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FREE TISSUE
TRANSFER
• Description of Plastic Surgery
• Reconstruction Ladder
REGIONAL
FLAPS
LOCAL FLAPS
SKIN GRAFTS
• Recontruction Triangle
• Analysis of the defect and problem
• Selection of the best method
• Reconstruction Method
PRIMARY
CLOSURE
SECONDARY
HEALING
Monday 23 March 15
• Sample of Cases
• Originally derived from the Greek “plastikos”
– to mold and reshape
• Plastic Surgery is a specialty
– adapts surgical principles and thought
processes to the unique needs of each
individual patient by remolding, reshaping and
manipulating bone, cartilage and all soft
tissues.
• Plastic Surgery is NOT concerned with a
– given organ system
– region of the body
– age group
Monday 23 March 15
• Plastic Surgery
– the solution of difficult wound healing and
surgical problems
• Plastic Surgery
– restoration or creation
• the best function
• form and structure of the body with a superior
aesthetic appearance
– ultimately enhancing
• a patients quality of life
Monday 23 March 15
• the importance of treating the patient as a
whole
– plastic surgeons are concerned with the effect
of the outcome on the entire patient
• The challenge of plastic surgery
– the combination of the surgeon’s judgment and
problem solving abilities with surgical
technique at any given moment
• Plastic surgeon often acts as a
• “last resort” surgical consultant
• “the surgeon’s surgeon.”
Monday 23 March 15
• The American Board of Plastic Surgery
– the specialty of plastic surgery deals with the
repair, replacement, and reconstruction of
physical defects of form or function involving
the skin, musculoskeletal system,
craniomaxillofacial structures, hand,
extremities, breast and trunk, and external
genitalia.
Monday 23 March 15
• the scope of the operations performed by
plastic surgeons is broad
– Defects of the body surface
• from injuries, previous surgical treatment, or
congenital deformities
– Congenital anomalies
– Craniofacial surgery
– Hand surgery
– Microvascular
– Cosmetic surgery
Monday 23 March 15
Monday 23 March 15
Plastic, Reconstructive and Aesthetic Surgery
Monday 23 March 15
Plastic, Reconstructive and Aesthetic Surgery
PLASTIC SURGERY
Monday 23 March 15
Plastic, Reconstructive and Aesthetic Surgery
PLASTIC SURGERY
Reconstructive
Monday 23 March 15
Aesthetic
plastıc surgery
•
Reconstruction
•
Monday 23 March 15
After being damaged, to form an
mold the thing by getting piece and
materials together
PLASTIC SURGERY
Surgical Principles
Thinking/Planning
METHOD
SELECTION
Meet the patient and region spesific
needs
Monday 23 March 15
PLASTİK CERRAHİ
•
TEMEL PRENSİPLER
•
DÜŞÜNCE/PLANLAMA SÜRECİ
•
UYGULAMA
•
Innovasyon
•
Standart ya da tam kabul edilmiş çözümü olmayan
sorunların çözümü
•
Monday 23 March 15
Mevcut çözümden daha iyi bir sonuç elde edebilmek
FREE TISSUE
TRANSFER
REGIONAL
FLAPS
LOCAL FLAPS
SKIN GRAFTS
PRIMARY
CLOSURE
SECONDARY
HEALING
Monday 23 March 15
FREE TISSUE
TRANSFER
ON
TI
NC
FU
LOCAL FLAPS
FO
RM
REGIONAL
FLAPS
SKIN GRAFTS
SAFETY
PRIMARY
CLOSURE
SECONDARY
HEALING
Monday 23 March 15
FREE TISSUE
TRANSFER
DEFECT
REGIONAL
FLAPS
LOCAL FLAPS
PLASTIC
SURGEON
•ETIOLOGY
•ANATOMIC REGION
•Function
•Aesthetic
•Blood flow
•Type of tissue
•SIZE OF DEFECT
KNOWLEDGE
EXPERIENCE
ENVIROMENT
SKIN GRAFTS
PRIMARY
CLOSURE
SECONDARY
HEALING
Monday 23 March 15
PATIENT
•AGE/SEX
•CO-MORBİDİTİES
•JOB
•SOCIAL STATUS
•EXPECTATIONS
DEFECT
RESULTS
PLASTIC
SURGEON
PATIENT
Monday 23 March 15
•ETIOLOGY
•ANATOMIC REGION
•Function
•Aesthetic
•Blood flow
•Type of tissue
•SIZE OF DEFECT
KNOWLEDGE
EXPERIENCE
ENVIROMENT
•AGE/SEX
•CO-MORBİDİTİES
•JOB
•SOCIAL STATUS
•EXPECTATIONS
• SECONDARY HEALING
SERBEST
DOKU
– wound left open to heal spontaneously
– maintained in inflammatory phase until wound
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
closed
• Spontaneous wound closure depends on
– contraction and epithelialization
• Contraction results from centripetal force in
wound margin probably provided by
– myofibroblasts
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
• Epithelialization proceeds from wound
margins towards center at 1 mm/day
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
• Although contraction (the process of
contracting) is normal in wound healing, one
must beware of contracture
– contraction of scar and is a pathological
deformity
• Secondary healing beneficial in some
wounds
–
–
–
–
–
Perineum
Heavily contaminated wounds
Scalp
Finger tip
Nasal Tip
• Primary Healing
SERBEST
DOKU
BÖLGESEL
DOKU
– wound closure by direct approximation,
• Debridement of non-viable tissue and
irrigation of the wound can minimize
