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Hi, everyone, which is waiting a few more minutes to see if any more people join, and then we'll get started. Okay. So welcome to the plastic surgery series. Um, today we've got a senior registrar, Mohammed from Plymouth, Who's going to give us a talk on free for an emergency. Uh, so I hand over to you around, Okay. Hello? Hello, everybody. Uh, Jennifer introduced me. My name is Mohammed Abdurajak, and I'm one of the plastic surgeon stores in Ramos. Uh, today we're going to talk about three for emergencies. Uh, this talk is mainly relevant for doctor doing the ankles, especially plastics maxillofacial and the immunity, uh, calls nurses covering wars with labs and the staff, and medical and nursing school students who may develop interest in such procedures in the future. What are we going to cover today? We will start by defining what the free flap is and given a few examples about these procedures. And then we're going to talk about why these procedures can turn into an emergency and how to monitor free for labs and how to deal with free flap emergencies. And at the end of the session, we will see some photos as clinical scenarios to get used to how different emergencies look like in real life. First of all, what's the free flab? So free flap basically is a tissue transferred from a body part to another part. But in order for it to survive, it has to be transferred with its blood vessels and these blood vessels, and it's most two recipient vessels in the area where it's transferred to In this photo we see here, this is the flab in the middle photo. This is the flab, and we have the vessels coming out of the flaps. And these same vessels are the one we see in the right photo under the microscope connected to the recipient vessels to provide blood supply to this piece of flab and keep it alive. And this is a photo of how the theater team looks for these surgeries. It's a recent, uh, specialty. So the first free flap done on human was done on the 1972 and then after that, it developed extensively. Now that most reconstructive surgeries of different body parts have a free flap element in it, free flap is called a free flap because it can come from anywhere in the body so it can come from a leg, as in this photo, come from a thigh, come from the abdomen, come from the arm. And also it can be either skin like the flaps on the left on the right hand side of the photo or muscles like the photos on the left hand side, the left hand side of the, uh, figure. These are a few examples, So in this photo, we can see in the upper photo. There is a defect on the leg, which was reconstructed by a skin free flap taken from a size of the patient. And we can see how it looks after the surgery and on the right hand side how it looks a few months later. And such a such a surgery is very crucial to reconstruct this patient's food and leg. Otherwise, he would have had amputation. This is another example with a patient who had a band contraction of his two, and in order to after release of this contraction, he ended up with this defect that was reconstructed with a skin flap as well. And this is the third example where a defect in a sole of the food was reconstructed. These photos show a different group of patients, and these 22 photos are found patients who have head and neck cancers and the photo on the right. It shows a patient who had his pharynx removed and the tube you see here is a new pharynx reconstructed using a free flap technique taken from his side and on the left side, this patient had his tongue taken out because of cancer and reconstructed with skin flap as well. This photo is a different example with a patient who had a big part of his cheaply constructed with a free flap. This is not the only thing this patient, who is a different category of patients as well, who had a massive been affecting his neck. And in order to resurface this and the least the contraction he needed a skin free flap. And this is another example of a mangled hand, and we can see on the upper left hand side photo how bad the effect is and on the lower hands on the lower right side, how good reconstruction is. And this is another example as well. This vision, he has a very difficult keloid to manage, and after excising this Cloyd, it was reconstructed with a flap. And this one is a baby who is only nine months old, and he was born with this congenital defect and was reconstructed by a muscle and skin taken from his back and on the right, on the right side of the screen, you can see how it looked a few months after the surgery. Compared to the left side of the photo. This is a different category of flats, which is which are muscle flaps that can be either used to cover a defect or to do function in this patient. We can see there is a big defect on the leg where the blade they're fixing the fraction and all in order to cover this, a muscle was taken from his side, Brazil's muscle and used to reconstruct the defect. And on the lower left photo we can see here this mist looking tissue, which is a skin graft, put over the muscle flab and despite it doesn't look very nice. In the beginning, we can see on the right hand side in food to D how good it looked few months after. This is a different example, and I brought these photos in order to show you how a healthy muscle flap looks and how it looks after a skin graft in for E and how it looks few months later in full two F. This is another muscle