9 - Plastic Surgery and Skin Grafting

Question 1

Incision planning

Answer 1

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

Question 2

Skin tension lines

Answer 2

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

Question 3

Study on blood supply

Answer 3

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

Question 4

Angiosomes – THREE MAIN ARTERIES ***

Answer 4

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

Question 5

What you need to know for exam about angiosomes

Answer 5

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

Question 6

Skin incisions

Answer 6

• 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

Question 7

Wound closure tension

Answer 7

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

Question 8

Wound closure suturing

Answer 8

o	Simple Interrupted 
o	Retention Sutures
o	Apical Sutures
o	Mattress Sutures
o	Subcuticular Sutures

Question 9

How can you classify skin flaps?

Answer 9

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

Question 10

Local flaps advantages and disadvantages

Answer 10

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”

Question 11

Types of skin plasty

Answer 11

• V-Y Flap
• Y-V Flap
• V-Y Island Flap
• Z Skin Plasty

Question 12

V-Y flap

Answer 12

***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

Question 13

Y-V flap

Answer 13

***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

Question 14

V-Y island flap

Answer 14

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

Question 15

Z-skin plasty

Answer 15

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

Question 16

Skin grafting

Answer 16

• 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

Question 17

Full thickness vs split thickness

Answer 17

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)

Question 18

Epidermis and dermis grafting

Answer 18

• 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

Question 19

Recipient site preparation

Answer 19

Site must be well vascularized
o Granular wound

Void of necrotic and nonviable tissue

Void of infection
o Bacterial count

Question 20

Harvest sites

Answer 20

• 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

Question 21

Split thickness skin

Answer 21

• 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

Question 22

Split thickness skin graft harvesting

Answer 22

• 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

Question 23

Skin graft meshing - NEED TO KNOW (AKA “pie crusting”)

Answer 23

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

Question 24

Application of split thickness skin graft

Answer 24

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

Question 25

Postoperative care

Answer 25

• Strict elevation for 5 to 7 days
• Gradual increase in dependency
• Four to five weeks before maturity of graft can tolerate shear from walking

Question 26

Skin graft healing

NEED TO KNOW FOR EXAM

Listen for details here

Answer 26

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)

Question 27

Skin graft complications

NEED TO KNOW FOR EXAM

Answer 27

Hematoma –> Prevents capillary budding

Infection –> Pseudomonas and Beta-hemolytic strep –> “bacteria eat the graft” ***

Seroma

Shearing