Plastic Surgery SC023: I Want To Look Better: Plastic And Reconstructive Surgery Flashcards
Plastic surgery
Plastic: Mold / Form
- Surgical operations from head to toe
- Optimal tissue handling, design, transfer and reshape for **forms and restoration of **functions as primary goals
- With enhanced ***feeling (psychosocial of patients)
2 main streams:
- Plastic and Reconstructive surgery
- Aesthetic / Cosmetic surgery
Areas of interest:
- Congenital deformities
- Skin and soft tissue cancer / scar management
- Trauma / Facial fracture / Burn / Wound
- H+N / Craniofacial
- Breast / Trunk + Abdomen
- Hand and extremities
- Microsurgery and flap surgeries
- Aesthetic and aging
Wound closure and healing
Primary closure
- wound closed with approximation of wound edge surgically e.g. ***clean surgical wound, cut wound
Delayed primary closure
- wound remains open for few days before surgical closure
- allow drainage and cleansing, decrease risks of infections in ***contaminated wounds e.g. dog bite wound
Secondary closure (Secondary intention)
- wound closure by **granulation, epithelialisation and contraction
- indicated for **infected, contaminated wound e.g. abscess
- prolonged inflammatory phase, healing with increase **scarring and **contracture
Closure techniques to achieve good outcome
- Ensure haemostasis (e.g. haematoma underneath will not allow wound edge to oppose each other very well)
- Ensure viability of tissue
- Obliterate dead space
- Good approximation of tissue in layers (e.g. skin to skin, fat to fat —> if in stepping (e.g. fat to dermis) —> scarring may occur)
- Use of subcuticular closure (i.e. sutures in dermal plane) / fine dermal interrupted suturing to minimise scar / stitch marks
- Avoid tension / pressure on wound
- Appropriate timing for stitches removal (otherwise re-epithelialisation along suture tract —> more scar formation)
Skin anatomy and blood supply
Skin:
- Epidermis
- Dermis
- Subdermis
Blood supply to skin:
Fasciocutaneous vessels
—> ***Perforating branches through muscles (∴ necessary to include muscles in the flap to preserve these branches to nourish the skin)
—> Subdermal plexus
—> Subepidermal
5. (Axial —> Random)
**∴ Importance of identification (using Doppler) and preservation of **perforators during flap reconstruction
Concept of angiosomes
Angiosome: A **composite unit of skin and underlying tissue supplied by a **source vessel
- Flaps are designed based on knowledge of angiosomes of the respective region
- A flap contains >=1 angiosomes
- Area outside the angiosome territory will NOT be supplied by the source vessel
- Common named flaps / free design of perforator flaps
Example:
1. Transverse rectus abdominis myocutaneous flap (TRAM flap)
- Free flap: based on **Inferior epigastric vessels
- Pedicle flap: based on communicating branches from **Superior epigastric vessels
- 4 zones of TRAM (Zone 1 contain most circulation —> Zone 4 least circulation)
- further away from the perforator —> less reliable of blood supply
- Radial forearm flap
- based on Radial artery
***Skin graft
- Transfer of tissue ***without usual source of blood supply (vs Flap: transfer of tissue with preservation of its original blood supply)
- Depends on ***good recipient bed for blood supply and subsequent establishment of new vasculature (take time: ~1 week for new vessels to grow into skin graft)
—> good recipient bed: muscles
—> poor recipient bed: tendons, bones
—> factors preventing new vessels growing: pressure, infection
Types of graft:
1. Autograft (from same individual e.g. split thickness skin graft)
2. Allograft (from same species e.g. cadaveric liver / kidney transplant)
3. Xenograft (from another species e.g. procine skin graft)
Classification of Skin graft:
1. **Split thickness (STSG)
- Epidermis + **Partial dermis
- **Easier take
- **Greater contraction
- Donor site healed by **re-epithelialisation
