Surgery

Plastic Surgery
BA, MD

PLASTIC AND RECONSTRUCTIVE SURGERY o Can be done as long as you close primarily and you know
Plastic
that there will be no deformity that will follow
Surgery • Tertiary Intention
o Delayed wound closure → dependent on Wound
Classification
Defects -
Aesthetic Form and o Example: patient with a rupture Appendicitis → after
Function doing the operation, most surgeons would leave the
Subcutaneous Tissue Layer open because chances of
abscess formation is very high
Cosmetic Congenital Acquired → Some surgeons would flush the Subcutaneous Layer
thoroughly and then close the wound
• “Plastic” → Greek Word “Plastikos” which means “to mold” o Parameters:
• 2 Aspects of Plastic Surgery: 1. Leave the wound open until you think the bed is
1. Aesthetic already clean (no purulent discharge, granulation
2. Defects tissue is forming well, very vascular)
• The Defects may either be: • Step 3: Skin Graft
A. Congenital (e.g., Cleft Lip) o Would apply to LARGE WOUNDS that you cannot directly
B. Acquired close or those wounds that would form deformity if you
• Priciples: close it primarily
o Correct Diagnosis o Taken from donor site without any vessel supplying it
o Formulation / Planning → RECONSTRUCTIVE LADDER • Step 4: Local Tissue Transfer (Local Flap)
WOUND HEALING o Vascular supply is INTACT
Skin Incisions • Step 5: Distant Tissue Transfer
o Chest Wall Reconstruction / Breast Mound
Reconstruction
• Step 6: Tissue Expanders
o Placement of a balloon that will expand
o Once you create adequate tissue to cover the defect, you
can remove the expander and close it as a Local Tissue
Transfer
• Step 7: Free Tissue Transfers (Free Flap)
o Transect the vessels and relocate it to the recipient site
• The purpose is for the surgeons to start from
• In making incisions, especially in the face, you need to follow Purpose the simplest first before going to the more
the Skin Lines complex
• Skin Lines: Classification of Operative Wounds Based on Degree of Microbial
1. Langer’s Line – skin tension vectors observed in the Contamination
stretched integument of cadavers exhibiting rigor • 1-5.4% chance of infection
mortis • Elective, non-emergency, non-traumatic,
o Lines that stayed in the Linear Fashin primarily closed
2. Borges’ Line – vectors of relaxed skin tension, reflect Clean • No acute inflammation
the action of underlying muscle • No break in technique
3. Kraissl’s Line – run along neutral wrinkles and skin
• Respiratory, Gastrointestinal, Biliary, and
creases, tend also to follow the Relaxed Skin Tension
Genitourinary Tracts are not entered
lines (RSTL)
• 2.1-9.5%, 9.4-25% chance of infection
4. Relaxing Skin Tension Lines (RSTL) - lay perpendicular
to and more accurately reflect the action of underlying • Urgent or emergency case that is otherwise
muscle clean
• RSTL is followed because when you make incisions along • Elective opening of Respiratory,
Clean-
these lines, there will be less scar formation → aesthetically Gastrointestinal, Biliary, or Genitourinary
Contaminated
pleasing Tract with minimal spillage (e.g.,
Reconstructive Ladder Appendectomy) not encountering infected
urine or bile
• Minor technique break
• 3.4-13.2% chance of infection
• Non-purulent inflammation
• Gross spillage from Gastrointestinal Tract
• Entry into Biliary or Genitourinary Tract in
Contaminated the presence of infected bile or urine
• Major break in technique
• Penetrating trauma <4 hours old
• Chronic open wounds to be grafted or
covered
• 3.1-12.8% chance of infection
• Purulent inflammation (e.g., abscess)
• Preoperative perforation of Respiratory,
Reconstructive Ladder Reconstructive Elevator Gastrointestinal, Biliary, or Genitourinary
Dirty
• For Traumatic Wounds, the Reconstructive Ladder is being Tract
followed • Penetrating trauma >4 hours old
• Step 1: Allowing the wounds to heal by SECONDARY • Decide what you will use in the
INTENTION Reconstructive Ladder
o Secondary Intention – allowing the wounds to heal on its 2 Types of Wound Healing
own • Regenerative Healing:
o Can be used in treating SMALL and CLEAN WOUNDS o Characterized by the restoration of the structure,
• Step 2: Direct Tissue Closure (Primary Intention) function, and physiology of damaged or absent tissue
o Closing the wound without leaving any defect through o Uses Stem Cells and Growth Factors to hasten healing
Sutures, Staples, etc. and minimize scar formation
o Parameters: • Reparative Healing:
1. Clean Wound (no necrotic tissue; if wound is dirty, o Characterized by wound closure through scar formation
you can irrigate)
2. Close the Wound through Suture, Staples, and
Adhesives
3. Check how the scar would heal

