Advanced Reconstructive Surgery

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1 Advanced Reconstructive Surgery Christopher A. Adin, DVM, DACVS Assistant Professor Small Animal Surgery University of Florida Objectives Know terminology for classification of skin flaps Understand characteristics of axial pattern flaps Know pathophysiology of free skin grafting, principles of application List appropriate skin closure techniques for head/extremity wounds Skin flaps Classification Blood supply Vascularized - Resistance to infection - Any tissue bed - May withstand radiation therapy - Rapid healing (once and done) Non-vascularized - Technically simple, covers large tissue defects - Requires vascular tissue bed - Poor resistance to infection or radiation Skin flaps Classification Vascularized Subdermal (Random) plexus flap - Terminal branches of direct cutaneous arteries - In panniculus and subcutis Skin flaps Classification Vascularized Axial pattern flapssupplied by named direct cutaneous artery/vein - Island arterial flap - Free vascularized skin flap Skin flaps Classification Non-Vascularized (Free skin grafts) Full thickness vs partial thickness Meshed vs non-meshed 1

2 Skin flaps Classification Composition Cutaneous flaps Composite flaps - Myocutaneous - Osteomyocutaneous Skin flaps Classification Location Local flaps- subdermal plexus flaps based on local tissue - Advancement flaps - Rotational flaps Distant flaps- subdermal plexus flaps based on distant tissue - Direct - Indirect Principles Principles Use your hands, use your imagination Steve Swaim, UGA Use the simplest technique possible Steve Swaim, UGA Principles Principles Use the simplest technique possible Steve Swaim, UGA Use the simplest technique possible Steve Swaim, UGA 2

3 Principles Know your anatomy Have multiple plans ready Warn clients of need for revisions Shave and aseptically prepare LARGE areas Options YAWN Are you NUTS?! Primary Closure (+/- tension relieving techniques) Delayed primary closure Secondary closure Walking sutures Local flaps (advancement or rotational) Skin grafts Axial pattern flaps Vascularized free flaps Problem areas Advantages Have defined cutaneous blood supply Radiation/infection resistant Durable, full thickness skin Maintain hair growth Instant closure Disadvantages Don t reach distal extremities, esp. dogs Large donor site closure Variable cosmesis Principles Dissect deep to panniculus or subcutis Trans-illuminate Bridging incision Tacking sutures Closed suction drainage 3

4 Thoracodorsal Flap Anatomic boundaries Thoracodorsal Flap Coverage - Shoulder, axilla, cranial thorax - Extends to MID ANTEBRACHIUM in DOG - Extends to CARPUS in CAT Thoracodorsal Flap Examples 4

5 Caudal Superficial Epigastric Flap Anatomic boundaries Caudal Superficial Epigastric Flap Species differences - Caudal 4 glands (glands #2-5) in dogs - Caudal 3 glands (glands #3-5) in cats Caudal Superficial Epigastric Flap Coverage - Flank, lateral thigh, stifle, inguinal, perineal - Extends to mid tibia in dogs - Extends to hock in cats 5

6 Caudal Superficial Epigastric Flap Examples 6

7 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 7

8 Therapy for questionable flaps Dextrans Vasodilators Leeches Therapy for questionable flaps Types Partial thickness - Higher % survival - Poor hair growth/cosmesis - Require special equip. - Painful/hairless donor site Types Full thickness - No special equipment - Still have good survival - Some hair growth, good durability - Donor site closed/cosmetic Types Meshed - Prevents fluid accumulation - Increases area by up to 3X 8

9 Types Punch grafts Technique Measure defect Technique Harvest donor skin Technique De-fatting graft Technique Meshing Technique Tacking 9

10 Technique Non adherent dressing and bulky bandage Immobilize for 2 weeks Don t peek for 3 days Biology Adherence Plasmatic imbibition Inosculation Penetration and ingrowth Appropriate recipient beds Fresh muscle (fascia removed) Granulation tissue Inappropriate recipient beds Bone Tendon Fascia Infected Irradiated Specialized Skin Lip margin Specialized Skin Foot pads Pad transposition 10

11 Specialized Skin Foot pads Specialized Skin Eyelid Pad transposition Specialized Skin Specialized Skin Eyelid 11

12 12

13 Questions? 13

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