SPECIALITY SURGERY ## Graft ### Split thickness skin graft (STSG) * **Donor site** * AKA Thiersch graft * Epidermis & part of dermis taken * m/c donor sites: * Anterolateral thigh * Buttocks * Only dressing done for donor site after harvesting graft * Donor site can be reused * **Recipient site** * Secondary contracture: Occurs when graft has been placed on the recipient bed * Better survival of graft ### Full thickness skin graft (FTSG) * **Donor site** * AKA Wolfe graft * Epidermis & whole dermis taken * m/c sites: * Post auricular skin * Supra/infraclavicular skin * Donor site sutured after harvesting graft * Donor site cannot be reused * **Recipient site** * Primary contracture: * Occurs immediately after harvesting graft * Depends on dermis * Cosmetically better * More resistant to trauma ### Images and Descriptions * **Image:** Humby's knife * **Image:** STSG: Punctate hemorrhages * **Image:** Healed STSG donor site * **Image:** FTSG (showing a full-thickness skin graft procedure) * **Image:** Meshing of STSG * **Description:** * Increases surface area of graft * Prevents hematoma formation * **Diagram (a):** Shows a skin graft being passed through a meshing device. * **Diagram (b):** Shows the meshing device. * **Diagram (c):** Shows the appearance of a meshed skin graft. * **Diagram (d):** Shows the meshed graft applied to a wound. ### Graft Survival: methods 1. Imbibition: 1 - 2 days. 2. Inosculation: 2-4 days (Graft draws nutrients by giving out buds). 3. Neovascularization: >4 days (Anastomosis of graft & recipient). ### Causes of graft failure: 1. Seroma/hematoma formation (m/c). 2. Infection. 3. Movement/shearing force. 4. Poor recipient bed: * Excessive granulation tissue. * Lack of periosteum. * Infected recipient bed. * **Image:** Graft failure ## Flaps Flap has independent blood supply. ### Random Flaps: * Based on dermal vessels. * e.g : V-Y plasty/Z-plasty. * Elongation of wound. * Helps in post burn contractures. ### Diagram: Z-plasty * **Description:** Shows three variations of Z-plasty incisions: 30° angle, 45° angle, and 60° angle. A downward arrow indicates the resulting scar shape after transposition of the flaps. * **Associated text:** * 30° angle Z-plasty with bidirectional arrow pointing to 25% length gain * 45° angle Z-plasty with bidirectional arrow pointing to 50% length gain * 60° angle Z-plasty with bidirectional arrow pointing to 75% length gain (with a 90° angle shown at the central limb post-transposition) ### Diagram: V-Y plasty * **Description:** Shows a series of three diagrams illustrating the V-Y plasty technique for wound closure or lengthening. The first diagram (top) shows a V-shaped incision. The second diagram (middle) shows the flap advanced. The third diagram (bottom) shows the wound closed in a Y-shape. ### Rhomboid/Limberg flap: * Type of random flap. * Used in pilonidal sinus. * **Image:** Rhomboid flap (showing before and after a rhomboid flap procedure) ### Axial Flap: Based on known blood vessels. 1. Deltopectoral flap: Floor of mouth reconstruction * **Image:** Deltopectoral flap 2. PMMC: Pectoralis major myocutaneous flap, m/c used in head & neck surgery * **Image:** PMMC flap markings 3. Abbe Estlander flap: Angle of mouth & lip reconstruction * **Image:** Abbe Estlander flap 4. Latissimus dorsi flap: Based on thoracodorsal pedicle * **Image:** Latissimus dorsi flap markings and post-operative appearance ### Abdominal Flaps: 1. TRAM: Transversus rectus abdominis myocutaneous flap. * Muscle used for flap with bidirectional arrow pointing to Increased risk of incisional hernias * **Image:** TRAM flap pre-operative markings 2. DIEP: Deep inferior epigastric artery perforator flap * Only skin + fat with bidirectional arrow pointing to No abdominal wall weakness. * Best flap for breast reconstruction. * **Image:** DIEP flap markings and intra-operative view ### Free Flap: Disconnected from donor site with bidirectional arrow pointing to Anastomosed at recipient site. 1. Radial artery forearm flap: * Used for head & neck surgery. * Prior test: modified Allen's test. * **Image:** Radial artery forearm flap harvest 2. Free fibular flap: * Based on peroneal vessels. * Use: mandibular reconstruction. * **Diagram:** Anatomy of the lower leg showing the anterior tibial artery, popliteal artery, peroneal artery, and muscle cuff, relevant to a free fibular flap. ### Mathes and Nahai Classification for Axial Flaps: * **Mathes