Presentation & Management of Common Problems in Plastic Surgery Presented by Anas Albarrak Ali Alsaleemi Hasan Alomaish

Notes with blue color mean doc’s notes

Plastic surgery includes many types: Reconstructive surgery, Craniofacial surgery Hand surgery, Microsurgery, and the treatment of burns.

Reconstructive plastic surgery Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma , injury, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Reconstructive Ladder IMP. a range of techniques of managing wounds and repairing defects. The surgeon should start on the lowest rung and move up until a suitable technique is arrived at. secondary intention primary intention skin graft skin flap

secondary intention: do nothing leave it to heal by secondary intention e.g. abrasion. Primary intention: also called primary closure or first step You can use sutures, staples, wound glue, and adhesive strips to close the edges of the wound directly and splint the wound in the position that will give the best cosmetic result.

skin grafts If there is skin loss, with a healthy bed of tissue underneath - for example, an uncomplicated burn— A skin graft is an autologous (material is taken from one part of a patient to another anatomical site on the same patient) The graft is a sheet of living cells without a blood supply Skin grafts provide a source of cells to grow over the damaged area and act as biological dressings to protect the wound.

Grafts may be full thickness or split thickness. 1- A full thickness graft is including the whole dermis, from the donor site.(better but more difficult to survive ) 2- Split thickness grafts are the epidermis and only part of the dermis. NOTE: the bed must be vascularized . DON’t put a graft on bone or cartilage

A skin graft used to help heal a leg ulcer

Meshing To increase the size of the graft When we have limited area of donor

Skin flaps: A skin flap consists of skin and subcutaneous tissue that survives based on its own blood supply. Use a skin flap for wound coverage when inadequate vascularity of the wound bed prevents skin graft survival.

Local flap: Use local flaps for defects that are adjacent to the donor site.

Free flap: "Free" implies that the tissue, along with its blood supply, is detached from the original location ("donor site") and then transferred to another location ("recipient site").  

Tissue expansion (we use it to take a flap or agraft) insert the inflatable expander beneath the skin and periodically, over weeks or months, injects a saline solution to slowly stretch the overlaying skin. excess skin is grown purposely by expansion remove it and transplant it to another site where skin was lost.

Craniofacial surgery Craniofacial surgery is divided into pediatric and adult craniofacial surgery. Pediatric craniofacial surgery involves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, craniosynostosis, and pediatric fractures. Adult craniofacial surgery deals mostly with fractures.

CLEFT LIP AND PALATE: Cleft lip and palate: Congenital deformity caused by abnormal facial development during gestation: Types: Types of cleft lip : 1- INCOMPLETE a small gap or an indentation in the lip . 2- COMPLETE Continues into the nose Lip cleft can occur as one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

Less common than cleft lip In most cases, cleft lip is also present.   Cleft palate: Less common than cleft lip In most cases, cleft lip is also present. Usually affect soft palate and posterior third of hard palate. Palate cleft can occur complete (soft and hard palate) incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate).   When cleft palate occurs, the uvula is usually split. The hole in the roof of the mouth caused by a cleft connects the mouth directly to the nasal cavity.

Symptoms & signs: cleft lip is obvious at birth Cleft palate is discovered after routine inspection Feeding difficulties If not treated: may have speech and hearing problems

V.Imp slide peirre-robin sequence .micrognathia, glossoptosis and cleft palate (MCQ) Treatment of cleft lip/palate Cleft lip treatment: operation at 10 weeks. Cleft palate treatment : .The operation is done at 9-12 months

Craniosynostosis Craniosynostosis a condition in which the sutures (soft spots) in the skull of an infant close too early, causing problems with normal brain and skull growth. Premature closure of the sutures may also cause the pressure inside of the head to increase and the skull or facial bones to change from a normal, symmetrical appearance.

Hand surgery Hand surgery is concerned with acute injuries and chronic diseases of the hand and wrist, correction of congenital malformations of the upper extremities, and peripheral nerve problems (such as brachial plexus injuries or carpal tunnel syndrome).

* Congenital anomalies present at birth: 1-problems in development of the parts: Radial clubhand: involves all of the tissues on the radial side (thumb side) of the forearm and hand. There may be shortening of the bone, a small thumb, or absence of the thumb. operated on around 6 months of age.

ulnar clubhand: less common than a radial clubhand ulnar clubhand: less common than a radial clubhand. involve underdevelopment of the ulnar bone or complete absence of the bone.

Ulner clubhand Radial clubhand

Preoperation Postoperation ( Ulnarization procedure )

Know the names 2-failure of parts of the hand to separate: Syndactyly is the most common congenital hand deformity There is a familial tendency to develop this deformity. This deformity usually involves both hands. two types of syndactyly: simple syndactyly - involves fusion between only the tissues of the fingers. complex syndactyly - involves fusion between the bones.

