GENERAL PRINCIPLES

Planning Management

Accurate evaluation of deformity depends

on:

Degree of tissue displacement

Extent of deformity

Functional disability
Ex.: Apparent VS true defect

Aids in planning:

Photographs
X-rays
Inorganic implants

Team approach
Psychiatric evaluation

Regional entities of the face

1. TEMPORAL
2. FRONTAL
3. SUPRAORBITAL
4. ORBITAL
5. AURICULAR
6. INFRAORBITAL
7. ZYGOMATIC
8. NASAL
9. PAROTID-MASSETERIC
10.LABIAL
11.BUCCAL
12.MENTAL

Human proportions of Leonardo Da Vinci

(based on the geometric
proportions of the face
and body that is an
acceptable cultural
standard)

Methods of repair:

Direct closure
Skin grafts
Skin flaps
Inorganic implants

Direct closure elliptical incision

a.
b.
c.
d.
e.

Clean wound
Ragged edges smooth edges
Subq undermining no tension
Fine absorbable dermal or subq sutures
Fine monofilament non-absorbable sutures

*Elective incisions should be made along the lines

of minimal tension
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Skin grafts - Skin which is completely removed

from its donor site and transplanted into a
recipient area
A. Split-Thickness Skin Graft (STSG)
-Epidermis and partial thickness of dermis
-Plasmatic Circulation in the first 48-72 hours
-Take is assured
-Three types: thin=<0.01, moderate=0.0120.018, thick=0.018-0.025
-Contains epidermal appendages that triggers
re-epithelialization
-Source: thigh, buttocks, abdomen
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B. Full-Thickness Skin Grafts (FTSG)

-Full thickness of epidermis and dermis
-Donor sites closed primarily
-Contains hair follicles that may grow in
recipient sites
-Contracts less than STSG
-Remove fat to ensure Take
-Source: upper eyelid, post-auricular area,
flank, groin, arm, wrist (flexor areas)
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C. Composite Grafts
-Skin + other tissues e.g. subq, cartilage, bone,
conjunctiva,
-Source: nose, eyelid, ear, scalp
-Maximum size: 1 cm all around

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Care of a Skin Graft

A. Donor Area (Proper Color Match)
-For STSGNo infection
Cover with gauze and allow
to dry
Source again after 10-14days
-For FTSG Direct closure
No hematoma
B.
Recipient Site
-No infection
-Good granular tissue (bright pink,
bleeds easily)
C. Tie-over Bolus Dressing
-Pressure
-Immobilization

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SKIN FLAPS
composite of skin and subQ tissue with a
pedicle that is transferred from a donor to a
recipient site
Vascular Anatomy:
MUSCULOCUTANEOUS
Segmental vessels muscle perforators
Skin perforators

DIRECT CUTANEOUS
segmental vessels skin perforators

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Flap Classification:

AXIAL PATTERN FLAP

RANDOM PATTERN FLAP

Contains at least 1 AV systemno AV system; subject to L:W ratio

Delays, Age
Ex. Superficial Temporal Flap
Ex. Cross Leg Flap

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KINDS OF FLAPS:
1. V-Y ADVANCEMENT FLAP
- obtains small amounts of length
2. Z-PLASTY
Advantages:
- lengthens a scar contracture
-disperses a scar
- realigns a scar
Disadvantages
- elongates a scar excessively
- enlarges the area it occupies
CLASSICALLY: TWO TRIANGULAR FLAPS OF SKIN AND SUBQ
TISSUE OF EQUAL SIZE, DELIMITED BY THREE INCISIONS OF
EQUAL LENGTH, CUT AT A 60 DEGREE ANGLE.
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3. ROTATION FLAPS
- semicircular, and adjacent to the defect
- rotated around on a fixed pivot point

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4. ADVANCEMENT FLAPS
- only for areas with excess skin
- place flap under tension, release later
after the flap has vascularized
5. TRANSPOSITION FLAPS
- transfer tissues on a different plane from that
of defect, thru an angle

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5. TRANSPOSITION FLAPS
- transfer tissues on a different plane from that
of defect, thru an angle

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6. BIPEDICLE FLAPS

- advancement flaps with 2 pedicles

7. INTERPOLATION FLAPS
- local flaps that require wide undermining
8. BILOBED FLAPS
- only for small defects
- eliminates the need to graft donor site

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7. INTERPOLATION FLAPS
- local flaps that require wide undermining
8. BILOBED FLAPS
- only for small defects
- eliminates the need to graft donor site

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8. BILOBED FLAPS
- only for small defects
- eliminates the need to graft donor site

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9. ISLAND FLAP
- skin, subQ, and direct cutaneous A&V
10. MICROVASCULAR FLAP
- completely remove skin, subQ, muscle, bone,
with at least one artery and two veins; transport to
a distant recipient site and reconnect all

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11. DISTANT FLAPS, JUMP FLAPS, TUBE FLAPS,

WALTZING LAPS
- flap from a distant site is attached to a
carrier then transferred from the carrier to
recipient site.

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SCARS
Factors that affect scar formation:
1. amount of scar tissue

p/a of hematoma and/or infection

age/sex

site of injury
2. tension lines of skin surface
3. position of scar in relation to the joint
4. shape of a scar
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KELOIDS
abnormal proliferation of fibrous tissue in the
dermis characterized by:
- elevation and extension laterally
into surrounding normal tissue
- has continued growth and absent
significant regression
- has a profound tendency to recur
after excision
- tends to grow along skin lines
- has a genetic/racial predisposition
- predilection areas: upper half of the
body with head, neck, shoulders and arm as
common sites
- TX: pressure, steroids

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HYPERTROPHIC SCARS:
- does not exceed original wound dimensions
- never becomes distorted but is uniformly
raised and wide
- only the rate of collagen production exceeds
its absorption

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