Adherence: first phase - Phase 1: what takes place? - Phase 2: what takes place?

Phase 1- contraction of fibrin strands (pull graft closer to bed) Phase 2- fibrin converts to _fibroblasts_, leukocytes, phagocytes---\> _fibrous adhesion_

Skin flaps, Skin grafts (slide 6, 7, 13) Flashcards by Meleah McMillen

What is the order of graft incorporation? (4)

Adherence 2. Plasmatic Imbibition 3. Inosculation 4. Vascular Ingrowth

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****State the stage of graft incorporation and at the timeline *****

-Anastomosis of cut ends of graft vessels with recipient bed (trying to kiss each other)

48/72 hours to 6 days ****Inosculation

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State the stage of graft incorporation and at the timeline:

Ingrowth of new vessels from the bed into graft (new lymph vessels by day 4 or 5 - 0.5 mm/day -Controlled by cytokines (just like in open wounds) -Re-innervation (feeling) (around 3 weeks) careful of paresthesia

Vascular Ingrowth (48hours) to (6-8 days)

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State the stage of graft incorporation and at the timeline:

-Graft vessels dilate and pull fibrinogen free, serum like fluid and cells into graft via capillary action -Nourishes wound prior to blood vessel development

Plasmatic Imbibition (0-72 + hours)

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State the stage of graft incorporation and at the timeline: ?

-Phase 1- contraction of fibrin strands (pull graft closer to bed)
-Phase 2- fibrin to fibroblasts, leukocytes, phagocytes—> fibrous adhesion

Adherence Phase 1: 0-72 hours Phase 2: (72 hours - 10 days)

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Fill in the blanks

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Describe what Flull thickness MESHED skin grafts are?

Numerous slits cut in parallel, staggered rows to allow the graft to expand in 2 directions to increase size.

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In full thickness meshed skin grafts, what does the meshing provide: _____, _____, _____?

Meshing provides:

Drainage
Flexibility
Conformity

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What are the indications for full thickness meshed skin grafts?

___1____

___2____

___3____

Allow drainage from a wound with minor exudate (bleeding/oozing)
To cover larger defects
For construction of irregularly shaped surfaces whch are difficult to immobilize

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What is recommended for most grafting needs*******?

****Nonexpanded, full thickness mesh graft

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Identify what this is?

Full Thickness Meshed Skin Graft

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Inosculation involves ________ of cut ends of ______ _____ within recipient bed (trying to kiss each other)

Anastomosis; graft vessels

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Vascular Ingrowth is stage ___ is ingrowth of _____ vessels from the ____ into the graft and there is new _______ ______ by day ___ or ___

stage 4; new; bed; lymph vessels; 4 or 5 days

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Vascular ingrowth (stage 4) happens at a rate of ______ and is Controlled by ______ (just like in open wounds). ______ takes place around 3 weeks

0.5 mm/day; cytokines; Re-innervation

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Plasmatic Imbibition:

Graft vessels ____ and pull ______ free, serum like fluid and cells into graft via ______ ______ -Nourishes wound prior to blood vessel development. This _____ wound prior to ____ _____ development

dilate; fibrinogen; via capillary action; Nourishes; prior to blood vessel develop.

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Adherence: first phase

Phase 1: what takes place?
Phase 2: what takes place?

Phase 1- contraction of fibrin strands (pull graft closer to bed)
Phase 2- fibrin converts to fibroblasts, leukocytes, phagocytes—> fibrous adhesion

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What makes up the subdermal plexus? (3)

SQ (deep) Plexus
Cutaneous (middle)
Subpapillary (superficial)

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For the subdermal plexus flaps, the flaps include SKIN and SQ which receive blood supply from the collateral connection to the SQ plexus and is ______ selected

Randomly

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Full thickness “tongues” of skin are Detached from surrounding skin along 3 of 4 quadrants and Stretched & rotated into adjacent defect, flap survival relies on??

remaining collateral circulation from the remaining cutaneous attachment and its vasculature which is the SDP

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Subdermal plexus flaps ensure adequate _____ and ______ of surrounding skin

redundancy and vascularity

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Subdermal Plexus flap lengths need to be at least as _____ as the wound, ideally ____times the length. And the width Base slightly wider than overall width of flap.

long; 1.5

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*****What are the 6 Halsted’s Principles

Great Minded Organized People Eliminate distrActions

1. Gentle Tissue Handling

2. Meticulous control of hemorrhage

3. Observe strict aseptic technique

4. Preserve blood supply to tissues

5. Eliminate dead space

6. Appose tissues accurately with minimal tension

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What do you want to be careful with in subdermal plexus flaps?
Elevation ____ from the SQ muscle = _____ metabolic requirements on the flap

Careful dissection during undermining, Don’t disturb SDP

Away; reduced

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What are the different classification types of Subdermal plexus flaps??

