Reconstructive Plastic Surgery Flashcards
What are the reasons for reconstructive plastic surgery?
Malignancy e.g. skin, breast, sarcoma
Trauma
Burns
Infection e.g. necrotising fasciitis
Pressure ulcers
Vascular ulcers
What are the different type of wounds seen in the context of trauma?
Abrasion: scraping or friction-based injury with some tissue loss (usually partial thickness) - managed conservatively after a thorough scrub
Laceration: separation of tissues from an external force that should be apparent from the outside
Degloving: shearing injury that causes separation of tissue layers, which can be apparent from the outside or beneath the surface
Avulsion: detachment of tissue at an insertion site e.g. nail plate avulsion, tendon avulsion
Crush: sustained blunt force trauma causing significant soft tissue damage that might not be visible
What needs to be considered when managing wounds?
Reconstruction is semi-elective/wholly-elective, so you can think about making the perfect patient and the perfect wound
Patient factors:
Haemodynamic stability
Presence or absence of sepsis
Glucose control
Perfusion status
Anaemia
Smoking status
Motivation to comply with post-op regime
Wound factors:
Presence of infection
Adequate/inadequate debridement
Presence of foreign material
What are the principles of debridement?
Debridement is the systematic excision of devitalised tissue
Debridement should be performed in a systematic manner e.g. superficial to deep approach
To identify whether tissue is viable or not, use the 4 C’s:
- Contractility
- Colour
- Consistency
- Capillary bleeding
What is the reconstruction ladder?
A way of describing reconstructive options from least invasive to most invasive:
- Secondary intention
- Primary closure
- Delayed primary closure
- Skin grafting (split thickness, full thickness)
- Tissue expansion
- Flaps (local, regional, free flap)
What is grafting?
Taking tissue from one area of the body (donor site) and placing it down onto a wound bed (recipient site)
The graft will receive blood supply in a PASSIVE manner entirely from the recipient site (no surgical attachment of vessels)
Grafts are most commonly used for skin, as well as bone and nail beds
What is a split-thickness skin graft?
A full thickness epidermis and partial thickness dermis graft.
This leaves the dermal appendages behind at the donor site, so the donor site regenerates from the stem cells within the dermal appendages.
The donor site is treated as a partial thickness wound which should heal within two weeks, and it will be covered with a layered dressing (e.g. Hypafix) during that time. After it’s healed, it can be used to harvest grafts again.
Where are split-thickness grafts most commonly harvested from?
Relatively flat areas of skin in a non-weight bearing area
- Lateral thigh
- Buttocks
- Arms
- Lower back
What are full-thickness skin grafts?
A full thickness epidermic and full thickness dermis graft.
This means the donor site has no capacity to regenerate and has to be closed directly.
This limits the amount of skin that can be taken and it has to be done in an area of low skin tension.
What is the physiology of graft take?
Adherence - formation of fibrin bonds which starts immediately
Plasmatic imbibition - serum from the wound bed migrates and gets absorbed by the graft in order to provide nutrition, occurs around day 2-4
Revascularisation - vascular network develops from day 2-3, includes inosculation (direct anastomosis between existing graft vessels and wound bed vessels) and neovascularisation (new vessel formation)
Remodelling/Maturation
The graft is most vulnerable during the first 3 days because the fibrin bonds are less robust than the collagen which gets laid down later
What are the advantages and disadvantages of split-thickness skin grafts?
Advantages:
- They can cover a large area
- They can be meshed
- Minimal primary contracture
- Reliable with good take usually
Disadvantages:
- Secondary contracture
- Contour defects
- Colour mismatch and hair growth in unwanted areas (a feature of all grafting)
- Less robust than a flap
- Donor site can scar, bleed and be very sore
What are the advantages and disadvantages of full-thickness skin grafts?
Advantages:
- Better aesthetic results, less scarring and secondary contracture is less common
- More resistant to trauma
- Easier donor site wound care
- More likely to grow with the individual
Disadvantages:
- Primary contracture
- They can’t be used to cover a large area
- They are more vulnerable to failure because they require more blood supply
What are the contraindications to grafts?
There are very few absolute contraindications and the context/urgency/alternatives has to be accounted for
Considerations include:
Co-morbidities
Immunosuppression
Smoking status
Diabetes control
What are the considerations when choosing a method of reconstruction?
Aim to use the least invasive procedure as per the reconstructive ladder, but wound or patient factors may force a step-up
Characteristics of the defect to be repaired:
- Grafts cannot be used in places that don’t form granulation tissue e.g. bone, metalwork, tendon and cartilage
- How robust does the reconstruction need to be?
- What tissue needs to be replaced and will there need to be vascularisation?
- Is there any dead space that needs to be filled?
Characteristics of the patient
- Is the patient fit enough for a 12 hour flap operation?
- Healing potential
- Co-morbidities
- What donor sites do they have available?
- Smoking status
- Motivation
What causes a graft to fail?
Local factors:
- Factors preventing direct contact with the wound bed e.g. shear forces, haematoma, fluid, active infection
- Colonisation of the wound bed with Group A Strep or Pseudomonas
- Radiotherapy at the site -> leads to late graft failure
- Ongoing pressure
Systemic factors:
- Sepsis
- Co-morbidities e.g. diabetes, vascular disease, heart disease
- Smoking
