Flaps in orthopaedics

Flaps in orthopaedics:

Flaps in orthopaedics Zameer Ali 1

Diagrammatic representation of cross section skin:

Diagrammatic representation of cross section skin 2

Skin grafting and classification:

Skin grafting and classification 3

Classification on basis of thickness:

Classification on basis of thickness Split thickness skin grafting Full thickness skin grafting 4

Diagramatic representation of skin:

Diagramatic representation of skin 5

Species of origin :

Species of origin Species of origin 1. Autologous (Auto) graft 2. Homologous (Homo, Allo) graft 3. Heterologous (Hetero. Xeno) graft 6

STSG (Thierish graft):

STSG (Thierish graft) It usually contains epidermis and part of dermis. Thickness ranges from .01 (very thin) to .016 intermediate thickness) to .020 (thick graft) 7

Split thickness skin grafting :

Split thickness skin grafting STSG are useful for early resurfacing following burns ,immediate coverage of traumatic defects or surgical excision defect especially when area is too wide to use full thickness graft and replacement of defect caused by full thickness graft is quite large 8

STSG (Thierish graft):

STSG (Thierish graft) When vascularity of recipient area is doubtful STSG is more likely to take than full thickness graft 9

STSG (Thierish graft):

STSG (Thierish graft) Split thickness graft may be used as a definitive treatment in areas where durability of skin and function of underlying structures are not of prime consideration Otherwise it must be used temporary to be later replaced by a more suitable type of graft 10

STSG:

STSG STSG 11

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When free skin grafts are to be obtained, it is well to remember that "the thinner the graft, the better the take," and yet when the graft is expected to be permanent, "the thicker the graft, the better the function 13

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." A thick graft is better able to withstand friction and constant use than a thin one and will contract only about 10%; a thin graft may contract 50% to 75%. 14

Sites from which to obtain full-thickness skin grafts. Groin or medial aspect of arm is preferable :

Sites from which to obtain full-thickness skin grafts. Groin or medial aspect of arm is preferable 15

STSG wolfe graft:

STSG wolfe graft 1) considerable secondary contraction 2) may develop pigmentation later on 3)Epidermis +partial dermis 4)No need to cover donor site 5) Quicker healing of donor site Little contraction/shrinkage usually Little /no pigmentation Epidermis + whole of dermis Donor site to be covered by STSG Lesser healing of donor site 16

Factors affecting uptake of graft:

Factors affecting uptake of graft 1. Recipient site capable for producing capillary bud. 2. Approximation between the graft and recipient site (: No hematomaor infection) 17

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3. Immobilisation during the phase of grafting 6. Subsequent behavior of free graft 18

No take :

No take 1. Compact bone 2. Bare cartilage 3. Bare tendon 4. Heavily irradiation of tissue 19

A. Take:

A. Take 1. Fat, fascia. 2. Muscle, tendon sheath. 3. Periosteum. Perichondrium, Cancellous bone tissue 20

Instruments for taking graft:

Instruments for taking graft 21

Humby knife:

Humby knife 22

Taking STSG:

Taking STSG 23

Graft taking with weck knife:

Graft taking with weck knife Technique of removing split-thickness skin graft from flexor surface above elbow with Weck knife. 24

Reese dermatome :

Reese dermatome Large area of skin is removed by adhering to tape mounted on drum Thickness is measured by shimmer that measures distance between drum and blade 25

Reese deramtome:

Reese deramtome 26

Pneumatic dermatome :

Pneumatic dermatome 27

mesher:

mesher 28

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Skin flaps :

Skin flaps Skin flaps are composed of skin and subcutaneous tissue temporarily attached by vascularized pedicle to donor site 31

Filletted graft from injured finger :

Filletted graft from injured finger 32

Classification:

Classification l. Due to blood supply 1. Random pattern flap 2. Axial pattern flap 33

Types of skin flaps :

Types of skin flaps Random pattern flaps Axial flaps Island flaps 34

Axial flap:

Axial flap Limited by available vessels Based on direct cutaneous vessels Random flap at distal tip 35

Axial flap:

Axial flap Axial pattern flaps allow a safe length-to-width ratio of at least 3:1, the possibility of covering either the dorsal or palmar surface, and a sufficiently long pedicle to allow arm and hand movement. Because such flaps usually do not require a delay in detachment of one end, they are useful for coverage of acute hand injuries. 36

Random pattern flap:

Random pattern flap Most common Based on subdermal plexus Unpredictable Length:width of 3:1 or 4:1 37

Random pattern flap:

Random pattern flap A randomn pattern flap is one perfused by musculocutaneous arteries located in pedicle of flap and connected to dermal and subdermal plexus 38

Due to site of flap :

Due to site of flap 1. Local flap 2. Distant flap 39

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Flap coverage can be used in the primary closure of a hand wound or in a secondary procedure to replace scars, skin of poor quality, or necrotic skin. 40

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flap can be obtained locally or from a distant part. If the area to be covered is small, a local flap may be indicated, 41

Local flap (thenar flap) :

Local flap (thenar flap) 42

Tests for flap circulation:

Tests for flap circulation Blanch test (Capillary circulation returns within 4 seconds after blanching if more time is consumed suggestive of vascular insufficiency However above test gives no clue about venous drainage 43

Flourescein test :

Flourescein test The flourscein test is accurate method of evaluating skin flap circulation 44

Flap survival:

Flap survival increased width of base would increase surviving length but feeding vessels have same perfusion pressure 45

Principles of skin flap surgery:

Principles of skin flap surgery 1) The recipient and donor area must be brought in position and an over sized pattern is applied 46

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2 ) local flaps are preferred because they provide similar texture and cololr charecteristics 47

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3) Axial pattern flaps based on specific arterio venous system are better than random pattern flaps 48

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4) elderely patients are not good candidates for large flaps because of arteriosclerotic changes 5) the flap should not be subjected to kinking or pressure ( dressing over flap should be avoided ) 49

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6) Hematoma formation jeoparadizes flap Complette haemostasis ,use of suction drainage and delay of flap transfer when haemostasis is doubtful will reduce hematoma formation 50

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7) transfer should be delayed when adequate vascularity of flap is doubtful When transfering a flap from distance raw area produced by raising flap must be eleminated this is achieved by 51

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A) bringing donor area and recipient area close B) immediate application of STSG C) forming hinge flap adjacent to recipient area . 52

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Flap separation should be delayed till 21 st day once vascularization of flap at recipient area is doubtful. 53

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Flaps should not be in tension 54

Delay of flaps :

Delay of flaps Instead of raising and immediately transferring flaps , flaps may be partially divided in stages before transferring This will increase vascularity and ensure survival of flap 55

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Local flaps may be designated as 1 advancement, 2 rotation 3 translation 4 transposition types. 56

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Skin to be used for a local flap should not be damaged, since necrosis may occur. Developing a local skin flap requires undermining and minimal tension on the flap. 58

Advancement flap:

Advancement flap Use of an advancement flap involves mobilizing a small flap of skin to cover an adjacent defect without using a skin graft for the donor defect. 59

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These are used to cover fingertip amputations. Rotation flaps are raised on a curved radius with undermining of the flap and closed under modest tension without a skin-grafted donor defect 60

Translation flaps :

Translation flaps Translation flaps usually are rectangular and are used to close an adjacent defect. The flap is moved around a pedicle base and is closed without tension. Translation flaps require a skin graft for the donor site 61

Translation flaps :

Translation flaps 62

Translation flaps :

Translation flaps Translation flap raised from skin in continuity with area of skin loss. Donor area is covered by graft. 63

Transposition flaps:

Transposition flaps Transposition flaps usually are moved across an adjacent area of normal skin to close an adjacent defect without tension. Skin grafting at the donor site is necessary ... 64