- **Larger area of donor site
-
**Full thickness (FTSG)
- Epidermis + **Entire dermis
- **Improved cosmesis (Better colour matching)
- **Less contraction
- Donor site to be closed **primarily
- Preferred for facial defects, hands, over joints
- **Limited size of donor site and graft size
***Skin flap
- Transfer of tissue with ***preservation of its original blood supply
Classification:
According to blood supply:
1. Random (no definite blood vessels supply, simply reticular / plexus of vessels)
2. Axial (a definite blood vessel supply)
3. Reverse flow flap
According to **Design of flap:
1. Advancement
2. Transposition (e.g. bilobe flap)
3. Rotation
4. Interpolation
—> **Elasticity and ***Vascularity of skin for vector changes important in flap design
—> Affected by aging skin, scar tissue around
According to **Proximity of tissue:
1. Local (e.g. **Nasolabial flap)
2. Regional (e.g. **Forehead)
3. Distant (e.g. **LD flap)
4. Free (e.g. ***Free ALT)
According to ***Tissue transferred:
1. Cutaneous (e.g. Skin flap)
2. Fasciocutaneous (e.g. Radial forearm)
3. Myocutaneous (e.g. TRAM)
4. Osteomyocutaneous (e.g. Fibula for mandible reconstruction)
Vascular pattern of muscle and flap designs
Flap survival depends on preserved vasculature and vascularised tissue captured and transferred
Type 1: Single vascular pedicle (e.g. tensor fascia lata)
Type 2: Dominant pedicle + minor pedicle (e.g. gracilis)
Type 3: 2 Dominant pedicles (e.g. gluteus maximus, rectus abdominis)
Type 4: Segmental vascular pedicles (e.g. sartorius)
Type 5: Single dominant pedicle + secondary segmental pedicles (e.g. LD, pectoralis major)
Z plasty for scar revision
- Based on elasticity of skin and undermining of surrounding tissue
- Skin can be stretched and rotated
Advantages:
- Lengthening of scar (if there is contracture)
- Change direction of scar
- Break pulling effect on scar
Disadvantages:
- New scars
Modification:
- Multiple Z plasty
- W plasty
Resection and Reconstruction
Surgical approach:
1. Open surgery
2. Minimal invasive surgery (minimise scar)
3. Other destructive devices (no direct incision)
- Cauterisation
- Cryosurgery
- Topical agents
- Laser ablation
- Radiofrequency
- Focused ultrasound
Area to be resected determined primarily by **pathology —> reconstruction comes **second
- Adequate resection with ***clear margin for cancer surgery
—> BCC 2-3 mm margin
—> SCC 1 cm margin
—> Sarcoma 2-3 cm margin
Reconstruction:
- based on ***Reconstruction ladder: simple to complicated (Primary closure —> Secondary intention —> Skin graft —> Local flap —> Pedicle flap —> Free flap)
- balanced by:
1. Amount of tissue loss
2. Availability of surrounding donor tissue
3. Complexity of procedures
4. Expertise available
5. Cosmetic and functional outcomes
***Reconstruction ladder
Simple to Complicated
1. Primary closure
2. Secondary intention
3. Skin graft (Split thickness, Full thickness)
4. Local flap
5. Pedicle flap
6. Free flap
Autogenous tissue vs Implant
Autogenous tissue:
- Depends on availability of donor tissue
- Donor site morbidity
- Less infection once taken
- Lifelong
- Living issue with possibility of healing
- Examples: TRAM flap, Skin graft, Cartilage graft
Implants:
- for Structural volume / support
- Foreign body reaction
- Infection / extrusion
- Material fatigue, breakage
- Capsular fibrosis / pain
- Cost
- Examples: Breast, Nose, Medpor (bone graft), Metal implants
Common diseases in Plastic surgery
- Congenital deformities
- Cleft lips and palates
- Craniofacial syndromes, Microtia
- Soft tissue tumours e.g. Neurofibromatosis
- Haemangioma, Vascular malformation
- Melanocytic lesions and pigmentation
- Others - Skin and soft tissue cancer / scar management
- Trauma / Facial fracture / Burn / Wound
- H+N / Craniofacial
- Breast / Trunk + Abdomen
- Hand and extremities
- Microsurgery and flap surgeries