Advancement
Pivotal flaps
Plasty
Distant

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What are the names of the **Pivotal** subdermal plexus flaps? (3)

* Rotation * Transpositional * Interpolation

Classified SDP flaps according to how the skin is moved/stretched\*\* Shift skin **without rotation**

**Advancement**

\*\*Classify the SDP flap according to how the skin is moved/stretched\*\* – Procedure where shape of tissue is altered – Essentially advancement & rotating flap depending on the letter

Plasty

\*\*Classify the SDP flap according to how the skin is moved/stretched\*\* – Created from a region of skin not adjacent to wound – “\_\_\_\_” or ___ flap – Rarely utilized in Vet Med

Distant: pouch or hinge flap

\*\*Classify the SDP flap according to how the skin is moved/stretched\*\* – has a linear axis • 3:1 Rule = Flap length : Width àDo not surpass – Typically transposed from 45 to 180 degrees into defect

Pivotal flap: **Transposition**

\*\*Classify the SDP flap according to how the skin is moved/stretched\*\* – curvilinear configuration • Designed immediately adjacent to the defect & are **best used to close** _____ defects

Pivotal flap: Rotation; best used to close triangular

\*\*Classify the SDP flap according to how the skin is moved/stretched\*\* Has a linear configuration, base is located at some distance from the defect?

– Pivotal flap: **Interpolation**

– Pivotal flaps: Interpolation and Rotation both have a linear confirguration/ curvilinear. SO how do they differ?

**1. Interpolation**: Differs in that its base is located at some distance from the defect • Thus the pedicle must pass over or under intervening tissue **2. Rotation**: curvilinear configuration • Designed immediately adjacent to the defect & are best used to close triangular defects

Don't do SDP flaps until recipient bed has healthy _____ \_\_\_\_\_\_

granulation tissue

For SDP flaps, What is most commonly seen in flaps from lateral flank and thorax and why? What should you consider doing to prevent?

Seroma (bc large amount of dead space) so conside a closed suction drain or compressive bandage Post op

Infection, seromas, desensitization through self trauma, skin edge dehiscence from tension or infection, and global flap necrosis are all common complications of SDP flaps.... * What is the most common cause of global flap necrosis and when do you generally see it and what do you do to prevent?

**– Compromise of blood supply** **• Iatrogenic (most common),** thrombosis, self-trauma – Usually apparent 2-3 days PO • Let tissue declare but don’t delay debridement of clearly devitalized flap

How are axial pattern flaps different from SDP flaps in terms of relianace, vasculature supply, perfusion, and general shape??

* Pedicle flaps that **rely** on a direct cutaneous **artery & vein** at the **base** of the flap * **Terminal branches of these vessels** _supply the subdermal plexus_ * Have **better perfusion than pedicle flaps** w/ a circulation from the subdermal plexus alone * Generally are elevated & transferred to cutaneous defects w/in their radius = Usually **rectangular or L-shaped**

Axial pattern flaps are most commonly used to for?

used to facilitate wound closure after tumor resection or trauma

Compare the axial pattern flap survival rate compared to SDP flap?

Survival rate = ~ 2x that for subdermal plexus flaps of comparable size à MORE ROBUST

What is the the name of the Most consistent & reliable axial pattern flap showing near 100% flap survival w/ clinical usage. State the landmarks (3)? And what it is used for in terms of repair areas (5)?

Caudal superficial epigastric (axial pattern flap) 1. Inguinal 2. Preputial 3. Perineal 4. Thigh 5. Stifle **Landmarks:** – Medial - midline of abdomen – Lateral – Parallel to medial at equal distance from teats – Length – Variable, can include last 4 glands

Desribe where the Thoracodorsal Axial pattern flap is based on and located?

