Flaps and Graft
Introduction:
The surface of the skin is important as biological layer
for homeostasis .
without skin wounds healed by secondary intention
with fibrosis and contracture .
Grafts
-Tissue that are transferred without their blood supply.
-Its used for closing defect that cant be closed primarily.
-It consist of epidermis and some or all of the dermis.
-Require vascularization from the bed into which they are
placed for survival.
Types
1-split thickness skin graft .(theirsch graft)
-cover all size wound.
- provides temporally closure.
-All the epidermis together with some dermis.
-Thicker dermis( brisk punctuate bleeding).
the
more durable will be the graft
difficult will be the
donor site healing.
-The thicker graft will heal with less contracture.
-Thinner donor site heals better.
-Hairless and don’t sweat and can be perforated to allow
escape of exudates and improve the take.
2-full thickness skin graft (wolf graft):
-whole dermis with the underling fat trimmed away.
3-composit graft
It’s a full thickness skin graft containing element of fat
or
even cartilage as well for
building missing element usually in nose eyelid or finger
tip
-Both full thickness and composite graft require the best
handling and post operative nursing
4-nerve graft usually sural nerve
5- tendon graft :
Usually the Palmaris longs or plantaris tendon for injury
loss
-Full thickness skin graft have the greatest sensory
return because of greater availability of neuralimmal
sheaths hair follicles which demonstrate the growth of the
donor site
How does skin graft survive
a-inhibition phase:(inhibit the plasma).
b- kissing phase:
48 hr. later a fine anastamotic connection made
which lead to inosculation of blood capillary growth
then complete the healing processes with fibro
blast maturation which cause adherence of the graft
-granulation will support graft ?(no bone/tendon)
Donor site :
-epidermis regenerates from the immigrations of
epidermal cells (hair follicle & adnexial structures).
-Donor site my be used again in split thickness graft.
-In full thickness graft site must be closed primarily because
there are no epithelial structure.
Site:
Any where site can be used but color, texture, thickness of
dermis ,vascularity and donor site morbidity are
considerable factor
Example :Skin graft above the clavicles color match with face defect
Scalp, abdominal wall , buttock especially in children and
thigh are common donor site for split thickness skin graft
Flaps
-Flaps are tissue that are transferred with a blood supply.
Types:
1-Ramdom flaps: 3 sides of rectangle bearing no specific
relation ship to where the blood supply enters
2-Axial flaps :much longer based on known blood vessels
supplying the skin , enable many long thin Flap to be
safely moved across long distance
3-Pedicle island flaps :the axial blood supply can be swung
around an a stalk or even fully islanded & the pedicle
buried.
4-Free flaps :The blood supply isolated ,disconnected and
then reconnected at the new site using micro surgery
5-Composit flaps :Various tissue are transferred together
skin with bone or muscles
6-Perforated flaps: it’s a sub group of axial flaps in which
tissue isolated on a small perforating vessels
Indication of flaps and graft
1-Trauma :
- soft tissue lost
- Hand and lower limb injuries
-Faciomaxilly
-Burn
2-Cancer:
-skin , head and neck , soft tissue , breast.
3-Congenital :
-Clefts and craniofacial malformation
-Skin , giant nevi and vascular malformation
-Urogenital
-Hand and limb malformation
4-Miscellaneous :
-Bells (facial palsy)
- pressure sore
-aesthetic surgery
-chest wall reconstruction
local flaps
-Its flap that raised next to a tissue defect in order to
reconstruct it
Types or pattern
1-transposition flap
2-z-plasty for lengthening scar tissue
3-rhomboid flap in chest and back
4-advancement flap for flexor surface
5-rotation flap for convex surface
6-V-Y flap for finger tip
7-Bilobed flap for .for the nose
8-Bipedical flap eyelid
Care of the flaps
After removal flaps should be observed for
1-Tissue color
-If pale and cold mean no arterial inflow
-If blue means no venous out flow which some times
treated by leech
2-Warmth
3-Turgor
4-Assess blanching and capillary refill time .
Distant flaps
-To repair defects in which local tissue is inadequate, distant flaps
can be moved on long pedicles that contain the blood supply.
-These flaps can carry large composite skin parts for
reconstruction very great distances, e.g. from the abdomen to
the chest (for breast reconstruction), or from the chest to the
face.
-myocutaneous flap
-fasciocutaneous flap
Free tissue transfer (or free flap)
Advantages
■ Being able to select exactly the best tissue to move
■ Only takes what is necessary
■ Minimises donor site morbidity
Disadvantages
■ More complex surgical technique
■ Failure involves total loss of all transferred tissue
■ Usually takes more time unless the surgeon is experienced
Causes of failure
Grafts
1-Pus : B-haemolytics streptococcus can destroy the graft
2-Exudates dead tissue beneath the skin
3-Residual dead tissue beneath the skin
4-Haematoma
5-Shearing forcer
Flaps
1-Poor anatomical knowledge
2-To much tension flap
3-Local or systemic sepsis
4-Too tight dressing around the pedicle
The best advice is to keep the
patient wet , warm and
comfortable