Plastic Surgery

Introduction Plastic surgery is defined as any procedure used to correct or restore either form or function to a body part. It deals with body modification and reconstructive surgery as well as surgery for aesthetically pleasing purposes.

History Body reconstruction surgery was done as early as 2000 B.C.E by the famous Indian surgeon, Sushruta. Nose and ear reconstruction were the first procedures done.

History WWI was the biggest booster to plastic surgery. It produced the two “fathers” of modern plastic surgery, New Zealander Harold Gillies and American Vilray Blair. Gillies even performed the first male-to-female sex change operation in 1951! Gillies Blair

Techniques and Procedures

1) Skin Grafting A skin graft is the replacement of a patient’s skin. Required after major skin loss from a burn, major trauma or infection (i.e. flesh eating bacteria). Usually plastic surgeons are called in to do skin grafts. They plan their cut lines on the patients and close and remove sutures or staples in a particular sequence in order to minimize scarring.

2)Reconstructive Surgery It is performed to correct function, but in some cases may be used to generate a more normal appearance. Common procedures include tumour removal, facial reconstruction, hand repair, breast reduction and breast reconstruction (after a mastectomy).

3) Microsurgery The reconstruction of missing tissues usually by the transfer of tissue from another part of the body. Called microsurgery because the doctor uses a microscope in order to see the vessels and fibres he/she needs to connect after the tissue has been transferred.

4) Cosmetic Surgery Deals with enhancement of appearance for non-medical reasons. Includes any “lifting”, augmentation or implant insertion. Nose jobs, face lifts, Botox, collagen injections, breast augmentation and tummy tucks are the most common. Brazilian Butt lifts are starting to challenge though. ;)

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

Wound closure Factor influencing wound healing General factors Cannot be readily controlled by surgeon Systemic effect of steroids Nutrition Uncontrolled DM Chemotherapy Chronic illness

Management of the clean wound Goal - close wound as soon as possible to prevent infection, fibrosis and secondary deformity

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

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.

Management of the wound Type of wounds and their treatment Abrasion Contusion Laceration Avulsion Puncture wound

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.

Skin graft Classification By species By thickness 1 Autograft 2 Allograft (homograft) 3 Xenograft (heterograft) By thickness 1 Split thickness ( thin, medium, thick ) 2 Full thickness

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

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

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

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

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)

Flaps Classification 1 Random pattern flaps 2 Axial pattern flaps ( arterial flap) 3 Musculocutaneous flap (myocutaneuos)

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

Cleft Lip/Palate Anatomy Classification Prevalence Etiology Pathophysiology

Cleft Lip/Palate Classification - Incomplete - Complete - Unilateral - Bilateral

Cleft Lip

Cleft Lip

Cleft Lip

Cleft Palate Classification - bifid uvula submucous cleft palate - Cleft of secondary palate - Cleft Palate Unilateral - Cleft Palate Bilateral

Cleft Palate

Cleft Palate

Cleft Palate

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