Plasty with a full-thickness displaced flap. Skin grafting, Free (full-thickness and split flaps) and non-free (local tissues and pedicle) skin grafting Types of skin grafting surgery

Skin plasty is a surgical operation to replace skin defects that have arisen after injuries, burns or surgical interventions. However, now it has become popular to do plastic surgery simply at will. Initially, it was believed that it was necessary to resort to such methods only in exceptional cases, when it was necessary to correct the defect after any damage to the upper layers of the epidermis.

History of skin grafting

Skin surgeries to restore the nose were used in ancient Egypt, as well as in ancient India many years before our era. Plastic surgery using skin plastics is described in the works of A. Celsus. In 1597, a treatise on plastic surgery by G. Tagliacozzi was published in Bologna, which describes a method for transplanting a skin flap taken from the upper limb to replace the cut off parts of the face, in particular for nose plastic surgery.

Skin plasty was further developed in the works of domestic scientists. Yu. K. Shimanovsky in 1865 published a fundamental guide to plastic surgery "Operations on the surface of the human body."

In 1869, J. Reverden justified and performed free skin grafting.

Russian surgeons P. Ya. Pyasetskip (1870), A. O. Yatsenko (1871), S. M. Yanovich-Chainsky (1870) improved free skin plastic surgery. The method of operation with a round skin stalk on a feeding leg, which was widely used in plastic surgery, was developed in 1916 by V.P. Filatov.

In 1930, Douglas (B. Douglas), and in 1937 Dragstedt and Wilson (L. Dragstedt, N. Wilson) proposed a method of skin surgery with perforated skin flaps, which was improved during the Great Patriotic War by B. V. Larin ( 1943), Yu. Yu. Dzhanelidze (1945), N. N. Blokhin (1946).

A new stage in the development of techniques began after the creation of the dermatome by Padgett (E. S. Padgett, 1939), M. V. Kolokoltsev (1947 - adhesive, 1952 - electric disk), which made it possible to perform surgery with split skin grafts of various thicknesses.

Types of skin plastics

There are primary and secondary (early and late) skin grafting. Primary is performed in the next few hours after injury, secondary - after the formation of granulations (early operation), ulcers and long-term non-healing wounds (late skin grafting). Depending on the source of the skin area to be taken, autoplasty, homoplasty and heteroplasty are distinguished; according to the modern nomenclature, homoplastic is alloplasty, heteroplastic is xenoplastic.

Indications for skin surgery

Reconstructive surgery is indicated for wounds accompanied by extensive skin defects (for example, with scalped wounds of the lower leg, hand), immediately after surgical treatment or at a later date, after the formation of granulations, when a secondary suture cannot be applied to the wound.

Also, a similar technique is used to close defects formed after excision of deforming scars, neoplasms, tuberculous skin lesions, during plastic surgery in maxillofacial surgery, during operations for elephantiasis and malformations of the limbs (for example, syndactyly). Plastic surgery has been especially widely used in the treatment of burns to close granulating wounds after necrectomy.

Contraindications

Skin plasty is prohibited in severe condition, exhaustion of the patient, elevated temperature and significant bacterial contamination of the wound, sepsis. The thing is that such operations are quite difficult to tolerate by the body.

Preoperative preparation during secondary skin grafting is of great importance for graft engraftment. It includes a complete high-calorie nutrition of the patient with a sufficient amount of proteins and vitamins, blood transfusion, as well as preparation of the tissue defect area to be closed. With long-term non-healing wounds and ulcers, preparation for skin surgery includes cleansing the wound surface from necrotic tissues, eliminating pathogenic microbial flora and an acute inflammatory process. For this purpose, treatment with dressings with various antiseptic solutions, sulfonamides, antibiotics and enzymes is used, taking into account the phase of the wound healing process. Granulations and scars are excised, the bottom of the ulcer or wound is carefully treated. Plastic surgery of fresh wounds is carried out after full surgical treatment, as well as under local or general anesthesia, depending on the surface area of ​​the operated area.

Skin grafting methods

The following methods of such an operation are proposed:

• free skin plastic;
• not free;
• on the feeding leg;
• combined.

Loose skin grafting

When using this method, skin areas are completely separated from the donor site and transplanted to the defect area. A distinction is made between split and full-layer skin grafts in free skin grafting.

J. Reverdon (1889) transplanted small areas of the epidermis with an area of ​​2 - b mm 2 onto the granulating surface. SM Yanovichaisky (1870) transplanted skin grafts 4 - 12 mm 2 in size containing the epidermis and part of the dermis, successfully using this method for the first time to close defects after gunshot wounds.

Davis (J. S. Davis, 1914) transplanted skin grafts, including up to 8/4 of the entire thickness of the skin.

Thiersh (K. Thierscn, 1874) proposed a method of operation with a thin split graft containing only the epidermis. Small thin strips of the epidermis were cut with a special knife and transplanted onto granulating wounds.

Ollier (L. Ollier, 1872) performed plastic transplants of large sizes, up to 4 - 8 cm later he used transplants for skin plastics in the entire thickness of the skin.

Blair (V. P. Blair) and Brown (J. B. Brown, 1929) used a manual method of splitting the skin, with which they managed to obtain dermoepithelial grafts of various areas with a thickness of 0.3 - 0.4 mm.

The dermatomal operation with a split calibrated, that is, a predetermined thickness, graft has become widespread.

In our country, the works of N. N. Blokhin, B. A. Petrov, M. V. Kolokoltsev, E. I. Shumilkina, T. Ya. Aryev, A. K. Tychinkina and other surgeons are devoted to such surgery with a split dermatome graft. In the dermatome technique, thin skin grafts are placed on a previously prepared wound surface and covered with a pressure bandage. On the second day, a careful dressing change is mandatory to avoid displacement of the graft with a dried bandage. Thicker dermatome grafts are used for operations on the face, palmar surfaces of the hands, in the area of ​​the joints and plantar surfaces of the feet. The skin area used for plastic surgery (donor) is covered with a sterile bandage; it can be reused for plasty after 8-10 days, and if necessary - repeatedly, which is especially important in the treatment of extensive burns.

