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Reconstructive surgery

Surgical reconstructive ladder

  1. Secondary intention
  2. Direct closure
  3. Skin graft
  4. Flap: local / distant / composite / island flaps
  5. Tissue transfer

 

Factors affecting reconstruction

  1. Patient
    • Motivation
    • Health
    • Healing factors - nutrition, vitamins
    • Donor site cost vs benefit
  2. Wound / defect
    • Size and complexity
    • Anatomy and blood supply/vascularity
    • Availability of local tissue
    • Timeframe (ie. open tibias should be closed pretty quickly - innit?)

 

 

Skin graft

  • Skin transferred from one location to another on same individual
  • Consists of epidermis + variable amounts of dermis
  • "Takes" by acquiring blood supply from health donor bed
  • Independent of blood supply (see skin graft - which needs it's blood supply)
  Split thickness (STSG) Full thickness (FTSG)
Anatomy
  • Epidermis + variable amount of dermis
  • Harvested using dermatome (Watson & braithwaite modifications of Humby knife) or gas-powered dermatomes
  • Epidermis regenerates from "adnexal elements of skin" - hair follicles, sebacous glands and sweat glands
  • Dermis does not regenerate

 
  • Epidermis + dermis
  • Preserved skin characteristics (more collagen content, dermal vascular plexuses, epithelial appendages)

(Skin cannot grow back and donor site needs to be closed primarily)

Advantages
  • Large areas can be covered (skin can be put through mesh)
  • Less likely to fail
  • Less contraction at graft site (important for hands and joints - that need movement)
  • Better cosmesis
Disadvantages
  • Increased graft contraction at donor site
  • Poor cosmesis
  • Creates second wound at donor site which needs caring for
  • Donor site must be primarily closed
  • More likely to fail because of greater amount of tissue requiring vascularisation
Recipient sites
  • Any large wound
  • Line cavities
  • Resurface mucosal defects
  • Close flap donor sites
  • Resurface muscle flaps
  
Donor site

Any part of body but in particular areas

  • Easily concealed by clothing
  • Position of easy post-operative care
  • Capable of providing adequate tissue

 

Upper thigh, upper inner arm, scalp, buttock

 

Skin Flap

  • Tissue/tissues transferred from one site to another maintaining a vascular pedicle

Classification of skin flaps

  1. Site
    • Local
    • Distant: Free flap
  2. Contents
    • Tissue capable of transfer
  3. Random / axial
    • Not based on an artery
    • Based on an artery

fds

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