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 Surgery
Plastic Surgery
BA, MD

Phases of Wound Healing Factors Contributing to Impaired Wound Healing

• Phases: Local Factors Systemic Factors
1. Hemostasis / Inflammatory (2-3 days) 1. Arterial Insufficiency 1. DM
o Immediate Phase – actively bleeding wound → 2. Venous Insufficiency 2. Malnutrition
Hemostasis – will try to stop the bleeding 3. Edema 3. Vitamin Deficiency
o After Hemostasis, Platelets will create a Fibrin Clot 4. Infection 4. Chemotherapy
o These Platelets will attract other cells in 2-3 days 5. Pressure 5. Smoking
o Inflammatory Phase: 6. Radiation 6. Aging
→ First cell to be attracted by the Platelets would 7. Glucocorticoids
be the NEUTROPHILS, followed by the 8. Minerals
MACROPHAGES, and FIBROBLASTS • Wounds usually close around 2 weeks
2. Proliferative (day 4-week 3) • Stalled Wounds: 2 weeks to 3 months
o Starts with the arrival of Fibroblasts • Chronic Wounds: >3 months
o Fibroblasts will create Type 3 Collagen o Since the wound is chronic, the cells tend to try and close
3. Maturation / Remodeling (6 mos-1 year) it regularly → continuous cell division → might produce
o Converts Type 3 Collagen to Type 1 Collagen Metaplasia
o Metaplasia may increase the chance for the development
of Carcinoma
• Arterial Insufficiency
o Lack of nutrients → cells will not survive
• Venous Insufficiency
o Vicious cycle because if you don’t have venous drainage,
the blood will pool inside
o Once the blood pools, there will be EDEMA → pressure
within the area
o Pressure will compromise the Arterial Circulation
o Hematoma Formation → a very good medium for
infection
• Radiation
o Targets not just the tissues but also the vessels →
Vasculitis due to Fibrosis
• Systemic Factors
o Malnutrition → the body needs protein to heal
• MONOCYTES / MACROPHAGES are important → will elaborate o Vitamin Deficiency →
plenty of the Growth Factors a. Vitamin C – very important in the formation of
• KERATINOCYTES → will try to do Epithelialization Collagen
• ENDOTHELIAL CELLS → will try to promote ANGIOGENESIS – b. Vitamin A – needed for patients taking
needed so that the healing tissue will have adequate immunomodulating substances (e.g.,
nutrition and oxygen to further multiply Glucocorticoids and Chemotherapeutic Drugs)
• TYPE 1 COLLAGEN → needed so that the scar formed is not because Vitamin A counteracts their effects
hard, elevated, or large c. Vitamin E – should NOT be given because it disrupts
Name Source Description the platelet function
Vascular o Smoking → will affect the vessels; advise the patient to
Endothelial stop smoking at least 2 weeks before surgery
Endothelial Cells Promotes Angiogenesis
Growth Factor
o Aging → cells will also age
(VEGF)
o Minerals → Zinc is needed because it would promote
Macrophages,
Promotes Angiogenesis Wound Healing
Fibroblast Growth Mast Cells,
Stimulates Endothelial Cell SUTURES
Factor 2 (FGF-2) Endothelial Cells,
Migration and Growth
T Lymphocytes • Maintain wound closure
Enhances Proteoglycan and • Enhance wound healing
Platelet-Derived Platelets,
Collagen Synthesis
Growth Factor Macrophages,
Recruits Macrophages and • Tense Wounds → will lead to infection due to prolonged
(PDGF) Endothelial Cells inflammatory phase
Fibroblasts
Stimulates Collagenase • The physical characteristic of a suture material determines
Epidermal Growth Platelets,
Factor (EGF) Macrophages
secretion by Fibroblasts to its utility:
remodel Matrix 1. Configuration
Promotes Angiogenesis 2. Diameter
Enhances chemoattractant 3. Capillarity and Fluid Absorption
gradients, induces adhesion
Platelets, molecule expression, and 4. Tensile Strength
Macrophages, T promotes proinflammatory 5. Knot Strength
Transforming 6. Elasticity
and B Cells, molecules that stimulate
Growth Factor-β
(TGF-β)
Hepatocytes, Leukocytes and Fibroblast 7. Plasticity
Thymocytes, Migration 8. Memory
Placenta Induces ECM Synthesis by
• Easy to Handle
inhibiting Protease activity
and up-regulating Collagen • High Tensile Strength
and Proteoglycan Synthesis • Knot Security
• Neutrophils Properties • Minimal Tissue Reaction
o 24-48 hours • Resist Infection
o Phagocytosis • Good Elasticity and Plasticity to Accommodate
• Macrophages Swelling
o 48-96 hours • Types:
o Cell Proliferation, Matrix Synthesis, Remodeling, A. Absorbable
Angiogenesis 1. Natural – Catguts
• T Lymphocytes 2. Synthetics – Polyglycolic, Polydioxazone,
o 1 week Polycaprone Glycolide
o Wound Strength: B. Non-Absorbable
1. 2 weeks – will have 20% wound strength 1. Nylon
2. 10 weeks – 80% wound strength 2. Polypropolene
• Fibroblasts → ECM, Remodeling 3. Silk
• Endothelial Cells → Angiogenesis 4. Braided Polyester
• Minimal fibrous tissue beneath 5. Stainless Steel
Epithelialization • Diameter:
• Smaller wounds
Wound • Larger wounds o In the Face → the higher the number, the smaller the
Contraction diameter