B. A. Petrov (1950), Mowlem Mowlem, 1952) and Jackson Jackson, 1952) used this technology with ribbon-like alternating cleaved and homotransplants to close wounds after extensive burns. K. p. was made at the end of the 3rd week after the burn. Auton with homotraisilantates covers the entire wounded surface. Homotransplants slowly dissolve, autografts, gradually growing to the sides, cover the granulations. Thin flaps with a thickness of 0.1 - 0.2 mm are used; they engraft better than thick ones, do not require fixation to the edges of the wound and are almost not subject to retraction. With an insufficient supply of skin, with extensive burns, Gabarro (R. Gabarro, 1943) proposed a "vintage" method - with small rectangular grafts.

Lawson (O. Lawson, 1870) and A. S. Yatsenko (1871) offered full-layer free plasticity. The sizes of grafts are 2-4 or 6 mm 2 . Krause (F. Krause) in 1893 applied transplants up to 20-25 cm 2 .

P. Ya. Pyasetsky (1870), for better engraftment, immersed skin grafts into holes, which he had previously made in granulations. This "submersible" method of skin transplantation was later improved by Brown (W. Braun, 1920) and Alglav (G. Alglave, 1927). Brown transplanted small epidermal grafts with a granulation needle. Alglav loaded full-thickness skin grafts under the granulations or into wells created by scraping the granulations. A perforated sieve flap is used to close large skin defects. Douglas first applied circular incisions in the graft area, after which the skin flap was cut off, leaving round skin areas for the donor wound to be healed. Dragenet and Wilson made linear incisions on the skin graft. The donor wound was sutured tightly. The creation of holes in the graft contributed to good drainage of the wound and made it possible to increase the area of ​​the graft.

One of the varieties of full-layer free skin plasty is the replantation of skin flaps completely torn off at the time of injury, proposed by V.K. Krasovitov in 1935. The method of replantation of skin flaps to Krasovitov for scalped wounds of the head and limbs is successfully used in emergency surgery. When contaminated, scalped skin is washed with soap and a brush in running water, oil stains are removed with ether, after which the skin flap is immersed in rivanol solution.

The subcutaneous tissue is removed using a dermatome, the skin flap is dried and transplanted to the wound. Skin replantation is acceptable within 6 hours after injury, however, methods have been developed that can significantly lengthen the viability of the skin flap.

Non-free skin grafting

This technique includes grafting with local tissues and grafts from distant parts of the body on a temporary pedicle. K. i. local tissues is carried out by mobilization of the wound or with the help of additional (laxative) incisions. To prevent tension on the edges, one or two parallel cuts are made on the edges. Small notches are also applied to the entire thickness of the skin near the wound. For large wounds, sliding figured methods of operations are used. Various variants of longitudinal incisions have been developed for closing round defects in wounds of various shapes (oval, triangular, rectangular), as well as sliding flaps for plastics of square defects - at the suggestion of Yu. K. Shimanovsky (1864).

Operation by counter movement of adjacent triangular flaps was recommended by A. A. Limberg in 1963; it is used to close skin defects after excision of tightening scars in the area of ​​the joints of the extremities, face, small skin tumors, as well as for long-term non-healing wounds of the extremity. Triangular flaps are cut out of the skin together with subcutaneous tissue so that the angles of their tops are equal to 30-45 or 60°. Triangular flaps with an angle of 30° are used on the face, where the blood supply conditions are better. On the extremities, it is recommended to use flaps with an angle of 45 or 60 °, which provide better blood supply. The flaps are separated and after hemostasis they are mutually moved and brought together with sutures without tension.

Bridge skin grafting

The bridge-like method of the operation consists in closing skin defects with the help of bridge-like flaps, including the skin and subcutaneous tissue. To close the wounds of the hand or forearm, a bridge flap is cut out from the skin of the anterior or lateral surface of the abdomen. Such plastic surgery on the leg is also used to close wounds in the area of ​​​​the joints by moving the skin flap adjacent to the wound (Indian method). Relatively rarely (mainly for large ventral hernias), cutis-subcutis recommended by S. P. Shilovtsev is used.

Combined Methods

N. V. Almazova (1923) used the Indian method for plastics of tissue defects on the face.

This method is also used to close defects in the limb stump. The wound surface formed at the site of the displaced flap, if necessary, is closed with a split skin graft. With the Italian method, a pedicled flap is cut out in areas of the body remote from the defect. The method is used more often to close skin defects on the limbs (hands, lower legs, groans). The first stage of the operation includes cutting out a skin flap, suturing the donor wound, and fixing the graft to the edges of the skin defect. At the second stage, its leg is cut off (after the engraftment of the flap). With the help of the Italian method it is possible to close skin defects with an area of ​​45-70 cm 2 .

To close more extensive defects, a combined operation is used, in which the flap bed is closed with a split graft. One of the methods of combined K. p. is the Tychinkina method, which includes three stages. Initially, a skin flap with a wide base is cut out and it is separated from the underlying tissues. The wound surface of the feeding leg of the flap and the entire wound area of ​​the donor site are closed with a split skin autograft, after which the cut flap is returned to its place and fixed with sutures. After 2 weeks, the flap is again separated from the bed, the granulations on its inner surface are removed and sutured to the refreshed edges of the defect. After 4-5 weeks, the feeding leg is cut off. This method is especially indicated when closing defects on the "working" surfaces of the limbs.

Filatov's method of plasty with a round skin stalk is widely used in plastic surgery in maxillofacial surgery to replace various defects of the face, on the hand, with fistulas of the pharynx, esophagus, and larynx.

