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U. Reconstruction
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C hapter Outline
·
Graft
·
Skin Grafts
·
Flaps
·
Abdominoplasty
GRAFT
Graft: It is transfer of tissue from one area to other without its
blood supply or nerve supply.
Autograft: It is tissue transferred from one location to another
on the same patient.
Isograft: It is tissue transfer between two genetically identical
individuals, i.e. between two identical twins.
Allograft: It is tissue transfer between two genetically different
members, e.g. kidney transplantation (Human to human)
(Homograft).
Xenograft: It is tissue transfer from a donor of one species to a
recipient of another species (Heterograft).
SKIN GRAFTS
·
Tendon
·
Tendon Repair
·
Tendon Transfer
·
Tendon Graft
Contraindications
SSG cannot be done over bone, tendon, cartilage, joint.
PREREQUISITE
B
x Healthy granulation area
xx b-haemolytic streptococci load less than 10
otherwise graft failure will occur
Technique
¾
Donor area—Commonly thigh, occasionally arm, leg,
forearm;
Knife used is Humby’s knife; Blade is Eschmann
blade, Down’s blade; Using Humby’s knife graft is taken,
punctate bleeding is observed which says that proper
graft has been obtained.
DIFFERENT INSTRUMENTS USED TO HARVEST THE SKIN
B
GRAFT
x Humby’s knife
x Watson modification of Humby’s knife
x Power dermatome is also used (Brown)
x Sterilised razor blade can be used with a specialised device to
harvest small grafts under local anaesthesia
¾
Donor area is dressed and dressing is opened after 10
days, not earlier.
5
per gram of tissue,
Skin Grafting: It is transfer of skin from one area (donor area)
to the required defective area (recipient area). It is an autograft.
Types
1. PARTIAL THICKNESS GRAFT
(Split-thickness skin graft—SSG)
Also called as Thiersch graft, is removal of full epidermis +
part of the dermis from the donor area.
It may be: (1) Thin SSG; (2) Intermediate SSG; (3)Thick SSG
(depending on the amount of thickness of dermis taken).
INDICATIONS
B
x Well-granulated ulcer
x Clean wound or defect which cannot be apposed
x After surgery to cover and close the defect created
For example:
– After wide excision in malignancy
– After mastectomy
– After wide excision in squamous cell carcinoma
– Graft can survive over periosteum or paratenon or perichon-
drium
A
B
Figs. 1.601A and B: Split skin grafting knife and set; and harvesting.
Fig. 1.602: Commonest donor area for spilt skin grafting is thigh.
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CHAPTER 1U General Surgery: Reconstruction
¾
Recipient area is scraped well and the graft is placed after
making window cuts in the graft to prevent the development of seroma. Graft is fixed and tie-over dressing is
placed. If graft is placed near the joint, then the part
is immobilised to prevent friction which may separate
the graft. On 5th day, dressing is opened and observed
for graft take up. Mercuro chrome is applied over the
recipient margin to promote epithelialisation.
Stages of Graft Intake
1. Stage of plasmatic imbibition: Thin, uniform, layer of plasma
forms between recipient bed and graft.
2. Stage of inosculation: Linking of host and graft which is
temporary.
3. Stage of neovascularisation: New capillaries pro liferate into
graft from the recipient bed which attains circulation later.
Note:
Graft is stored at low temperature of 4°C for not more than 21 days.
Disadvantages of SSG
Contracture of graft. Two types:
Primary contracture means SSG contracts signi ficantly
A.
once graft is taken from donor area (20–30%). Thicker
the graft more the primary contracture.
B. Secondary contracture occurs after graft has taken up
to recipient bed during healing period, due to fibrosis.
Thinner the graft more the secondary contracture.
Seroma and haematoma formation will prevent graft take up.
Infection; Graft failure.
Loss of hair growth, blunting of sensation.
Dry, scaling of skin due to nonfunctioning of sebaceous
glands. So after healing, oil (coconut oil) should be applied
over the area.
A
B
C
Advantages
Technically easier.
Wide area of recipient can be covered. To cover large area
like burns wound, graft size is increased by passing the graft
D
Figs. 1.63A to D
Happiness is not desnaon, it is a manner of travelling.
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A
SRB’s Manual of Surgery
E
Fig. 1.603E
Figs. 1.603A to E: Technique of split skin grafting.
