plastic and reconstructive surgery essential for student

8/7/2019 Plastic and Reconstructive Surgery Essential for Student

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Plastic and ReconstructiveSurgeryEssential for Student

Associate Prof. Vichai Chichareon

Division of Plastic SurgeryPrince of Songkla University


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Plastic Surgery

Reconstructive surgery

Aesthetic Surgery


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Plastic Surgery

Basic Principles of Plastic Surgery Congenital anomalies of Head and Neck

Craniofacial anomalies

Cleft Lip/Palate

Maxillofacial Surgery, Trauma Reconstruction Aesthetic Head and Neck Cancer, Tumor

Burn

Hand surgery, Congenital Trauma Tumor Infection

Urogenital Anomalies

Aesthetic Surgery


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Plastic Surgery

Wound closureFactor influencing wound healing

Local factors

Tissue trauma

Hematoma - associated with higher infection rate

Blood supply

TemperatureInfection

Technique and suture materials only importantwhen factors 1-5 have been controlled


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Plastic Surgery

Wound closureFactor influencing wound healing

General factorsCannot be readily controlled by surgeon

Systemic effect of steroids

Nutrition

Uncontrolled DM

Chemotherapy

Chronic illness


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Plastic Surgery

Management of the clean wound

Goal - close wound as soon aspossible to prevent infection, fibrosisand secondary deformity.


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Plastic Surgery


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Plastic Surgery


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Plastic Surgery

Management of the clean woundGeneral principles

1 Immunization

2 Pre-anesthetic medication if needs3 Local anesthesia use epinephrine

adjuvant unless contraindicated,eg., digit,tip of penis

4 Tourniquet5 Cleansing of surrounding skin do NOT

use strong antiseptic in the wound itself


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Plastic Surgery

Management of the clean woundGeneral principles

6 Debridement

Remove clot and debris, necrotic tissue

Copious irrigation good adjunct to sharpdebridement

7 Closure - atraumatic technique to approx. dermisConsider undermining of wound edges to

relieve tension.8 Dressing must provide absorption, protection,

immobilization, even compression, and beaesthetically acceptable.


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Plastic Surgery

Management of the woundType of wounds and their treatment

Abrasion

ContusionLaceration

Avulsion

Puncture wound


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Plastic Surgery

Wound dressings1 Protect the wound from trauma

2 Provide environment for healing

3 Antibacterial medicationprovide moistureand control microorganism.

4 Splinting - casting

For immobilization to promote healingDo not splint too long may promote joint stiffness

5 Pressure dressings

May be useful to prevent dead space, seroma,hematoma

Do NOT compress flaps tightly

6 Do NOT leave dressing on too long before changing


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Plastic Surgery

Grafts and FlapsSkin protects the body from outside invaders and prevents

loss of the fluids, electrolytes, protein, ect. Skin may bereplaced by spontaneous epithelialization and contraction or bya graft or flap.

Skin graft

A skin graft is separated completely from its bed (donor

site) and transplanted to another area (recipient site) from wich

it must receive a new blood supply.


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Plastic Surgery

Skin graftSplit thickness

1 Includes epidermis and part of dermis

2 Some dermal skin appendages ( sweat glands, hair follicles

and sebaceous glands) remain, from which donor site heals byepithelialization.

3 Thickness varies from thin to thick

A higher percentage of *take* (survival) is more likelywith a thinner graft

Recipient site wound contraction is less with a thickergraft


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Plastic Surgery4 Uses

Large areas of skin loss

Granulating tissue beds

May be meshed to allow increase area of coverage

5 Procurement methods

free hand ( razor blade or knife)Dermatome

6 Donor site

Heals by epithelialization from wound edges and skinappendages

A moist environment hastens epithelialization

Requires care to prevent infection which can convert itto full thickness skin loss


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Plastic Surgery

Full thickness1 Includes epidermis and all dermis2 Provides better coverage but is less likely to take than a

split thickness skin graft because of greater thickness and slowervascularization.

