Plastic and Reconstructive Surgery: DR Yaseen Abdullah Plastic Surgeon

Plastic and reconstructive
surgery
Dr Yaseen Abdullah
Plastic surgeon
Learning objectives
To understand
• The spectrum of plastic surgical techniques used to
restore bodily form and function
• The relevant anatomy and physiology of tissues
used in reconstruction
• The various skin grafts and how to use them
appropriately
• The principles and use of flaps
• Plastic : Greek word : to mould or shape
• Plastic and reconstructive surgery involve using
various techniques to restore form and function to
the body when tissues have been damaged by
injury , cancer, or congenital loss
The scope of plastic surgery
The tools of reconstruction are used for a wide range of conditions:
●● trauma:
●● soft-tissue loss (skin, tendons, nerves, muscle);
●● hand and lower limb injury;
●● faciomaxillary;
●● burns;
●● cancer:
●● skin, head and neck, breast, soft tissue sarcoma;
●● congenital:
●● clefts and craniofacial malformations;
●● skin, giant naevi, vascular malformations;
●● urogenital;
●● hand and limb malformations;
●● miscellaneous:
●● Bell’s (facial) palsy;
●● pressure sores;
●● aesthetic surgery;
Secondary intention
Primary closure
Classification of wound closure and healing
●● Primary intention
Wound edges opposed
Normal healing
Minimal scar
●● Secondary intention
Wound left open
Heals by granulation, contraction and epithelialisation
Increased inflammation and proliferation
Poor scar
●● Tertiary intention (also called delayed primary intention)
Wound initially left open
Edges later opposed when healing conditions favorable
Skin grafts
• a surgical operation in which a piece of healthy skin
is transplanted to a new site on a patient's body.
• Transferred without their blood supply
• Skin grafts can be:
• A split-thickness skin graft (STSG) is a skin
graft including the epidermis and part of the
dermis.
• A full-thickness skin graft (FTSG)consists of the
epidermis and the entire thickness of the dermis.
STSG can be harvested by electrical power
dermatome
Or by hand held knife
STSG
recipient site
Thicker knife-gap settings give rise to fewer but brisker
bleeding points on the donor site
STSG
donor site
heal by epithelialization
Meshed grafts have more size and less haematoma risk
but they are ugly with more contracture
Split-thickness skin grafts
●● Thicker knife-gap settings give rise to fewer but
brisker bleeding points on the donor site.
●● Thicker grafts heal with less contracture and are
more durable.
●● Thinner donor sites heal better.
●● Grafts are hairless and do not sweat (these
structures are not transferred).
FTSG
donor site
closed by primary intention
?How does a skin graft survive
How does a skin graft survive?
• imbibition of plasma from the wound bed intially
• after 48 hours, fine anastomotic connections are

made, which lead to inosculation of blood.
• Capillary ingrowth then completes the healing

process with fibroblast maturation.
Because only tissues that produce granulation will

support a graft, it is usually contraindicated to use
grafts to cover exposed tendons, cartilage or
Causes of graft failure
• Pus
• Haematoma
• Exudate
• Dead or non vascularized bed
• Shearing force
• group A β-haemolytic Streptococcus can
destroy split grafts completely (and also
convert a donor site to a full-thickness defect
Skin flaps
• A skin flap consists of skin and subcutaneous
tissue that survives based on its own blood
supply.
• Transferred with their blood supply
Classification of flaps according to blood
supply
• Random flaps have no named blood supply
• Axial flaps are supplied by a named artery and vein. This

allows for a larger area to be freed from surrounding and
underlying tissue, leaving only a small pedicle containing
the vessels.
– Pedicled flaps remain attached to the donor site via a pedicle
that contains the blood supply
– Island flap attached only to the blood vessel
– free flap: Fully detached from vascular supply and
reconnected to recipient vessels using microvascular
Classification of flaps according to location
a. Local flap: Shares side with the defect

b. Regional flap: In same region of the body as
the defect, but does not share defect
margin.
c. Distant flap: Not in the region of the defect,
located in a different part of the body
Classification of flaps according to Method of transfer
a. Advancement
b. Transposition
c. Rotation
Eg. Local (transposition, random)flap: share
border with the defect
Eg.Distant , axial
Transposition Z plasty
to lengthen scar contracture
Tissue expansion
A technique that involves placing a device –
usually an expandable balloon constructed
from silicone – beneath the tissue to be
expanded, and progressively enlarging the
volume with fluid while the overlying tissue
accommodates to the changed vascular
pressure
Tissue expansion
Advantages
●● Well-vascularised tissue
●● Tissue next to defect, so likely to be of similar consistency
●● Good colour match
Disadvantages
●● Multiple expansion episodes (sometimes painful)
●● Cost of device
●● High incidence of infection and extrusion (especially limbs)
Free flap
• A free flap is a piece of tissue that is
disconnected from its' original blood supply,
and is moved a significant distance to be
reconnected to a new blood supply. ... The
blood vessels feeding the flap are usually very
small and the “re-plugging” of the flap is done
through microvascular surgery
Free tissue transfer (or free flap)
Advantages
●● Being able to select exactly the best tissue to move
●● Only takes what is necessary
●● Minimises donor site morbidity
Disadvantages
●● More complex surgical technique
●● Failure involves total loss of all transferred tissue
●● Usually takes more time unless the surgeon is
experienced
Signs of arterial insufficiency
a. Cool temperature
b. White color
c. Slow capillary refill >2 seconds
d. Slow or absent pinpoint bleeding
e. Low turgor
. Signs of venous insufficiency
a. Increased temperature
b. Blue to purple color
c. Brisk capillary refill <2 seconds
d. Brisk pinpoint bleeding, dark in color
e. Increased turgor, tense, swollen
f. If congested, unwrap, release sutures and consider leech
The most common causes of flap failure are:
●● poor anatomical knowledge when raising the flap
(such that the blood supply is deficient from the start);
●● flap inset with too much tension;
●● local sepsis or a septicaemic patient;
●● the dressing applied too tightly around the pedicle;
●● microsurgical failure in free-flap surgery (usually
caused by
problems with surgical technique);
●● tobacco smoking by patient.
‘Wet, warm and comfortable’
The best advice for postoperative flap care for
major tissue transfers is to keep the patient
‘wet, warm and comfortable’.
This means that the patient should be well
hydrated with a hyperdynamic circulation, a
very warm body temperature and well-
controlled analgesia to reduce catecholamine
output.

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Plastic and reconstructive

• after 48 hours, fine anastomotic connections are

• Capillary ingrowth then completes the healing

Because only tissues that produce granulation will

• Axial flaps are supplied by a named artery and vein. This

a. Local flap: Shares side with the defect

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