N. A. Bogoraz used the Filatov stem to create a penis. The Filatov stem can be formed in various areas of the body. To form a flap, two parallel incisions are made so that the length is 3-4 times the width of the graft. After otsenarovka the skin wound is sutured, the stem is formed from the flap by applying interrupted explanatory sutures. The edges and legs of the stem are especially carefully formed, avoiding tension in the seams. After 12-14 days, one of the feeding legs of the stem is cut off and transplanted to the area of ​​the defect, if the stem is located near the defect. When the stem is located at a considerable distance from the defect, the end of the stem is first transplanted to the hand or forearm, and after a while its other end is transplanted to the defect area. Before stem migration, a test is carried out to assess the state of blood supply by pulling the base of the remaining stem with a thin rubber band. It is also used to train the blood supply of the stem by clamping the legs 2-3 times a day, gradually increasing the time for applying a tourniquet or clamp from 5 minutes to 2 hours for 2-4 weeks.

A semi-lunar incision is made on the brush, corresponding to the size and shape of the end of the stem. Perhaps closer to the base of the stem, the skin is cut circularly, the fiber is excised for 1.5-2 cm, after which the end of the stem is cut off, immersed and fixed with catgut sutures to the bottom of the hand wound. Interrupted silk sutures are applied to the skin of the stem and the wound of the hand. The second leg of the stem is cut off after 6 weeks. and produce plastic defect. To close the defect, one can first implant one stem or alternatively implant both stem legs near the defect, followed by defect plasty.

Curly stems are proposed for rhinoplasty: four-legged, in the form of the letter "T", a cross with the formation of three stems at one end.

Depending on the purpose of plastic surgery, to close the defect, a complete or partial straightening of the stem is performed. The skin scar is excised along the stem, the incision is deepened, concentric adhesions are dissected and the subcutaneous tissue is dissected with longitudinal incisions and partially or completely excised.

When performing rhinoplasty, the stem is completely freed from subcutaneous tissue, preserving the supply vessels. When performing plastic surgery of the cheeks for cosmetic purposes to restore the contours, as well as plastic surgery of the plantar surfaces of the foot, the subcutaneous tissue is left in the required amount. For tamponade of bone cavities, the distal part of the stem is used after excision of the skin. The proximal part of the stem is straightened and used to close the skin defect.

The average duration of plasty with a migrating round Filatov stem is 3- per month. It includes five stages: stem formation (2-4 weeks), stem migration to the raceme (4-6 weeks), stem transfer from the raceme to the defect (4-6 weeks), cutting off the stem from the raceme and spreading on the defect ( 3-8 sub.) and leg correction (3-6 weeks).

The disadvantage of plastic surgery with the Filatov stem, in addition to the duration, is the difference in the color of the skin of the stem and the skin around the defect, which is important when performing plastic surgeries on the face. L. M. Obukhova, for cosmetic purposes, suggested deepithelization of the stem during facial plastic surgery. After excision of the epithelium, a gradual formation of a thin flat pinkish scar occurs. The stem takes on a color close to the color of the face.

V. P. Filatov proposed, in addition to the typical, so-called. sharp stem with one feeding leg. One end of the sharp stem is left free or can be used to close the defect; due to its good blood supply, such a stem is also used to create complex transplants.

After the surgical procedure, a bandage is applied to the donor wound and the area of ​​the skin graft, which is recommended to be moistened with fir balm to prevent drying and facilitate change. The sutures are removed on the 6th or 8th day.

After surgery: results

The most common complications after surgery are suppuration, partial or complete necrosis of the graft. They are observed with tension and insufficient vascularization of the graft. According to most authors, engraftment of skin grafts occurs in 90-96% of cases.

In surgical practice, skin grafting is used for therapeutic and prophylactic purposes.

The main tasks of skin plastics are:

1. Closure of defects in integumentary tissues.

2. Prevention of the development of infection in wounds and other injuries (burns, frostbite), inflammatory diseases and other pathological processes accompanied by loss or violation of the integrity of integumentary tissues.

3. Prevention of loss of proteins, fluids and other biological substances. This is especially important for extensive and deep burns.

4. Restoration of the functions of the musculoskeletal system.

Indications for the use of skin plastics are the following pathological conditions:

a) acute injury with violation and loss of integumentary tissues. In these cases, skin plasty is performed as soon as possible after the injury, and sometimes on an emergency basis, during the initial treatment of the wound;

b) the consequences of traumatic injuries in the presence of extensive and multiple defects in integumentary tissues;

c) acute and chronic inflammatory processes with the presence of defects in the integumentary tissues that form after radical removal of the focus, for example, with carbuncle or osteomyelitis. In these cases, primary skin grafting is used;

d) diseases of the vascular system (atherosclerosis, endarteriosis, thrombophlebitis, etc.) with malnutrition and necrosis of integumentary tissues (closure of trophic ulcers by the skin);

e) neurotrophic disorders of integumentary tissues, except for vascular disease. In this case, the pathological process comes from the nervous and hormonal systems, which leads to disruption of the trophism of integumentary tissues, necrosis and ulcers;

f) defects of integumentary tissues after removal of tumors. Here it is given to use skin plastics not only to close the defect, but sometimes also for cosmetic purposes, especially with defects after removal of tumors on the face. It should be noted that skin grafting for defects after removal of tumors can be performed only after radical removal of tumors.

Skin grafting methods can be divided into the following main groups.

5. By the connection of tissues with the body of the recipient:

a) plastic with free flaps (according to Tirsh, Yanovich-Chainsky, A. S. Yatsenko-Krause, etc.);

b) plastic surgery with a flap on a feeding leg (ancient methods of Chinese and Indian medicine, the Italian method, Filatov's stem, etc.).

6. By the origin of the material (autoplastic, homoplastic, heteroplastic).

7. According to the type of material preparation for plastic surgery (fresh, preserved, lyophilized skin).

8. According to the technique of plastic production (simple methods, plastic using dermatome devices, etc.).

The choice of skin grafting method depends on many factors. These include: anatomical conditions in the area of ​​the proposed plastic surgery; physiological disturbances in the body, especially the state of the neurovascular organs both throughout the body, and especially at the site of a tissue defect; the extent and depth of tissue damage; trophic disorders; factors of immunity and species compatibility of donor and recipient tissues (with homo- and heteroplastics); age and condition of the patient; technical capabilities and equipment of the medical institution.