flap, but in this time it's not used to cover a defect, but instead to to get a function. So those patients he had what's called to be, uh, he had a contraction of his tendons. They were not functioning anymore. And he needed to have the muscle in order to move his fingers. And we can see how good the muscle is doing. There's a different patient who has a very difficult infection on his scale, ended up having to remove a big part of it, and then we constructed it with a muscle flap. You can see in the left hand side a big flap taken from his back with the mesh tissue around over it, which is the skin graft. And despite it doesn't look very nice here on the right hand side, it looks way better after a few months. These examples are not to, uh, give you more details about the flaps, and it's the only message I want you to get that they are called the free flaps because they are free and they can be taken from anywhere in the body and used to reconstruct anywhere. So as the examples you already saw, it can be taken from different body boards in constructing variable body boards. It can be used in different pathologies, and also it can be used in multiple age group, ranging from a baby to a very old patient. And that's why even if you are not part of a team would have these three flaps, you will encounter them in your practice. For example, if you're a pediatrician, you you will find you will end up with one of these patients on your world, and you're going to look after him or her and so on. And after these multiple examples, and to simplify things, you don't need to worry about where this lab is coming from and what actually this flab is used to reconstruct. The main thing you need to think about is that whether this is a skin flap which is going to look like the photo on the left side or a muscle flap, which will look like a photo on the right hand side. And these two looks. These are the healthy looking skin flap and muscle flap, and we'll come to the biological one's later. And these two examples here show how skin flap and muscle flap blocks, Uh, without considering where it's coming from. So if this muscle flap on the right hand side was taken from the thigh, it will not look any different from a muscle taken from the back and so on. And then we come to the next question why such elective surgeries can turn into an emergency. They are all the construction of wounds that are done. Electively. The reason for that is multiple. First of all, they are precious reconstructive surgeries, So each lab of these take about 6 to 12 hour surgery takes a big team to do them, which is about 15 staff members, including doctors, nurses and all the team, and also they are usually the used to reconstruct difficult defects, so they are usually the last results of reconstruction, and losing them will cause a a great mobility for the patients. The second thing that as we mentioned before, these different body parts or tissue from different body parts taken are taken with the blood supply and with these lab emergencies, which happens when this blood supply is interrupted. This tissue have critical ischemia time, which varies between the skin and muscle. It's shorter and muscle. But if there was a delay in fine and detecting and managing these emergencies, these vicious reconstruction tissues will will end up dead. And lastly, which is the good news is that salvages possible. And, uh, when these emergencies are detected early, even a very, uh, bad looking flab. If it directed very early, it can be salvaged relatively easier than doing another flat. And here we talked about how to monitor a free flap patient, and this is what you need to know if you're on call, and then you get hold that there is a new flat done today and please come to hand over, see the flab and see the patient so that you are going to look after this patient overnight or during your shift. Unlike anything in the medicine, any patients in the medicine, you have to monitor a general factors including meaning patient is, well perfused and the local factors monitoring the flab itself. The benefactors. If the patient is not very well, perfused, the flab is definitely not going to be profused. And then it's going to be, uh, lost. And the important things for the flare ups are to keep the patient having a good BP, having a good urine output warm enough so that he doesn't have fathers bathroom or on his peripheries or and then affecting the perfusion of the flab. And also specific patients have specific needs, including trauma patients or cancer patients and local include position, which is very important color of the flab. Capillary refill, which means when you press on the flab and check how long it takes for the blanching to become red again. Warmth of the flap together, which means the consistency of the flap, whether it's soft and legs or tense double signals, which you are going to talk more in more details later. And flab scratches your last result, and usually done only if, um, you have problems with the flaps because the flat monitoring is done very frequently in the in the first few days, it can be up to every 15 minutes, and you can't scratch the flap every 15 minutes. This photo here, which we are going to use a lot in this presentation, shows a happy patient with the radiator heat to keep him warm with PCA to keep him pain free. He has nutrition. He has IV fluids in order to keep him well hydrated. And it has the urine back to monitor his urine output. And