Plastic Surgery

IntroductionPlastic 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 GraftingA 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 SurgeryIt 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) MicrosurgeryThe 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 SurgeryDeals 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 healingLocal 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 healingGeneral 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 principles1 Immunization2 Pre-anesthetic medication if needs3 Local anesthesia – use epinephrine adjuvant unless

contraindicated, eg., digit,tip of penis4 Tourniquet5 Cleansing of surrounding skin – do NOT use strong

antiseptic in the wound itself

Management of the clean wound

General principles6 Debridement• Remove clot and debris, necrotic tissue• Copious irrigation good adjunct to sharp• debridement7 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 dressings1 Protect the wound from trauma2 Provide environment for healing3 Antibacterial medication provide moisture and control

microorganism.4 Splinting - casting• For immobilization to promote healing• Do not splint too long – may promote joint stiffness5 Pressure dressings• May be useful to prevent dead space, seroma,hematoma• Do NOT compress flaps tightly6 Do NOT leave dressing on too long before changing

Plastic Surgery

• Grafts and FlapsSkin protects the body from outside invaders and

preventsloss of the fluids, electrolytes, protein, ect. Skin may bereplaced by spontaneous epithelialization and

contraction or by a graft or flap.• Skin graftA skin graft is separated completely from its bed (donorsite) and transplanted to another area (recipient site)

from wich it must receive a new blood supply.

Skin graft

Classification• By species1 Autograft2 Allograft (homograft)3 Xenograft (heterograft)

• By thickness1 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 thickA higher percentage of *take* (survival) is more likelywith a thinner graftRecipient site wound contraction is less with a thicker graft

Plastic Surgery• 4 UsesLarge areas of skin lossGranulating tissue bedsMay be meshed to allow increase area of coverage• 5 Procurement methodsfree hand ( razor blade or knife)Dermatome• 6 Donor siteHeals by epithelialization from wound edges and skin

appendagesA moist environment hastens epithelializationRequires care to prevent infection which can convert it to full

thickness skin loss

Plastic Surgery

Full thickness1 Includes epidermis and all dermis2 Provides better coverage but is less likely to take than asplit thickness skin graft because of greater thickness and slowervascularization.3 Donor site is full thickness skin loss and must be closed primarily

or with split thickness skin graft4 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 bydiffusion 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 < 104 .Immobilization5 .Poor vascular bed - bare bone, tendon,irradiated area6. Inspection of the graft prior to day 4

Graft survival

7. Graft loss most commonly the result ofHematoma/seroma under the graftShearing forces between graft and recipient sitePoorly vascularized recipient siteInfection/ 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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