Flaps vs Grafts. Ronen Avram, MD MSc FRCSC

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1 Flaps vs Grafts Ronen Avram, MD MSc FRCSC

2 POS Keratoacanthoma is not a malignant tumor!

3 Methods of Reconstruction Reconstructive Ladder Primary closure Primary Delayed Secondary Intention Skin Graft Pedicled flap Local vs distant Free tissue transfer Muscle vs fasciocutaneous

4 Skin Graft Very, very thin tissue composed of epidermis and variable amounts of dermis Split thickness Full thickness Meshed vs sheet grafts 12.jpg

5 Skin Graft Split thickness Full thickness Entire thickness of skin

6 Skin Graft

7 Split thickness, meshed graft

8 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).

9 Skin Graft We re gonna make it to the other side! Woohoo!!! WOUND SURFACE Diffusion across wound surface

10 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

11 Avoid skin grafts Major vessels (ie. femoral vessels) blowout Major organs ie. bowel Radiated tissues

12 Do not skin graft. Bone Bare tendon

13 Full thickness burns bilateral legs

14 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!)

15 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

16 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

17 Pedicled flaps

18 Pedicled Flaps LOCAL vs DISTANT ie. Random pattern flaps ie. TRAM, Pec Major & Deltopectoral (H&N recon), groin flap

19 Pedicled flaps Random pattern flaps Advancement flaps Sometimes just a bunch of undermining Transposition flaps Limburg/rhomboid flaps Rotation flaps

20 Advancement flaps

21 Advancement flaps V-Y (pronounced vee-why)

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24 Transposition flaps the numbers. Dufourmentel b b 60 b a c 120 b a a c c

25 Transposition Flaps 120

26 Transposition flaps more numbers Respect length (Y) to width (X) ratios 2:1 Y should be no more than twice X 3:1 (Head & Neck) X Y

27 Rotation flaps

28 Rotation Flaps X 5-6X

29 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

30 Forehead Flap Supratrochlear/supraorbital arteries

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32 What about free flaps? Free flaps are like regular pedicled flaps but they don t cost anything!!!

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35 Why is the blood supply reconnected? What about osmosis? Skin graft Free Flap Limited penetration

36 Forget Osmosis! Think ANASTOMOSIS Donor site (site of wound) Free Flap

37 ANASTOMOSIS

38 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!)

39 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.

40 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

41 Are free flaps better? Not necessarily but Greater flexibility Pedicled flap reach limited by stalk Minimize morbidity Less likely to sacrifice muscle

42 Why don t we free flap everything? Expertise $$$$$$$ & Must respect reconstructive ladder

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44 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

45 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!!!

46 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!!!

47 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

48 OR vs Leech

49 Hirudo Medicinalis Leeches are very small with limited sucking ability Anticoagulant (hirudin) Bleeding post leech detachment Antibiotic prophylaxis (aeromonas hydrophila) Ciprofloxacin 3 rd gen ceph Crossmatch for blood

50 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!

51 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)

52 DIEP vs TRAM Transverse dissection through abdomen. TRAM on right and DIEP on left (and below).

53 DIEP/TRAM Abdomen and breast marked preoperatively. Height of abdominal skin harvest determined by the amount of laxity.

54 DIEP Skin incisions made with umbilicus preserved on stalk.

55 DIEP Flap being elevated

56 DIEP Perforators are dissected out. No muscle is sacrificed and innervation is preserved. Medial row Lateral row

57 DIEP Flap usually elevated on 1-2 perforators. Remainder of the perforators are cut and clipped at the level of the fascia.

58 DIEP Flap of skin and fat is removed with only vascular pedicle attached. No muscle is sacrificed and innervation is preserved.

59 Recipient Vessels Internal Mammary Resection of costal cartilage, Sub-periosteal Rare incidence of pneumothorax.

60 DIEP reconstruction, delayed

61 DIEP reconstruction, immediate

62 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 neurotization (using MABC or LABC) Hair-bearing skin can be incorporated Bone from radius (10-12 cm length, 40% radius) can be incorporated

63 Lower Extremity Reconstruction 3 weeks post ORIF exposed hardware

64 Lower Extremity Reconstruction hardware removal, conversion to external fixator coverage w ith fasciocutaneous ALT flap

65 Lower Extremity Reconstructi on Necrotizing Fasciit is multiple skin graf t attempts debridement & coverage with ALT flap

66 Decompressive craniotomy with necrosis of craniotomy skin flap; reconstruction with ALT free flap