9 - Plastic Surgery and Skin Grafting Flashcards
Incision planning
Necessary Length
o Aggressive Retraction
o Skin Tears – avoid skin tears by just lengthening the incision
o Compromise Procedure
Proper Orientation
o Easier Dissection
Healing
o Skin heals “side to side,” not “end to end”
o This means that a 1 inch incision takes the same amount of time as a 2 inch incision
Skin tension lines
Relaxed Skin Tension Lines (RSTL) - like the lines across the top of your wrist
o Borges and Alexander – described more recently, MORE COMMONLY USED
o Incisions should be made parallel to RSTL - then it is EASIER to close
Langer Lines or Cleavage Lines
o (1861) cadavers, determined by making skin biopsies, determining direction of collagen
o Cut in direction of lines, same idea – allows better healing
Study on blood supply
Angiosomes
o Blocks of tissue that are feed by source arteries
o Six (6) distinct angiosomes in the foot originating from three main arteries
o There are DIRECT arterial-arterial connections between these three main arteries
Article = Attinger et al. (2006), MUST READ
Angiosomes – THREE MAIN ARTERIES ***
Posterior Tibial
o Calcaneal branch (heel)
o Medial Plantar (instep)
o Lateral Plantar (lateral midfoot and forefoot)
Peroneal
o Anterior Perforating (lateral anterior upper ankle)
o Calcaneal branch (plantar heel)
Anterior Tibial/Dorsalis Pedis
o Anterior Ankle and dorsum of foot
What you need to know for exam about angiosomes
NOTE - angiosomes can be MAPPED out with the use of a Doppler for surgical planning
***NEED TO KNOW - what angiosomes are, how many there are, what they are, how you map them
Skin incisions
- 10 or 15 scalpel blade
- Incision perpendicular to skin with counter-pressure
o “Skiving” – they cut the skin at an angle - You want to make one incision through dermis in one even stroke
o “Belly of the blade” – start with contacting the skin with the tip of the scalpel, then drop your hand to have the belly of the blade contact the skin then make your cut
Wound closure tension
Avoid Tension
o Mobilization and undermining (like a face lift – makes skin more mobile)
o Take a hemostat, lift up the skin, separate skin from underlying fascia, then you can suture without tension
Wound closure suturing
o Simple Interrupted o Retention Sutures o Apical Sutures o Mattress Sutures o Subcuticular Sutures
How can you classify skin flaps?
Type of blood supply
Shape and movement of a local flap
o Rotate around a point to cover a deficit
o Advanced to cover a deficit - MOST OF WHAT WE DO ARE ADVANCEMENT FLAPS - Straight line from donor site to recipient site
Local flaps advantages and disadvantages
Advantages
o Match skin color, texture, hair growth and thickness all the same location
Disadvantages
o Vascular compromise - Skin will necrose and die, meaning another surgery and skin graft
o “Handle with care”
Types of skin plasty
- V-Y Flap
- Y-V Flap
- V-Y Island Flap
- Z Skin Plasty
V-Y flap
***General*** o Advancement Flap o “V” shaped skin incision o Sides of “V” advanced o Closed wound resembles a “Y
***Indications*** o Excision of skin lesion o Scar tissue o Joint contracture (MPJ) o Skin contracture o Lengthens IN LINE (PARALLEL) to incision
Technique (not tested) o Apex of “V” proximal or distal o Incision to subcutaneous tissue o Undermine outward o Gently hold (retract) tissue, no tension o Apical stitch and suture
Y-V flap
***General*** o Advancement flap (not as common) o “Y” shaped skin incision o “V” portion advanced o Closed wound resembles a “V”
Indications
o Release tension at right angle to Y-V
o Scar tissue
o Lengthens PERPENDICULAR to incision
V-Y island flap
General
o Good for wounds or a mole removal
o You can excise the area in a rectangle
o Then free the skin up under the excision
o When you close it, it will look like a Y
o Called an island flap because you have created an
island of skin to move it to cover the open wound
o NEED to assure vascularization for the “island”