he has the vital, uh, data chart here and locally. You look the flab here, and then you check the temperature, the color, the capillary, refill, the balls and the position. Okay, This is an example of a post operative lab protocol done for the royal. And? And I took this from my unit, and you can see hear that birthday. So in the first day, the flab has to be monitored every half hour day, one every half hour, and then every 24 hour every and then every hour. And then the monitoring become less frequent after all afterwards. And the reason for that is that most of the flab emergency problems happen the first three days. And that's why this protocol is arranged this in this way. Also, you can look that there are other things to monitor, including urine output, including IV fluids, including pain, medications and all of the other things we mentioned in the previous diagram. This also is a different protocol done for the breast free flaps taken from the same unit. And it has the same items, but in different ways. And here we talked about wh So w is basically device is made to detect pulses, and when you examine the patient, normally you can feel the pulse. But for flab, the blood vessel is so small that is very difficult to feel it. And then you have to use devices like do blood in order to detect the double A signal. And and there are different types of dollars. But the main two types are either external, which which looks like the one on the left hand side which is basically has a probe. And you put it over the flap and you listen to the double a signal or internal, like the one on the hand side, and you can see there is a device their connected to a wire and this wire will be inserted in surgery similar to the photo on the other hand side, where it detects a double a signal from the patient and all. What you need to do with this is to turn the machine on and then you will listen to the double a signal. But again, these details are not important. The most important thing is to know what you are listening to. So there are two types of signals which are either arterial or venous. And I use my hand as example here. So this is how you listen to an arterial balls, which looks like a strong heart beat beat. And here, where you, uh this is how a venous, uh, signal looks, which looks like a wind or venous hum. Yeah, and I will repeat it again. Uh huh. Oh, okay. And then we'll come to what is a free flap emergency. So, as we mentioned before, this is a flat which has an artery which provides the blood supply to the flab and vein which drain the blood out of the flab. And by maintaining the circulation, this maintained the nutrition and the survival of this flat and the emergencies would be mainly one of two things. Either a congested slab, which means the vein has a problem. So it's an outflow problem, which means blood is going in through the artery but can't go out, which means too much blood in the lab. And we're going to take to to talk about how this looks clinically or ischemic lab, which means an inflow problem. So there is no enough blood going through the artery. And so the flap is not getting getting, uh, enough blood going in and usually any free flap emergency start as one of the two. But if there is any delay, then it will be both involved. So, for example, if you have a vein that's obstructed and then the flashes congested with the artery flowing after some time, the flap will be so full of blood that the pressure and the flag will be too high, which will end up with the artery not working as well, and vice versa. If the artery stopped working and despite the vein is bitten after some time with the stagnation of blood in the flab, the vein will end up with somebody as well. And this is this gives you an idea about how important is to detect these problems very early and act quickly as soon as possible. Let's start with the first problem, which is the congested lab or out flow blockage. This is more common in three flaps, and we see this more often for than an ischemic lab. And the reason for that is that the arterial blood flow is strong. That usually is not the cause of the problem. In this foot, you can see two flaps. The flat on the left hand side is a congested flab, and the flab on the right hand side is a normal flab. And if you compare between the two, you can tell there's a flat on the left hand side, which has a lot of blood in it. Grab is it's warden explosion color. It has a breast community fell, so if you press on it and then take your finger out, the blood will come back less than one second, and also, if you scratch it it, you will find a dark and brisk bleeding. The other thing that if you put a double a signal, you will find a good arterial signals, especially if you if you detect it early because the artery is still going. This is another example of a congested flab taken to theater for salvage. You can see how the flab is. Swollen is pollution color, uh, and it stems as well, and you can see how the vein that you can see in the lower part here is from both. Also, this is another example with a lady who had a breast reconstruction, and this is how the congested lab looks. You can compare it to the normal skin around it's lotion. Color your breath that it will have a brisk capillary refill, and if you scratch it it it will bleed quickly and dark blood and on the right hand side. This is the photo of the patient after salvage, and this shows you how detecting this early and active monthly