PLASTIC AND RECONSTRUCTIVE SURGERY

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“….the application of anatomical knowledge

to restore form and function…”

?• Hands• Aesthetics• Microsurgery• Craniomaxillofacial• Burns• Congenital• Trauma and oncology reconstruction

Anatomy of Circulation

• The blood reaching the skin originates from deep vessels

• These then feed interconnecting perforator vessels which supply the vascular plexus

• Thus skin fundamentally perfused by musculocutaneous or septocutaneous perforators

Anatomy of Circulation

• The vascular plexuses of the fascia, subcutaneous tissue and skin are divided into 6 layers

Angiosomes• Similar to a skin dermatome is a composite block of 3

dimensional tissue supplied by a named artery

• Entire skin surface of the body is therefore perfused by a multitude of angiosome units

• First studied by Marchot 1889, expanded by Salmon 1930 and more recently by Ian Taylor

Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113.

• 3D composite of tissue supplied by an artery & draining vein

• Direct perforators are more common in the limbs, whereas indirect perforators predominate in the torso

SKIN: Physiology & Function

• Epidermis:– protective barrier (against mechanical damage,

microbe invasion, & water loss)– high regenerative capacity– Producer of skin appendages (hair, nails, sweat &

sebaceous glands)

SKIN: Physiology & Function

• Dermis:– mechanical strength (collagen & elastin)– Barrier to microbe invasion– Sensation (point, temp, pressure, proprioception)– Thermoregulation (vasomotor activity of blood

vessels and sweat gland activity)

Reconstructive ladder

• Primary closure

Simple closure

• Best result• No tension• Technique

dependent• Sutures• Staples, Tape,

Adhesive

Reconstructive ladder

• Primary closure• Delayed primary closure

Reconstructive ladder

• Primary closure• Delayed primary closure• Secondary intention

Reconstructive ladder

• Primary closure• Delayed primary closure• Secondary intention• Graft– Transfer of tissue with no intrinsic blood supply

Graft• Layers of the skin• Split vs Full• Other grafts–Bone– Tendon–Nerve–Composite

Skin Grafts: Classification

• Full thickness skin grafts:- epidermis & full thickness of dermis

• Split skin graft: - epidermis & a variable proportion of dermis- thin, intermediate or thick

Split skin graft

What is a Flap?

• 16th century Dutch word “flappe”– ….something that hangs broad and loose ,

fastened only by one side..”

What is a Flap?

• A flap is a unit of tissue that may be transferred from a donor to a recipient site while maintaining its blood supply.– Flaps can be characterized by their component parts

• cutaneous, musculocutaneous, osseocutaneous

– Their relationship to the defect • local, regional, or distant

– Nature of the blood supply• random versus axial

– The movement placed on the flap • advancement, pivot, transposition, free, pedicled

Mathes & Nahai 1981Muscle Flap Classification

Fasciocutaneous flapsCormack & Lamberty (BJPS 1984)

• Type A – multiple perforators in the flap base– no discrete origin– may be combination of direct or indirect

perforators• Type B – pedicle or free flap based on a single

perforator• Type C – multiple segmental perforators from

the same vessel

Nahai-Mathes Classification

Reconstructive ladder

• Primary closure• Delayed primary closure• Secondary intention• Graft– Transfer of tissue with no intrinsic blood supply

• Flap– Transfer of tissue with intact blood supply

Flaps• Simple or random patterned –based on movement (advancement,

rotation, transposition• Complex - named anatomic blood supply• Local vs distant• Pedicled vs Free (microvascular)