A correct understanding of the wound process, the correct choice of the plasty method, taking into account all the individual characteristics of the state of the body, a high level of asepsis and surgical technique, and the reasonable use of targeted antibiotics enable surgeons, traumatologists and orthopedists to widely use skin plastic surgery. This greatly improves the quality of surgical care.

A general description of the experience of using skin-plastic operations is given in Table. 1:

Table 1.

Skin plastic surgery

What is required to achieve success in skin plastic surgery?

The conditions for obtaining a positive result of skin grafting are as follows:

1. good blood supply to the defect area of ​​the integumentary tissues;

2. the presence of a well-developed granulation tissue in the area of ​​a wound or ulcer (in chronic processes);

3. absence of necrotic tissue in the area of ​​the wound or ulcer;

4. absence or weak development of pathogenic flora in a wound or ulcer;

5. good hygienic condition of the skin surrounding the wound or ulcer, i.e., the area of ​​the upcoming skin plasty;

6. viability of transplanted tissue.

Based on these prerequisites, it should be pointed out that the conditions for skin grafting are most favorable in patients with fresh wounds and fresh burns in the first 6 hours from the moment of injury. This is a long established fact. The situation is different in patients with chronic processes, where the conditions of blood supply in the area of ​​wounds or ulcers and all other conditions on which the success of the operation depends are not very favorable. Therefore, our task is to prepare these conditions for a favorable outcome of the operation. In the preoperative period, we carry out the following preparation of patients:

1) general hygienic and general preventive measures - periodically hygienic baths, antibiotics intramuscularly or by mouth with a preliminary check of the sensitivity of microbes to antibiotics from the source of a wound or ulcer, vitamins according to the individual needs of the patient, general ultraviolet irradiation;

2) the wound or ulcer is prepared during the first period of the wound, inflammatory process, until it is freed from necrotic elements and pathogenic flora and the second period begins with a well-developed granulation tissue. In this regard, periodically! inoculations are made from a wound or ulcer in order to determine the nature of the microflora and prints from wounds - ulcers in order to check the reactivity of tissue elements.

In the first period of the wound process, various antiseptics and antibiotics in solutions are used topically. To combat microflora 1 in a wound or ulcer, as well as to stimulate the reactivity of the organism, the wound or ulcer is irradiated with an ultraviolet lamp each time the dressing is changed. The types of antiseptics and antibiotics used depend on the type of microorganisms in the wound, the nature of the wound - ulcers, the stage of the process and the individual characteristics of the organism. Long-term use of antibiotics both intramuscularly and locally on wounds - ulcers is impractical for two reasons: a) the body gets used to them, resistant types of microorganisms are produced in the wound, and hence the soil is created for the development of fungi and b) the regeneration process in the wound - the ulcer is delayed.

To prevent the negative effect of antibiotics both on the wound process and on the body as a whole, it is necessary to periodically check wounds - ulcers for fungal species, alternate the use of antibiotics with antiseptics, and if fungal species are present or even suspected of their presence in the wound, it is very useful to apply topically 1% solution of methylene blue.

During the operation it is necessary: ​​1) strict observance of asepsis; 2) prepare a bed for skin plastics in such a way that the soil for the transplanted material has a good blood supply, there should be no necrotic or mucus tissues in the wound - an ulcer, and scar tissue and thrombosed vessels (arterial and venous) in the subgranulation layer. For this purpose, the wound or ulcer should be excised to healthy tissue elements. Only after this, tissues can be transplanted onto refreshed soil; 3) with ulcers that have developed on the basis of varicose veins and especially thrombophlebitis, it must be borne in mind that the full success of skin grafting in these cases can only be achieved by performing a radical operation for varicose veins or thrombophlebitis. We perform such operations at once, starting with ligation of the main vein from the center (necessarily above the thrombus), removal of the entire affected vein and its branches (according to any of the existing methods), excision of thrombosed or dilated veins with the tissue surrounding them (always sclerosed, edematous, mucoid) in the area of ​​the ulcer and the surrounding area. After that, one or more skin flaps are transplanted onto the area of ​​the excised ulcer. In this case, the best is a flap taken from the patient himself from the upper third of the thigh at the time of exposure, ligation and excision of the main vein; 4) skin plastic surgery for trophic ulcers due to arterial disease (atherosclerosis, endarteriosis, primary calcification of the arteries, etc.), in addition to general preparatory measures to improve local blood circulation, mainly capillary, requires special methods to be performed during operations. These include: a) ligation of the saphenous main vein, in some cases (with high thrombosis of the main artery) ligation of the femoral vein; b) economical, very careful excision of the surface layer of the ulcer, without affecting the deeper tissues; 5) any skin plastic surgery should be performed with complete anesthesia and end with circular infiltration of soft tissues, above the transplant site, with a solution of 0.25% novocaine with antibiotics (penicillin and streptomycin, 1 million units each in a dilution of 100 ml of 0.25% novocaine) ; 6) transplanted flaps must be fixed to the edges of the skin defect with interrupted thin catgut sutures; 7) it is advisable to apply a dry aseptic bandage to the surgical field, in some cases, the first layers of the bandage, directly applied to the flaps, should be impregnated with some kind of colloidal solution (vaseline oil, gelatin solution, etc.). P.).