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The advantages of a local flap over one from a distant part are that the involved part is not tied to the distant donor and that in many instances finger motions may continue 65

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Flag flap:

Flag flap "Flag flap." A, Skin can be moved over distance to palmar surface or to neighboring digit. B, "Flagstaff" contains the pedicle consisting of dorsal vein, dorsal branch of digital artery, and dorsal branch of digital nerve 67

dorsoulnar thumb flap :

dorsoulnar thumb flap The circulation to the dorsoulnar side of the hand and thumb has been further elucidated by Brunelli et al., leading to the development of the dorsoulnar thumb flap 68

dorsoulnar thumb flap :

dorsoulnar thumb flap Dorsoulnar flap harvested from inner side of thumb metacarpophalangeal area reaches distal area of thumb 69

CROSS-FINGER FLAPS:

CROSS-FINGER FLAPS CROSS-FINGER FLAPS useful for covering a defect of the skin and other soft tissues on the volar surface of the finger when tendons and neurovascular structures are exposed and a small amount of subcutaneous fat is needed. 70

CROSS-FINGER FLAPS:

CROSS-FINGER FLAPS They also are useful for some amputations of the thumb These grafts are best avoided in patients over 50 years of age, in hands with arthritic changes or a tendency to finger stiffness for some other reason, or if local infection is present 71

Cross-finger flap.:

Cross-finger flap. 72

Cross-finger flap.:

Cross-finger flap. Cross-finger flap. Laterally based pedicle flap has been raised from middle finger and has been applied to distal pad of index. donor finger and bridge between two fingers have been covered with split-thickness skin graft 73

Principles of three types of local flaps:

Principles of three types of local flaps . In each type, defect to be covered is converted into triangular one. Flap may be rotated or transposed or both. Defect created by transposing flap must be covered with split-thickness graft. 74

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Flap rotating about a pivot point - Rotation - Transposition : Rhomboid flap - Z-Plasty 75

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Skin coverage by pedicle method provides a well vascularized cover for underlying vital structures with minimum scaring relaxing all tissues within the part and improving local blood supply and nutrition 76

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Flaps withstand wear and tear of rough usage as soon as nerve supply returns to them A skin flap is best method of resurfacing palm of hand and volar surface of fingers 77

Axial pattern flap :

Axial pattern flap An axial pattern flap (arterial flap ) contains at least one specific direct cutaneous artery within its longitudinal axis Artery lies in subcutaneous layer just superficial to muscular fascia therefore flap thickness should include subcutaneous fat and deep fascia 78

Axial pattern flaps :

Axial pattern flaps Examples Deltopectoral flap Hypo gastric flap Superficial inferior epigastric flap Groin flap Superficial circumflex iliac artery flap 79

Abdominal flaps:

Abdominal flaps Traditionally, flaps from the abdomen have been used as tubed pedicle flaps or as direct flaps. 80

Axial pattern abdominal flaps:

Axial pattern abdominal flaps The tubed pedicle technique requires the formation of a bipedicle tube and 6 weeks of maturation followed by detachment of one end of the tube to be applied to the hand, followed by another 3 to 6 weeks before the flap is completely detached and "inset" into the defect. 81

Abdominal flaps:

Abdominal flaps The direct abdominal flaps typically are limited in their length-to-width ratio because of the random circulation. It rarely is safe to use such a flap with a length-to-width ratio that varies significantly from 1:1. 82

A random pattern abdominal flap:

A random pattern abdominal flap A random pattern abdominal flap to be applied to the hand should have its base either distal, toward the superficial epigastric vessels, usually on the same side as the affected hand, or proximal, above the umbilicus toward the thoracoepigastric vessels, usually on the opposite side 83

A random pattern abdominal flap:

A random pattern abdominal flap The flaps above the umbilicus should not be used in a patient with a "barrel chest" with chronic lung disease.. 84

A random pattern abdominal flap:

