PLASTIC RECONSTRUCTIVE

SURGERY
Sidney Lee Duane Uy, MD, DPBO-HNS
PRINCIPLE OF WOUND HEALING

COLLAGEN SYNTHESIS
EPITHELIALIZATION
WOUND CONTRACTURE
 COLLAGEN SYNTHESIS
EARLY PHASE:
- poorly organized
- low strength/mass ratio
- low tensile strength
MATURE PHASE:
- more compact
- greater tensile strength
 COLLAGEN SYNTHESIS

Collagen synthesis
- Oxygen, Vitamin C
Collagen lysis
- result from digestion of Collagenase
- inhibited by corticosteroid

synthesis lysis
 EPITHELIALIZATION:

- starts migration of undamaged epithelial cells from

the wound margins
- starts few minutes and last for 48 – 72 hours
- should need adequate debridement of eschar, fibrin,
wound debris
 WOUND CONTRACTURE

- centripetal movement of wound edges

- maximal between 5 – 15 days
- mediated by myofibroblast
- responsible for ectropion, trap-door deformities
- inhibited by corticosteroid, skin grafting
 LOCAL ANESTHETICS
I. ESTERS:
1. Cocaine – 150 to 200 mg
- mild euphoria, mental alertness
- fight or flight reaction
- extreme excitement, convulsion and coma
2. PROCAINE:
a. Chlorprocaine – least toxic
b. Tetracaine – longest activity
- most potent
- undergo slowest hydrolysis
 LOCAL ANESTHETICS
II. AMIDES:
Lidocaine:
- onset is immediate
- with or without epinephrine
- 4.5 mg/Kg or 300 mg without epinephrine
- 7.5 mg/Kg or 500 mg with epinephrine
 FACTORS AFFECTING ANESTHESIA

1. Dosage of drugs
2. Presence or absence of vasoconstrictors
3. Pharmacologic properties of the drug
4. Site of Injection
Vasoconstrictors in Anesthetics
1. Decrease blood flow
2. Prolong effect of drugs
3. Minimize the amount of drugs needed
4. Less of the drug is absorbed
Wound Closure
 Methods of Wound Closure

1. Primary intention –
skin edges
approximated using
any acceptable
closure method

2. Secondary intention
– wound heals via
epithelialization and
contraction
 Methods of Wound Closure

3. Third
intention/delayed
primary intention

– wound left open for

short period of time
and then closed by
primary intention
 Methods of Wound Closure

4. Skin graft – epidermis

+ part of dermis

5. Mobilized Flaps
pedicled flap
local flap
distal flap
free flap
 FACTORS AFFECTING WOUND HEALING
1. Choice of Instruments
2. Suture material
3. Surgical incision planning
 CHOICE OF INSTRUMENTS
- lightweight needle holder
- skin hooks
- use Brown-Adson ( fine multiple sharp teeth
tissue forceps
- small knife
 SURGICAL MATERIAL
A. Absorbable vs. non absorbable
B. Monofilament vs. Braided
 SURGICAL MATERIAL
Absorbable suture materials: Nonabsorbable suture materials
Plain catgut silk, cotton
Chromic catgut nylon,
Vicryl

Monofilament sutures Braided sutures

nylon, catgut silk, cotton
vicryl
 SURGICAL MATERIAL

Monofilament suture is made of a

single strand.

This structure is relatively more

resistant to harboring
microorganisms.

The monofilament sutures exhibit

less resistance to passage through
tissue than multifilament suture.
SURGICAL MATERIAL

Multifilament suture is
composed of several
filaments twisted or
braided together.

These materials are less

stiff but have a higher
coefficient of friction.
SURGICAL TECHNIQUE
1. Functional and cosmetic goal
2. Size of defect
3. Availability of local tissues
4. Condition of the patient
5. Experience of the physician
SURGICAL INCISION PLANNING
A. Surgical Closure technique
Mattress suture
simple interrupted suture
continuous/running suture
subcuticular
B. Relaxed Skin Tension Lines
Surgical Closure
Simple Interrupted Suture
Vertical Mattress Suture
Horizontal Mattress Suture
Continuous Interlocking Suture
Subcuticular Suture
RELAXED SKIN TENSION LINES