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 Surgery
Plastic Surgery
BA, MD
• Simple Interrupted
• Vertical or Horizontal Mattress
Closure Methods • Subcuticular Continuous or
Interrupted
• Continuous Running
Simple Interrupted
• Entry of the needle is 90deg to
get more of the Dermis
• Wider at the base of the wound
for better approximation.
• Make sure it’s not too tight or
close because this would
induce TISSUE NECROSIS
• Knots should be placed in one
plane and have equal distance
• If knots are too close to each
other → VASCULAR
INSUFFICIENCY
• Close wound in a free manner,
there should be NO TENSION
Vertical Mattress Suture
• Evert the edges → as the
wound would heal, the edge
would go down → flatten
• It consists of a simple
interrupted stitch placed wide
and deep into the wound edge
and a second more superficial
interrupted stitch placed
closer to the wound edge and
in the opposite direction
Horizontal Mattress Suture
• Better if it’s not under tension
• Covers huge area
• The suture is passed deep in
the dermis to the opposite
side of the suture line and
exits the skin equidistant from
the wound edge (in effect, a
deep simple interrupted
stitch).
Tip Stitch
• Used for CORNERS
• Begins on the side of the
wound on which the flap is to
be attached.
• The suture is passed through
the dermis of the wound edge
to the dermis of the flap tip
Subcuticular Stitch
• A running subcuticular suture
is a buried form of a running
horizontal mattress suture.
• It is placed by taking
horizontal bites through the
papillary dermis on
alternating sides of the wound
• No suture marks are visible,
and the suture may be left in
place for several weeks.
• Timing of Removal of Sutures:
A. Face: 5-7 days
B. Extremities: 7-10 days
• Timing is important because the scar formed afterwards
would also depend on the timing of removal → may form
Suture Marks
o For example, in the face, you can remove it after 5 days
but if you see that it’s still healing, you can place surgical
tapes on the wound to bind the tissue together
OTHER METHODS
• Very easy to use but very painful to
Staples
remove
• If the wound is not tensed and it is on
Surgical Tapes
the RSTL, you can just places tapes
• Usually used in infants
Biologic or
• Absorbable → more difficult to use
Synthetic
Adhesives because it will last longer (>10 days or
more) → scar would not look good
EXCESSIVE WOUND HEALING
• Extends beyond the wound
• Elevated levels of TGF-β
• Autosomal Dominant
Keloids
• Increased Type III Collagen
• If the scar extends BEYOND the wound
margin → Keloids
• Occurs when you close an area that is
tensed
Hypertrophic • Does not extend beyond the margins
Scar • Prolonged Inflammatory Phase
• Increased wound tension
• More common in areas of tension
SKIN GRAFTS
• Indications for Skin Graft:
1. Big wounds that cannot be closed primarily
2. Takes >2 weeks to close by itself
• Skin Grafts vs Skin Flap:
o Skin Graft → healthy skin is removed from the donor site
and transplanted to a new site of the body → NO BLOOD
SUPPLY (AVASCULAR)
o Skin Flap → has a vessel either from the Dermal Plexus or
a specific vessel that is supplying the flap; BETTER than
Skin Graft
Skin Graft Skin Flap
• 2 Types:
A. Split Thickness
a. Thiersch Ollier - Thin
b. Blair Brown - Intermediate
c. Padgett - Thick
B. Full Thickness
a. Wolfe – Entire Dermis + Epidermis
• Donor:
A. Autograft → from your own self
B. Isograft → twin of the patient is the donor
C. Allograft or Homograft → graft from a different person
(e.g., Amnion or Cadaver Skin)
D. Xenograft or Heterograft → graft from other species
(usually Bovine; Tilapia can be used in burn patients)
• Autograft and Isograft → better because it gets incorporated
in the skin
• Allograft and Xenograft → act as a dressing; will be removed
afterwards due to Rejection Factor
PHASES OF GRAFT SURVIVAL
• Phases:
1. Plasmatic Imbibition (24-48 hours)
2. Inosculation and Capillary Ingrowth (>48 hours)
3. Revascularization (5th to 6th day)
• The graft should be immobilized during the first 2 phases
• “Imbibition” → “Drinking”
• The graft will survive by drinking the
Plasmatic nutrients in the recipient bed (e.g.,
Imbibition protein, oxygen)
• Graft should always be in contact with
the bed during this phase
• Dermis has vessels → these vessels will
try to reconnect with the vessels on the
Inosculation and recipient bed
Capillary • When they reconnect, the graft area will
Ingrowth have its blood supply
• Graft should not be moved during this
phase
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 Surgery
Plastic Surgery
BA, MD