help to save such a reconstruction. This is another example of a patient to have to freeze labs on to reconstruct any defect, and one of them had a congestion problem. And you can see the difference between the two flaps, especially in the, uh image D or the lower image and all the examples I show it so far. Well, for skin flaps, muscle flaps can also get congested and they are more tricky and more difficult to detect. This patient has had a muscle flap taken from the back or latissimus dorsi flab. And you can see how the muscle, instead of looking like a fresh pink like a fresh piece of steak. Instead it looks dark, bluish, full of blood. And if you scratch it it it will breathe brisk and cold blood as well. You can't escape a refill in muscle because of the nature that they are red in color already. And if you break them, they don't launch like the skin, which makes monitoring more difficult. And that's why in some patients you may take a piece of skin with the muscle. Not because you need this piece of skin, but just to help monitoring the muscle. How would you manage a congested flab? And we are back to our happy patient. You do the same. So you get called about a congested flab. You go as soon as possible. You check the patient, you start by checking the general things, checking that the patient is warm, not in pain. Check that he has a good, vital signs. He is well hydrated, his urinal, but is normal. And then you check the position, which is very important in congestion because it can be as simple as the patient is a wrong position that is compressing on his veins. And that's why they are included and also the other signs of congestion, as we talked about. And then you call for help and you call for help as soon as you get concerned and to give you more example about this. If you have a muscle flap that's struggling in order to avoid permanent changes in the muscle, you have to solve it within three hours. And this includes all the time from your detecting it to taking the vision to theater, to doing the surgery and salvaging it. And in real life, this is very tight, and that's why you have to detect it as soon as possible. And then we come to the second problem, which is a ski mia or in flow problem, And this will be the opposite of congestion. So the artery is not flowing blood in the flap, so the flab has very, uh, doesn't have much blood, which means the flab is shrunk. It's pale in color. It has like a very fell. So you press on it, you can't see any plunging or instead, it doesn't feel back. Will be minimum slow bleeding if you scratched it. And also absent double a signal. Unlike the venous flaps venous problem. And then this example, you can see in the top, uh, photo in the lower part of it. There is a lab here, and in the lower part of the flab is more white. The flab is the bar to chest X on it. The other boss our skin graft. So it's a different thing, and you can see the flag is white and it's shrunk. It's not swollen like the congested one, and if you did a capillary refill, it will be slow. And if you scratch it it it will not bleed or bleed very slowly. This is another example, and this lady she had the breast reconstruction. Actually, most of her flab are inside, and the only this only circulate the only part of the flap that we can see, and you can see how white it is compared to the rest of the flab and its chemical. And of course, we see a small stitch here, which is where we mark the Doppler signal is which, in this patient you won't be able to hear. What do you do for sciatic lab? We come back to our happy patient and we do the same. We do general measures. First, check the patient is warm and check. The patient is not in pain well hydrated and has good vital signs and your in outlook. And then check the flab, including the position, the color, the temperature, the capillary refill and the bleeding and also called for help as soon as possible. And now we come to the last part of our presentation, which is basically more pictures to see in order to get used to how these different labs look in different conditions, which hopefully will help when you see these patients in real life. So I'm going to go through a patient by a patient and explain what's going on there. So this lady, she had a breast reconstruction on the right hand side, and a few hours later, the on call person was called to check on her because there was concerns about the color. And as we can see, the color is darker, the flood is swollen, and if we breast honest, it will be brisk. So this is an example of flab, congestion or outflow problem. And this photo is after the patient was taken to theater and the vein problem corrected, and you can see how the color improved much. I'll go back and forth again. So this is when it was in the world and here where it was few minutes after repairing the vein. And this is shows us how these problems, if detected early, can be salvageable, and they save the patient another big surgery and a long course of difficult treatments. This is another patient with the breast flap as well, which looks congested, and it's dark in color. And we are talking only about the central circular board because the rest of the flab is inside and we can see how dark in color it is for president. It will be breast, and if we check the bleeding, it will be rabid and dark bleeding. This is another lower lymph lab, which you can see the congestion which started in the referee's and getting towards the