B
Figs. 1.607A and B: Donor area of split skin graft in the thigh and
graft placed over raw area in the leg.
Fig. 1.604: Skin stapler can be used to fix the SSG to the
margin of the recipient bed.
Fig. 1.605: Humby’s knife with Eschmann blade.
Fig. 1.606: Harvesting a skin graft.
A
B
Figs. 1.608A to C: Mesher used in split skin grafting to increase its
surface area to cover wider area like burns wound. A large defect can
be covered by this. It can cause expansion of skin up to six times.
C
through a Mesher which gives multiple openings to the graft,
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which can be stretched on the wider area like a net. It can
cause expansion up to 6 times.
Graft take up is better; Donor area heals on its own.
Note:
Mercurochrome/merbromin once used as a local applicant to the edge of
the grafted area (SSG) and small raw areas to promote epithelialisation. It
is applied once a day. But it is no longer used now.
2. FULL THICKNESS GRAFT (Wolfe Graft)
It includes both epidermis + full dermis.
It is used over the face, eyelid, hands, fingers and over the
joints. It is removed using scalpel blade. Underlying fat
should be cleared off properly. Deeper raw donor area is
closed by primary suturing. If large area of graft is taken,
then that donor area has to be covered with SSG which is a
disadvantage in full thickness graft.
COMMON SITES OF DONOR AREA
B
x Post-auricular
x Groin crease
Advantages
¾
Colour match is good. Especially for face. No contracture
x Supraclavicular
(unlike in SSG).
¾
Sensation, functions of sebaceous glands, hair follicles
are retained better compared to SSG.
¾
Functional and cosmetic results are better.
Disadvantages
¾
It can be used only for small areas.
¾
Wider donor area has to be covered with SSG to close
the defect.
OTHER GRAFTS
B
x Composite graft which includes skin + fat + other tissues like cartilage
x Tendon graft; Bone graft; Nerve graft; Venous graft; Corneal graft
x Combined graft (allograft + autograft)
x Reverdin graft (Jacques-Louis Reverdin, Swiss surgeon): It is
a pinch graft taken from the skin and seeded in to the needed
raw area.
FLAPS
It is transfer of donor tissue with its blood supply to the recipient
area.
Parts of Flaps
Base, pedicle, tip of flap. Vasculature is usually through the
pedicle in the centre of the flap. Tip is the place where often flap
goes for necrosis.
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CHAPTER 1U General Surgery: Reconstruction
INDICATIONS
B
x To cover the wider, deeper defects
x To cover over bone, tendon, cartilage
x If skin graft repeatedly fails
Types
1. Random pattern flaps: Here vascular basis is subdermal
plexus of blood vessels. No known blood vessel is supplying
A
B C
Figs. 1.609A to C: Mesh graft placed over donor area and
photo of it, once it takes up.
A
Figs. 1.610A and B: (A) Traumatic exposure of the bone. Flap is needed
to cover this defect. It could be cross leg flap or rotation flap. Skin
grafting is not possible in this situation, (B) Flap which has taken up
well-placed over the defect on the bone with osteomyelitis.
Goals and actions must meet.
B
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SRB’s Manual of Surgery
A
Figs. 1.611A and B: (A) Hand-held Doppler to hear audible signal
of perforator to do rotation flap in the leg, (B) Different methods of
immobilisation is needed for flap and SSG. Fixation is often used in
limbs.
it. Rectangular flap with length to width ratios 1:1 or less than
1.5:1.
2. Axial pattern flaps: Here superficial vascular pedicles pass
along their long axes, e.g. forehead flap, deltopectoral flap,
groin flap. Anatomically a known blood vessel is supplying
it. It is long lengthy flap.
B
Fig. 1.613: Groin flap is based on superficial circumflex iliac artery. It can
be used in defects in hand and forearm. It is a cutaneous flap.
Fig. 1.614: Rotation flap. It is commonly used in gluteal region in
managing bedsores.
Fig. 1.612: Anatomy and blood supply of a skin flap.
Anatomical types depending on the types of tissue in the flap:
1. Cutaneous flap: Forehead flap, deltopectoral flap.
2. Fasciocutaneous flap: Radial forearm flap, scapular flap,
lateral arm flap, groin flap.
3. Muscle flap: Gluteus maximus muscle flap, gracilis flap,
tensor fascia lata muscle flap.
4. Myocutaneous flap: Pectoralis major myocuta neous flap,
latissimus dorsi flap—composite flap.