and Nahai Type I** * Dominant pedicle: 1 * Minor pedicle: - * Muscle: * Gastrocnemius * Rectus femoris * Tensor fascia lata * **Mathes and Nahai Type V** * Dominant pedicle: 1 * Minor pedicle: multiple * Muscle: * Pectoralis major * Latissimus dorsi ### Flap Failure: D/t vessel blockade. * **Indicator: Temperature** * Arterial block: Cold * Venous block: Warm * **Indicator: Color** * Arterial block: Pale * Venous block: Congested * **Indicator: Capillary refill** * Arterial block: Reduced * Venous block: Quick * **Indicator: Pinprick** * Arterial block: Downward arrow Blood flow (Decreased Blood flow) * Venous block: Upward arrow Blood flow (Increased Blood flow) * **Image:** Breast flap failure/////////new page//////-**VASCULAR SURGERY** **Acute Arterial Occlusion** * **Features:** * Most common cause: Embolus (most common source leads to Heart). * History of ischemic heart disease; History of Atrial Fibrillation (Irregularly irregular heart beat). * **Clinical Features (6Ps):** * Pain * Pallor * Paresthesia * Poikilothermia (Cold limbs) * Pulselessness * Paresis/paralysis (Late signs) * **Management:** * Investigation of Choice (IOC): Doppler/Duplex Scan. * Treatment (Rx): Patient presented within 6-8 hours: * **If Yes (presented within 6-8 hours):** 1. Embolectomy using Fogarty's balloon. * Complication: Reperfusion injury. * Leads to: Muscle swelling. * Leads to: Fasciotomy. * **If No (presented Late):** 1. Gangrene (+). 2. Leads to: Amputation. * **Diagram Descriptions:** * Diagram illustrating acute arterial embolus shows no collaterals. * Image showing a Fogarty's balloon. * Image showing an embolectomy angiogram demonstrating revascularization. **Chronic Arterial Occlusion** * **Features:** * Gradual occlusion (Due to thrombus) leads to Formation of collaterals. * **Clinical Features:** * Intermittent claudication leads to Cramping pain. * Rest pain (leads to Progressive pain). * Gangrene (leads to Progressive pain). * **Diagram Description:** * Diagram illustrating chronic arterial occlusion shows formation of collaterals. **Differentials** * **Intermittent claudication:** * Cramping pain after walking a certain distance. * Pain is one level below site of occlusion. * Due to substance P. * Progresses to rest pain. * **Osteoarthritis:** * Maximum pain on first step. * Pain in affected joint. * **Neurogenic claudication:** * Pain varies with posture: * Bending forward: Relieved. * Standing straight: Aggravated. * Due to lumbar canal stenosis. **Boyd's Classification** * **Class 1:** Pain on walking, which reduces as patient continues to walk. * **Class 2:** Pain on walking; patient is able to walk despite pain. * **Class 3:** Pain forces patient to stop. * **Class 4:** Pain at rest. **Site of Obstruction** * **1. Aortoiliac:** * Buttock claudication (Earliest). * Pain in thigh & calves. * Bruit over aortoiliac region. * Impotence in males (Leriche Syndrome). * **2. Iliac:** Thigh pain. * **3. Femoropopliteal:** Calf pain. * **4. Distal obstruction:** Ankle pain. **Investigations** * **Investigation of Choice (IOC):** Doppler or Duplex (Doppler + B-mode USG) scan. * **Ankle Brachial Pressure Index (ABPI):** * Formula: ABPI = Maximum systolic BP at ankle / Maximum systolic BP at brachial artery * **ABPI Values and Inference:** * Value: > 1.4; Inference: Calcified vessels (Diabetes Mellitus/Chronic Kidney Disease). * Value: 0.9 – 1.4; Inference: Normal. * Value: < 0.9; Inference: Intermittent claudication. * Value: < 0.4; Inference: Chronic Limb-Threatening Ischemia (CLTI). * Value: > 20% drop after exercise; Inference: Flow limiting arterial disease. * **Bailey updates:** * Patients with ABPI < 0.5 are twice as likely to deteriorate more than those with > 0.5. * Gradually decreasing ABPI: Sign of imminent limb loss. * For every 0.1 decrease in ABPI below 0.9 – Risk of cardiac mortality increases by 10%. * **Note: CLTI (Chronic Limb-Threatening Ischemia):** * Ischemic rest pain, ulceration/gangrene. * Requires urgent assessment & treatment. * **Toe Brachial Index (TBI):** * Used in Diabetes Mellitus patients with ABPI > 1.4. * More reliable: Digital arteries are rarely affected by sclerosis. * TBI < 0.6 indicates an arterial lesion. * **Digital Subtraction Angiography (DSA):** * Only done if intervention is planned. * Provides dynamic arterial flow + anatomy of vessels. * Complications: * Bleeding. * Renal dysfunction. * Dissection. * Aneurysm. * Thrombosis.