- Aesthetic and aging
Cleft lips and palates
- Unilateral / Bilateral, Incomplete / Complete
- Cleft lip, Cleft palate, Cleft lip + palate +/- Cleft nose deformities
- Repair of cleft lip at 3 months —> Surgical correction of muscle, mucosa, skin
- Repair of cleft palate at 9 months —> Surgical closure of hard + soft palate
- Multidisciplinary approach for **appearance and **function (speech and articulation, hearing and middle ear effusion, small maxilla and dental malocclusion, facial growth and facial apperance)
Congenital ear deformities
- Microtia (Small ear)
- Prominent ears (Bat ears)
- Crypotia (Cartilage framework partially buried under the skin)
- Corrected by rearranging the tissue / add in cartilage framework through single / staged procedures
Vascular malformations and Pigmentation
- Small lesions can be ***excised and closed primarily
- Large lesions need resection + ***reconstruction (e.g. skin graft / flaps)
- Non-surgical modalities of treatment can be considered for different pathology (e.g. **laser, **sclerotherapy, ***interventional RT with embolisation in selected patients)
Example:
- Congenital nevus with excision + local flap from back of neck
- Primary excision of haemangioma + full thickness skin graft over left upper eyelid
Laser for removal of cutaneous pigmentation:
- Based on different photo-selective properties for **Vascular (Haemoglobin: e.g. Port-wine stain, Telangiectasia) / **Pigmented (Melanin: e.g. Nevus of Ota, Facial freckles) lesions
- Repeated multiple sessions are required
- Effect variable and not effective for deep lesions
Skin and Soft tissue cancer
Different ***pathology + differentiation determine margin for curative resection:
- BCC 2-3 mm margin
- SCC 1 cm margin
- Sarcoma 2-3 cm margin
- Intraoperative frozen section guidance for clearance in selected cases
- Resection followed by Primary closure / Reconstruction depending on size of defect —> follow Reconstruction ladder
Skin graft for facial defect
- Primary closure may be impossible after cancer resection and cause deformities on facial anatomy
- Use local flap / skin graft for reconstruction to restore skin coverage and contouring
- Full thickness skin graft preferred to provide good cosmetic outcome in terms of:
—> Colour matching
—> Contour
—> Texture
Common local flaps for nose reconstruction:
- Nasolabial flap
- Bilobe flap
- Forehead flap
Hypertrophic scars and keloids
Hypertrophic scar
- excessive scar that does not extend beyond the boundaries of the wound
Keloid scar
- excessive scar that extends **beyond the boundaries of the original wound and **grow in size with time
- recurrence common after treatment
Problems of unsightliness, pain, recurrent infection
Treatment:
1. Observation
2. Corticosteroid injection
3. Pressure therapy
4. Surgical excision / debulking / RT
- only excision often lead to recurrence
Burn and Scald injury
- Recovery depends on depth (degree) + extent of injury (%TBSA) of injury
- Superficial burn usually heal well with minimal scarring
- Infection + poor wound care will deepen the wound and adversely affect wound healing
- Deep dermal injury result in scar formation and contracture, leading to poor cosmetic and functional outcomes —> skin graft coverage to improve cosmetic + functional outcome
- Post burn reconstruction improves the appearance + functional outcomes
Principles of care in burn reconstruction:
1. Prevention + management of scar
- pressure garment + mobilisation
- Correction of contractures
- scar release, various local plasties and flaps, skin graft for skin tissue loss e.g. FTSG for ectropion of eyelids, correction of microstomia, eversion of lip correction, neck scar release - Skin and dermal replacement
- skin graft +/- dermal substitutes, flap reconstruction after scar excision - Adjuvant therapy
- hair and eyebrow transplant
- CO2 resurfacing of skin
