Chapter 8: Plastic Surgery

Skin Grafting
Local Cutaneous Flaps
Local Muscle and Myocuteneous Flaps
Fasciocutaneous Flaps Microsurgery and Free
Flaps Diagrams of Skin Flaps
 PLASTIC SURGERY

When considering soft tissue reconstruction one always needs to go

through a decision tree in evaluating options from the simplest to
most complex reconstructive technique depending upon the
patient's health, resultant changed biomechanics, and soft tissue
defects location:
1. Allow the soft tissue defect to heal by secondary intention
2. Close the wound primarily
3. Apply a split thickness or full thickness skin graft
4. Use a local fascial, fasciocutaneous, muscle or musclocutaneous flap
5. Use a microvascular free flap transfer

Skin Grafting
1. Definitions:
a. Consists of harvesting epidermis with a varying thickness of
accompanying dermis and placing it on a recipient base.,
b. Split thickness: Includes epidermis and a portion of dermis (the more
dermis included, the thicker the graft)
c. Intermediate split thickness: contain more dermis
d. Thick split thickness grafts: contains most dermis
f. Full thickness grafts: contain all the epidermis and dermis, no fascia or
fat but has the sweat and sebaceous glands
g. Grafts can be autografts (same individual), allografts (same species),
isografts (twins), and xenografts (different species)
h. A free skin graft is completely detached from the body during its
transfer from the donor site

2. Anatomy of skin:
a. The epidermis represents 95% of the skin thickness and dermis 5%
b. The dermis contains sebaceous glands, except in the palms and soles
c. The dermis is principally made up of collagen and elastin
d. The subcutaneous tissue contains the sweat glands and hair follicles
(except in the palms and soles that lack hair)
e. The blood supply arises out of a vascular network that lies on top of
fascia and sends vertical branches up through the subcutaneous tissue and
dermis. The vessels arborize along the way and terminate as capillary buds
between the dermal papillae (the thinner the graft, the more vessels are
transected)

3. Preparation of the recipient site:

a. Must have no infection for a successful graft (a bacterial count of less
than 100,000/gram of tissue) To sterilize a wound:
i. Surgical debridement
ii. Topical Sylvadine for 4-5 days plus IV antibiotics: or
iii. Biological dressings (pig skin or amnionic membranes) plus IV antibiotics
b. Must be well vascularized for a successful graft (pH at 7.4, Tcp 02> 40 mm
Hg and epithelialization at the border)
c. If the wound is fresh then you can graft onto dermis, fat, fascia,
paratenon, or periosteum
d. You cannot graft onto cortical bone or tendon
e. Granulation tissue contains bacteria and must be removed at the time of
grafting
f. Hemorrhage must be controlled
g. Thorough irrigation

4. Split thickness skin graft:

a. The thinner the graft the higher the chances of a successful take, due to
in part to the higher number of transected blood vessels through which
primary revascularization can be established
b. The thinner graft will shrink more at it heals (about 50-70% of its size)
because the decreased amount of dermis is less effective in inhibiting
secondary contraction
c. The thinner the graft the greater the chance for hyperpigmentation
d. The thinner the graft, the more susceptible it is to trauma, because of the
absence of rete pegs and the loss of lubricating sebaceous glands
e. A thin skin graft is usually .012-.013 inches thick
f. Donor site bleeding minimized with topical thrombin or dilute
concentration of epinephrine and dressed with Xeroform or Scarlett Red,
Opsite or Tegaderm, and/or Biobrane (semipermeable dressing)
g. Recipient site bleeding must be controlled (topical thrombin or dilute
epinephrine) and if not place the skin graft back onto the donor site and
return to the OR in 24-48 hours
h. Graft cut with a BrownAire or Zimmer air driven dermatome are reliable
(can be cut by a Humby or Goulian knife by hand but is difficult). For power:
i. Set desired width by using a width guard (either 5 cm, 8 cm, 10 cm)
ii. Set thickness by turning knob (usually .012-.013") and introduce a
#15 scapel blade between the cutting blade and base to check thickness

NOTE* A # 15 scapel blade is the proper thickness of the graft, so by placing this
blade into the dermatome, provides a double-check

i. Meshing the donor graft allows for removal of hematomas or seromas and
increases its size (do not mesh at a ratio greater than 1 1 /2 to 1)
j. Inset the graft using a Stent tie-over dressing (or a bolster dressing). The
bolster is built by first placing Xeroform® on the wound then normal saline
soaked cotton in the center. The nylon suture used at the wound's
periphery are then crossed over and tied to each other, forcing out the
water in the cotton. This allows the graft to conform exactly to the
recipient site
h. The foot and leg should then be placed in a posterior splint to eliminate
movement/shearing
i. Dressing changed in 5-7 days if meshed, and if unmeshed at 48
hours to check for fluid accumulation (if accumulation occurs, it should be
aspirated with a needle
j. The graft on the extremity should be kept elevated for 7-10 days, until
venous circulation is fully established