5. Osteomyocutaneous flaps: Radius with brachio radialis and
skin, rib with intercostal muscles and skin—composite
flap.
Fig. 1.615: Pectoralis major myocutaneous flap.
A
B
Figs. 1.616A and B: Transposition flap.
6. Local rotation flaps, transposition flaps: When the flap
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moves laterally it is called as transposition flap. When the
flap rotates laterally towards defect it is called as rotation
flap. Transposition flap is squarely designed which moves
laterally to close the defect creating a larger area on its
original place which has to be covered with split skin graft.
7. ‘Z’ plasty: It is a procedure which involves transposition
of two interdigitating triangular flaps. There is change in
direction as well as gain in length of the common limb of
Z. Angle size and length of the limb are the most important
factors. It is used in managing contracted scars, facial scars,
Dupuytren’s contracture and to cover the excised defects
like pilonidal sinus (example). There should be transverse
skin slack available equal to the length between the axes of
Z. It can be single or multiple Z plasty. Complications are
flap necrosis near the angle tip, infection, failure.
8. Free flaps: Vascular pedicle of the flap, both artery and
vein are anastomosed to recipient vessels using operating
binocular microscopes.
9. Omental flaps.
10. Island flap: Localised flap is swung around a stalk from
the donor area to the recipient area often with the pedicle
buried underneath the skin bridge in between. Pedicled flap
is also an island flap.
AREAS WHERE FLAPS ARE COMMONLY USED
B
Oral cavity, neck, breast, limbs (leg), buttock, bedsores.
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CHAPTER 1U General Surgery: Reconstruction
Fig. 1.617: Technique of ‘Z’ plasty. It is used in contracture release.
Dupuytren’s contracture and pilonidal sinus.
A
Fig. 1.619: Technique of V-Y plasty and Y-V plasty.
Fig. 1.620: Bilobed flap is used in lesions of the nose commonly.
B
Figs. 1.618A and B: Rhomboid flap
Fig. 1.621: Advancement flaps, used in distal defects.
Goodness is the only investment that never fails.
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Note:
• Flaps mobilised from donor area with its pedicle is placed and sutured
to recipient area. Once flap takes up usually in 3–6 weeks, base of the
flap is cut and sutured to recipient area.
• Saltatory flap is mobilising the flaps in stages from distant donor area
towards recipient area. It requires many staged surgeries and long-term
hospitalisation.
SRB’s Manual of Surgery
Fig. 1.622: On table marking of glabellar flap to place after
excising a lesion in the root of the nose.
• Waltzing is a technique wherein flap is moved from donor area and
attached adjacent to the recipient defect area. Later in 2nd stage, it is
moved towards the defect formally. It reduces the tension on the flap
and increases the success rate.
ADVANTAGES OF FLAPS
B
x Good blood supply, good take up
x Gives bulk, texture, colour to the area
x Allows required movements in the recipient area. For example,
jaw movements after pectoralis major flap after wide excision with
hemiman dibulectomy for carcinoma cheek
x Cosmetically better
DISADVANTAGES OF FLAPS
B
x Long-term hospitalisation
x Kinking, rotation and flap
necrosis
• Positioning of the patient for long time is important to have a good flap
take up which is a real discomfort to the patient.
• Delaying of the flap after mobilisation is done to reorient its blood
supply so as to decrease flap necrosis and increase flap survival.
Delaying period is 10–14 days. Flap is raised properly as required and
resutured to same place so as to allow the formation of reorientation
of vasculature near the tip of the flap. This delayed flap is raised again
in 10–14 days to place in required area.
x Infection
x Staged procedure
Different Flaps Used are:
Forehead Flap
It is fasciocutaneous flap from forehead based on anterior
branch of superficial temporal artery. Superficial temporal
artery is terminal smaller branch of external carotid artery. It
begins under the parotid behind the neck of mandible, runs
vertically upwards, crossing the root of zygoma at preauricular point; 5 cm above the zygoma it divides into anterior
and posterior branches. Anterior branch anastomoses with
supraorbital and supratrochlear branches of ophthalmic
artery. Artery supplies scalp of temple region and side,
parotid, ear, facial muscles. Superficial temporal artery gives
transverse facial artery which runs from anterior margin
of parotid, and middle temporal artery which runs deep to
temporalis muscle.
