Plastic Surgery

Plastic and reconstructive surgery

By Dr Muslim Kandel 2017

Whats plastic surgery?

Its is a correction of deformities due to congenital, post-traumatic and post- operative to restore and optimize function and shape.

Divided into 2 parts: Reconstructive surgery: congenital e.g. cleft lip and palate, acquired deformities -accident, burn. Aesthetic or cosmetic surgery: reshape normal structure of body to improve the patient appearance e.g. rhinoplasty, face lift.

Anatomy of skin:

Layers of skin
It consists of epidermis and dermis. 1-Epidermis: is the outer layer composed of keratinized stratified squamous epithelium, it divided into:• Stratum germinatirum (germinal layer ) which rest on dermis and generate the cell of stratum corneum.• Stratum corneum: This is the desquamating dead superficial layer...

2-Dermis:

which is 20 times thicker than epidermis, it consists of non-cellular connective tissues (collagen and elastic fibers) and ground substances . It divided into: • papillary dermis (Upper & thin).• reticular dermis (Lower &thick) which extended form papillary dermis to subcutaneous tissues. Dermis contained skin appendages :-sweat gland, blood vessels, lymphatics and pilosebaceous units

3-Subcutaneous layer:

the skin is connected to the underlying bone and deep fascia by layer of areolar tissues that varies in thickness, * it prominent in palm and sole, and absent in eyelid.

Blood supply of skin:

1-Major vessels: deep to muscle (musculocutaneous) perforators which pass perpendicular through the muscle and deep fascia dermosubdermal plexus which supply the skin. 2-Direct cutaneous artery: superficial to muscles then dermo-subdermal plexus

General principles

wound healing:
Whats the wound? It is a breach in normal tissue continuum as a result of blunt or sharp trauma may be accidental injury or surgical

Phases of wound healing:

1-inflammatory phases: 2-3 days, vasoconstriction to achieved hemostasis , vasodilatation with infiltration of neutrophils,monocytes and limited number of lymphocytes 2-Proliferative phase: day 3 to -3weeks epithelization collagen synthesis. 3-Remolding phase: 6 month-1 year increase in collagen production and breakdown,. Wound strength increase as collagen reorganized and vascularity decrease.

Phases of wound repair

Inflammatory proliferative remodeling

how wound healing occur ?(Methodes of wound healing)

1- Primary intention in sharply incised wound , like surgical wound - little or no tissue is lost -very small scar

2- Delayed primary intention

In crushed contaminated wound , leave wound opened .--- more scar tissue develops.

3- Secondary intention

--Wounds heavily contaminated -- significant loss of tissue 1-) They gradually become filled with 'granulation tissue' then closed by the processes of contraction and epithelialization , 2-) sometime gap difficult to close so skin grafts or flaps are required to close the wound. A graft is a piece of tissue that is moved without its blood supply and relies on its recipient bed to re-establish a blood supply. A flap is a piece of tissue that is moved maintaining its blood supply and is not reliant on the recipient site for its vascularity

Factors affect wound healing

A) general :- Ca , DM , Malnutrition , jaundice , septecaemia . steroid . Vit. C deficiency , uremia B) local :- poor blood supply (tension , atherosclerosis , ).infection , poor alignment, foreign body , local X ray

Principles of wound closure:(Wound preparation)

1-When the wound is clean direct closure by approximation its edge s-- no everted or inverted --without tension.To be heal by primary intension2-When the wound is lacerated delay closurePreperation of wound for few days or weeks then either -- delay primary suturing -- healing by secondary intention ( graft , flap )

clips

suture

Wound preparation

1- Wound cleansing and irrigation (washing) to remove foreign bodies and decrease the numbers of bacteria. 2- Wound debridement removal of dead tissues , is more conservative in the face than in other areas of the body because severely damaged skin often survives because of the rich facial blood supply Method of debridment:• Mechanical: sharp or blunt excision of dead tissues.• Gauze: repetitive application of moistened gauze. • Chemical: topical enzyme application

Wound debridement

Close it
Remove dead tissues
Leave it open

3-avoiding excessive retraction and pressure on wound

by irrigation and moist pack should be used to prevent wound desiccation.4-aseptic technique: such as hand scrubbing, using of sterile instrument5-hemostasis: as bleeding can cause ischemia and hematoma can lead to infection  1-Electrocautery. 2-clamped or suture. 3-Topical hemostatic e.g. fibrin glue..

6-antibiotics: which indicated for the fallowing: • Acute wound with surrounding cellulitis with gross contaminated. • Human or animal bit. • Immunosuppressed or diabetic patient. •Valvular heart disease to prevent endocarditis

Scar

Scar is residual visible mark of wound , almost all wound result in scar Which pass in 3 stages :- I- 0-4 w fine nonncontrectil II- 4-12 w thick hard contracted III- 12w- 6 mounths soft white , relax

Factors affect scar

1- position (ie sternum ) 2- age ( adult > child ) 3- race ( nigroo> whites ) 4- direction of wound (skin lines) 5- bad alignment of wound 6- Stability of wound ( joint) 7- Wound infection 8- Poor blood supply ( may cause necrosis and slughing) Types of scar Leanear scar ( surgical ) Area scar (burn )

Good scar

Bad scar

Complication of scar

1-Hypertrophy of scar ( which not extend beyond wound ) 2-kiloid (continue enlarge after 6 mounths beyond wound ) 3-contrection ( deformity, limitation of joint ) 4-streching due to tension of stitches cause larger scar. 5-malignent changing (Marjolin ulcer ) 6-hyperpigmentation or depegmentation

To minimizes scar formation should be :-1- skin lines (Langer s lines) - In the face 'wrinkle lines‘ - hairline such as the eye brow and forehead skin, 2- minimal skin tension3- good preparation & deprdment of wound 4- good alignment of wound 5- use less irritant stitches ( nylon , PDS. Steel wire ) , subcutical maneuver better than interrupted , 6 -fixation of wound specially at joint (splinting ) 7- early removal of stitches 3-5 days in face While in abdomen ( 7-8 d )8-avoid dogs ears at the angles of wound (elliptical better than circular)


Langer s lines

To avoid dogs ear

A- sub cuticial B- mattress
A
BB

Keloid formation

Is an extreme overgrowth of scar tissues which continue after 6 monthes extend beyond site of incision , due to inhibition of maturation of fibrous tissues for unknown cause , its regarded type of fibroma. Usually occur at face , sternum , shoulder ( unlike hypertrophic scar which occur at flexer surface ) Treatment : - 1-germent ( continue pressure ) 2- intradermal injection of trimeselon 3- radiotherapy 4- scar revision in difficult cases

kiloid

Hypertrophic scar

Keloids and Hypertrophic Scars

hypertrophy
Keloid
(1) Rarely familial
more familial
(2) develop soon after injury
up to a year later.
(3) may subside in time
rarely do
(4) more likely to cause contracture over joint surface
rarely do
(5) no treatment necessary
i. Triamcinoloneii. Excision – high recurrence rate


hypertrophic scar injection of (kenalog )trimesolon