5. Physiologic phases in skin graft take:

a. Plasmatic imbibation phase during first 48 hours (graft is ischemic at this
time)
b. Inosculatory and capillary growth phase phase starts after 48 hours when
capillary budding from the recipient bed makes contact with the graft.
c. Circulation occurs between the 4th and 7th day

6. Full thickness skin graft:

a. Best donor site for full thickness grafts are the flexor surfaces such as the
groin, anticubital fossa, and popliteal fossa, and then closed primarily, leaving
a linear scar.
b. The length to width ratio of the donor graft should be at least 3-1
c. The donor graft is then sewn into the recipient site
d. Perforations should be made into the donor graft to allow for seroma
removal
e. Revascularization is more tenuous with a full thickness graft than with a
split thickness graft
f. Full thickness graft usually takes primarily, there is no contraction of the
wound, lubrication of the skin is normal, and there is no change in skin
color or texture
g. Neurotization occurs in the following order: pain, light touch, then
temperature
h. Sensory recovery starts at 4 weeks and can take up to 1-2 years

7. Reasons for graft failure:

a. Lack of compression of the graft to the recipient site
b. Movement/shearing
c. Infection (second most common cause)
d. Seroma
e. Hematoma (most common cause)

NOTE* It is important that the pressure on the graft does not exceed 30 mm
Hg or else blood flow to the graft will be compromised

Local Cutaneous Flaps

1. Anatomic principles of skin flaps:
a. It is not the length to width ratio but rather the presence of an artery at
the base of a flap that determines its success. Therefore the preoperative use
of a doppler enables one to determine whether the flow to a particular area of
the foot is antegrade or retrograde (the flow can be redirected due to an
occlusion of either the anterior tibial or posterior tibial artery)
b. A defined area of skin receives blood from 3 sources
i. Cutaneous artery: direct cutaneous arteries run in subcutaneous fat parallel
to the skin, and are usually accompanied by two venae commitantes
(veins that drain the area supplied by the cutaneous artery)
ii. Musculocutaneous artery
iii. Fasciocutaneous arteries
c. The flaps that have a direct blood supply (direct cutaneous artery flaps)
have a larger length to width ratio, than traditional random flaps and can
be used as:
i. Axial pattern flaps (traditional name) and can be used as a pedicle flaps (a
flap dissected free at its base, of most of the tissue surrounding the artery
and veins thus giving the flap added mobility)
ii. An island flap: where the vascular pedicle is dissected completely free for
a certain length and the flap is transferred to a local site separate from the
donor site while the pedicle is buried under intervening tissue
iii. A free flap: where the pedicle is totally detached and then hooked up
by microsurgery to recipient vessels anywhere in the body
d. Musculocutaneous flaps consist of muscle, subcutaneous fat and
skin, with the muscle receiving its blood supply according to one of 5
patterns

NOTE* In the foot it is preferable to harvest the muscle without the overlying
skin paddle as skin graft over the muscle, as the blood supply to the
overlying skin has a very narrow range and can cause significant donor defects if
harvested as a unit

e. The fasciocutaneous system is the chief source of blood supply to the

skin. It arises from a major regional artery as perforators that pass along
the fascia between muscle bellies and then fan out at the level of the
deep fascia (an example is along the long axis of the 3 arteries, posterior
tibial, anterior tibial, and peroneal
i. Example of a faciocutaneous flap of the foot is the medial plantar flap

NOTE* A random flap with is obligate 1:1 length to width ratio in the foot is a
flap based on unknown vascular anatomy. Axial pattern flaps have an
identifiable blood flow at their base and have a length to width ratio
that depends upon the angiotome which the artery serves. These flaps
must be preplanned, and can be extended beyond their angigtomes
using delay principles

2. Local flaps:
a. Local flaps are adjacent to the defect and are either rotated on a pivot
point or are advanced forward from their base to cover a defect. They
include a minimum of the epidermis, dermis and subcutaneous tissue. The
donor site is either closed primarily or skin grafted
b. Flaps that rotate about a pivot point
i. Rotation flap: is designed when a pie shaped triangle defect is created to
remove a lesion or preexistent defect. The flap includes skin and
subcutaneous tissue
ii. Transposition flap: are rectangular in shape with rounded edges and can
be rotated 900
iii. Limberg flap: is a type of transposition flap that depends on the looseness
of the adjacent tissue, and is used when the defect has a rhomboid shape
(angles of 60° and 1200)
iv. Z-plasty is a type of rotation flap that is used to lengthen an existing scar
and to reorient them along lines of minimal tension. The Z-plasty consists of
3 limbs of equal length on the shape of a Z, and the angles between the
limbs can vary from 30° to 900, and the wider the angle the more the
theoretical gain in length

