Principles In Plastic Surgery

Lucy S.
Outline
• Obtaining a fine-line scar
• Closure of skin wounds
• Skin grafting
• Skin flaps
• Z-Plasty
• Reconstructive ladder
Plastic surgeons are the ultimate specialists but are also
the modern day general practitioners, unrestricted by
organ system, disease process, or patient age!
Definitions of plastic surgery
• The phrase, plastic surgery, is derived from the Greek "Plastikos,"
meaning to mold or to shape
• Problem-solving specialty
• Surgery of the skin and its contents
OBTAINING A FINE-LINE SCAR
• The final appearance of a scar is dependent on:
- The type of skin
- Location on the body
- The tension on the closure
- The direction of the wound
- Other local and systemic conditions
- Differences between individual patients
- Surgical technique
Con’t…
• Certain anatomic areas tend to produce unfavorable scars - shoulder
and sternal area
• Eyelid incisions almost always heal with a fine-line scar
• Scars are less obvious and less prone to widening in older individuals
because of the stretched-out skin, combined with changes in the
subcutaneous tissue wrinkling
• Children may heal faster but do not heal better
Con’t…
• Relaxed skin tension lines Wrinkle lines
• Lie perpendicular to the long axis of the
underlying muscles
• Maximal contraction occurs when a scar
crosses the lines of minimal tension at a
right angle
 Con’t…
• To obtain a fine-line scar
- Minimize damage to the skin edges with atraumatic technique
- Debride necrotic or foreign materials
- Tension-free closure
- Place sutures that are not excessively tight and are removed promptly
- Wound-edge eversion
CLOSURE OF SKIN WOUNDS
• Precise approximation of the skin edges without tension*
• Wounds that are deeper than skin are closed in layers -- eliminate
dead space and dec. wound dehiscence
• Sutures should be placed with the knot superficial to the loop of the
suture (not buried) except dermal sutures
Suturing Techniques
• Simple Interrupted Suture
- The gold standard and the most commonly employed suture
- Passes into the deep dermis
- Place the suture at the same depth on each side of the incision or wound
- Sutures are placed 5 to 7 mm apart and 1 to 2 mm from the skin edge
Con’t…
• Vertical Mattress Suture
- Used when eversion of the skin edges is desired
- Tend to leave the most obvious and unsighdy
cross-hatching if not removed early
• Horizontal Mattress Suture
- For reliable skin edge approximation and eversion
- Advantageous in thick glabrous skin (feet and hand)
Con’t…
• Subcuticular Suture
- Interrupted or running
- Absorbable or nonabsorbable suture can be used,
with the latter to be removed at 1 to 2 weeks after suturing
• Half-buried horizontal mattress suture
- To have the knots on one side of the suture line with no
suture marks on the other side
- Example: when insetting the areola in breast reduction
Con’t…
• Continuous Over-and-Over Suture / running simple sutures
- Can be placed in a locking fashion to provide hemostasis
- Especially useful in scalp closures
- Not nearly as precise as interrupted sutures
Con’t…
• Skin Staples
- For long incisions
- To position a skin closure or flap temporarily before suturing
• Skin Tapes
- Buried sutures are often required in addition to approximate deeper layers,
relieve tension, and prevent inversion
- Also be used after skin sutures are removed to provide added strength to the
closure
• Skin Adhesives
- In areas where there is no tension on the closure
Methods of Excision
• Lesions of the skin can be excised with elliptical, wedge, circular, or
serial excision
• Elliptical Excision
- the most commonly used technique
- excision of inadequate length may yield "dog-ears”
• How to remove a dog ear
Con’t…
• Wedge Excision
- Lesions located at or adjacent to free margins
Con’t…
• Circular Excision
- When preservation of skin is desired (tip of the nose) or the length of the scar
must be kept to a minimum (children)
- can be closed with a purse-string suture
SKIN GRAFTING
• A graft is something that is removed from the body, is completely
devascularized, and is replaced in another location
Skin Graft Types
• classified as either split-thickness or full-thickness, depending on the
amount of dermis included
• Split thickness skin grafts contain varying amounts of dermis, whereas
a full-thickness skin graft contains the entire dermis
• All skin grafts contract immediately after removal and again after
revascularization in their final location
1. Primary contraction - immediate recoil of freshly harvested grafts as a result
of the elastin in the dermis
2. Secondary contraction - contraction of a healed graft and is a result of
myofibroblast activity
• A full-thickness skin graft contracts more on initial harvest (primary
contraction) but less on healing (secondary contracture) than a split-
thickness skin graft
• The number of epithelial appendages transferred with a skin graft
depends on the thickness of the dermis present
• Skin grafts are reinnervated by ingrowth of nerve fibers from the
recipient bed and from the periphery
• Hair follicles are transferred with a full-thickness skin graft
Requirements for skin graft survival
• Depends on the ability of the graft to receive nutrients and vascular
ingrowth from the recipient bed
• Skin graft revascularization occurs in 3 phases
1. First phase
- Lasts 24-48hrs
- Process of serum imbibition
- A fibrin layer binds the graft to the bed
- Absorption of nutrients in to the graft occurs by capillary action
2. Second phase
- Inosculatory phase
- Recipient and donor end capillaries align
3. Third phase
- Kissing capillaries – graft revascularization
To optimize take of skin graft
• Prepare recipient site
• Close contact b/n the skin graft and recipient bed
• Avoid hematomas and seromas under the skin graft