It is used for defects in cheek (carcinoma, cancrum oris) and
nasal reconstruction.
Standard forehead flap is taken from forehead above the level
of eyebrow starting from the opposite side of the midline
with base just above the zygoma. Width of the flap is usually
about 3–4 cm. Flap is dissected from the distal end of the
marked area going deep up to epicranium, raising the flaps
using scissor dissection. Flap is held up using skin hooks.
Fig. 1.623: Saltatory flap. Flap raised from the abdomen is reached to the cheek in stages—from abdomen to wrist; from wrist to cheek.
Fig. 1.624: Waltzing of flap.
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CHAPTER 1U General Surgery: Reconstruction
A
Figs. 1.625A and B: Forehead flap based on superficial temporal artery. It is fasciocutaneous flap.
Flap is rotated towards the defect area in the cheek. Inner
area of the flap is covered with split skin graft. Donor flap
area is covered with another split skin graft. After 3 weeks,
base of the flap is disconnected; remaining proximal part of
the flap can be replaced into forehead donor area. SSG over
donor flap area takes up well. This flap often can be rotated
under (deep to) the zygoma also.
A lined forehead flap can be used. After flap elevation, under
surface of the flap is lined by split skin graft prior to rotation.
This grafted lined flap is resutured into the donor area for 2
weeks until undersurface of graft takes up well; after 2 weeks
flap is rotated towards the defect area (cheek).
Delaying of the flap is often done in forehead flap. Flap after
elevation, is replaced into the original position to have optimum
vascular reorientation; after 2 weeks it is again rotated towards
defect. Delayed flap reduces the flap necrosis chances.
Often bipedicled forehead flap (Narayanan’s flap) is used
taking both from anterior and posterior branches of the
superficial temporal artery. This flap is moved to defect in
cheek with anterior branch part staying outside and posterior
part will line the mucosal area.
A different type—middle forehead flap is used for nasal
reconstruction.
Problems—poor color match, contraction of flap and donor
area is cosmetically nonacceptable.
B
Deltopectoral cutaneous flap (Bakamjian flap)
It is based on first three perforating branches of the internal
mammary artery (mainly 2nd perforator). Flap runs horizontally across the chest wall anteriorly towards shoulder
tip from its base over the sternal border. Its upper border
is along the line of the clavicle; its lower border is along the
line of anterior axillary fold line. Raw area often requires a
spilt skin grafting. It is usually rotated upwards often with
waltzing. It is tubed and attached above. Tube is drained to
prevent any collection to occur.
Fig. 1.626: Deltopectoral cutaneous flap.
Great achievements begin with small opportunities.
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Rotation angle is important to prevent any kinking in the
pedicle. It is usually used to cover the defects in cheek,
chin, mastoid and parotid region. Often flap is delayed to get
adequate length.
Groin flap
It is based on superficial circumflex iliac artery which is 2–3
cm below and parallel to the inguinal ligament. Artery originates from femoral artery over medial border of the sartorius
and ends at anterior superior iliac spine. 1:1 rectangular flap
with deep fascia is used. Secondary defect can usually be
closed with sutures. It is used mainly for defects in wrist/
SRB’s Manual of Surgery
forearm where positioning is easier.
A B
Figs. 1.627A and B: Groin flap used for burns defect in the hand.
Latissimus dorsi muscle/myocutaneous flap
It is based on thoracodorsal artery, a branch of subscapular
artery. Skin over the upper and anterior border of latissimus
dorsi is used for transfer. It is commonly used to cover the defect
after mastectomy. But it does not give the bulk. It is technically
easier. It can be used as muscle flap also. It helps as skin cover.
Prosthesis is needed to place underneath to provide bulk in
post-mastectomy defect.
Pectoralis major myocutaneous flap (PMMF)
It is based on the pectoral branches of thoracoacromial artery.
Usually skin below and medial to nipple over the muscle is
used. Muscle pedicle is made as broad as skin. It is used to
cover the defect over the cheek/neck/pharynx/intraoral lesions
after wide excision with removal of skin over the tumour. Vessel
marking is 2 cm medial to coracoid process, obliquely below
the clavicle at the junction between middle third and outer third.
Skin with muscle is dissected from the deeper structures like
ribs, intercostal muscles and pectoralis minor. Flap is raised
upwards up to the coracoid. Lateral pectoral vessels if possible
are retained, otherwise can be sacrificed. Defect below is usually
closed primarily with sutures. Often it needs spilt skin grafting.
