Plastic and Reconstructive Surgery Essential for Student
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Transcript of Plastic and Reconstructive Surgery Essential for Student
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Plastic and ReconstructiveSurgeryEssential for Student
Associate Prof. Vichai Chichareon
Division of Plastic SurgeryPrince of Songkla University
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Plastic Surgery
Reconstructive surgery
Aesthetic Surgery
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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
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Plastic Surgery
Wound closureFactor influencing wound healing
Local factors
Tissue trauma
Hematoma - associated with higher infection rate
Blood supply
TemperatureInfection
Technique and suture materials only importantwhen factors 1-5 have been controlled
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Plastic Surgery
Wound closureFactor influencing wound healing
General factorsCannot be readily controlled by surgeon
Systemic effect of steroids
Nutrition
Uncontrolled DM
Chemotherapy
Chronic illness
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Plastic Surgery
Management of the clean wound
Goal - close wound as soon aspossible to prevent infection, fibrosisand secondary deformity.
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Plastic Surgery
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Plastic Surgery
Management of the clean woundGeneral principles
1 Immunization
2 Pre-anesthetic medication if needs3 Local anesthesia use epinephrine
adjuvant unless contraindicated,eg., digit,tip of penis
4 Tourniquet5 Cleansing of surrounding skin do NOT
use strong antiseptic in the wound itself
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Plastic Surgery
Management of the clean woundGeneral principles
6 Debridement
Remove clot and debris, necrotic tissue
Copious irrigation good adjunct to sharpdebridement
7 Closure - atraumatic technique to approx. dermisConsider undermining of wound edges to
relieve tension.8 Dressing must provide absorption, protection,
immobilization, even compression, and beaesthetically acceptable.
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Plastic Surgery
Management of the woundType of wounds and their treatment
Abrasion
ContusionLaceration
Avulsion
Puncture wound
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Plastic Surgery
Wound dressings1 Protect the wound from trauma
2 Provide environment for healing
3 Antibacterial medicationprovide moistureand control microorganism.
4 Splinting - casting
For immobilization to promote healingDo 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
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Plastic Surgery
Grafts and FlapsSkin protects the body from outside invaders and prevents
loss of the fluids, electrolytes, protein, ect. Skin may bereplaced by spontaneous epithelialization and contraction or bya 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.
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Plastic Surgery
Skin graftSplit 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 byepithelialization.
3 Thickness varies from thin to thick
A higher percentage of *take* (survival) is more likelywith a thinner graft
Recipient site wound contraction is less with a thickergraft
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Plastic Surgery4 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 skinappendages
A moist environment hastens epithelialization
Requires care to prevent infection which can convert itto full thickness skin loss
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Plastic Surgery
Full thickness1 Includes epidermis and all dermis2 Provides better coverage but is less likely to take than a
split thickness skin graft because of greater thickness and slowervascularization.
3 Donor site is full thickness skin loss and must be closedprimarily or with split thickness skin graft
4 Uses
Usually on the face for better color match
On the finger to avoid contractureAnywhere that thick skin or less contraction of therecipient site is desired
Limited by size of defect to be closed
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Graft survival1 Both split and full thickness grafts take innitially bydiffusion of nutrition from the recipient site (plasma imbibition)
2 Revascularization generally occurs between day 35
by either reconnection of blood vessels in the graft to recipientsite vessels or by ingrowth of vessels from the recipient site intothe 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
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Plastic Surgery
Graft survival7 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
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Plastic Surgery
FlapsClassification
1 Random pattern flaps
2 Axial pattern flaps ( arterial flap)3 Musculocutaneous flap (myocutaneuos)
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Plastic Surgery
Flapsuses1 Replace tissue loss due to trauma or surgical
excision
2 Provide skin coverage through which surgery canbe carried on latter
3 provide padding over bony prominences
4 Bring in better blood supply to poorlyvascularized bed
5 Improve sensation to an area (sensate flap)
6 Bring in specialized tissue for reconstruction suchas bone or functioning muscle
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Cleft Lip/PalateAnatomy
Classification
PrevalenceEtiology
Pathophysiology
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Plastic Surgery
Cleft Lip/PalateClassification
- Incomplete
- Complete
- Unilateral
- Bilateral
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Cleft Lip
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Plastic Surgery
Cleft Lip
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Cleft Lip
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Cleft PalateClassification
- bifid uvula submucous cleft palate
- Cleft of secondary palate
- Cleft Palate Unilateral
- Cleft Palate Bilateral
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Plastic SurgeryCleft Palate
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Plastic Surgery
Cleft Palate
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Plastic Surgery
Cleft Palate
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Plastic Surgery
Cleft Lip/PalateTiming of primary repair
Lip
PalatePrinciples of primary repair
Secondary repair
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Cleft Lip/PalateTeam conceptBecause of multiple problems with speech,
dentition, hearing, ect. management of the patient with a cleft
should be by an interdisciplinary team, preferable in a cleftpalate o craniofacial clinic.
Cleft Lip/Palate and Craniofacial CenterPrince of Songkla University
Every second Monday of the month 13:00 (1:00 pm.)
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Plastic Surgery
Pressure soreEtiology
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 occurafter as little as two hours of continuous pressure.
Paraplegic and nonparaplegic patients
Most common sites Greater trochanter, iscial
tuberosity, sacrum and the heel
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Plastic Surgery
Pressure soreClassification
Grade I Erythema of skin
Grade II Skin ulceration and necrosisinto subcutaneous tissue
Grade III Grade II plus muscle necrosis
Grade IV Grade III plus exposedbone/joint involvement
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Pressure soreTreatment
1 Prevention Best treatment
Keep skin clean and dry
Frequent turning of patient
(at least every 2 Hours)
Pressure in special areas may bepartially relieved with foam cushionflotation mattresses.
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Plastic Surgery
Pressure soreTreatment
2 Preoperative
Debride necrotic tissue
Whirlpool and appropriate dressing
Systemic antibiotics as indicated
X-rays, bone scan and/or bone biopsy
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Plastic Surgery
Pressure soreTreatment
3 Operative
Adequate ulcer excision
Excise involved bone and smoothbony prominence
Wound closure with local skin ormyocutaneous flap
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Plastic Surgery
The end