The last issue that must be resolved in the process of preparation and production of skin grafting concerns the transplanted tissue. Despite the fact that there is no true engraftment of the transplanted tissue, however, maintaining the viability of the transplanted flap or flaps for a certain period is of paramount importance. From this point of view, a fresh skin flap has great advantages over preserved and lyophilized flaps. If it is not possible to take a fresh flap from the patient who undergoes skin grafting, then a fresh flap can be taken from another person. This is easily done in a large surgical facility where daily operations are performed, and without any harm to the operated, for example, for uncomplicated hernia and similar so-called clean cases, skin can be taken for grafting. This, of course, requires the complete health of the donor, checking his Wassermann test and other serological reactions, checking the reactions for the compatibility of the blood of the donor and the recipient. If this presents difficulties, then the homografts should be preserved or lyophilized. Preservation is carried out within 7-8 days according to the method of V.P. Filatov. In these cases, there is no reason to be afraid of immunological, anaphylactic and other dangerous reactions in patients undergoing skin grafting. We have never had any complications of this kind.

If it is necessary to obtain very large skin flaps to cover large areas in patients, mainly with a burn wound, it is possible to use flaps taken from the skin of amputated limbs in patients with vascular diseases (atherosclerosis, endarteriosis). If these patients are fully checked for all the serological indicators outlined above, then this skin is transplanted, as fresh, immediately after the amputation. If these conditions are not met, then the skin is preserved and skin grafting is performed 7-8 days after the flap is taken.

In conclusion, it should be pointed out that skin grafting is of great importance not only purely biological, medical, but also economic and state. This operation should become much more widespread in our country than is currently the case. For this, it is necessary to expand the network of special institutions, to equip them appropriately and to carry out scientific research on the entire problem of surgical plastics in depth.

Bibliography:

1. Amiraslanov A.Yu., Svetukhin A.M., Yakomi V.V. and other Skin plastics in purulent surgery//In Sat: Skin plastics in purulent surgery: materials of the international. symposium.-M.-1990.-p.6-8
2. Atyasov N.I., Ryazantsev E.V., Tsilikina O.V. Early necrectomy as a way to prepare a burn wound for plastic surgery // Interuniversity collection of scientific papers "Modern methods of diagnosis and treatment in medicine." -Saransk, 2000.-e. 88-90
3. Blokhin H.H. Skin plasty//M.-1955.-227 p.
4. Dzhanelidze I.I. Free skin grafting in Russia and the Soviet Union.-L.-1952.-127 p.
5. Lagvilava M.G. Early autodermoplasty of extensive circular deep burn wounds, means and methods for its provision: Abstract of the thesis. diss. . Dr. med. Sciences.-M.-1991.- 22p.
6. Tychinkina A.K. Skin plastic surgery//M.-1972.-152 p.

SKIN PLASTY- an operation to replace skin defects that have arisen after injuries, burns or surgical interventions.

Story

K. p. for the restoration of the nose was used in ancient Egypt and ancient India many years before our era. Plastic operations with the use of K. p. are described in the works of A. Celsus. In 1597, in Bologna, a treatise on plastic surgery by G. Tagliacozzi was published, in which a method of transplanting a skin flap taken on the upper limb to replace the cut off parts of the face, in particular for nose plastics, is described. K. the item has received the further development in works of domestic scientists. Yu.K. Shimanovsky in 1865 published a fundamental guide to plastic surgery "Operations on the surface of the human body." In 1869, J. Reverden justified and performed free skin grafting. Russian surgeons P. Ya. Pyasetsky (1870), A.O. Yatsenko (1871), S. M. Yanovich-Chainsky (1870) and others improved free K. p. P. Filatov.

In 1930, Douglas (V. Douglas), and in 1937, Dragetedt and Wilson (L. Dragstedt, H. Wilson) proposed the method of K. p. perforated skin flaps, which was improved during the Great Patriotic War by B. V. Parin (1943), Yu. Yu. Dzhanelidze (1945), H. N. Blokhin (1946). A new stage in the development of K. p. began after the creation of a dermatome by Padgett (E. S. Padgett, 1939), M. V. Kolokoltsev (1947 - adhesive, 1952 - electric disk), which made it possible to produce K. p. with split skin grafts of various thicknesses (see Dermatomes).

Distinguish between primary and secondary (early and late) K. p. Primary is performed in the next few hours after injury, secondary - after the formation of granulations (early K. p.), ulcers and long-term non-healing wounds (late K. p.). Depending on the source of the skin, autoplastic (see), homoplastic (see) and heteroplastic (see Heteroplasty, xenoplasty) are distinguished; according to the modern nomenclature homoplastic - alloplasty, heteroplastic - xenoplastic.

Indications

K. p. is indicated for injuries accompanied by extensive defects of the skin (for example, with scalped wounds of the lower leg, hand, etc.), immediately after surgical treatment or at a later date, after the formation of granulations, when the wound fails to impose a secondary seam (see). K. p. is also used to close defects formed after excision of deforming scars, neoplasms, tuberculous skin lesions, during plastic surgery in maxillofacial surgery, during operations for elephantiasis and malformations of the limbs (eg, syndactyly). K. p. received especially wide application at treatment of burns for closing of the granulating wounds, after necrectomy.

Contraindications

K. p. is contraindicated in severe condition, exhaustion of the patient, elevated temperature and significant bacterial contamination of the wound.

Preoperative preparation

Preoperative preparation during secondary K. p. is of great importance for engraftment. It includes a complete high-calorie nutrition of the patient with a sufficient amount of proteins and vitamins, blood transfusion, as well as preparation of the tissue defect area to be closed. With long-term non-healing wounds and ulcers, preparation for K. p. includes cleansing the wound surface from necrotic tissues, eliminating pathogenic microbial flora and an acute inflammatory process. For this purpose, treatment with dressings with various antiseptic solutions, sulfonamides, antibiotics and enzymes is used, taking into account the phase of the wound healing process. Granulations and scars are excised, the bottom of the ulcer or wound is carefully treated. K. p. of fresh wounds is carried out after a full surgical treatment.

K. item is carried out under local or general anesthesia.

Methods

The following methods of K. p. are proposed - free, not free on the feeding leg, and combined. With free K. p., skin areas are completely separated from the donor site and transplanted to the defect area. A distinction is made between split and full-layer skin grafts in free skin grafting.

