Introduction to Plastic Surgery and Skin Grafting Techniques PDF

Introduction to Plastic Surgery and Skin Grafting Techniques KELLY J. JOHN, DPM, MHA, FACFAS, DABPM ASSISTANT PROFESSOR, COLLEGE OF PODIATRIC MEDICINE AND SURGERY CLINICAL PODIATRIC BIOMECHANICS AND SURGERY 2024 INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Copyright Notice: This pres...

Introduction to Plastic Surgery and Skin Grafting Techniques KELLY J. JOHN, DPM, MHA, FACFAS, DABPM ASSISTANT PROFESSOR, COLLEGE OF PODIATRIC MEDICINE AND SURGERY CLINICAL PODIATRIC BIOMECHANICS AND SURGERY 2024 INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws CPMS Mission Statement: To educate a diverse group of highly competent and compassionate podiatric health professionals to improves lives in a global community. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Dr. Kelly John, Assistant Professor, College of Podiatric Medicine and Surgery, Employed by Des Moines University, West Des Moines, Iowa. Disclosure: Financial— No relevant financial relationship exists. Nonfinancial— No relevant nonfinancial relationship exists. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Excellent Sources – Dr. Peter Blume INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Objectives *Identify the soft tissue forces that govern the correct planning of incisions, including Langers Lines, Relaxed Skin Tension Lines (RSTL) and angiosomes. *Identify incision techniques for common pathologies and related complications. *Demonstrate knowledge of basic random flaps. *Identify the indications for skin grafting, sites of harvest, complications and treatment of donor sites. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Plastic Surgery Surgery Cosmetic * Reconstructive Surgery * It is a common misunderstanding that the word plastic in plastic surgery means artificial. Rather, the word originated from the ancient Greek word “plastikos”, which means to mold or give form. * Plastic surgery is used to repair and reconstruct missing or damaged tissue and skin. The main aim of plastic surgery is to restore the function and appearance of tissue and skin so it's as close to normal as possible. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Part I INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES CREATING AN OPENING IN THE SKIN Incision planning Incision placement is selected by: 1) target tissue exposure 2) skin tension lines 3) adjacent neuro and vascular structures INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Contour Lines of the Skin LINES OF MINIMAL MOVEMENT LINES OF MAXIMUM MOVEMENT * Relaxed Skin Tension Lines (RSTL) * Lines of maximum extensibility (LME) * Langer’s Lines * Karl Langer 1861, cadaver study, didn’t take into account body movement * RSTLs mapped on foot and ankle in 1962 by Borges and Alexander INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin incisions according to contour lines * Skin tension is important is incisional and wound healing * An incision across the skin’s maximal tension will result in a stretched, hypertrophic scar * decreased tension on wound edge yields better cosmesis and potentially faster healing * an incision made parallel to the RSTLs (within) has less tension * an incision perpendicular to RSTLs has minimal available movement and therefore more tension INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Contour Lines of the Skin Clinical and Histological Proof that Surgical Incisions along Skin Folding Lines Result in Optimal Scars Citation: Lemperle G. Clinical and Histological Proof that Surgical Incisions along Skin Folding Lines Result in Optimal Scars. Arch Orthop. 2020; 1(2): 61-67. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Incision planning Incision placement is selected by: 1) target tissue exposure 2) skin tension lines 3) adjacent neuro and vascular structures INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Pedal Angiosomes – Blood Supply foot and Ankle * Concept of angiosomes in the body: G. Ian Taylor – Australia ◦ A 3D block of tissue supplied by a single source artery incorporating all surgical layers including bone, muscle, fascia, subcutaneous tissue and skin. * Christopher Attinger, MD Johns Hopkins * Bauer Sumpio, MD Yale * Peter Blume, DPM Yale In the foot, 6 angiosomes from 3 primary source arteries INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Pedal Angiosomes – Blood Supply foot and Ankle * Lower extremity is a peninsular end organ * anastomotic communications between the terminal branches * the single source artery (popliteal artery) branches give all the vascular supply to the foot and ankle ◦ Anterior tibial artery ◦ Posterior tibial artery ◦ Peroneal artery * Incision planning: target tissue exposure, skin tension lines, adjacent neuro and vascular structures * From an entirely VASCULAR perspective: an incision within an angiosome is safe with a palpable or Dopperable source artery * an incision made within an angiosome with a compromised primary artery, is made to avoid disruption of the collateral flow of the adjacent angiosome Source artery anastomoses chart – Attinger, et. al INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Blood Supply to the Foot and Ankle *classic article: Hidalgo, D. A., and Shaw, W. W. Anatomic basis of plantar flap design. Plast. Reconstr. Surg. 78: 267, 1986. * A subdermal arteriolar plexus links the dorsalis pedis with the lateral plantar artery in a circumferential wraparound pattern INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Pedal Angiosomes – Posterior Tibial Artery A = Medial Calcaneal angiosome B = Medial plantar angiosome C = Lateral plantar angiosome INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Pedal Angiosomes – Anterior Tibial & Peroneal Arteries Anterior tibial: Dorsalis pedis angiosome (D) Peroneal Artery Angiosomes: 1) Anterior perforating (2) 2) Lateral Calcaneal (E) INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Pedal Angiosomes – Ideal incision at the juncture of two pedal angiosomes is at the exact border of both so that each side of the incision has adequate flow from the respective source arteries INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Instrumentation for skin incision INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Incision planning – how will you make the incision A. Incorrect = skived B. Correct = vertical Providing tension on the incision helps separate the tissue layers and maintain control of incision depth INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Incision planning – how will you make the incision Draw “crosshatches” for skin re-approximation, but don’t create crosshatches. One smooth cut, not “death by a thousand cuts”. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Part II INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES CLOSING AN OPENING IN THE SKIN Closing an opening in the skin INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Methods to close the incision INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Good techniques for skin closure 1) leveled conjunction of both wound edges ◦ No side-to-side step off (A) ◦ No vertical step off (B) 2) Everting skin margins ◦ Brings like margins together (dermis to dermis) ◦ Inverted margins has risk of unlike tissue approximation (dermis to epidermis) larger scar forms as a bridge between the two tissue types needs to develop INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Sutures – Where to place & how many? The timing of nonabsorbable suture removal varies with the anatomic site: -Face – 5 days -Neck – 5 days -Scalp – 7 to 10 days -Trunk and upper extremities – 7 days Place sutures with equal spacing until gapping reduced and minimal tension -Lower extremities – 8 to 10 days -Digits, palm, and sole – 10 to 14 days INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Closing techniques Reduction of “dog ear” INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Everted skin margins initial appearance vs final appearance Too much tension or lack of eversion INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Closing a wound with a skin defect – Basic ellipse * Defect in the skin due to excision of lesion or ulcer * Basic fusiform ellipse with ratio of 3:1 and 30-degree (30°) angles of apices * Undermining may be needed * Suture linearly INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Closing a wound with a skin defect – “S” incisions INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Closing a wound with a flap or graft FLAP – a transfer of tissue with its own blood supply intact. *Random – blood supply by random intradermal or subdermal plexus through the pedicle of the flap ◦ Advancement: pedicle, bipedicle, V to Y ◦ Rotational: classic, transpositional, interpolation *Axial – blood supply is through an anatomically recognized arteriovenous system ◦ Dr. Bennett’s lecture GRAFT – transfer of tissue without its own blood supply. The survival of a skin graft depends entirely on the blood supply from the recipient site. ◦ Split thickness ◦ Full thickness ◦ ◦ ◦ ◦ Autograft Allograft Xenograft Synthetic skin substitutes INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Advancement procedure: V – Y and variations V–Y Y–V Single V- Y island flap Double V – Y island flap *Require undermining to advance the flap *Only moderate coverage utility INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES V – Y and variations V–Y Double V – Y island flap Single V- Y island flap INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES The Apical Stitch INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Z- Plasty * Tissue rearrangement to redirect tension * One central incision and lateral arms * The imaginary line connecting the two lateral arms will become the new arm * This transposition of tissue will change the contracture from vertical to transverse * The standard Z-plasty has 60-degree (60°) angles with central arm and limbs of equal length INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Z- plasty The percentage increase of length with different angle sizes: ◦ 25% increase in length with 30-degree angle ◦ 50% increase in length with 45-degree angle ◦ 75% increase in length with a 60-degree angle Changing the length of the central arm can also increase final length Orienting the original lateral arms as close as possible to relaxed skin tension lines (RSTLs) is crucial to achieving desired reduction of contracture. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Z- Plasty The standard Z-plasty has 60-degree (60°) angles with central arm and limbs of equal length INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES The Apical Stitch INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Double opposing Z plasty Planimetric z-plasty Double opposing semi-circular Double-Z rhomboid Four-flap Z-plasty V –Y –S-plasty (Dollar-plasty) W-plasty INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES A –T closure Advancement Flaps * Movement of the flap is forward with sliding, stretching, and pushing of tissue to cover defect *Undermining is necessary and carried out down to the level of subcutaneous fat *Moderate coverage potential, therefore limited utility – cannot cover large defects *Single or double advancement flaps INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Advancement Flaps INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Rotational Flaps * Revolve around a fixed pivot point * Redistribute tension from defect to donor site * Classic * Satterfield- Jolly, Cantanzariti-Wehman * Single-lobed, Double-lobed Classic INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Rotational Flaps SATTERFIELD -JOLLY CANTANZARITI-WEHMAN INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Rotational Flaps SINGLE LOBED DOUBLE LOBED INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Transpositional Flaps * Classic or simple: primary movement allows rotation at the pivot point to close a rectangular defect. The secondary defect is closed with skin graft. * Rhomboid: Standard = 90 degrees Limberg = 60°/ 120 degrees INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Transpositional Flaps STANDARD RHOMBOID (90 DEGREES) LIMBERG RHOMBOID ( 60/120 DEGREES) INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Double Rhomboid lida double transposition Dufourmentel rhomboid Webster 30° Triple Rhomboid The Reading Man transpositional INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Interpolation Flaps * A two-stage flap * The base of the flap does not directly border the recipient site. * Step 1: The flap is elevated, and the tip is inset into the defect; the donor site is closed, with exception of the pedicle * Step 2: Once the flap is revascularized, the pedicle is released from the base, and remaining open sites are closed. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts * Free tissue that is transplanted * The skin graft (the transplanted tissue) relies entirely on the recipient site’s blood supply for survival. * Skin grafting has largely been replaced by synthetic skin substitutes Autograft (autogenous graft) = donor and recipient are same individual Allograft (homograft) = transferred from one person to another Xenograft (heterograft) = donor is non-human to human recipient (e.g. porcine) Isograft = from one genetically identical person to another (e.g. identical twin) INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts Blood vessels of the skin are in the dermis. The epidermis is avascular. Therefore, a skin graft should contain some dermis in order to have viability. Full thickness (FTSG): Epidermis and entire dermis Split thickness (STSG): Epidermis and a variable portion of the dermis ◦ Thin = 0.008-0.012 inches of dermis ◦ Intermediate = 0.012-0.016 inches of dermis ◦ Thick = 0.016-0.020 inches of dermis INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Graft Harvesting SPLIT THICKNESS SKIN GRAFTS INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Graft Harvesting FULL THICKNESS INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts – Recipient site Recipient Site preparation - Topical debridement - Mechanical debridement - Porcine (or other biologic ) graft The bacterial count should be < 105 organisms per gram of granulation tissue INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES The bacterial count should be < 105 organisms per gram of granulation tissue TRADITIONAL : 24- 26 HOURS RAPID SLIDE : 15 MINUTES INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts – Xenograft A case for the use of Xenograft – Porcine Graft * xenograft has limited use because on antibodies to donor graft leads to rejection. * no donor site on your patient * used as a temporary biological dressing in “prewounding” the recipient site to stimulate formation of blood vessels. Then when permanent autograft is placed, the phases of wound healing are accelerated. * Will be able to determine if wound bed is clean enough as gram negative bacteria thrive in porcine graft * after 3-4 days porcine graft will be removed, and autograft placed. If porcine graft was not progressing in graft “take”, the autograft, will not take either, but “no harm done” to the patient. INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts – Healing INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts – Healing & Contraction PRIMARY SECONDARY More common in FULL thickness skin grafts which have more dermis SPLIT thickness skin grafts less resistant than full thickness to secondary contracture Occurs when graft is pulled away from the DONOR site Occurs after the graft is placed of the recipient site Elastin fibers in dermis have recoil properties Myofibroblasts in the recipient bed pull on the graft Full thickness skin grafts will retract approximately 44% The more dermis, the less pull INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts – Meshing and Pie Crusting Meshing: ◦ Expands the skin graft to cover larger areas ◦ Allows graft to adhere to irregular surfaces ◦ Allows fluid to drain, reducing chance of hematoma or seroma ◦ Healed skin will have a crisscross pattern Meshing Pie Crusting: ◦ No crisscross appearance of healed skin ◦ Allows some fluid to drain, but not as well as meshing ◦ Minimal expansion Pie crusting INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts – Dressing Stent or Bolster Dressing ◦ Applies pressure to decrease fluid accumulation (hematoma seroma) ◦ Reduces mechanical shearing forces Negative pressure wound therapy (NPWT) or Vacuum Assisted Closure (Wound VAC) ◦ Accelerates would healing ◦ Removal of interstitial fluid ◦ Increases oxygen and nutrient delivery therefore increased vascularity and granulation ◦ Decreases bacterial colonization ◦ Disadvantage: attached to pump INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Substitutes Biological ◦ ◦ ◦ ◦ ◦ Porcine Cadaver allograft Amnionic Cultured epithelial autografts Fish skin Synthetic ◦ Dermagraft™ ◦ Apligraft™ Electrospun membranes Bioengineered smart skin substitutes INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Skin Grafts – Reasons for failure Graft Survival (graft “take”) and Reasons for Failure: ◦ ◦ ◦ ◦ ◦ Hematoma, seroma Movement Poor recipient vascularity Contamination, infection Technical error ◦ Applying dermis side up ◦ Excess pressure or stretching ◦ Poor tissue handling not using atraumatic technique INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES Introduction to Plastic Surgery and Skin Grafting Techniques QUESTIONS? INTRODUCTION TO PLASTIC SURGERY AND SKIN GRAFTING TECHNIQUES