• Immobilization of the graft
Skin Graft Adherence
• 2 phases of graft adherence
• First begins with placement of the graft on the recipient’s bed –
adheres by fibrin deposition
• Lasts approximately 72hrs
• Second phase involves ingrowth of fibrous tissue and vessels in to the
graft
Meshed Skin Graft Sheet Skin Graft
• Cover a larger area • Continuous uninterrupted
• Allows drainage surface (superior aesthetic result)
• “pebbled” appearance • Don’t allow serum/blood to drain
(aesthetically unacceptable) • Need a larger skin graft
The Donor Site
• Epidermis regenerates from immigration of epidermal cells originating
in the hair follicle shaft and adnexal structures
• The dermis never regenerates
• The no. of STSG harvested from a donor site is dependent on donor
dermis thickness
• FTSG donor site is closed primarily b/c there are no remaining
epithelial structures for re-epithelialization
• Thin split thickness harvest site heals within 7 days
Post-operative Care
• Causes of graft failure
- Collection of blood/serum beneath the graft – hemostasis, meshed graft
- Movement on graft on the bed; interrupting revascularization – bolster
dressing
- Infection – careful preparation of recipient site, early inspection of grafts
applied to contaminated bed
- Wounds that contain 10⁵ organisms per gram tissue will not support a skin
graft
• Protect donor site from mechanical trauma and desiccation – adaptic
Biologic Dressings
• Skin grafts can be used as temporary coverage of wounds as biologic
dressings until definitive procedure
• In large burns where there is insufficient skin to be harvested for
coverage, skin substitutes can be used: human allografts (cadaver
skin), amnion, or xenografts (such as pig skin)
• Synthetic skin substitutes such as silicone polymers and composite
membranes can also be applied
• Cultured human epidermis - fragile b/c of the lack of a dermis
SKIN FLAPS
• Has its own blood supply
• Consists of skin and subcutaneous tissue
• Transferred with a vascular pedicle or attachment to the body being
maintained for nourishment
• Required for:
- Covering recipient beds that have poor vascularity
- Covering vital structures
- Reconstructing the full thickness of the eyelids, lips, ears, nose, and cheeks
- Padding body prominences
"Old fashioned" classification of skin flap
Principles
• The flap is designed slightly longer than needed
• Measure twice, cut once
• Ensure that the line of greatest tension from the pivot point to the
most distal part of the flap is of sufficient length
• Local skin flaps are of two types:
- Flaps that rotate about a pivot point (rotation, transposition, and
interpolation flaps)
- Advancement flaps (single-pedicle advancement, V-Y advancement, Y-V
advancement, and bipedicle advancement flaps)
Flaps Rotating about a Pivot Point
• Have a pivot point and an arc through which the flap is rotated
• The radius of this arc is the line of greatest tension of the flap
• A skin flap rotated about a pivot point becomes shorter in effective
length the farther it is rotated
Rotation Flap
• Is a semicircular flap of skin and subcutaneous tissue that rotates
about a pivot point into the defect
• The donor site can be closed by a skin graft or by direct suture
• A back-cut or a Burow triangle can be used if the flap is under
excessive tension
 Transposition Flap
• Is a rectangle or square of skin and subcutaneous tissue that is
rotated about a pivot point
• Donor site is closed by skin grafting, direct suture, or a secondary flap
from the most lax skin at right angles to the primary flap
Eg: bilobed flap
Bilobed Flap
• The Limberg flap
- a type of transposition flap
- depends on the looseness of adjacent skin
- designed for rhomboid defects with angles of 60⁰ and 120⁰
Advancement Flaps
• Are moved directly forward into a defect without any rotation or
lateral movement
• Are single-pedicle advancement, the V-Y advancement, and the
bipedicle advancement flaps
• Are also used in the movement of expanded skin
Single-pedicle Advancement Flap
• Is a rectangular or square flap of skin and subcutaneous tissue that is
stretched forward
• Advancement is accomplished by taking advantage of the elasticity of
the skin and by excising Burow triangles lateral to the flap
 V-Y Advancement Technique
• a V-shaped incision is made in the skin, after which the skin on each
side of the V is advanced and the incision is closed as a Y
• can be used to lengthen such structures as the nasal columella,
eliminate minor notches of the lip, and, in certain instances, close the
donor site of a skin flap
Z-PLASTY
• Applied to revise and redirect existing scars or to provide additional
length in the setting of scar contracture
• The limbs of the Z must be equal in length to the central limb, but can
extend at varying angles (from 30° to 90°)
• The classic Z-plasty has an angle of 60° and provides a 75% theoretical
gain in length
• Gain in length is in the direction of the central limb of the Z and
depends on the angle used and the length of the central limb
Planning and Uses of the Z-Plasty
• The resulting central limb will be perpendicular to the original central
limb
• In scar revision, the final central limb should lie in the direction of the
skin lines
• Large Z-plasties do not look good on the face and it is better to use
many tiny Z-plasties
• Also used to correct Congenital skin webs
• Circumferential scars are amenable to lengthening using Z-plasties,
especially in constricting bands of the extremities
W-Plasty
• Involves excising the scar in multiple small triangles that are so
situated that they interdigitate
• The triangles must be made very small to avoid worsening the
appearance of the scar
• Does not lengthen a contracted scar line
• Both techniques more than double the length of the scar
RECONSTRUCTIVE LADDER
End!