Advanced Reconstructive Surgery

Objectives
Advanced
Reconstructive Surgery
Know terminology for classification of skin flaps
Understand characteristics of axial pattern flaps
Know pathophysiology of free skin grafting, principles
of application
Christopher A. Adin, DVM, DACVS
Assistant Professor
Small Animal Surgery
University of Florida
List appropriate skin closure techniques for
head/extremity wounds
Skin flaps
Skin flaps
Classification
Classification
Blood supply
Vascularized
Vascularized
-
Resistance to infection
-
Any tissue bed
-
May withstand radiation therapy
-
Rapid healing (once and done)
Subdermal (Random)
plexus flap
Non-vascularized
-
Technically simple, covers large tissue defects
-
Requires vascular tissue bed
-
Poor resistance to infection or radiation
Non-Vascularized (Free skin
Axial pattern flapssupplied by named direct
cutaneous artery/vein
Free vascularized skin flap
In panniculus and
subcutis
Classification
Vascularized
-
-
Skin flaps
Classification
Island arterial flap
Terminal branches of
direct cutaneous arteries
Pavletic, Atlas
Skin flaps
-
-
grafts)
Full thickness vs partial
thickness
Meshed vs non-meshed
Pavletic, Atlas
Pavletic, Atlas
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Skin flaps
Skin flaps
Classification
Classification
Location
Composition
Local flaps- subdermal plexus flaps based
on local tissue
Cutaneous flaps
Composite flaps
-
Advancement flaps
-
Rotational flaps
-
Myocutaneous
Distant flaps- subdermal plexus flaps
-
Osteomyocutaneous
based on distant tissue
Pavletic, Atlas
Principles
-
Direct
-
Indirect
Principles
Pavletic, Atlas
“Use your hands, use your imagination…”
“Use the simplest technique possible”
Steve Swaim, UGA
Principles
Steve Swaim, UGA
Principles
“Use the simplest technique possible”
Steve Swaim, UGA
“Use the simplest technique possible”
Steve Swaim, UGA
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Principles
Options
YAWN…
YAWN…
Know your anatomy
Primary Closure (+/- tension relieving techniques)
Delayed primary closure
Secondary closure
Have multiple plans ready
Walking sutures
Local flaps (advancement or rotational)
Warn clients of need for revisions
Skin grafts
Shave and aseptically prepare LARGE areas
Axial pattern flaps
Vascularized free flaps
Are you NUTS?!
Problem areas
Axial Pattern Flaps
Advantages
Have defined cutaneous blood supply
Radiation/infection resistant
Durable, full thickness skin
Maintain hair growth
“Instant” closure
Axial Pattern Flaps
Disadvantages
Axial Pattern Flaps
Principles
Don’t reach distal extremities, esp. dogs
Dissect deep to panniculus or subcutis
Large donor site closure
Trans-illuminate
Variable cosmesis
Bridging incision
Tacking sutures
Closed suction drainage
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Axial Pattern Flaps
Axial Pattern Flaps
Thoracodorsal Flap
Thoracodorsal Flap
Anatomic
Coverage
boundaries
-
Shoulder, axilla, cranial thorax
-
Extends to MID ANTEBRACHIUM in DOG
-
Extends to CARPUS in CAT
Pavletic, Atlas
Axial Pattern Flaps
Axial Pattern Flaps
Thoracodorsal
Flap
Examples
Axial Pattern Flaps
Axial Pattern Flaps
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Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
Caudal Superficial
Epigastric Flap
Anatomic
boundaries
Pavletic, Atlas
Axial Pattern Flaps
Axial Pattern Flaps
Caudal Superficial
Caudal Superficial Epigastric Flap
Epigastric Flap
Coverage
Species differences
-
in dogs
-
-
Flank, lateral thigh, stifle, inguinal, perineal
-
Extends to mid tibia in dogs
-
Extends to hock in cats
Caudal 4 glands (glands #2-5)
Caudal 3 glands (glands #3-5)
in cats
Pavletic, Atlas
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Axial Pattern Flaps
Axial Pattern Flaps
Caudal Superficial Epigastric Flap
Examples
Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
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Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
Axial Pattern Flaps
Viability Assessment
Dyes
-
Fluorescein
-
Disulphine blue
Stab wound analysis
-
PCV >54% (Kerrigan and Daniel, Plastic Recon Surg, 1983)
Visual and tactile changes delayed 4-5 days
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Axial Pattern Flaps
Axial Pattern Flaps
Therapy for questionable flaps
Dextrans
Vasodilators
Leeches
Axial Pattern Flaps
Therapy for questionable flaps
Free Skin Grafts
Types
Partial thickness
Free Skin Grafts
Types
-
Higher % survival
-
Poor hair growth/cosmesis
-
Require special equip.
-
Painful/hairless donor site
Free Skin Grafts
Types
Full thickness
-
No special equipment
-
Still have good survival
-
Some hair growth,
good durability
-
Meshed
-
Prevents fluid accumulation
-
Increases area by up to 3X
Donor site
closed/cosmetic
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Free Skin Grafts
Types
Punch grafts
Free Skin Grafts
Technique
Harvest donor
Free Skin Grafts
Technique
Measure defect
Free Skin Grafts
Technique
De-fatting graft
skin
Free Skin Grafts
Free Skin Grafts
Technique
Technique
Meshing
Tacking
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Free Skin Grafts
Technique
Free Skin Grafts
Biology
Non adherent dressing and bulky
Adherence
bandage
Plasmatic imbibition
Immobilize for 2 weeks
Inosculation
Don’t peek for 3 days
Penetration and ingrowth
Free Skin Grafts
Appropriate recipient beds
Fresh muscle (fascia removed)
Granulation tissue
Free Skin Grafts
Inappropriate recipient beds
Bone
Tendon
Fascia
Infected
Irradiated
Specialized Skin
Lip margin
Specialized Skin
Foot pads
Pad transposition
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Specialized Skin
Foot pads
Specialized Skin
Eyelid
Pad
transposition
Specialized Skin
Specialized Skin
Eyelid
Cases
Cases
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Cases
Cases
Cases
Cases
Cases
Cases
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Cases
Questions?
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