Loose skin grafting

J. Reverden (1869) transplanted small areas of the epidermis with an area of ​​2-6 mm 2 onto the granulating surface. S. M. Yanovich-Chainsky (1870) transplanted skin grafts 4-12 mm 2 in size, containing the epidermis and part of the dermis, for the first time successfully applying this method of K. p. to close defects after gunshot wounds. Davis (J. S. Davis, 1914) transplanted skin grafts, including up to 3/4 of the entire thickness of the skin. Thiersch (K. Thiersch, 1874) offered K. p. a thin split graft containing only the epidermis. Small thin strips of the epidermis were cut with a special knife and transplanted onto granulating wounds. Ollier (L. Oilier, 1872) performed plastic surgery with transplants of large sizes, up to 4-8 cm 2 , later he used transplants in the entire thickness of the skin for K. p. Blair (V. P. Blair) and Brown (J. B. Brown, 1929) applied a manual way of skin splitting, by means of to-rogo they managed to receive dermoepithelial transplants of various area 0,3 0,4 mm thick. Dermatomal K. p. has become widespread with a split calibrated, i.e., predetermined thickness, graft. In our country, the works of H. N. Blokhin, B. A. Petrov, M. V. Kolokoltsev, E. I. Shumilkina, T. Ya. Aryev, A. K. Tychinkina and other surgeons are devoted to a split dermatome transplant. . With dermatomal K. p., thin skin grafts are placed on a previously prepared wound surface and covered with a pressure bandage. On the second day, a careful dressing change is mandatory to avoid displacement of the graft with a dried bandage. Thicker dermatomal grafts are used for the purposes of K. p. on the face, palmar surfaces of the hands, in the area of ​​\u200b\u200bthe joints and plantar surfaces of the feet. The skin area used for plastic surgery (donor) is covered with a sterile bandage; it can be reused for K. p. after 8-10 days, and if necessary, repeatedly, which is especially important in the treatment of extensive burns.

B. A. Petrov (1950), Mowlem (R. Mowlem, 1952) and Jackson (D. Jackson, 1952) used K. p. ribbon-like alternating split auto- and homotransplants to close wounds after extensive burns. K. p. was made at the end of the 3rd week after the burn. The entire wound surface was closed with auto- and homotransplants. Homografts slowly dissolve, autografts, gradually growing to the sides, cover the granulations. Apply thin flaps with a thickness of 0.1-0.2 mm; they engraft better than thick ones, do not require fixation to the edges of the wound and almost do not undergo retraction. With an insufficient supply of skin, with extensive burns, Gabarro (P. Gabarro, 1943) proposed a “branded” method of K. p. - small rectangular grafts placed on the wound surface at various intervals.

Full-layer free K. p. suggested Lawson (G. Lawson, 1870) and A. S. Yatsenko (1871). The sizes of grafts are 2-4-6 mm 2 . Krause (F. Krause) in 1893 applied transplants up to 20-25 cm 2 for K. p.

P. Ya. Pyasetsky (1870), for better engraftment, immersed skin grafts into holes, which he had previously made in granulations. This "submersible" method of skin transplantation was later improved by Brown (W. Braun, 1920) and Alglave (P. Alglave, 1927). Brown transplanted small epidermal grafts with a granulation needle. Alglav immersed full-thickness skin grafts under the granulations or in wells created by scraping the granulations. A perforated sieve flap is used to close large skin defects. Douglas first applied circular incisions in the graft area, after which the skin flap was cut off, leaving round skin areas for epithelialization of the donor wound. Dragstedt and Wilson made linear incisions on the skin graft. The donor wound was sutured tightly. The creation of holes in the graft contributed to good drainage of the wound and made it possible to increase the area of ​​the graft.

One of the varieties of full-layer free K. p. is the replantation of skin flaps completely torn off at the time of injury, proposed by V.K. Krasovitov in 1935. The method of replantation of skin flaps according to Krasovitov for scalped wounds of the head and limbs is successfully used in emergency surgery . When contaminated, scalped skin is washed with soap and a brush in running water, oil stains are removed with ether, after which the skin flap is immersed in rivanol solution.

The subcutaneous tissue is removed using a dermatome, the skin flap is dried and transplanted to the wound. Skin replantation is acceptable within 6 hours. after injury, however, methods have been developed that can significantly lengthen the viability of the separated skin flap.

Non-free skin grafting

Non-free skin grafting includes grafting with local tissues and grafts from distant parts of the body on a temporary pedicle. K. p. with local tissues is carried out by mobilizing the edges of the wound or with the help of additional (laxative) incisions (Fig. 1). To prevent tension of the edges, one or two parallel cuts are applied to them. Small notches are also applied to the entire thickness of the skin near the wound. For large wounds, sliding curly methods of K. p. are used. Various types of longitudinal incisions have been developed to close round defects and wounds of various shapes (oval, triangular, rectangular), as well as sliding flaps for plastic surgery of square defects - at the suggestion of Yu. K. Shimanovsky ( 1864).

To. the item by counter movement of adjacent triangular flaps was recommended by A. A. Limberg in 1963; it is used to close skin defects after excision of tightening scars in the area of ​​the joints of the extremities, face, small skin tumors, as well as for long-term non-healing wounds of the extremity. Triangular flaps are cut out of the skin together with subcutaneous tissue so that the angles of their tops are equal to 30-45 or 60°. Triangular flaps with an angle of 30° are used on the face, where the blood supply conditions are better. On the extremities, it is recommended to use flaps with an angle of 45 or 60 °, which provide better blood supply. The flaps are separated and after hemostasis they are mutually moved and brought together with sutures without tension (Fig. 2).

Bridge method K. p. consists in closing skin defects with the help of bridge-like flaps, including skin and subcutaneous tissue. To close the wounds of the hand or forearm, a bridge flap is cut out from the skin of the anterior or lateral surface of the abdomen (Fig. 3). K. p. on the leg is also used to close wounds in the area of ​​\u200b\u200bthe joints by moving the skin flap adjacent to the wound (Indian method). Relatively rarely (mainly for large ventral hernias), cutis-subcutis recommended by S. P. Shilovtsev is used.