•$Grafts are not placed in bare bones, SKIN FLAPS

cartilages, and tendon because these
structures do not have blood supply
• The only time you can “move” the graft
to inspect it
• Graft Take of 90% is good enough
Revascularization • There are new vessels that are formed
and has reconnected already
• Do not open the graft until the 5th – 6th
day, preferably 7th – 10th day
• Do no try to open the graft immediately
• A fishy odor with yellowish discharge is NORMAL because
this is the serum • Flaps are elevated from a donor site and transferred to the
o If it’s purulent and has a foul smell → exudate → recipient site with an INTACT VASCULAR SUPPLY.
INFECTION • It survives by carrying its own blood supply until new blood
• How can you be sure that the bed is not infected anymore vessels from the recipient site are generated
before you place your graft? • Tissue may be transferred from an area adjacent to the
o WOUND CULTURE AND SENSITIVITY defect → Local Flap
o Tissue Culture is more reliable → if the bacteria count is o It may be described based on its geometric design, be
100,000 – the bed is STILL INFECTED advanced, or both
o For MRSA → a count of 10,000 already indicates that it is • Skin Flap is more reliable than Skin Graft
still infected • Classification:
Graft Contraction A. Random Pattern Flap → no specific vessel supplying it;
STSG (Thin) STSG (Thick) FTSG being supplied by the DERMAL PLEXUS in that area
Dermal Content + ++ +++ a. Transposition Flap
1st Contraction + ++ +++ 1. Z Plasty
2nd Contraction +++ ++ + 2. Limberg Flap
Engraftment (Survival) +++ ++ + 3. Dufourmentel
4. Interpolation (Island Flap)
Durability + ++ +++
b. Advancement Flap
Pigmentation +++ ++ +
1. Single Pedicled
Resist Desiccation + ++ +++ 2. Bipedicled
Recipient Bed + ++ +++ 3. V-Y Advancement
Appearance + ++ +++ c. Rotation Flap
• Primary Contraction refers to the IMMEDIATE REDUCTION IN 1. Bilobed Flap
SIZE of the Skin Graft, directly after it has been harvested B. Axial Pattern Flap → designed with a specific named
from its donor site. vascular system that enters the base and runs along its
o FTSG decreases by 38% axis.
• Secondary Contraction refers to the reduction in size of the 1. Replace LIKE with LIKE
Skin Graft AFTER the transfer (once it is healed) 2. Think of RECONSTRUCTION in terms of
o More on STSG Units
• If it is going to contract, do not place it on flexor areas or Principle of
3. Always have a PATTERN and a BACKUP
areas where you need the defect to be closed without Flap Surgery
PLAN
contraction (e.g., face, hands) 4. Steal from Peter to pay Paul
• Hematoma 5. Never forget the Donor Area
• Movement A. RANDOM PATTERN FLAP
Graft Failure
• Bed Necrosis
• Infection

Advancement
Flap
• The rectangular flap advances into the
rectangular defect
• Mesh Grafts • The red triangular excisions are Burow
o Used in large areas → grafts that would have to be Triangles, which may be used to adjust the
expanded tension of closure
o Best color match
CASE #1

Rotation Flap

• The semicircular flap rotates into a

triangular defect.

