Plasty of long scars (Z-plasty)
For the surgical correction of extensive scar bands, the technique of combined figures of opposing triangular flaps is used. Instead of forming a single large figure, surgeons perform a series of sequential Z-shaped incisions along the entire length of the scar. This allows tension to be evenly distributed and effectively lengthens the tissues.
In complex clinical situations, standard solutions are insufficient. In these cases, complex combinations of figures according to A.A. Limberg's diagrams are used:
- Multi-flap technique: formation of 3–4 or more flaps within a single operative field.
- Asymmetry and angles: angles of 60° and 36.5° are used, which determine the degree of rotation.
- Spatial redistribution: transposition of multiple flaps allows tissue lengthening in several vectors simultaneously, eliminating severe facial deformities.
Free skin grafting
Free grafting involves the transfer of a skin graft completely devoid of blood supply from the recipient bed. Depending on thickness, three types of flaps are distinguished:
- Thin flap (0.2–0.3 mm). Includes the epidermis and papillary dermis. Does not require suture fixation on the recipient bed. Engrafts excellently, but has low plastic value, shrinks significantly, and may ulcerate from pressure.
- Split-thickness flap (0.5–0.7 mm). Captures part of the reticular dermis. Shrinks less, is sufficiently mobile, and can be folded. It must be fixed with sutures on the wound. The donor wound is not sutured and heals within 2–3 weeks.
- Full-thickness flap. Contains all layers of the skin down to the subcutaneous tissue. Does not deform, maintains mobility, glandular secretory function, and hair growth. The donor bed after harvesting a full-thickness flap must be sutured.
Harvesting material for small defects (3–6 cm) is performed manually (with a scalpel) from the retroauricular or supraclavicular regions. For extensive grafts, a dermatome is used, and the donor areas are the abdomen, thighs, and arms.
Pedicle flap (Filatov pedicle)
V.P. Filatov developed a universal method for closing deep defects — the tubed pedicle. This is a mobilized skin-fat strip sewn into a closed tube (with subcutaneous fat inward, epidermis outward). The pedicle has a body, a nourishing end, and a flap end.
According to the timing of use, flaps are divided into:
- Acute: during formation, one end is immediately implanted into the defect (the ratio of skin strip length to width is 2:1).
- Chronic: require a "maturation" period before migration (ratio 3:1). They can be moved by "inchworm" advancement or migrate over long distances with intermediate transplantation to the forearm.
In the first days, the nutrition of the pedicle comes solely through the pedicle base. On the 7th day, anastomoses appear, and by days 14–18, vascular connections are fully restored. Innervation returns very slowly — up to 6–8 months.
Planning and engraftment features
To close a defect, the area of the skin portion of the Filatov pedicle is patterned with a margin — 15–20% larger than the area of the wound itself. This compensates for tissue loss during multi-stage flap migration.
A key clinical property of the Filatov pedicle is that its tissues engraft equally successfully in both healthy and irradiated areas. This has made primary skin plasty possible in cancer patients after radiation therapy.
Historical fact: previously, surgeons attempted to "condition" the pedicle during the maturation period by periodically compressing the pedicle base with a tourniquet to stimulate blood flow. However, studies have proven that such manipulations only scar the nourishing vessels and suppress tissue respiration, which is why pedicle conditioning has now been completely abandoned.
Briefly: answers to topical questions
What classic stages does the migration process of a chronic Filatov pedicle to the face include?
The migration process of a chronic Filatov pedicle to the face is carried out in stages and includes maturation and sequential transfer through an intermediate zone.
- Maturation — ingrowth of blood vessels into the pedicle within 10–14 days.
- First stage of transfer — 4 weeks later, one end of the pedicle is severed and sutured to the arm (onto the forearm or the anatomical snuffbox region).
- Second stage of transfer — 10–14 days after engraftment to the arm, the second end is severed from the donor site (e.g., abdomen) and implanted into the defect area on the face.
What methods of local skin plasty using adjacent tissues are used on the face besides Z-plasty?
Besides Z-plasty, other geometric techniques of local plasty with adjacent tissues are used to close facial defects.
- Tissue excision and wound edge approximation — linear closure used to remove scars, ulcers, and neoplasms.
- Tissue incision and wound edge spreading — used for suturing the Filatov pedicle base or free skin grafting.
- V-Y plasty — a V-shaped incision is closed in the shape of a Y letter, which ensures advancement of the flap.
- Rotational transposition — rotation of a harvested triangular flap to close a defect.
Layers and sutures in free grafting: Thin — sutures NOT needed (papillae only). Split-thickness — sutures needed (cuts into the reticular layer). Full-thickness — both the wound and donor site are sutured (full thickness).
Class and exam questions
How does free transplantation differ from tubed pedicle plasty?
A free graft is completely severed from its donor site and loses its vascular connections. A pedicle flap is always nourished by the body via the pedicle at all stages of migration.
Why is the term "tubular pedicle" considered incorrect?
Inside a correctly formed Filatov pedicle, there is no empty space (tube) — the longitudinal edges of the skin are turned inward so that the subcutaneous adipose tissue is in tight contact. The correct name is the tubed pedicle.
What happens to the donor site after harvesting a split-thickness graft?
The donor wound is not sutured. It spontaneously epithelializes under ointment dressings within 2–3 weeks due to the proliferation of epithelium from preserved skin appendages.
What else to study on this topic
- Technique of forming the base of the Filatov pedicle using opposing triangular flaps.
- Complications of free skin grafting: causes of graft necrosis and retraction.
- Analysis of the area of through-and-through defects of the oral mucosa and skin to calculate the volume of plastic material.
- Specifics of free mucosal grafting in blepharoplasty.
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