center of the flat, and you can see how it's getting worse. And this is as well as a congested slab. And this video shows an example of rabbit or quick or brisk capillary refills so you can see you can see pressing on the flap, and it feels very quickly, okay, and this is another example of brisk capillary refill. That's very difficult, actually. To see the the refill, I repeat it again. It happened so quickly that you don't you may not even see the refill. Okay, Okay. This example looks like a muscle flap, which looks swollen. But I brought this example to show you this muscle is normal because despite the fact it looks swollen, it is not close in color. The skin graft over it looks like healthy and it's not dark, and if you scratch it it it's not going to get a brisk bleeding. The reason I brought this photo is not to cause confusion, but mainly to refer to a very important fact that in the beginning of any shift, you have to go and check the flaps. Was the person who is doing the shift before the reason for that that you get an idea how this flat looked because to an inexperienced, inexperienced boy, you made mistake a flap that's normally looking as a flag, which has a problem. And that's why it's important to see it in the beginning of the drift so that you can monitor any change of the flab and become concerned. This other photo is a flag on the lake, which has X mark on it, and you can see compared to the rest of the skin of the food, it's popular. And if you did a Doppler signal on the X mark, you will not be able to hear a Doppler signal, which means this flab has an inflow problem or ischemic flab. And it was salvaged and on the right hand side that showed the flag after salvage. This other example of a lab, which which looks more bluish in color. But because it was detected early, it's before it become more dark, and this lab was salvaged, uh, successfully and healed without any problems. Later on, the steps on the flag is to mark where to put the double to listen to the signal, and in this video will show that because his condition not which is out flow problem and the artist is still working. You can still so we can still hear an arterial signal and this example of lab scratch and so you can see how it bled quickly. And the blood coming out is dark colored. This is another example with a flat. So this patient, she had the breast reconstruction, and after a few days, she she was discharged at home. And unfortunately, she presented to any later with this And this is a completely did flat that we couldn't solve it anymore because it's already too late, uh, to do anything. And this is also an example of how an any doctor can get a flare up despite the fact that, uh, and you don't do flaps, but they still have to deal with the vision. Sometimes this is another muscle flap, which was a test a muscle flap taken from the back and covered with a skin graft. And from the photo here, you can see the muscle. Even with the skin graft over it, you can still see that the flab is darker in color and swollen. Oh, so, uh, in this lab because it's an outflow problem, the double war and and it was detected early. The Doppler signal was still very clear. Uh, and this and that will solve it successfully as well. To sum up, three slabs have variable indications invariable groups of patients. It's a very growing subspecialty, which provides a very, uh, robust and the good reconstruction solution, even for the most difficult defects. And the management of these patients was big defects. Change it massively recently because of this option available. The second thing is that what you're looking at on your own call is either this is a skin or a Muslim flab. When you monitor, you need to look at both at the general and local factors and for the emergencies. You need to think if there's a congested or ischemic lab, and lastly, it's a British reconstruction. Please managed monthly and call for help as soon as possible. And thank you. Any questions? Thank you know like a great talk. If anyone's got any questions, can you just post them in the chat? Does it look like there are any questions? You know, that's fine? Uh, that's fine. If there's any questions about that later. I'm happy to answer them through email. Okay. Oh, okay. Do you have any advice for specialty training applications? Uh, you mean for plastics? Yeah. I mean, I mean, I didn't go through the training process because I was trained abroad. And, uh, I'm using a different road, So I I don't think I would be the best person to advise about that. But from my experience, really, is that you have to check the application very early in your training. So from the start of your even core training and then build it while you go, and the last thing you want is to get to the end of your core training and then get surprised about what's required. But this is the only thing I can advise. You don't have much experience with that. It would probably be covered in another talk. Possibly as well. Um, there's another question that says, uh, restoration, uh, inspiration exposing the TB is supposed to be managed. Uh, split skin graft or four seconds. Skin graft can split thickness. Skin graft survive on exposed bone. Okay, that's a good question. Um, this is a very tricky thing. So The answer to this is that a splitting his his skin graft on exposed bone can survive cannot survive unless there is a healthy Prosteum underneath. So if there is a healthy periosteum, it can survive the cases