- lines of fascial expression

- perpendicular to the longitudinal axes of facial
muscle fibers
- wrinkles
RSTL VS. LANGER’S LINE
SURGICAL INCISION PLANNING
OPTIONS to minimize visual impact of scars:
1. to hide the incision where it will not be seen ( inside
inside hairline)
2. to place incision in a wrinkle/skin crease.
3. to place it where it can be seen but not noticed
i.e. junction of 2 anatomic regions (parotidectomy)
between the face and the ears
4. to place the incision in a region where the resulting scar
will not cast shadow in the face I.e. below the brow or jaw
a. Subciliary
b. Lower eyelid
c. infraorbital
 MOBILIZED GRAFTS & FLAPS
Skin Grafts Split Thickness Skin Graft
Full Thickness Skin Graft

Skin Flaps Local Flap

Distal Flaps

Free Flaps
 Skin graft
• Harvested completely devascularized skin
• Survival depends on the ability of the graft to
receive nutrients
• 3 essentials
– Viable recipient bed
– Close contact between graft and bed
– Immobilization of the graft
 Skin graft

Imbibition Inosculation Neovascularization

24 – 48 3 – 5 days 5 – 7 days
hours
Absorption Meeting of New blood vessels
vessels
 SKIN GRAFT
1. Split-thickness skin graft
2. Full thickness skni graft
3. Dermal Graft
4. Composite Graft
 SPLIT THICKNESS SKIN GRAFT
1. Thin or translucent split thickness skin graft
= Thiersch Graft
- 0.10 inch thickness
2. Intermediate Split thickness skin graft
- 0.17 inch thickness
3. Thick split thickness skin graft
- 0.225 inch
FULL THICKNESS SKIN GRAFT
= WOLFE’S GRAFT
- epidermis and full dermis
Advantage of Thin Skin Graft
1. Better take
2. Require less nourishment

Disadvantage of Thin Skin Graft

1. More contraction
2. Less resistant to injury
Advantage of Thick Graft
1. retain more of the characteristics of normal
skin, including color, texture, and thickness
2. Contract less
3. Resistant to trauma

