Plastic and Reconstructive. SurgeryEssential for Student. Associate Prof. Vichai
Chichareon. Division of Plastic Surgery. Prince of Songkla University ...
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 wound General 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 wound General principles 6 Debridement Remove clot and debris, necrotic tissue Copious irrigation good adjunct to sharp debridement 7 Closure - atraumatic technique to approx. dermis Consider 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 healing Do 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
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 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 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 Surgery 4 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 thickness 1 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 closed primarily 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 survival 1 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 survival 7 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 Flaps A 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 Flaps Classification 1 Random pattern flaps 2 Axial pattern flaps ( arterial flap) 3 Musculocutaneous flap (myocutaneuos)
Plastic Surgery
Plastic Surgery Flaps uses 1 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/Palate Anatomy Classification Prevalence Etiology Pathophysiology
Plastic Surgery Cleft Lip/Palate Classification - Incomplete - Complete - Unilateral - Bilateral
Plastic Surgery Cleft Lip
Plastic Surgery Cleft Lip
Plastic Surgery Cleft Lip
Plastic Surgery Cleft Palate Classification - bifid uvula submucous cleft palate - Cleft of secondary palate - Cleft Palate Unilateral - Cleft Palate Bilateral
Plastic Surgery Cleft Palate
Plastic Surgery Cleft Palate
Plastic Surgery Cleft Palate
Plastic Surgery Cleft Lip/Palate Timing of primary repair Lip Palate Principles of primary repair Secondary repair
Plastic Surgery Cleft Lip/Palate Team 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 University Every 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, iscial tuberosity, 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
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