– inflammation which will facilitate the healing
process
• Dermis
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
– should be accurately approximated with
sutures
– is the strength layer of the wound repair
– skin glue
• if the wound is limited to partial thickness
depth
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
• Scar may be
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
– red
– raised,
– pruritic at peak of collagen synthesis
• Thinning, flattening and blanching of scar
occurs
– over approximately 9-12 months in
• Final result of scar depends
– largely on how the dermis was approximated
– can be influenced by tension of the closure,
location and presence or absence of
complicating environmental factors
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
• FACTORS INFLUENCING WOUND
HEALING
• Local factors MOST IMPORTANT because
we can control them
– Tissue trauma - must be kept at a
minimum
– Hematoma - associated with higher
infection rate
– Blood supply
– Temperature
– Infection
– Technique and suture materials
• ONLY IMPORTANT when factors 1-5 have
been controlled
• GENERAL FACTORS
SERBEST
DOKU
BÖLGESEL
DOKU
• Can not be readily controlled by surgeon
– Systemic effects of steroids
– nutrition
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
– chemotherapy
– chronic illness, etc.,
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
•LANGER’S LINES
SERBEST
DOKU
•Natural lines of skin tension
•Perpendicular to the long axis of mimetic
BÖLGESEL
DOKU
muscles
•To minimize visible scar, elective incisions
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
are least noticeable when placed parallel
•Two advantages:
•the scar is parallel or within a natural
skin crease, which camouflages the scar
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
•the location places the least amount of
tension on the wound.
22
Monday 23 March 15
• SKIN GRAFTS
SERBEST
DOKU
BÖLGESEL
DOKU
– harvested from a donor site and
transferred to the recipient site without
carrying its own blood supply
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
– It relies on new blood vessels from the
recipient site bed to be generated
• ENDİKASYONLAR
SERBEST
DOKU
– Primer kapatılamayan travmatik yaralar
– Onkolojik rezeksiyon sonrası defektler
BÖLGESEL
DOKU
– Yanık rekonstrüksiyonu
– Skar kontraktürü serbestleştirilmesi
– Doğumsal deri eksiklikleri
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
• Sindaktili
• BAŞARISIZLIK NEDENLERİ
– Avasküler alıcı yatak
– İnfeksiyon
– Hematom
PRİMER SÜTÜR
– Seroma
– Sıyrılma
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
• FLAPS
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
F
L
E
P
L
E
R
– Flaps are elevated from a donor site and
transferred to the recipient site with an intact
vascular supply.
– Flaps can be used when the wound bed is
unable to support a skin graft or when a more
complex reconstruction is needed.
26
Monday 23 March 15
• Px
– Age: 67
– Co-Morbidities
• None
• Disease
– Trikolemmal Ca.
– Defect after resection
• Whole occipital region
• Depth
– CT: No bone invasion but near to bone
• Anatomical Features
– Touch area
• Postop. RT
• High Probability
Monday 23 March 15
• Decision porcess to closure
– Skin Grafting
•
•
•
•
Not appropriate
Calvarial bone without periosteum
Touch surface when lying down
RT
– Local Flaps
• Large transpositon flap
– Seems o.k. But not the best
– Kept in mind as plan B
– Regional Flap
• Trapez Skin-Muscle Flap
– Free Flap
• Plan C
Monday 23 March 15
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
• SERBEST FLEP
F
L
E
P
L
E
R
-
1552 Pare
Vasküler onarım yapılabilir
-
1759 Hallowell Brachial arter onarımı
-
1897 Murphy İlk vasküler anastomoz tarifi
-
1964 Malt İlk klinik mikrocerrahi uygulama
Kol replantasyonu
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
-
1965 Tamai İlk Parmak replantasyonu
-
1970 Buncke Serbest omentum ile scalp
-
1973 Daniel ve Taylor kasık flebi
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
• SERBEST FLEP
F
L
E
P
L
E
R
– Lokal ya da bölgesel fleplerin
kullanılamadığı durumlar
• Enfeksiyon
• Enflamasyon
• Radyoterapi
• Yetersiz doku
DERİ GREFTLERİ
• Yetersiz pedikül uzunluğu
• Yetersiz rotasyon arkı
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15
• Kabul edilemez verici alan morbiditesi
• FREE FLAPS
SERBEST
DOKU
BÖLGESEL
DOKU
LOKAL DOKU
AKTARIMLARI
F
L
E
P
L
E
R
– detached at the vascular pedicle and
transferred from the donor site to the
recipient site.
– They require re-anastamosis of the
artery and vein to recipient vessels at
the recipient site.
DERİ GREFTLERİ
PRİMER SÜTÜR
SEKONDER
İYİLEŞTİRME
Monday 23 March 15