Disadvantage of Thick Graft

1. Poor take
DERMATOME

Padgett Dermatome
DERMATOME

Skin Graft Knives

 DERMATOME

Electric Dermatome Air-compressor Dermatome

LOCAL FLAPS
1. Advancement Flaps
2. Rotation Flaps
3. Transposition Flaps
 ADVANCEMENT FLAPS
1. Simple Advancement Flap
2. Rectangular Advancement Flap
ADVANCEMENT FLAPS
 ROTATION FLAP
- curved flaps that is undermined
- immediately adjacent to the defect and pivot
around its arc
 Simple Rotation
- use to fill a triangular defect
- flap is design as a semi-circle and rotated as a
semi-circle and rotated into position
- necessary to excise a Burrow’s triangle
Simple Rotation
 V-Y Rotation Flap
- pivot point of the flap is designed in the shape of
V and closed in the shape of Y
 O-Z Rotation Flap
- use two opposing inverted semicircular rotation
flap to close a circular defect
 Transposition Flap
- simple transpositional flap outline adjacent
to a defect, elevated and transposed into position
OVER an intervening bridge of skin
 Bilobed Transposition
- consist of 2 transpositional flaps that are outline
adjacent to the defect
- designed 90o to the defect and to each other
 Rhomboid Transposition Flap
- design to fill a rhombic defect with apical 60o and
the side 120o, a flap equal to size of the defect is then
contructed parallel to one side of the defect
REGIONAL / DISTAL FLAP
I. CUTANEOUS FLAP
II. MYOCUTANEOUS FLAP
CUTANEOUS FLAP
- main use is for large skin loss
- good color match
- no contraction
 CUTANEOUS FLAPS
A. Deltopectoral Flap
B. Temporal Flap
C. Midline Forehead Flap
 Blood Supply
Pattern
RANDOM Pattern – major blood vessels of the skin
enter the subdermal plexus at the most
proximal point of the flap
AXIAL Pattern – blood vessels supply the whole
length of the flap in an axial pattern
BLOOD SUPPLY PATTERN
 FLAP AND BLOOD PATTERN
BLOOD FLOW BLOOD SUPPLY
CUTANEOUS
Deltopectoral Axial Internal Mammary
Temporal Axial Superficial Temporal
Forehead Axial Supraorbital.
Supratrochlear
MYOCUTANEOUS
Pectoralis Major Axial Thoracoacromial
Latissimus Dorsi Axial thoracodorsal
 Deltopectoral Flap
- axial pattern blood supply
- first 4 perforating branches of the Internal
Mammary artery
Deltopectoral Flap
 Deltopectoral Flap
INDICATIONS:
1. Replacement of neck and facial skin loss
2. Closure of pharyngeal fistula
3. Reconstruction of the pharynx
Deltopectoral Flap
Deltopectoral Flap
 Temporal Flap
-axial pattern, based on the superficial temporal
artery
-Indications:
1. Orbital and base of the skull surgery
2. Nasal reconstruction
Temporal Flap
 Midline Forehead Flap
- axial pattern based on supratrochlear
vessels
INDICATIONS:
1. Reconstruction of the medial canthal region
2. Reconstruciton of nasal tip defect
Midline Forehead Flap
Midline Forehead Flap
Midline Forehead Flap
Midline Forehead Flap
Midline Forehead Flap
Midline Forehead Flap
 MYOCUTANEOUS FLAP
- Reliable
- allow single-stage restoration of function
- accompanying muscle provide protection for
carotid artery
- add contour to neck and jaw
Pectoralis Major Myocutaneous
Flap
- axial pattern based on thoracoacromial artery
and lateral thoracic artery
INDICATIONS:
1. Closure of oropharyngeal defect
2. Repair of oropharyngeal fistula
3. Repair of facial defect
Pectoralis Major Myocutaneous
Flap
Latissimus Dorsi Myocutaneous
Flap
- axial pattern myocutaneous flap based on
thoracodorsal artery
INDICATIONS:
1. Reconstruction of Scalp and craniofacial defect
2. Reconstruction of temporal bone defect
3. Reconstruciton of large cervicofacial defect
Latissiumus Dorsi Myocutaneous
Flap
 Free Flaps
• Radial forearm flap
• Anterolateral thigh flap
• Fibular osteocutaneous free flap
 ADVANTAGES OF FREE FLAPS
1.Versatility in tissue
2.Versatility in orientation & reach
3.Better form & function
4.Single-stage complex reconstruction
5.Multiple potential donor sites
6.Simultaneous resection & harvesting
7.Donor sites are out of field of prior treatment
8.Better postoperative irradiation tolerance
9.Independent blood supply for compromised tissues
10.Allows better functional & dental rehabilitation
11.High success rates
12.Only available option for some patients
COMPLICATIONS OF
WOUND HEALING
 KELOIDS & HYPERTROPHIC
SCARS
Hypertrophic scar – raised scars that remain or
stay within the boundaries of original wound
Keloids – hypertrophic scar that grow beyond the
confines of original wound
 Treatment:
Intralesional steroid injection
Excision & scar revision
Pressure
 TRAP DOOR DEFORMITY
- most common cause is irregular shaped wound
- lacerations w/c produce a slanting or oblique wound
of varying thickness
- due to chronic edema of the flap with vascular and
lymphatic compromise
- treatment is excision with adequate undermining
and Z-plasty
 UNSIGHTY SCAR
Treatment: broken line scar revision
dermabrasion
injection of filling material
 DERMABRASION
- mechanical abrasion, in successive layers of
epidermis and upper dermis
MECHANICAL – with the use of drill or motor
with abrading surface
CHEMICAL – phenols, trichloroacetic acid
DERMABRASION
Z & W- PLASTY
 THE AGING FACE

DUE TO:
gravitational forces
repetitious pull of facial muscle
loss of elasticity
exposure to sun and wind
 Aging Face
Rhytidectomy – correction of facial wrinkles
Blepharoplasty – removal of baggy eyelids
Submental Lipectomy – removal of submental fat
RHYTIDECTOMY
 RHYTIDECTOMY

Fibrous tissue between muscle

and skin

from temporalis & frontalis

muscle superiorly and extends
downward to become
continuous with the platysma

closer relationship with CN VII

& facial blood vessels
BLEPHAROPLASTY
BLEPHAROPLASTY
Thank you!