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Flaps vs Grafts Ronen Avram, MD MSc FRCSC POS Keratoacanthoma is not a malignant tumor! Methods of Reconstruction Reconstructive Ladder • Primary closure • Primary • Delayed • Secondary Intention • Skin Graft • Pedicled flap • Local vs distant • Free tissue transfer • Muscle vs fasciocutaneous Skin Graft • Very, very thin tissue composed of epidermis and variable amounts of dermis • Split thickness • Full thickness • Meshed vs sheet grafts http://www.lifespan.org/adam/graphics/images/en/89 12.jpg Skin Graft Split thickness Full thickness Entire thickness of skin Skin Graft Split thickness, meshed graft Skin Grafts how do they survive? Graft Osmosis (plasmatic imbibition) of delicious, necessary nutrients, oxygen, etc. Over time (3-4 days), new blood vessels will form and communicate with new skin (inosculation). Skin Graft We’re gonna make it to the other side! WOUND SURFACE Woohoo!!! Diffusion across wound surface what can I skin graft ? Most viable tissue • Dermis • Fat • Fascia • Muscle • Periosteum • Thin tissue around bone • Paratenon • Thin tissue around tendon • Blood vessels • etc Avoid skin grafts… • Major vessels (ie. femoral vessels) • blowout • Major organs • ie. bowel • Radiated tissues Do not skin graft…. • Bone • Bare tendon Full thickness burns bilateral legs What about flaps? • Flaps are ‘fatter’ pieces of tissue • Variable composition • • • • • Skin & fat Muscle & fat Bone & fat/skin Muscle only Etc. •These are flapjacks (not surgical flaps!) Why flap?? • Provide cover for exposed bone, tendon, major vessels, organs. • Provide bulk • ie. breast reconstruction • Provide durability • Wounds in radiated fields may not tolerate skin grafts • Impaired osmosis How to flap… Flaps may be pedicled or ‘free’ • Pedicled • Flap tissue is never fully detached • Remains anchored on its blood supply • Forehead flap • Pedicled TRAM Pedicled flaps Pedicled Flaps • LOCAL ie. Random pattern flaps vs DISTANT ie. TRAM, Pec Major & Deltopectoral (H&N recon), groin flap Pedicled flaps • Random pattern flaps • Advancement flaps • Sometimes just a bunch of undermining • Transposition flaps • Limburg/rhomboid flaps • Rotation flaps Advancement flaps Advancement flaps V-Y (pronounced vee-why) Transposition flaps the numbers…. Dufourmentel • 60 à 30 • 120 à 150b b 60° a c 120° b a b a c c Transposition Flaps 120° Transposition flaps more numbers • Respect length (Y) to width (X) ratios • 2:1 à Y should be no more than twice X • 3:1 (Head & Neck) X Y Rotation flaps Rotation Flaps X 5-6X Axial pattern flaps • Defined blood supply centered within flap • More robust/predictable • Length to width ratios less relevant • Random pattern design terminology not necessarily applicable • Forehead flap • TRAM flap Forehead Flap Supratrochlear/supraorbital arteries What about free flaps? Free flaps are like regular pedicled flaps but they don’t cost anything!!! Why is the blood supply reconnected? What about osmosis? Skin graft Limited penetration Free Flap Forget Osmosis! Think ANASTOMOSIS Donor site (site of wound) Free Flap ANASTOMOSIS Some flaps you may have heard of… TRAM Transverse Rectus Abdominis Myocutaneous Flap DIEP Deep Inferior Epigastric Artery Perforator Flap ALT Anterolateral Thigh Flap (MY FAVORITE!) How many free flaps are there? Cutaneous flaps • Scapula • parascapula Fasciocutaneous flaps • Forearm flaps • Thigh flaps • Lateral arm Myocutaneous flaps • Rectus abdominis • Gracilis • Latissimus dorsi Osteocutaneous flaps • Fibula • Scapula • Iliac crest • Radial forearm Visceral flaps • Jejunum • Gastro-omental flap Curr Opin Otolaryngol Head Neck Surg 11:230, 2003. Free flaps Free flaps = free tissue transfer = microsurgical tissue transfer • Flap is completely detached with its blood