• Case: Recurrent Phyllodes Tumor in the Chest Wall

o Bridge (yellow circle) is needed for coverage
o Placement of flap over that area (red circle) ensures that Transposition
there will be no Secondary Contracture in that area, Flap
especially in the axillary area
• Limberg Flap
• This is a Transposition Flap, showing
closure of a rhomboid-shaped defect.

Page 4 of 6
 Surgery
Plastic Surgery
BA, MD

Muscle Flaps and their Blood Supply

• 5 Types:
1. Type 1 - 1 Vascular Pedicle (cannot be transected) →
Tensor Fascia Lata, Gastrocnemius
2. Type 2 – Dominant Pedicle and Minor Pedicle (can be
transected) → Gracillis
3. Type 3 – 2 Dominant Pedicle (can be transected) →
Gluteus Maximus
4. Type 4 – Segmental Vascular Pedicles (can be
transected) → Sartorius
5. Type 5 – 1 Dominant Pedicle and Secondary Segmental
Pedicles (can be transected) → Latissimus Dorsi
CASES

Rotation Flap Transposition Flap

Advancement Flap Bipedicle Flap

V-Y Advancement Flap MONITORING OF SKIN FLAPS

B. AXIAL PATTERN FLAP • Clinical Observation is the best method to assess a flap
• Includes: o Extremely Pale Flap may signify Arterial Insufficiency →
1. Groin Flap release few of the sutures and check
2. Scapular Flap o Blue Flap may be secondary to a failure of venous flow →
3. Temporal Flap medicinal leeches can be used; cannulation of vein
4. Deltopectoral Flap o
• Survival is better if you use an Axial Pattern Flap over the • Objective Tests: pH Monitoring, Transcutaneous O2 Tension,
Random Pattern Flap Doppler Ultrasound, and Laser Doppler, Surface
C. COMPOSITE FLAP Temperature Monitoring, Fluorescein Dye and Illumination
• Fasciocutaneous Flap → Radial Forearm Flap or with Wood Lamp
Anterolateral Thigh Flap COMPLICATIONS OF FLAPS
• Musculocutaneous Flap → provide motor function or • Includes:
structural support at the site of the reconstruction 1. Preoperative
• Osteomyocutaneous Flap → a segment of the 6th rib with the 2. Intraoperative
Pectoralis Major muscle, a segment of the Iliac bone with the 3. Postoperative
Internal Oblique muscle (Deep Circumflex Iliac Artery Flap), FINAL THOUGHTS
and a rib segment with Intercostal muscle, are examples of 1. Be thoughtful. Consider all options, simple to complex, prior
Muscle Flaps that may include bone to any flap surgery
• Island Flap 2. Be knowledgeable. Know and understand the anatomy,
Fasciocutaneous Flap blood supply, and quality of tissue available
Mathes-Nahai Classification 3. Be prepared for failure. Have a back-up plan available in
case the first plan fails
TISSUE EXPANSION
• 1956 – started by Charles Neuman
• 1970s – popularized by Radovan and Austed
• Creation of additional tissue
• Increase vascularity
Benefits • Predictable amount created
• Mathes-Nahai is more commonly used over the Nakajima • Same color/texture
1. A - Direct Cutaneous • Useful for many regions
2. B - Septocutaneous → between the muscle bundle • Round
3. C - Musculocutaneous → piercing the muscle Shapes • Rectangular
• It is better to include the fascia because it will increase the • Crescent
survival → strength of flap is better

Page 5 of 6
 Surgery
Plastic Surgery
BA, MD

• Cellulitis or Infection
• Exposure or Extrusion
o If the surgeon expanded the tissue
rapidly with high volume → Exposure or
Extrusion
Complications • Implant Failure or Rupture
o Too much expansion in a short amount
of time
• Flap Ischemia or Skin Loss
o Too much expansion in a short amount
of time

MICROSURGERY
• Magnification → because the vessels are
small
• Microsurgical Instruments
• Microsutures
Instrumentation • Solutions (Heparinized NSS/LRS,
Lidocaine, Papaverine)
o Should not clot → Heparinized
NSS/LRS
o Should not spasm → Lidocaine,
Papaverine
• Uses:
1. Blood Vessels
2. Nerves
• Healthy
o Pink, warm, Dopplerable pulses, and
soft but with tissue turgor
• Arterial Compromise
Flap o Pallid, cool, poor tissue turgor,
Characteristics Dopplerable pulse may still be
present
• Venous Congestion
o Tense, warm or cool, purple or bluish
tinge
AREAS WHERE YOU CAN HARVEST FLAP

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