Plastic and Reconstructive Surgery Essential for Student. Associate Prof. Vichai Chichareon Division of Plastic Surgery Prince of Songkla University

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1 Plastic and Reconstructive Surgery Essential for Student Associate Prof. Vichai Chichareon Division of Plastic Surgery Prince of Songkla University

2 Reconstructive surgery Aesthetic Surgery

3 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

4 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

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

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

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9 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

10 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.

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

12 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

13 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.

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

15 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

16 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

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18 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

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20 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

21 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

22 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)

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

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25 excision Flaps uses 1 Replace tissue loss due to trauma or surgical 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

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28 Cleft Lip/Palate Anatomy Classification Prevalence Etiology Pathophysiology

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

30 Cleft Lip

31 Cleft Lip

32 Cleft Lip

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

34 Cleft Palate

35 Cleft Palate

36 Cleft Palate

37 Cleft Lip/Palate Timing of primary repair Lip Palate Principles of primary repair Secondary repair

38 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.)

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40 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

41 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

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43 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.

44 Pressure sore Treatment 2 Preoperative Debride necrotic tissue Whirlpool and appropriate dressing Systemic antibiotics as indicated X-rays, bone scan and/or bone biopsy

45 Pressure sore Treatment 3 Operative Adequate ulcer excision Excise involved bone and smooth bony prominence Wound closure with local skin or myocutaneous flap

46 The end