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Planning is of the essence: a summary of reconstructive surgery techniques (Part 2)
Take a trip through the centuries and the evolution of surgical techniques to the life-giving work of today’s plastic and reconstructive surgeons (Part 2).
Read Part 1 of a summary of reconstructive surgery techniques here.
Transposition flaps
The classical transposition flap is rectangular and moves around a pivot point laterally to repair the defect.
More mobility to the flap can be obtained through a back cut at its base, moving the pivot point. This procedure reduces the width of the base of the flap and therefore reduces its blood supply. Not infrequently a skin graft is required to repair the donor defect.
Caption for top image: Plastic surgeon's stainless steel Watson skin graft knife. Private collection, Auckland. Photography: Ellen Smith.
Triangular flaps that transpose, advance and interdigitate
This involves the transposition and advancement of two interdigitating triangular flaps. This increases the length of one axis at the expense of shortening the other.
The Z-Plasty is pictured adjacent.
Hinge flaps
The flap is raised on its pedicle and turned through between 90 and 180 degrees, like the page in a book. It is particularly useful in creating an epithelial lining in nasal reconstruction. Once the lining has been restored another flap is required to cover the original flap donor site.
Skin grafting
Skin grafting is the transfer of cutaneous tissue from one portion of the body to another. Grafts are often used to cover large wounds. The rationale of skin grafts is to take skin from a donor site that will heal and transfer the skin to an area of need. Most importantly to survive, the graft must obtain a blood supply from its recipient site.
In 1869, Jaques-Louis Reverdin, a Swiss surgeon, presented a successful experiment of free skin grafting. By using the tip of a lancet, he harvested small pieces of skin from the arm of the patient and fixed them into the middle of the wound with a tented bandage. Today the procedure is known as “Pinch Grafting”. But Reverdin originally described these as epidermal grafts. Some years later he indicated that the graft had dermis in it as well.
Initially a piece of skin was pulled upwards (tented) with a pair of toothed forceps.The raised skin was then excised parallel with the adjacent skin.
This technique was used over many years. It left an unsightly donor site of rows of circular scar tissue. Various instruments have been designed to harvest this form of skin graft.
Split thickness skin grafts
Skin grafts, or ‘free’ skin grafts, refer to the pieces of skin that are removed from their original location and separated from their blood supply to be transferred to another region of the body. As the skin is completely removed from the donor site, free skin grafts are dependent on their survival in obtaining a blood supply from a new location.
A split thickness skin graft contains the epidermis and part of the dermis. The donor site will heal over 10 to 14 days, based on the remaining skin appendages in the dermis.
The earliest known split-thickness skin grafting method was developed by Ollier in 1872. His results revealed not only faster healing but also less scar formation. By covering the whole wound surface with skin grafts there was less scar contracture. Since these grafts included epidermis as well parts of the dermis, Ollier called his technique “dermo-epidermic grafting” Prof. Carl Thiersch, chairman of the surgery department in Leipzig, presented his technique at the 15th Congress of German Surgical Association in 1886 His technique advised to cut the skin with a razor blade as thin as possible via sharp horizontal incisions to produce thin strips of epidermis, only including small parts of dermis Thiersch’s technique obtained national publicity, which is known as “Thiersch Graft”. Caused by the similarity of both discoveries, the method is also known as “Ollier–Thiersch graft”.
Experienced plastic surgeons can remove grafts freehand and can control the depth by varying the angle of the knife in relation to the skin. Large grafts from the inner or back of the thigh could be obtained. Various modifications were made to this knife, but the essential parts were the blade, and the handle being balanced for ease of use.
The next great advance to the skin grafting knife was the addition of a roller. This was popularised by Graham Humby. The distance between roller and blade could be adjusted to the required thickness of the skin graft by calibration devices. This led to similar instruments being named the Humby skin grafting knife.
Experienced plastic surgeons can remove grafts freehand and can control the depth by varying the angle of the knife in relation to the skin. Large grafts from the inner or back of the thigh can be obtained.