalic vein. See you it can be repaired with a big
tissue in the forearm because you connect now the artery and the vein with the facial artery
and vein. That is free flap.

A. Definition of terms
• Free flaps: tissues that are transferred with their corresponding
vascular supply and anastomosed to recipient vessels
• Microvascular surgery: repair or anastomosis of small vessels under
the microspore • At the anastomotic site (Zone one), the newly flowing blood is
exposed to dysfunctional endothelial cells, the connective tissue
substrate of the vessel wall, and foreign biomaterial (the suture)
• Thrombogenicity at the anastomotic site is maximal for the 30
minutes after reperfusion
• The damaged endothelium and exposed connective tissue elements
B. Reconstructive Microvascular Surgery steps initiate the extrinsic pathway of thrombosis, leading to thrombin
• Preparation of recipient site formation, platelet accumulation and thrombosis at the anastomotic
o Resection of tumor or diseased tissues site
o Preparation of bony or soft tissues site • The activation of thrombin initiates a cascade of effects in the
o Exposure of recipient artery, vein, nerve microcirculation leading to vasoconstriction, leukocyte chemotaxis
• Elevation of donor tissue on a vascular pedicle and activation, edema of the endothelial cells and perivascular
o If harvest site is at the extremity, tourniquet is used spaces, and extravasation and formation of oxygen free radicals
o 250 mmHg: arm
o 350mmHg: leg E. Reperfusion Injury
• Transfer of donor tissue to the recipient site • Reperfusion injury is an inflammatory process modulated by the
o Partial insetting of the flap complex signaling mechanism of the immune system
o Vessel anastomosis • Reperfusion injury occurs when restored blood flow allows the influx
o Full insetting of the flap of inflammatory substrates that will ultimately destroy the flap
• The degree of injury incurred by the flap is influenced by many
C. Harvesting of Donor Tissue variables:
• Vascular pedicle should be carefully protected during flap elevation o Tissue type
and dissection o Temperature
• Avoid excess tension on the vascular pedicle o Times of ischemia
• After flap elevation, tourniquet is released to evaluate flap circulation o Perfusion pressures
• Vascular pedicle should not be divided until preparation at the o Pharmacologic pretreatment
recipient site is completed o Physiologic preconditioning
• Different types of tissues have different ischemia times
o Skin and bone can tolerate up to 3 hrs of ischemia
o Skeletal muscles and intestinal mucosa are less
tolerant
• Most surgeons would advocate microvascular anastomosis at 3 hrs
maximum ischemia time

D. Zones Of Perfusion
F. Medication for Flap Survival
• Zone 1
• Macrocirculatory system • Most surgeons would just use heparin flushing to improve flap
• Zone 2 survival rates
• Capillary system • Success rates: 90-99%
• Zone 3
• Interstitial system G. Types of Free Flaps
• Zone 4 • Radical forearm free flap
• Cellular System o Size: from flexor crease of the wrist to the antecbital
fossa
o Fasciocutaneus flap
• Anterolateral thigh flap
o Thicker flap

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TOPIC: WOUND HEALING

• Fibular free flap

o 25cm of bicortical bone
o Non-weight bearing

Additional recordings ulit kasi kung anu ano knkwento ni doc haha:
✓ For the tongue, you can use the forearm free flap, you do a hemi glossectomy
because you can connect the artery and vein
✓ For the nose and the check you can also use a free flap
✓ A big defect will need a free flap, that’s for the nose
✓ You can use it in the thigh as long as you know the vessels you will transpose
and anastomose
✓ Easiest is the forearm
✓ You can use the long bone for the mandible, fibula with the skin and reconstruct
the jaw

END

Tell me something. When I feel tired and afraid, how do you know just what to say to make everything alright?
I don’t think that you even realize the joy you make me feel when I’m inside your universe.