Local tissue plasty

Basic technique for defect closure

Facial surgeries (including ophthalmic surgery, maxillofacial and ENT procedures) often require the elimination of skin defects. In the presence of small skin defects, basic local tissue plasty becomes the optimal choice.

The essence of the technique lies in careful undermining and subsequent approximation of the wound edges. The mobilized edges must be sutured through the entire thickness. A critically important rule at this stage is placing sutures strictly without tension. This ensures ideal tissue layer apposition and prevents the formation of an aesthetically unacceptable retracted scar. In cases where sharp tissue tension cannot be avoided, the surgeon makes additional releasing incisions parallel to the main wound.

Skin flap surgery

In situations where the defect is more extensive, skin flap surgery is used. These flaps are designed to preserve a wide base, which is a prerequisite for maintaining adequate blood supply and complete innervation of the transferred area. The flap is transferred onto the exposed defect surface by sliding, avoiding any kinking.

A specific technique has been developed for rectangular defects:

1. Perpendicular incisions are made on opposite sides of the wound.
2. Quadrilateral flaps with wide bases are formed.
3. These flaps are undermined and advanced over the defect (interdigitated from two sides or just one).

The advantage of using local flaps is that defects are closed with full-thickness skin that has an absolutely identical appearance (color, texture) to the surrounding tissue. Among the disadvantages are the formation of new scars around the perimeter of the former defect and the inability to obtain a double flap, which is necessary, for example, when forming the alae nasi.

Transposed triangular flaps (Limberg flap)

For contracting facial scars, the method of transposed triangular flaps is widely used. The essence of this method lies in plasty using transposed symmetrical triangles. Technically, this is performed as follows:

• Parallel incisions are made in opposite directions from the ends of the excised scar.
• The scar is excised, resulting in two transposed triangular flaps.
• The flaps are mobilized and interchanged (transposed one over the other).

Thus, the defect formed by scar contraction is filled.

In cases where the surrounding tissues have varying mobility, plasty with asymmetrical triangles is used. The angle formation principle here is strictly regulated: the triangle with the larger apex angle is designed on the less mobile skin part, while the triangle with the acute angle is placed on the mobile part. For example, when eliminating a scar near the medial canthus, the wide triangle is taken from the less mobile skin under the eyelid, and the narrow triangle from the tissues between the dorsum of the nose and the inner canthus.

Pedicle flap surgery and skin strip

An alternative method is pedicle flap surgery. Such a flap is harvested from tissues near the defect and must match in shape and size. The pedicle of the flap can be short or long. A long flap pedicle gives the surgeon the ability to transfer the flap over an area of undamaged skin. At the same time, it is important to ensure that when the pedicle is bent, the vessels running within it are not compressed. The operation is completed by suturing the wound at the donor site. The disadvantage of this method is that it does not provide material to replace large defects or form double flaps.

There is also a strict technique for forming a tubed flap (skin strip):

1. A skin strip of the required length and width is outlined with two parallel incisions (the ratio must be 3:1 for adequate blood supply).
2. The incision is made through the skin, subcutaneous tissue, and superficial fascia.
3. The strip is rolled into a tube with the skin facing outward. The edges are sutured, ensuring subcutaneous fat does not protrude beyond the skin edges and hinder adaptation.
4. The defect at the strip harvest site is closed with interrupted silk sutures.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Ophthalmic surgery: eyelid operations
• Maxillofacial surgery: lip and alae nasi plasty
• Topographic anatomy of the superficial fascia of the face and neck
• Types and techniques of interrupted surgical sutures
• Blood supply to facial skin flaps

Other topics in the "Head Surgery" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.