Based on a cutaneous branch of the thoracodorsal artery & associated vein located at the caudal shoulder depression at a level parallel to the dorsal border of the acromion

Desribe where the Thoracodorsal Axial patterns flaps would be indicated for on the canine/feline body?

shoulder, forelimb, elbow, axilla and thorax – In cats = Extends to the carpus (Some dogs too)

What do have to tell owners with thoracodorsal APFlaps?

Partial flap necrosis in ~ 70 % of cases

Name the type of flap composed with skin with muscle, bone, and cartilage. Easy to access and elevate and have direct cutaneous arteroes exiting the muscle surface to supply overlying skin (used when more routine flaps aren't applicable)

Composite flap

What is the most common composite flap?

Myocutaneous (mm with skin)

What composite flap is best suited for thoracic defects (chest wall reconstruction) and can be used for forelimb defects

Latissimus Dorsi Myocutanous Flap

State the corresponding muscle flap area to the defect: * Chest wall defect

Latissimus dorsi

State the corresponding muscle flap area to the defect: * Facilitate repair of the diaphragmatic hernia

Transversus abdominis

State the corresponding muscle flap area to the defect: * Caudal abdominal hernia and tibial defects

Pectineus/Sartorius

State the corresponding muscle flap area to the defect: * Orbitonasal defects and complicated intraoral reconstruction

Temporalis

State the Flap: ## Footnote * Used to cover soft tissue defects, contribute to circulation and drainage, enhance healing, control adhesion & combat infection * **Stimulate formation of granulation tissue** to **allow earlier wound closure** w/ skin flaps or grafts Especially useful for **chronic non-healing wounds** involving the _thorax_, _abdomen_, _inguinal_ and *_**axillary\*\*\***_* areas

Omental Flap

Identify the type of flap:

**Advancement flap** (SDP flap category)

Identify the type of flap:

Pivotal SDP flap: **Rotation flaps**

Identify the type of flap:

Pivotal SDP flap: **Rotation flap**

Identify the type of flap:

Pivotal SDP flap: **Rotation flap**

Identify the type of flap: also state the name of a modified type

Pivital SDP flaps: **Transpositional flap** * A: **Elbow (forelimb) Fold Flap** * Modified type: **Z-plasty**

Identify the type of flap:

Pivotal SDP flap: **Transpostional Flank fold flap**

Identify the type of flap:

Pivotal SDP flap: **Modified Transpositional ( Z-plasty)**

Identify the type of flap:

Pivotal SDP flap: **Transpositional Flank fold**

Identify the type of flap:

Pivotal SDP flap: **Interpolation flap**

Identify the type of flap: how many procedures?

Pivotal SDP flap: **Interpolation Flap, involves 2 procedures**

Identify the type of flap:

**Distant Flap (main category)** *_SDP flap type_* **"Pouch Flap"**

Identify the type of flap:

Axial pattern Flaps (not apart of SDP flaps anymore)

Identify the BS for the corresponding numbers

Identify the type of flap:

Caudal superficial epigastric (APF)

Identify the type of flap:

Caudal Superficial Epigastric APF

Identify the type of flap:

Caudal superficial epigastric APF

Identify the type of flap:

Caudal superficial epigastric APF

Identify the type of flap:

Caudal superficial epigastric APF

Identify the type of flap:

Caudal superficial epigastric APF

Identify the type of flap:

Thoracodorsal APF

Identify the type of flap:

Thoracodorsal APF

Identify the type of flap:

Cranial Superficial Epigastric APF

Identify the type of flap:

Genicular APF

Identify the type of flap:

Deep circumflex Iliac APF

Identify the type of flap:

Latissimus Dorsi Myocutaneous Flap (composite flap)

Identify the type of flap:

External Abdominal Oblique (composite flap)

Identify the type of flap that would be recommeded:

Omental Flap

Identify the type of flap:

SDP Pivotal: _**Transpositional Flap\*\*\*\***_

Which type of hernia can cause a loss of domain?

Acute hernia will not cause a loss of domain chronic hernias in the abdomen will (not perineal small area so not loss of domain) **Definitely Chronic Diagphragmatic Hernia** also possibly chronic peritineopericardial diaphragmatic hernia