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Survives by osmosis from well-vascularized recipient site
(avascular)
Limited inflammatory reaction with little graft resorption
(<20% in autografts)
Requires coverage to prevent desiccation and infection
Scoring allows graft to be shaped (bending away from
scored side)
Symmetric carving, K-wire stabilization, harvest without
perichondrium, making central rather than peripheral cuts,
and waiting at least 30 minutes after carving before
placement at recipient site can be employed to decrease
warping
FAT GRAFTING
(See Chapter 6: Fat Grafting.)
COMPOSITE GRAFTS
Composed of two or more tissue components (eg, skin or
mucosa with cartilage, skin with fat, and full-thickness eyelid)
Indications
Nasal ala: prevent alar collapse
Nasal sidewall: prevent nasal valve obstruction
Nasal tip: provide structural integrity
Ear (anterior helical root): repair substantial auricular
defects, restoration of ear structure for glasses or hearing
aid placement
Eyelid: prevent ectropion and lid contraction from loss of
tarsal plate
Donor Sites: septal cartilage, auricular cartilage, and costal
cartilage
Graft Survival and Healing
Survival occurs via imbibition, inosculation, and then
revascularization.
Initial survival dependent on revascularization solely from
wound edges; thus, no portion of the graft should be >1 cm
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from wound edges.
Metabolic demand of graft limits size that will survive to 1.0-
1.5 cm width.
More prone to graft loss than other graft types.
PEARLS
1. The dermal side of skin graft can be distinguished from
epidermal surface by its shiny appearance (graft placed shiny
side [dermis] down).
2. Donor scars for harvesting of FTSGs should be oriented parallel
to relaxed skin tension lines.
3. Harvest of FTSGs from the volar wrist should never be
performed due to social stigma of wrist scar.
4. Patients should be warned that composite grafts often initially
appear cyanotic.
QUESTIONS YOU WILL BE ASKED
1. Name the stages and timing of skin graft healing?
Imbibition (24-48 hours), inosculation (48-72 hours), and
revascularization (4-7 days).
2. After skin grafting, does the donor or recipient site determine
characteristics of hair growth, sweating, and sensibility?
Hair growth assumes characteristics of the donor site, but only
has potential to return after FTSG, sweating assumes
characteristics of recipient site when glands are reinnervated,
and sensibility is incomplete and assumes characteristics of
recipient site.
3. What is the difference between primary and secondary
contraction and which type of skin graft is primarily affected by
each?
Primary contraction occurs immediately at the time of graft
harvest/application due to elastin fibers in dermis, greater in
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1.
2.
3.
FTSGs; secondary contraction occurs during the healing phase
of graft over 6-18 months, greater in STSGs.
4. Draw the layers of skin from epidermis to subcutaneous fat.
See Figure 1-1.
Recommended Readings
Azoury SC, Shakir S, Bucky LP, Percec I. Modern fat grafting techniques to the
face and neck. Plast Reconstr Surg. 2021;148(4):620e‐633e.
Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg.
2006;33(4):567‐577.
Hallock GG, Morris SF. Skin grafts and local flaps. Plast Reconstr Surg.
2011;127(1):5e‐22e.
*
Denotes common in-service examination topics.
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3
Flaps
Jennifer C. Lee and Widya Adidharma
OVERVIEW
Definitions
Angiosome: unit of skin and deeper structures supplied by
a source vessel; makes up the entire surface area of the
body
Perforator: a blood vessel that branches off a major named
vessel (or source vessel), supplying a particular tissue
territory, or angiosome
Flap: a volume of tissue that is transferred with its own
blood supply (in contrast to graft, which is revascularized
from recipient bed)
Pedicle: blood supply to a flap or segment of tissue
Pedicled flap: a flap that remains attached to its native
vascular supply when transferred
Free flap: a flap that is fully detached from its vascular
supply and reconnected to recipient vessels using
microvascular techniques
Flap Selection Considerations
Patient factors: goals of intervention, expectations, donor
site morbidity, comorbidities, history of radiation, cost of
care
Surgical considerations: defect location and size, missing
and exposed structures, viability of surrounding tissue (eg,
previous radiation, vascular disease, tissue necrosis),
available donor sites, donor site morbidity, pedicle length
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and caliber, technical demand, availability of microsurgery
equipment and team
FLAP CLASSIFICATION
Flaps can be classified by blood supply, method of transfer, and
tissue composition
BLOOD SUPPLY
Random pattern flap: raised without regard to any named
blood supply, relying on blood flow through subdermal plexus
(eg, bilobed flap)
Axial flaps: raised on dominant (named) arterial supply (eg,
radial artery flap)
Reverse flow flaps: dominant supply is divided, flap left to
survive on intact distally based vessels that form connections to
another blood supply system (eg, reverse sural)
Perforator flap: blood supply is a perforator from a dominant
feeding vessel
“Direct” vs “indirect” perforators (Fig. 3-1)
Figure 3-1 Mathes and Nahai
classification of fasciocutaneous
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flaps. Type A:direct cutaneous
perforator; type B:septocutaneous
perforator; type C:musculocutaneous
perforator.
Direct perforators course from the source vessel to the
skin without first supplying any other deep structure.
Examples: an axial vessel, a direct cutaneous vessel
(Mathes and Nahai Type A), or a septocutaneous
vessel (Mathes and Nahai Type B).
Indirect perforators first pass through an intermediary
structure before ultimately reaching the subdermal
plexus. Example: a muscle or musculocutaneous
perforator (Mathes and Nahai Type C), in which the
source vessel to the skin passes through and arises
from the underlying muscle.
Branching patterns of musculocutaneous perforators
Type 1 perforators pass almost directly from deep
fascia to subdermal plexus without branching.
Type 2 perforators branch in the adipose tissue just
before reaching the subdermal plexus, with branches
then running parallel to the flap surface.
Type 3 perforators follow deep fascia for an
indeterminate distance before eventually proceeding
into subcutaneous tissues.
Advantages of perforator flaps
Reduced donor site morbidity
Reduced postoperative pain
Faster recovery, shorter hospital stay
Less difficult to tailor or thin the flap for covering or
filling defects
Longer pedicle than with the parent musculocutaneous
flap
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METHOD OF TRANSFER
Local flap: shares side with the defect
Common types of local flaps (Table 3-1).
TABLE 3-1 Common Local Flap Methods of Transfer
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A. Single pedicled advancement flap with Bürow triangles.
(Modified from Thorne CH, Gurtner GC, Chung KC, Gosain
A, Mehrara B,Rubin P, Spear SL, eds. Grabb and Smith’s
Plastic Surgery. 7th ed. Wolters Kluwer; 2014. Figure 1.10.)
B. V–Y advancement flap. C. Rotation advancement flap. D.
Rhomboid flap. E. Bilobed flap. (From Hawn MT, ed.
Operative Techniques in Surgery. 2nd ed. Wolters Kluwer;
2023. Figure 5.29.8.). F. Z-plasty.
*Z-plasty: increasing angle of limbs increases percent
gain in length along the central limb (Table 3-2).
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Table 3-2 Z-plasty Angles and Theoretical Gain in
Length of Central Limb*
Multiple Z-plasties can be designed in series (Fig. 3-2).
Figure 3-2 Multiple Z-plasties.
Regional flaps: in same region of the body as the defect, but
does not share defect margin
Interpolated pedicle: two-stage technique where a pedicle
is kept intact initially between the flap and defect in the first
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