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flaps - WordPress.com
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
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