3 Donor site is full thickness skin loss and must be closedprimarily or with split thickness skin graft

4 Uses

Usually on the face for better color match

On the finger to avoid contractureAnywhere that thick skin or less contraction of therecipient site is desired

Limited by size of defect to be closed


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Plastic Surgery


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Plastic Surgery

Graft survival1 Both split and full thickness grafts take innitially bydiffusion of nutrition from the recipient site (plasma imbibition)

2 Revascularization generally occurs between day 35

by either reconnection of blood vessels in the graft to recipientsite vessels or by ingrowth of vessels from the recipient site intothe graft

3 Bacterial count at the recipient bed < 10

4 Immobilization

5 Poor vascular bed - bare bone, tendon,irradiated area

6 Inspection of the graft prior to day 4


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Plastic Surgery

Graft survival7 Graft loss most commonly the result of

Hematoma/seroma under the graft

Shearing forces between graft and recipient site

Poorly vascularized recipient site

Infection/ colonization


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Plastic Surgery

FlapsClassification

1 Random pattern flaps

2 Axial pattern flaps ( arterial flap)3 Musculocutaneous flap (myocutaneuos)


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Plastic Surgery


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Plastic Surgery

Flapsuses1 Replace tissue loss due to trauma or surgical

excision

2 Provide skin coverage through which surgery canbe carried on latter

3 provide padding over bony prominences

4 Bring in better blood supply to poorlyvascularized bed

5 Improve sensation to an area (sensate flap)

6 Bring in specialized tissue for reconstruction suchas bone or functioning muscle


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Plastic Surgery


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Plastic Surgery


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Plastic Surgery

Cleft Lip/PalateAnatomy

Classification

PrevalenceEtiology

Pathophysiology


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Plastic Surgery

Cleft Lip/PalateClassification

- Incomplete

- Complete

- Unilateral

- Bilateral


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Plastic Surgery

Cleft Lip


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Plastic Surgery

Cleft Lip


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Plastic Surgery

Cleft Lip


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Plastic Surgery

Cleft PalateClassification

- bifid uvula submucous cleft palate

- Cleft of secondary palate

- Cleft Palate Unilateral

- Cleft Palate Bilateral


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Plastic SurgeryCleft Palate


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Plastic Surgery

Cleft Palate


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Plastic Surgery

Cleft Palate


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Plastic Surgery

Cleft Lip/PalateTiming of primary repair

Lip

PalatePrinciples of primary repair

Secondary repair


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Plastic Surgery

Cleft Lip/PalateTeam conceptBecause of multiple problems with speech,

dentition, hearing, ect. management of the patient with a cleft

should be by an interdisciplinary team, preferable in a cleftpalate o craniofacial clinic.

Cleft Lip/Palate and Craniofacial CenterPrince of Songkla University

Every second Monday of the month 13:00 (1:00 pm.)


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Plastic Surgery


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Plastic Surgery

Pressure soreEtiology

Pressure transmitted to the tissue, especially over bony

prominences, exceeds the arteriolar or capillary pressure (35 mmHg).

Ischemia of tissue results. Initiation of pressure ulceration may occurafter as little as two hours of continuous pressure.

Paraplegic and nonparaplegic patients

Most common sites Greater trochanter, iscial

tuberosity, sacrum and the heel


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Plastic Surgery

Pressure soreClassification

Grade I Erythema of skin

Grade II Skin ulceration and necrosisinto subcutaneous tissue

Grade III Grade II plus muscle necrosis

Grade IV Grade III plus exposedbone/joint involvement


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Plastic Surgery


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Plastic Surgery

Pressure soreTreatment

1 Prevention Best treatment

Keep skin clean and dry

Frequent turning of patient

(at least every 2 Hours)

Pressure in special areas may bepartially relieved with foam cushionflotation mattresses.


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Plastic Surgery


2 Preoperative

Debride necrotic tissue

Whirlpool and appropriate dressing

Systemic antibiotics as indicated

X-rays, bone scan and/or bone biopsy


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Plastic Surgery


3 Operative

Adequate ulcer excision

Excise involved bone and smoothbony prominence

Wound closure with local skin ormyocutaneous flap


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Plastic Surgery

The end

plastic and reconstructive surgery essential for student

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