Plastic and Reconstructive Surgery Essential for Student

Associate Prof. Vichai Chichareon

Division of Plastic Surgery

Prince of Songkla University

Plastic Surgery

� Reconstructive surgery

� Aesthetic Surgery

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

Plastic Surgery

� Wound closure

Factor influencing wound healing

Local factors

Tissue trauma

Hematoma - associated with higher infection rate

Blood supply

Temperature

Infection

Technique and suture materials – only important when factors 1-5 have been controlled

Plastic Surgery

� Wound closure

Factor influencing wound healing

General factors Cannot be readily controlled by surgeon

Systemic effect of steroids

Nutrition

Uncontrolled DM

Chemotherapy

Chronic illness

Plastic Surgery

� Management of the clean wound

Goal - close wound as soon as possible to prevent infection, fibrosis and secondary deformity.

Plastic Surgery

Plastic Surgery

Plastic Surgery

� Management of the clean woundGeneral principles

1 Immunization

2 Pre-anesthetic medication if needs

3 Local anesthesia – use epinephrine adjuvant unless contraindicated, eg., digit,tip of penis

4 Tourniquet

5 Cleansing of surrounding skin – do NOT

use strong antiseptic in the wound itself

Plastic Surgery

� Management of the clean woundGeneral principles

6 Debridement

Remove clot and debris, necrotic tissue

Copious irrigation good adjunct to sharp debridement

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

8 Dressing – must provide absorption, protection,

immobilization, even compression, and be aesthetically acceptable.

Plastic Surgery

� Management of the wound

Type of wounds and their treatment

Abrasion

Contusion

Laceration

Avulsion

Puncture wound

Plastic Surgery� Wound dressings

1 Protect the wound from trauma

2 Provide environment for healing

3 Antibacterial medication provide moisture and control microorganism.

4 Splinting - casting

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

5 Pressure dressingsMay be useful to prevent dead space, seroma,hematoma

Do NOT compress flaps tightly

6 Do NOT leave dressing on too long before changing

Plastic Surgery

� Grafts and Flaps

Skin protects the body from outside invaders and prevents loss of the fluids, electrolytes, protein, ect. Skin may be replaced by spontaneous epithelialization and contraction or by a 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.

Plastic Surgery

� Skin graft

Classification

By species

1 Autograft

2 Allograft (homograft)

3 Xenograft (heterograft)

By thickness

1 Split thickness ( thin, medium, thick )

2 Full thickness

Plastic Surgery

� Skin graft

Split thickness1 Includes epidermis and part of dermis

2 Some dermal skin appendages ( sweat glands, hair follicles and sebaceous glands) remain, from which donor site heals by epithelialization.

3 Thickness varies from thin to thick

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

Recipient site wound contraction is less with a thicker graft

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 skin appendages

A moist environment hastens epithelialization

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

Plastic Surgery

Plastic Surgery

Full thickness1 Includes epidermis and all dermis

2 Provides better coverage but is less likely to take than a split thickness skin graft because of greater thickness and slower vascularization.

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 contracture

Anywhere that thick skin or less contraction of the recipient site is desired

Limited by size of defect to be closed

Plastic Surgery

Plastic Surgery

Graft survival1 Both split and full thickness grafts take innitially by

diffusion of nutrition from the recipient site (plasma imbibition)

2 Revascularization generally occurs between day 3 –5

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

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

Plastic Surgery

FlapsA flap is tissue transferred from one site to

another with its vascular supply intact. This may consist of skin, subcutaneous tissue, fascia, muscle, bone or other tissues (eg. Omentum)

Plastic Surgery

FlapsClassification

1 Random pattern flaps

2 Axial pattern flaps ( arterial flap)

3 Musculocutaneous flap (myocutaneuos)

Plastic Surgery

Plastic Surgery

Flaps uses1 Replace tissue loss due to trauma or surgical

excision

2 Provide skin coverage through which surgery can be carried on latter

3 provide padding over bony prominences

4 Bring in better blood supply to poorly vascularized bed

5 Improve sensation to an area (sensate flap)

6 Bring in specialized tissue for reconstruction such as bone or functioning muscle

Plastic Surgery

Plastic Surgery

Plastic Surgery

Cleft Lip/PalateAnatomy

Classification

Prevalence

Etiology

Pathophysiology

Plastic Surgery

Cleft Lip/PalateClassification

- Incomplete

- Complete

- Unilateral

- Bilateral

Plastic Surgery

Cleft Lip

Plastic Surgery

Cleft Lip

Plastic Surgery

Cleft Lip

Plastic Surgery

Cleft PalateClassification

- bifid uvula submucous cleft palate

- Cleft of secondary palate

- Cleft Palate Unilateral

- Cleft Palate Bilateral

Plastic SurgeryCleft Palate

Plastic Surgery

Cleft Palate

Plastic SurgeryCleft Palate

Plastic Surgery

Cleft Lip/PalateTiming of primary repair

Lip

Palate

Principles of primary repair

Secondary repair

Plastic Surgery

Cleft Lip/PalateTeam concept

Because of multiple problems with speech, dentition, hearing, ect. management of the patient with a cleft should be by an interdisciplinary team, preferable in a cleft palate o craniofacial clinic.

Cleft Lip/Palate and Craniofacial Center

Prince of Songkla UniversityEvery second Monday of the month 13:00 (1:00 pm.)

Plastic Surgery

Plastic Surgery

Pressure sore

Etiology

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 occur after as little as two hours of continuous pressure.

Paraplegic and nonparaplegic patients

Most common sites – Greater trochanter, iscialtuberosity, sacrum and the heel

Plastic Surgery

Pressure sore

Classification

Grade I Erythema of skin

Grade II Skin ulceration and necrosis into subcutaneous tissue

Grade III Grade II plus muscle necrosis

Grade IV Grade III plus exposed bone/joint involvement

Plastic Surgery

Plastic Surgery

Pressure sore

Treatment

1 Prevention – Best treatment

Keep skin clean and dry

Frequent turning of patient

(at least every 2 Hours)

Pressure in special areas may be partially relieved with foam cushion flotation mattresses.

Plastic Surgery

Pressure sore

Treatment

2 Preoperative

Debride necrotic tissue

Whirlpool and appropriate dressing

Systemic antibiotics as indicated

X-rays, bone scan and/or bone biopsy

Plastic Surgery

Pressure sore

Treatment

3 Operative

Adequate ulcer excision

Excise involved bone and smooth bony prominence

Wound closure with local skin or myocutaneous flap

Plastic Surgery

The end