NOTE* Clinically, 60° has been found to be the most useful and yields a theoretical
75% gain in length, however, the actual gain in length is anywhere from 28% to
45% less than calculated. The length of the center of the limb also determines
the amount of length gained, and the longer it is, the larger the gain

v. Interpolation flap: has a soft tissue pedicle with a distal skin island which is
rotated into a defect that is close to but not adjacent to the donor site
vi. Island flap: is a specialized interpolation flap where the only link between
the cutaneous flap and its bed is the neurovascular bundle. This can
be very useful in the foot, as the results are aesthetic, sensate, and
very functional
c. Advancement flaps:
i. Advancement flaps: are moved directly forward to fill a defect without
rotation or lateral movement. A rectangular incision of skin dissected out
and advanced into the defect thereby creating a folding of tissue at both
ends of its base (burrow's triangles), which are removed so that the
skin can be sutured together
ii. V-Y flap: is a V shaped flap whose sides are advanced creating a Y when the
incisions are closed. Can also use a double V to Y flaps when a defect is to
large for one (defects 3-4 cm wide)

Local Muscle and Myocutaneous Flaps

One can transfer simple muscle or muscle with overlying skin to cover a soft
tissue defect. It is critical to know the anatomic blood supply of the muscle
and skin

1. Abductor digiti minimi flap: Is a muscle flap used to fill defects of the lateral
ankle joint or skin

2. Abductor hallucis brevis muscle flap: The medial counterpart of the

abductor digiti minimi. If more bulk is needed it can be harvested with the
medial half of the flexor hallucis brevis muscle

3. Flexor digitorum brevis muscle flap: can only be considered in the well
vascularized non-diabetic foot, as its harvesting may lead to charcot changes
by weaking the midfoot arch
Fasciocutaneous Flaps
These flaps are thin, pliable, and reliable, however, are not as useful as muscle in
treating osteomyelitis because the blood flow per centimeter2 is
3-5 times less

1. Dorsalis pedis flap (direct cutaneous blood supply): Is a direct skin flap in
the foot, can be used as a free flap, its advantage is that it is thin and can be
used as a sensory flap if the superficial nerve is incorporated
a. The potential flap territory overlies the artery
b. It is mandatory to know when using this flap whether the arterial flow is
antegrade or retrograde, which vascular system supplies the first dorsal
metatarsal artery, and whether the anterior branch of the peroneal artery is
dominant (if the distal portion of the flap is supplied by the vascular blood
supply from the sole of the foot, then a delay of that portion of the flap
should be done to avoid distal flap necrosis)
c. Should be only used in well vascularized patients as a 2nd resort because
of donor site morbidity

2. Filet of toe flap (direct cutaneous blood supply): Similar characteristics as

that of the sole of the foot (it is filling and sensate), a toe has to be sacrificed.
It can be rotated locally, or carried with its neurovascular bundle for more
proximal placement

3. Lateral calcaneal artery fasciocutaneous flap (direct cutaneous blood

supply): Derives its blood supply from the calcaneal branch of the peroneal
artery. In order to dissect this flap, it is critical to doppler out the artery along its
full length, and the artery should lie along the mid axis of the flap which
allows for a 8x4cm vertical flap to be harvested. If the viability is
questionable, dissection is stopped and the flap delayed for 5-7 days. It is
best to start with a lateral incision down to the periosteum, and dissect
up in a retrograde fashion

4. Plantar flaps: The blood supply to the sole of the foot is supplied by the
medial and lateral branches of the tibialis posterior artery.
a. Lateral plantar artery flap
b. Medial plantar artery flap: better than the lateral artery flap because it is
based on the less important medial plantar artery and is designed over a
nonweight-bearing portion of the sole, and can include the abductor hallucis
ms. to give the flap extra bulk

Microsurgery and Free Flaps

This has revolutionized the ability to cover soft tissue defects. Can include
fasciocutaneous, musculocutaneous, osteocutaneous, and
osteomusculocutaneous flaps

1. Donor site does not include the foot, and donor site morbidity is minimal
2. The free flap has to have adequate inflow through one of the three distal
arteries (preferably the distal posterior tibial or dorsalis pedis). If adequate flow
does not exist, then revascularization via in-situ by-pass graft is mandatory
first

3. Free flap anastamosis, whenever possible, should always be done end to

side so that the distal flow is not compromised

4. For the dorsum of the foot a fasciocutaneous free flap from either the
parascapular area, the radial forearm, the lateral arm or the temporalis fascia
with STSG (the advantage are that these flaps are thin, have minimum
donor morbidity, and have reliable vascular pedicles

5. The muscle flap for the sole of the foot comes from either the serratus
anterior or gracilis muscle

6. If metatarsals and skin need to be replaced then a osteocutaneous flap

from the contralateral fibula is used, or parascapular osteocutaneous flap

NOTE* The advantage of using vascularized bone is that the risk of infection is
diminished and the bony union is more rapid

Diagrams of Skin Flaps