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
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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
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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
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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
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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.
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Pressure sore
Treatment
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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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