A random pattern abdominal flap 85

A random pattern abdominal flap:

A random pattern abdominal flap Lower abdominal flap may be made narrower in relation to its length if it contains superficial circumflex iliac artery and vein (lower right) or superficial epigastric artery and vein. 86

A random pattern abdominal flap:

A random pattern abdominal flap Abdominal flaps obtained from areas above the umbilicus usually avoid the fat "storage areas." If the flap is obtained from the infraumbilical area, the recipient grafted area usually increases in bulk, since the infraumbilical area skin adds fat 87

AFTERTREATMENT:

AFTERTREATMENT The flap should be inspected almost hourly during the first 48 hours for circulatory compromise produced by tension or torsion or for the development of a hematoma. 88

AFTERTREATMENT:

AFTERTREATMENT Sutures that appear to be too tight should be removed because the pressure they apply on the flap may be sufficient to produce ischemia. 89

AFTERTREATMENT:

AFTERTREATMENT If an area becomes necrotic, it should be excised and covered with a split skin graft. Gross infection from necrosis or hematoma usually results in failure. 90

AFTERTREATMENT:

AFTERTREATMENT The area should be redressed frequently to avoid offensive odor and reduce the chance of infection. Usually the flap can be safely detached after 3 weeks. In children this can be reduced to 2 weeks. 91

Groin Pedicle Flap:

Groin Pedicle Flap the iliofemoral (groin) flap, popularized by McGregor, was widely used in reparative and reconstructive surgery of the upper extremity. 92

Groin Pedicle Flap:

Groin Pedicle Flap 93

Groin Pedicle Flap:

Groin Pedicle Flap Advantages of the groin flap include (1) its location in an area sparse in hair, (2) minimal donor site morbidity, (3) multiple arteriovenous supply, (4) potential for incorporating bone with the overlying skin flap even when used as a pedicle flap, and (5) potentially large size. 94

Groin Pedicle Flap:

Groin Pedicle Flap Disadvantages include (1) problems with color matching, (2) possibility of damage to vessels from previous inguinal surgery, and (3) thickness of the flap in obese patients 95

Groin Pedicle Flap:

Groin Pedicle Flap The groin pedicle flap usually receives its arterial supply from the superficial circumflex iliac branch of the femoral artery. Its venous drainage is through the superficial inferior epigastric and superficial circumflex iliac veins. 96

Hypogastric (Superficial Epigastric) Flap :

Hypogastric (Superficial Epigastric) Flap it has proved extremely useful for coverage of the hand and forearm. Its arteriovenous pedicle consists of the superficial epigastric artery and vein The axis of the flap usually is oriented in a superolateral direction, with the base near the inguinal ligament centered at about the midpoint of the ligament. 97

Hypogastric (Superficial Epigastric) Flap :

Hypogastric (Superficial Epigastric) Flap 98

Hypogastric (Superficial Epigastric) Flap :

Hypogastric (Superficial Epigastric) Flap Flaps measuring up to 18 cm long × 7 cm wide have been used. Its advantages and disadvantages are similar to those described for the groin pedicle flap . 99

Hypogastric (Superficial Epigastric) Flap :

Hypogastric (Superficial Epigastric) Flap Usually a bone graft cannot be incorporated into the skin flap. During preoperative planning it is important to examine the abdomen on the affected side for the presence of previous surgical or traumatic scars that might have damaged the arterial supply. 100

Island flap :

Island flap The island flap has pedicle devoid of skin and consists of nutrient artery and vein 101

filleted graft:

filleted graft A filleted graft is a flap of tissue fashioned from a nearby part, usually a finger, from which the bone has been removed but in which one or more neurovascular bundles have been retained. 102

filleted graft:

filleted graft In the hand such a graft is indicated only when deep tissues such as tendons, nerves, and joints are exposed and when a nearby damaged finger is to be sacrificed because it is not salvageable; it is never used at the expense of a salvageable, useful part. 103

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