Skin Grafts and Flaps

Question 1

What is primary wound closure?

Answer 1

Accomplished through the use of staples, sutures, tapes or skin glue to reapproximate the wound edges.

Question 2

What is healing by secondary intention?

Answer 2

Leaving a wound open and allowing it to heal through contraction and epithelialisation. Can be successfully applied to small wounds i.e. of the fingertip

Question 3

What is the primary tool for harvesting skin grafts?

Answer 3

Dermatome

Question 4

What are the different types of skin grafts?

Answer 4

Full Thickness and Split thickness

Question 5

At what ratio are split thickness grafts meshed? Why are they meshed?

Answer 5

1:1 or 3:1

To increase coverage

Question 6

What is the difference between a split skin graft and a full thickness skin graft?

Answer 6

A full thickness graft includes the epidermis and the dermis. It most closely resembles normal skin including texture, colour and potential for hair growth. There is a slightly greater risk of non-adherence and the donor site may need a split skin graft if too large for primary closure. Full thickness grafts demonstrate greater primary contracture of the graft but less primary contracture of the grafted wound.

A split thickness consists of the epidermis and varying amounts of dermis depending on it’s thickness. The split skin graft demonstrates less primary contracture of the graft than full thickness but greater primary contracture of the grafted wound.

Question 7

What is the number one reason for skin graft failure?

Answer 7

Haematoma

Question 8

How should a skin graft be dressed?

Answer 8

Lubricating petroleum gauze to prevent shearing. Appropriate compression to reduce risk of haematoma - i.e. sponge. Local immobilisation increases chances of graft being successful and decreases shearing forces.

Question 9

When can rehabilitation commence following a skin graft?

Answer 9

Once adherence of a skin graft is recognised.

Question 10

When would a flap be used instead of a skin graft?

Answer 10

When there has been significant soft tissue loss and damage to underlying structures such that the vascular supply would not support a skin graft.

Question 11

What structures can be included in a local tissue flap?

Answer 11

Vascular supply, subcutaneous tissue, fascia, muscle, nerve, tendon and/or bone.

Question 12

What is an Axial pattern flap?

Answer 12

A single pedicle skin flap with an established arteriovenous system along the longitudinal axis.

Question 13

What is a random pattern flap?

Answer 13

A local skin flap with no arteriovenous supply.

Question 14

What is an island flap?

Answer 14

Is an axial pattern flap in which the skin bridge has been separated leaving only a vascular pedicle.

Question 15

What are the two different types of mobilisation techniques for flaps?

Answer 15

Rotational and advancement.

Question 16

In what sort of injury would a V-Y Advancement flap be indicated? How would you treat it?

Answer 16

The volar or lateral V-Y are indicated for small fingertip injuries. They offer a reconstructive dimension of 1-1.5cm.

Cover with non-adherent lubricating gauze and protected with a bulky dressing. Sutures are removed at two weeks and early arom is initiated.

Question 17

For what sort of injury would you use a Volar Advancement Moberg Flap? How would you treat it?

Answer 17

Defects of the pulp of the thumb ir other digital defects that are too large for a V-Y advancement.

Moberg’s may be advanced a distance of 1.5-2.0 cm.

This is a reliable sensate flap.

Dressed with nonadherent lubricatng gauze, followed by applicationm of protective dressing and orthosis.

Question 18

What is a Cross-finger flap?

Answer 18

Uses an elevated skin flap from the dorsal aspect of one finger to cover an open volar wound with exposed tendon or bone on another finger. The donor site is covered in a skin graft.

The flap is immobilised with a splint

The patient returns in 2-3 weeks for separation and insetting of the flap.

Initiate hand therapy at this time.

Question 19

What is a reverse cross-finger flap?

Answer 19

Involves dissecting an adipofascial flap beneath skin and placing this with a skin graft over the injurt site and the skin part of the flap is inserted back into donor site.

Therapy input as for cross finger flap.

Question 20

What type of injury are digital Island flaps good at reconstructing?

Answer 20

Distal or proximal defects of up to 2.5cm over lyin exposed joints/tendons.

The skin flap is created in the pattern indicated by the local defect and harvested based on the proper digital artery and vein. The donor site is reconstructed with a full thickness skin graft.

Question 21

Which nerve can be included in a radial forearm flap to alloow for an innervated flap?

Answer 21

Lateral antebrachial cutaneous nerve

Question 22

Which muscles can be taken as part of a radial forearm flap to allow for tendon reconstruction?

Answer 22

Palmaris longus or brachialis.

Question 23

What are the main disadvantages of a radial forearm flap?

Answer 23

Sacrifice of majoy forearm artery and unsightly donor site that requires grafting?

If patient has Ulnar hammer syndrom cannot use radial forearm flap.

Question 24

Where are posterior Interosseus Flaps most frequently used and what is the largest size of the flap?

Answer 24

Distal defects of the wrist, dorsal hand and first web space. Flap taken from dorsal forearm

8x15cm.

Any skin island greater than 4cm willneed grafting

Question 25

Which muscle can be included in a Lateral Arm Flap to allow for tendon reconstruction?

Answer 25

Tendon strip from triceps.

Can also be an osteocutaneous flap with part of humerus and can be used as a free flap.

Question 26

What defects are generally covered with a Lateral Forearm flap?

Answer 26

Large defects distally around the elbow.

As a free flap it can be used to cover the dorsum of the hand and the first webspace.

Size approx 15 x 18 cm

Question 27

What type of flap is a groin flap?

Answer 27

Axial patern flap.

Question 28

How long after the initial surgery is a Groin flap divided from its donor site?

Answer 28

2-3 weeks

Question 29

What artery does theGroin flap make use of?

Answer 29

Superficial circumflex iliac artery and concominttant veins.

Question 30

What artery is use in a parascapular and scapular flap?

What are these flaps commonly used for?

Answer 30

The circumflex scapular artery.

Rotated locally for voverage of sholder or proximal posterior arm defects.

As a free flap for forearm and dorsal hand defects.

Question 31

What areas can be covered using a Latissimus Dorsi Flap?

Answer 31

Harvested as a muscle or musculocutaneous flap it can cover defects of the shoulder and upper arm.

As a free flap it can cover more distal woulds

Question 32

Which vessels are taken with the Lat Dorsi flap?

How large can the flap be?

Answer 32

The thoracodorsal vessels

20 X 35 cm

Question 33

What is the standard post-op management of Local Tissue flaps?

Answer 33

Sterile Dressing with window cut out to allow direct observation,

Orthosis to immobilise appropriate joint.

Elevation to ensure no congestion in flap.

ROS 2/52

Early rehab programme commenced

Question 34

When would a surgeon consider free tissue transfer?

Answer 34

When local tissue transfers are limited due tot he locationof the defect, a vascular pedicle might not be long enougg to reach a particular defect, or the defect might be too large.

Question 35

What are some of the benefits of free tissue flaps?

Answer 35

Allow early mobilisation and rehabilitation

can include a combination of tissues trasnferred as a single unit and tailored specifically to a wound defect.