I showed. They are for lower lumbar reconstruction, which are mainly patients who have fraction. And if you have a fracture underneath, it's a completely different story is no longer just a skin loss. So, for example, you had a massive, uh, some patient had a road traffic accident ended up with, uh, skin laceration, either because of the trauma myself or because the bone went broken. It, uh, went through the skin. In this situation, you have to do excessive derived. Want to get a very good skin coverage, and you have to do a lab. You can't put a skin graft because you need a very well vascularized tissue, an order for the fracture to heal. So if you don't have a robust tissue over the fracture, the fracture of the bone itself is not going to heal. So in summary, to answer your questions, please. Skin graft is a good option if you have periosteum or you have muscle and you don't have a fracture. If you have a fracture, it's an open fracture. Then you have to go for a flap. You can't cover an open fracture with the flab with a skin graft. Thank you. I think, uh, split skin grafts will be covered in another topic. I think, uh, in the late September October, I think that's it with the questions. That's fine. So if everyone's able to fill in this feedback for me by scanning the QR code or I'll post the link in the chat as well, um, and then you'll get a certificate for attending today. Okay. And the next session will be, uh, trauma and my colleague Howard shoes going to, uh, do this decision with you on fifties of August Used as well. I'm going to put this slide back for anyone who wants to take the You are good. And I think there was some more questions. There's one more question. Okay, so you're, for example, covering, uh, plastics department overnight. Those specifically for a congested or ischemic flab while the patient is waiting for theater after a drawer consultant has already been informed. That's a very good question. Any so there is a step wise approach. So you go as soon as possible. See the patient, Check the general condition of the patient. You check. He's not in pain is well hydrated urinal, but is good. Uh, vital data is good. He he is not on any vasopressors or, uh and don't want generally. And then you examined the flab in a well let area. So you check the local signs, which we talked about, and then after that, you call for help. So you call your straw and then the restaurants will come check it again, and the first thing he's going to do is to take all the dressing down. And the reason for that is that sometimes the dressing itself will be pressing on the flab. And also we we usually don't leave the whole flab exposed for monitoring. We only exposed about, so you need to to see the rest of the flab and the check with our the rest of the leg stands. If there is any hematoma under the flag which can cause the congestion, if there's any sign of compartment syndrome in the wreckage, may be the reason of it as well And then after that, the main thing really is preparing the vision to theater some. In very few cases, you may have to take some stitches out, but I don't think this happens quite often at all. You just need to take the vision to theater, to take all the stitches out to see what's going on in the vein and examine, probably under the microscope, and salvage it. So I hope this answered your question, and these patients should go to theater as soon as possible. So, for example, you have a flat on a lower lamp. This is considered a limp seven procedure to save this flab. If you have a patient who has a flare up and head and neck were constructing Hispanics like the photo we we saw and this lab is failing. This can be a life threatening condition because his saliva will go into his corroded and he will end up with carotid blew out. So these three slabs, despite in in many of the photos, looks like a simple problem. But in certain cases they are very critical, and usually in hospitals. They need to go very, uh, urgently. I would say there's one more, more as well and just asking in regards to POSTOP wound dressing and keeping the wound Bible and presuming mean the flat. Do you recommend anything or what do you normally put on top of the flat postoperatively? Okay, that's a good That's a good question as well. So as we mentioned, there are two types of labs. Their skin flaps, which you have a piece of skin there and you have only a suture line that you need to cover. So in this, most probably we just bought. We stretched it. And then we bought, uh, Steri strips or me effects on the edges, and we leave the rest of the flab exposed. It's just a piece of skin. So this is for skin. For muscle flaps is different because the muscle flap is in the beginning, it's woozy. So it was a lot, even with the skin graft over it. And also, the graft tends to draw if you lift it exposed. So, in order to preserve the flab and the graft, usually you do, uh, another hand dressing, and usually we use a gel on it. Uh, rather than maybe it's really, uh, yeah, and, uh, And then you're both goes. And if you if it's lower limb, for example, you bought a cluster of Paris, but you make sure there's no tightness at all, so it has to be very loose. Otherwise, it pressed on the vessels of the flap. So muscle flaps? None other than the recent Yes, skin flaps. No need. You just manage it as a symbol wound. Okay. Thank you. Thank you. Thanks a lot. Thanks, everybody, for ending this. Have a lovely evening. Thank you. Bye bye.