Combined Methods

N. V. Almazova (1923) used indian way for plasty of tissue defects on the face (Fig. 4). This method is also used for closing defects in the limb stump. The wound surface formed at the site of the displaced flap, if necessary, is closed with a split skin graft. At Italian way a pedicled flap is cut out in areas of the body remote from the defect. The method is used more often to close skin defects on the limbs (hands, lower legs, feet). The first stage of the operation includes cutting out a skin flap, suturing the donor wound, and fixing the graft to the edges of the skin defect. At the second stage, its leg is cut off (after the engraftment of the flap). With the help of the Italian method K. p., it is possible to close skin defects with an area of ​​​​45-70 cm 2.

For closing of more extensive defects apply the combined To. the item, at a cut a bed of a rag is closed by the split transplant. One of the methods of combined K. p. is the Tychinkina method, which includes three stages. Initially, a skin flap with a wide base is cut out and it is separated from the underlying tissues. The wound surface of the feeding leg of the flap and the entire wound area of ​​the donor site are closed with a split skin autograft, after which the cut flap is returned to its place and fixed with sutures. After 2 weeks the flap is re-separated from the bed, the granulations on its inner surface are removed and sutured to the refreshed edges of the defect. After 4-5 weeks. cut off the feeding leg. This method is especially indicated when closing defects on the "working" surfaces of the limbs"

Plastic method round skin stalk Filatov has become widespread in plastic surgery in maxillofacial surgery to replace various defects of the face, on the hand, with fistulas of the pharynx, esophagus, and larynx.

N. A. Bogoraz used the Filatov stem to create a penis. The Filatov stem can be formed in various areas of the body (Fig. 5). To form a flap, two parallel incisions are made so that the length is 3-4 times the width of the graft. After separation, the skin wound is sutured, a stem is formed from the flap by applying interrupted silk sutures. The edges and legs of the stem are especially carefully formed, avoiding tension in the seams. After 12-14 days, one of the feeding legs of the stem is cut off and transplanted to the area of ​​the defect, if the stem is located near the defect. When the stem is located at a considerable distance from the defect, the end of the stem is first transplanted to the hand or forearm, and after a certain time, its other end is transplanted to the defect area. Before stem migration, a test is carried out to assess the state of blood supply by pulling the base of the remaining stem with a thin rubber band. It is also used to train the blood supply of the stem by clamping the legs 2-3 times a day, gradually increasing the time for applying a tourniquet or clamp from 5 minutes. up to 2 o'clock. within 2-4 weeks. (Fig. 6). A semi-lunar incision is made on the brush, corresponding to the size and shape of the end of the stem. Perhaps closer to the base of the stem, the skin is cut circularly, the fiber is excised for 1.5-2 cm, after which the end of the stem is cut off, immersed and fixed with catgut sutures to the bottom of the hand wound. Interrupted silk sutures are applied to the skin of the stem and the wound of the hand. The second leg of the stem is cut off after 6 weeks. and produce plastic defect. To close the defect, one can first implant one stem or alternatively implant both stem legs near the defect, followed by defect plasty.

Bibliography: Aryev T. Ya. Thermal lesions, L., 1966; Blokhin H. N. Skin plastics, M., 1955, bibliogr.; B u r and an F. Atlas of plastic surgery, trans. from Czech., vol. 1-3, Prague - M., 1967; In and l e with about in S. P., D m and t r and e-in and 3. E. and K u g l and to about in E. I. Primary and delayed skin plasty for injuries of the hand and fingers , M., 1973, bibliogr.; Dzhanelidze Yu. Yu. Free skin transplantation in Russia and the Soviet Union, L., 1952, bibliogr.; Zoltan Ya. Cicatrix optima, Operating technique and conditions for optimal wound healing, trans. from Hungarian., Budapest, 1977; To about l of e with N and to about in I. S. and In and x r and e in B. S. Surgical treatment of deep thermal burns, M., 1962, bibliogr.; Kolokoltsev M. V. Dermat and its use in free skin grafting, Gorky, 1947; L and m of er of A. A. Planning of local plastic operations on a surface of a body, L., 1963, bibliogr.; P and r and BV N. Skin plastics at traumatic injuries, M., 1943; PetrovB. A. Free transplantation of skin at big defects, M., 1950, bibliogr.; Petrovsky B. V. and Krylov V. S. Microsurgery, M., 1976; PovstyanoyN. E. Restorative surgery for burns, M., 1973, bibliogr.; You are a chink and on A. K. Skin plastic surgery, M., 1972, bibliogr.; Filatov V.P. Plastic surgery on a round stem, Vestn, ophthalm., t. 34, No. 4-5, p. 149, 1917; X and tr about in F. M. Defects and cicatricial fusions of a throat, cervical department of a gullet, a throat, a trachea and a technique of their elimination, M., 1963, bibliogr.; Shimanovsky Yu.K. Operations on the surface of the human body, Kyiv, 1865; Itsenko A. S. On the issue of transferring or grafting separated pieces of skin to granulation surfaces, diss., SPb., 1871; BohmertH. Hautersatz bei Verbrennungen mit Spalt-hautnetztransplantaten und Xenotrans-plantaten, B., 1974, Bibliogr.; B r ii with lene r H. Stiellappenplastik bei chronischen Unterschenkelwunden, Lpz., 1970, Bibliogr.; Chintz G. Grefa de piele libera, Bucuregti, 1974, bibliogr.; Douglas B. Sieve graft-stable transplant for covering large skin defects, Surg. Gynec. Obstet., v. 50, p. 1018, 1930; Padgett E. C. Calibrated intermediate skin grafts, ibid., v. 69, p. 779, 1939; Reconstructive plastic surgery, ed. by J. M. Converse, v. 1, Philadelphia, 1977; R e v e g d i n J.-L. De la greffe epidermique, Arch. gen. Med., t. 19, p. 276, 555, 703, 1872.