Pectoralis major flap can be used along with deltopectoral flap
with proper planning.
A
B
Figs. 1.628A and B: Pectoralis major myocutaneous flap used for
carcinoma cheek.
Gastrocnemius muscle flap
It is either medial or lateral and is commonly used to cover the
upper part of the tibia and knee joint. It is technically easier and
functional deficit occurring at donor area is insignificant. It is
rarely used as myocutaneous flap.
Transverse rectus abdominis muscle flap (TRAM flap)
It is either superior pedicle based on the superior epigastric
vessels or inferior pedicle based on the inferior epigastric
vessels. Superior pedicle based flap is used to cover postmastectomy area or chest wall defect. To cover post-mastectomy
area opposite side superior pedicle is used to reduce the arc
through which flap has to rotate (but rotating from opposite
side is technically difficult). Inferior pedicle flap is used to
cover the defects in groin and thigh. Proper marking of the
flap is essential. Skin incision is made like an ellipse. Anterior rectus sheath is cut in the line of incision and is raised
upwards carefully of the rectus muscle up to the xiphisternum.
Muscle is gently separated of the posterior rectus sheath with
care not to injure the epigastric vessels. Once dissection is
complete lower part of the muscle is cut in superior pedicle
to rotate upwards carefully. In the upper part again anterior
rectus sheath is opened to pass the flap towards the defect
in subcutaneous plane. TRAM flap gives bulk and contour
to the defect. But it is technically difficult. Usually opposite
side of the defect is taken as flap as it is easier to rotate from
opposite side. Defect in the abdomen usually needs mesh to
support and close. It is not possible to do this flap in obese
individuals and if patient has undergone laparotomy earlier
(with a lengthy scar). Inferior cut end of the inferior epigastric
artery in superior pedicle flap can be anastomosed to a vessel
in recipient bed to improve the perfusion (supercharging).
Inferior epigastric artery in inferior pedicle can be additionally
perfused using opposite inferior epigastric artery (recharging).
Radial forearm flap
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It is perfused from the radial vessels and raised on the flexor aspect
of the forearm. Perforating branches of these vessels supply deep
fascia and skin over it. Flap can be fasciocutaneous or osteofasciocutaneous/osteomyofasciocutaneous if radial bone is also used
as part of the flap. Radial forearm free flap is commonly used for
mandible defects. It is technically easier and safer. Flap is raised
along with skin, segment of the radius along its intermuscular
septum through which vessels pass and brachioradialis as components. Care is taken in dissecting vessels of the bed and not to injure
the radial nerve. In free flap artery is sutured to the recipient artery
like facial artery using microscope. Other similar flaps are—ulnar
forearm flap, scapular flaps, and vascularised fibular transfer.
Limberg flap
It is a type of rhomboid flap used in pilonidal sinus with base
at gluteal skin.
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CHAPTER 1U General Surgery: Reconstruction
B
Fig. 1.630B
Figs. 1.630A and B: Cross leg flap.
ABDOMINOPLASTY
It is reconstructive surgery done in morbid obesity to reduce
abdominal fat and skin as liporeduction procedure to maintain
the abdominal contour. It is often done along with bariatric
surgery. Lower horizontal lengthy incision with creation of new
umbilicus is done after excising adequately and abdominal wall
wound is closed.
Complications are: Wound infection and dehiscence; Meleney’s
gangrene mainly in diabetics, fat necrosis, septicaemia.
A
B
Figs. 1.629A to C: Rhomboid flap used to cover the defect after
excising a lesion in the arm.
C
Cross leg flap
It is commonly used to cover the defect in the foot/leg from
opposite leg.
A
Fig. 1.630A
A
C
Figs. 1.631A to D: Abdominoplasty—steps.
B
D
TENDON
Tendon is the continuity of the muscle to have its action at
the site especially in hand, foot and digits.
It is covered by synovial sheath with a thin layer of fluid in
between which allows smooth gliding of the tendon.
Tendon after injury heals by:
1. Intrinsic healing method occurs through synovial fluid when
tendon is not under stress.
2. Extrinsic healing method occurs through prolife ration of
fibroblasts across epitenon. It occurs when tendon is under
stress. It forms a mass of fibrous tissue at the site called as
“tenoma”. It may interfere with the proper gliding of the tendon.
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