Treatment: surgical separation

Others: duplications of digits: (polydactyly) more in ulnar side , but more difficult to repair in radial side -undergrowth of digits overgrowth of digits >> macrodactyly . clinodactyly radial or ulnar deviation of the digit. .camptodactyly flexion deformity .

duplications of digits

macrodactyly Camptodactyly

Carpal Tunnel Syndrome Compression of the median nerve in the carpal tunnel. causes impaired nerve conduction and compression paraesthesia and pain Related Conditions: Pregnancy RA OA Amyloidosis Hypothyroidism Diabetes mellitus Use of corticosteroids and estrogens Repetitive activities of the hand and wrist

Symptoms: Pain, paraesthesia in the thumb index and middle finger Symptoms: Pain, paraesthesia in the thumb index and middle finger.(median nerve distribution) Worse at night. Signs: Tinel’s sign >> symptoms with percussion over the median nerve. Phalen’s test >> symptoms with flexion of wrists. Thenar atrophy >> late sign.

Initially: night wrist splint, vitamin B6, NSAIDs, steroid injections Investigation: Nerve conducting study Treatment Initially: night wrist splint, vitamin B6, NSAIDs, steroid injections Indication for surgery: refractory symptom, thenar atrophy, thenar weakness Surgery: release transverse carpal ligament

Trigger finger Trigger finger is the popular name of stenosing tenosynovitis, a painful condition in which a finger or thumb locks when it is bent (flexed) or straightened (extended). Due to narrowing of the sheath that surrounds the tendon in the affected finger, or a nodule forms on the tendon. It is called trigger finger because when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.

Causes: Affected digits may become painful to straighten once bent Overuse, repetitive or frequent movement of the fingers . Trauma Accident Clinical Picture: Affected digits may become painful to straighten once bent Soft crackling sound when moved. Props back suddenly when straightened Usually worse in the morning and improve during the day

Treatment: local steroid injections and splinting (weeks to months) 70% will respond Surgery: cut the sheath that is restricting the tendon.

Tumors of the hand Most of them are benign and amenable for surgery. Classification of the hand’s tumors: Skin. Soft tissue. Bone. Metastatic.

Skin Tumors Squamous cell carcinoma (the commonest) Basal cell carcinoma rare Malignant Melanoma

Soft Tissue Tumors Ganglions >>the most common tumer in the hand MCQ Giant Cell Tumor Of Tendon Sheath Glomus Tumor Peripheral Nerve Tumors Ulnar Artery Aneurysm Epidermal Inclusion Cysts Sarcomas

Ganglions most common site Dorsal Wrist Ganglion 70 % of all hand tumors Caused by mucoid degeneration of fibrous connective tissue in joint capsules or tendon sheaths Women > Men (2-3X) Presents as mass +/- pain   Types of Ganglia most common site Dorsal Wrist Ganglion II. Volar Wrist Ganglion III. Flexor Tendon Sheath Ganglion IV. V. Carpal Bosses Mucous Cysts

Ganglions Treatment Observation Rupture Aspiration Injection Surgical Excision

Bone tumors: just read it Ewing’s Sarcoma Osteosarcoma Chondrosarcoma Enchondromas Osteochondromas Chondroblastomas Bone Cysts Osteoid Osteoma Osteoblastomas Giant Cell Tumor of Bone

Metastatic Tumors of the hand: Uncommon Associated with primary lung, kidney Distal phalanges Amputation recommended if life expectancy compatible

Cosmetic plastic surgery concerned with maintaining normal appearance, restoring it, or enhancing it beyond the average level toward some aesthetic ideal. It’s include : Facial plastic : Rhinoplasty ,facelift ,Collagen / Fat Injectable Fillers Body contouring : Abdominoplasty, liposuction, breast augmentation, Breast reduction.

Rhinoplasty The procedure can; Closed rhinoplasty open rhinoplasty complications; 1-repetitive surgery: a second procedure may be required to correct a minor deformity that occurs as a result of the initial rhinoplast 2- Nosebleed 3-burst blood vessels: tiny red spots on the nose to surface 4-scarring With the "open" procedure

Abdominoplasty   is a cosmetic surgery procedure used to make the abdomen more firm. This type of surgery is usually sought by patients with loose tissues after pregnancy or individuals with sagging after major weight loss. Types: 1-complete, or full abdominoplasty 2-A partial, or mini abdominoplasty 3- extended abdominoplasty is a complete abdominoplasty that extends to the fronts of the thighs and flanks (sides).

Contraindications 1-Obesity 2-Likely or planned future pregnancy Complication 1-Bleeding / Hematoma 2-Infection 3-Wound dehiscence 4-Abnormal scars 5-Umbilical deformity

liposuction Liposuction is a procedure that removes excess fat through a suctioning process. Although it is not a substitute for weight loss, it is a way of changing the body's shape and contour. Site of liposuction; the chin, on the hips, thighs, and stomach, and in the under arm and breast areas. complications : 1-injury to the skin or deeper tissue 2-irregular skin surface 3-greater risks if large areas are treated

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