Plastic & Reconstructive Surgery for defects: features & monitoring.

Jan J.Vranckx Plastic & Reconstructive Surgery UZ-Gasthuisberg, g KULeuven

Plastic & Reconstructive Surgery

Defects caused by trauma, burns, excision of tumors, congenital deformities, Composite defects composed of skin,dermis,SC,muscle, bone,cartilage, tendon, nerves, bloodvessels,hair,nails

Plastic & Reconstructive Surgery

Function : motor function, sensation Esthetical outcome : social reintegration Donor site morbidity : Rob Peter to pay Paul ?

Analysis of the defect

Features F of f the h recipient i i site: i

defect size, defect volume, tissue quality (zone of injury,irradiation, osteomyelitis)location recipient vessels

The donor tissue requirements

Tissue bulk bulk, Size Size,pedicle pedicle length

The analysis of a defect: Reconstructive Ladder

.

Cost-benefit of the option selected.

Primary suture Ski graft Skin ft Local flap Locoregional flap free tissue transfer

The analysis of a defect: Reconstructive Ladder

Cost-benefit of the option selected.

Primary suture Ski graft Skin ft Local flap Locoregional flap free tissue transfer

Perforators to the skin paddle

FC & MC & OC flaps

Muscle & MC flaps

1L 1-Locoregional i l flaps fl

Local flaps ( random or axial)

Small to medium sized defects Cave texture,color,skin creases,

Locoregional flaps
Skinflaps & Galea flap for reconstruction of scalp & face. C i f i l flaps Cervicofacial fl for f large l defects d f on the h (medial) ( di l) face f

Locoregional flaps
-Temporal Fascia/ muscle for nVII static/dynamic reconstr. -Trapezius,Pectoralis T i P li Major, M j LDF for f defects d f in i the h face f

Muscle flaps for bulk and vascularization

Latissimus Dorsi ( as free or pedicled muscle flap or MC flap)

Gastrocnemius:proximal third

JJ.Vranckx, Wondhelings Symposium

 pedicle di l concept t for f vascularization l i ti of f areola l

L Locoregional i l flaps: fl facts f t

- Blood Bl d vessel l pedicle di l remains i intact. i t t - Vascularization usually stable - Monitoring by checking capillary refill ( when cutaneous paddle) - Turgor, filling and color for muscle flaps - Doppler over pedicle: useful nb. beware of random underlying vessels ( Head & Neck !!!)

2 free 2free tissue transplantation transplantation free flaps & microsurgery

Free flaps & Microsurgery

-cost-benefit analysis of the defect and donor tissues:

what was function of the missing tissues ? what are the expectations for donor tissues ? reoperation on same site required ?

-Thus : which are best donor tissues ? -What W is the donor site morbidity y with those options p ?

1-Lower extremity reconstruction

- Lower third LL: defect usually more superficial - muscle flaps ( LDF, gracilis, VL)

Vranckx J.J., J J Van den hof B., B et al. al J. Reconstr.Microsurgery 20; 29-34, 2004.

-Proximal 1/3 LL : defect bulky : FC or MC flaps -Anterolateral thigh, MC gracilis, MC LDF

- Heel defects : pressure & volume requires skin paddle = large defects : require muscle + STG

2- Head & neck defect reconstruction

- tumor resection: soft tissues : - thin lining intra-orally : RFA, ALT - when bone invasion : vascularised bone: fibula + skin ; iliac crest + skin cave: recipient vessels for microsurgery ? due to radiotherapy py or earlier interventions when recidive ( neck dissections)
.

M l used Mostly d : radial di l forearm f flap fl

but: donor site morbidity !!

Vranckx JJ. et al. Microsurgery 20; 290,2000.

Donor site morbidity !!!

Tissue of choice for inner lining

Radial forearm fascia flap

A t i trachea Anterior t h reconstructions t ti with ith prelaminated flaps p p

Cutaneous Monitor

Combined RFA flaps

hypopharynx
Gastric Pull-up, RFA flap, Rectus Abdominis MC Flap, J j Jejunum fl flap + patch t h

Conclusie
Gesteelde flap of vrije flap met huideiland = fascio-cutane of musculo-cutane of osteo-cutane flap of osteomyo-cutaan p refill, kleur, vulling g (turgor) ( g ) capillaire hoogstand ter preventie van veneuze stase geen aangespannen circulaire verbanden warmte voor vasodilatatie

Monitoring
vrije j flap p zonder huideiland in de diepte p = bv. jejunum flap voor hypopharynx, radialis fascia flap op/rond trachea Doppler ; opgepast in hoofd/hals gebied monitor eilandje : capillaire refill, kleur

Jan.vranckx@uz.kuleuven.ac.be