supply and transferred to another site where blood supply is reconnected • ie. Free TRAM Are free flaps better? Not necessarily but… • Greater flexibility • Pedicled flap reach limited by stalk • Minimize morbidity • Less likely to sacrifice muscle Why don’t we free flap everything? • Expertise • $$$$$$$ • & • Must respect reconstructive ladder Arterial compromise • WHY? • Kink, clot, twist, hematoma, hypotension, etc • HOW DO YOU KNOW? • • • • • Pale color poor turgor absent cap refill Cool temperature Absent doppler signal Arterial compromise • WHAT DO YOU DO? • Get in your car and go to hospital immediately! • Provide instructions over phone to nursing staff and notify OR • SURGICAL EMERGENCY!!! Venous compromise • WHY? • Kink, clot, twist, hematoma, hypotension, etc • HOW DO YOU KNOW? • Purple, mottled color • Lots of turgor • brisk cap refill • Blood can’t get out • Cool temperature • doppler signal still present!!! Venous compromise/congestion/failure • WHAT DO YOU DO? • Get in your car and go to hospital immediately! • Good physician stuff • • • • • Check vitals Beware constrictive/restrictive dressings Pain control Check medications Check for hematomas • Need to make decision re:OR OR vs Leech Hirudo Medicinalis • Leeches are very small with limited sucking ability • Anticoagulant (hirudin) • Bleeding post leech detachment • Antibiotic prophylaxis (aeromonas hydrophila) • Ciprofloxacin • 3rd gen ceph • Crossmatch for blood Fat Necrosis • Refers to indurated fat in a portion of the free flap • Secondary (?) to partial venous and/or arterial insufficiency • Removal not required • May mimic tumor recurrence! Perforator Flaps • They’re awesome! • Longer vascular pedicle • Less morbidity to patient • The vessels that supply the blood to the flap are isolated perforator(s). These vessels may pass either through or in between the deep tissues (mostly muscle). • ie DIEP; Deep Inferior Epigastric Perforator Artery Flap, ALT (again, my favorite) DIEP vs TRAM • Transverse dissection through abdomen. • TRAM on right and DIEP on left (and below). DIEP/TRAM • Abdomen and breast marked preoperatively. • Height of abdominal skin harvest determined by the amount of laxity. DIEP • Skin incisions made with umbilicus preserved on stalk. DIEP • Flap being elevated DIEP • Perforators are dissected out. • No muscle is sacrificed and innervation is preserved. Medial row Lateral row DIEP • Flap usually elevated on 1 -2 perforators. • Remainder of the perforators are cut and clipped at the level of the fascia. DIEP • Flap of skin and fat is removed with only vascular pedicle attached. • No muscle is sacrificed and innervation is preserved. Recipient Vessels Internal Mammary • Resection of costal cartilage, Sub-periosteal • Rare incidence of pneumothorax. DIEP reconstruction, delayed DIEP reconstruction, immediate Radial Forearm Flap Advantages • Thin, pliable & reliable fasciocutaneous flap • Can harvest simultaneously with tumor excision (two teams ) • Single stage procedure • Long vascular pedicle (radial artery up to 20 cm) • Large caliber vessels • Can be used as a “conduit” for blood of a second flap • The whole volar surface of the forearm can be harvested on the radial artery. • Potential for flap neuroti zation (using MABC or LABC) • Hair-bearing skin can be incorporated • Bone from radius (10-12 cm length, 40% radius) can be incorporated Lower Extremity Reconstruction 3 weeks post ORIF exposed hardware Lower Extremity Reconstruction hardware removal, conversion to external fixator coverage w ith fasciocutaneous ALT flap Lower Extremity Reconstructi on Necrotizing Fasciit is multiple skin graf t attempts debridement & coverage with ALT flap Decompressive craniotomy with necrosis of craniotomy skin flap; reconstruction with ALT free flap