D. F. Skripnichenko.

The movement of skin flaps with their complete cutting off from the donor site and laying in another area for implantation refers to Free skin plasty, or skin transplants. The most common type of skin grafting is autodermoplasty, when the donor and recipient are the same person. Somewhat less frequently in clinical practice, allogeneic skin grafting is used and, extremely rarely, xenoplasty.

Main indications for free skin grafting are the presence of an extensive granulating surface (more than 5 cm 2) due to thermal damage (burn or frostbite), scalped wounds, as well as large trophic ulcers. These defects can be covered with an isolated flap, separate small pieces of skin, a layer of the epidermis, or a scraping of the skin epithelium. The transplantation of an isolated flap should be recognized as the most optimal method of autodermoplasty. In turn, depending on the thickness of the cut layer of the skin, full-thickness (full) and split flaps are distinguished.

Half layer skin flap represents the actual skin. Its thickness allows grafting only on a well-vascularized wound and in the absence of the risk of infection. Transplantation of a full-thickness flap is possible only on small wounds and is most often used during operations on the face or to close tissue defects on the palmar surface of the hand and fingers. The advantage of a full-thickness skin flap is its non-susceptibility to secondary retraction (wrinkling) and autopsy. The graft was guarded by careful separation of the flap with a sharp scalpel along a pre-planned incision without subcutaneous tissue. During the operation, you must follow

GL \B\ \\ III. RECOVERY SURGERY

good hemostasis and fix the flap to the edges of the wound with separate sutures. The Mev-io flap is sutured with separate sutures or closed with a split skin flap.

split skin flap consists of the epidermis and part of the skin itself, its transplantation is the most widespread. One of the advantages of a split skin flap is the ability to cover extremely extensive skin defects with a “mesh” autodermoplast, when the taken flap is perforated with a special device with through holes in a checkerboard pattern. This allows you to increase its surface area when stretched by 3-6 times. Another advantage is that there is no need to suture the donor site, and if necessary, its eptelized surface can serve as a source of skin again. A feature of the split skin flap is its tendency to primary wrinkling due to the reduction of collagen fibers, and the thinner the graft, the more pronounced this ability. In addition, thin split flaps can sometimes undergo autolysis.

To take the required size and thickness of the split flap, a special apparatus is used - a dermatome. Currently, two constructive systems of dermatomes are used - manual (Kolokoltsev, Paget-Hood) and electrically driven (rotary, sled). The graft is taken under general anesthesia (when working with a manual dermatome, it is possible to use local anesthesia). Obtaining a flap from the anterior or lateral surface of the thigh and buttocks does not present technical difficulties. On the skin of the donor site lubricated with petroleum jelly and stretched by an assistant, a dermatome installed at a certain depth of cut is applied and the rotating parts of the apparatus are set in motion by light pressure, moving it forward. The use of manual dermatomes involves the use of special glue to fix the skin area to be taken to the device (Fig. 8, 9).

After the flap is taken, the bleeding donor site is covered with sterile gauze and a pressure bandage is applied. Healing occurs on the 10-14th day due to the growth of the epithelium of the hair follicles and sebaceous glands. After washing, the graft itself is transferred to the granulating surface and carefully placed, gradually straightening it from the center to the periphery. Fixation of split skin flaps with sutures to the edges of the wound, as a rule, is not performed, but is carried out by means of a tight bandage.

CHAPTER XVIII RECOVERY SURGERY

Engraftment of free skin flaps occurs in several stages. Already in the first minutes and hours after the operation, the graft adheres to the granulating surface and fibrin falls out between them. For the speedy engraftment of the flap, its good nutrition is necessary. Diffusion of tissue fluid ensures the maintenance of the proper level of cell metabolism in a thin (0.21-0.3 mm) split flap. Thin flaps have another advantage - healing occurs without the formation of keloid scars and with a minimal risk of infection. The thinner the flap, the faster its engraftment occurs. Thick (0.75-1 mm) flaps are fed by the ingress of tissue fluid into

Rice. 8. Taking the flap with a knife for free skin grafting

Skin plasty is a surgical intervention in which the skin is restored on wound surfaces that cannot heal naturally.

Most often, skin grafting is used to close extensive skin defects - it is believed that a wound with an area of ​​​​more than 50 square centimeters will most likely not heal on its own and will require skin grafting.

A necessary condition for skin grafting is a good blood supply to the skin grafting area, otherwise the graft will not take root. That is why plastic is limited in the treatment of such long-term non-healing wounds as trophic ulcers and bedsores.

Indications for skin grafting:

Extensive skin defects (burns, wounds, defects after operations to remove large skin formations, scars)

Long-term non-healing chronic wounds.

Types of skin plastics

There are free and non-free skin plastics, as well as plastics with local tissues.

Loose plastic

It is carried out with a skin flap, which is transferred from a healthy area of ​​\u200b\u200bthe skin to the wound. There are various methods of free skin grafting - "islands", full-thickness flap, split flap. Currently, split-flap plasty is most commonly used. To do this, a thin strip of skin is removed from the donor area with a special tool (dermatotome). When removed, the instrument itself makes notches on the flap, thanks to which the flap can be stretched and closed rather large wound defects.

In the photo below - an example of skin plasty with a split flap

Wound before plasty:

The wound immediately after plastic surgery - the split flap is laid on the wound surface:

Healed wound:

Non-free plastic

The essence of the method is to transplant a pre-prepared flap on a vascular pedicle. For example, the classic version - Italian plastic surgery - closing a nose defect with a flap from the shoulder. To do this, a flap is isolated on the shoulder on a vascular pedicle, which ensures its good blood supply. The flap is fixed to the nose, in this position the patient is until the engraftment of the flap, after which the leg is crossed.

Plastic surgery with local tissues

With this type of plastic surgery, wound defects are closed without transferring skin flaps, by making additional incisions near the wound, as well as other techniques that allow closing the wound defect with tissues located near the wound.

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