Can do a DOUBLE (bottom image) for larger lesion
Z-skin plasty
General
o Rotational flap everything so far has been an “advancement flap”
o “Z” skin incision – the skin you lengthen is along the long diagonal line of the Z
o Transpose arms of “Z” to lengthen skin and relieve tension
o Lengthening along longitudinal axis and shortening along transverse axis –> 5th toe
o Any time you have a V, you have additional risk for avascular necrosis
Amount of lengthening
o The amount of lengthening achieved is based on the angle of the triangles and the length of the central arm
Angles o 30 degrees – 25% increase o 45 degrees – 50% increase o 60 degrees – 75% increase o 75 degrees – 100% increase
Skin grafting
- Initiate rapid wound healing
- Harvest epidermis with a variable thickness of dermis
- Split-thickness skin graft = Heal very quickly ***
o Epidermis and portion of dermis
o There are different portions you can do - Full-thickness skin graft
o Epidermis and all of dermis
Full thickness vs split thickness
NOTE - the properties of full-thickness are BETTER, but the risks are also HIGHER
Full thickness
- High nutritional requirements
- Good color
- Low contraction
- Fair durability
- Good sensation
- Excellent appendage function (hair, eccrine, sebaceous)
Split thickness
- Low nutritional requirement
- Poor color
- High contraction
- Poor durability
- Fair sensation
- Poor appendage function (hair, eccrine, sebaceous)
Epidermis and dermis grafting
- Epidermis represents 5% of total skin thickness
- Dermis accounts for remaining 95%
- Thinner grafts:
o Take better
o Contract more
o More hyperpigmentation
o More susceptible to trauma - The best of both worlds
o A medium split thickness graft, most common in podiatric medicine
Recipient site preparation
Site must be well vascularized
o Granular wound
Void of necrotic and nonviable tissue
Void of infection
o Bacterial count
Harvest sites
- Chest, stomach, buttock, anterior thigh, lateral thigh –> lateral thigh is most common
- Can also do a graft from the back of the calf, so it is within scope
Split thickness skin
- Air powered dermatome –> “mobile meat slicer”
- Separate sterile table (back table with all skin graft material on it)
- Measure amount of graft needed –> width guard 5, 8 or 10 cm
- Thickness set by using a #15 scalpel blade (0.015 inch)
- Donor site shaved and prepped
Split thickness skin graft harvesting
- Outline skin to be harvested and lubricate with mineral oil
- Skin placed under tension with tongue blade and dermatome used to harvest skin
- Skin graft is then stored in saline gauze
- Use topical thrombin/epinephrine to harvest site to stop bleeding, then use occlusive dressing
Skin graft meshing - NEED TO KNOW (AKA “pie crusting”)
Prevention of hematoma and seroma
o Better contact between graft and wound
o There is a way for the blood to get out
– Pooling blood/serous fluid would prevent contact
Coverage of larger wound
o Crisscross scar –> can cover a larger area with a smaller graft, allows more stretch
Application of split thickness skin graft
Graft applied to wound and pressed into place
Held in place with staples or sutures
Stent dressing with Xeroform and saline soaked cotton balls
o Prevents motion or shearing of graft
o Uses a little bit of compression, which helps the graft to adhere better
Ace bandage and splint used on top
Postoperative care
- Strict elevation for 5 to 7 days
- Gradual increase in dependency
- Four to five weeks before maturity of graft can tolerate shear from walking
Skin graft healing
NEED TO KNOW FOR EXAM
Listen for details here
Plasmatic imbibition –> 48 hours
o Nutrition
Inosculation –> 4-7 days
o Capillary growth and budding from the skin graft (corresponds to bed rest)
Venous and Lymphatic drainage –> 6th day (dependent leg before 6th day will “blow” graft off)
Skin graft complications
NEED TO KNOW FOR EXAM
Hematoma –> Prevents capillary budding
Infection –> Pseudomonas and Beta-hemolytic strep –> “bacteria eat the graft” ***
Seroma
Shearing
