Plastic & Reconstructive Surgery

Dr. Joaquino

February 8, 2012

Outline I. History of Plastic Surgery II. Scope of Plastic Surgery III. Principles of Plastic Surgery IV. Principles of Skin Grafts V. Principles of Skin Flaps

I. HISTORY OF PLASTIC SURGERY Plastic = Greek word plastikos to mold; blending of form and function You have to start with something to shape or mold and plastic surgery uses the tissues of the body Arbitrarily divided into: Reconstructive restore back to normal what has been caused by congenital anomalies, tumors or traumatic injury Aesthetic or cosmetic surpass what is normal
The division is arbitrary or artificial because you cannot separate the two.

Normal patients seeking treatment for defects; Widespread demand for elective surgery: Tummy tuck (1899) Facelift (1901) Eyelid surgery (1906) Sagging cheeks and double chins (1912) Fat injections (1920) Transsexual surgeries (1920s) Breast augmentation (1950) Liposuction (1970) 7. World War II Refinement in surgical techniques in plastic surgery Development of plastic surgery units Training programs were formed Specialty was started to be recognized
During this time, plastic surgery is considered only a minor specialty

A good reconstructive surgeon is also a good aesthetic surgeon since this always come hand in hand. 1. Early History 650BC Sushruta described the use of forehead flaps Group of potters in India restored tip of the nose which at the time was
commonly amputated as a form of punishment Lateral Forehead flap: The defect is so large that you have to fashion skin to vault over nose -> cover secondary defect with skin graft & form into ala -> once it gains its blood supply, you can shape it properly to a better looking nose Patient lost part of nose to infection -> borrow tissue from forehead (carrying the blood supply) -> resects after 2 week -> set the flap to cover defect, dissect the flap and discard it If patient lost nose to basal cell carcinoma-- borrow tissue from forehead (carrying the blood supply) -> resect after 2 weeks

8. Plastic Surgery Today Unique because it has no anatomic boundaries From top of the head to sole of the foot No age limit (from pediatrics to geriatric patients) (Pre-op) Planning is not algorithmic you develop your own techniques; thus a good plastic surgeon is innovative and able to modify old techniques to suit the patients needs No set or prescribed way of covering a defect It is a problem-solving discipline Surgeon should be innovative and always willing to experiment II. SCOPE OF PLASTIC SURGERY 1. Congenital anomalies 2. Maxillofacial/craniofacial
Hence overlap with head & neck surgery but usually this is under plastic surgery

3. Skin, head and neck tumors

Overlap with head & neck surgery

2. Roman Times Celsus (advancement flaps) - actually an incision to cover the central defect; skin will stretch; infections or cancer may cause the defect. 3. 16th Century 1597 Tagliacozzi (tube flaps)- from inner arm, attached to nose; described in detail how to immobilize the arm and transect after 2 weeks 4. 19th Century (2 great events): True renaissance of surgery as heralded by the (1) use of the scientific method (2) Use of anesthesia and antisepsis: helped greatly in the advancement of surgery in general Early surgeons: Von Graefe (1818) Zeiss (1838) Dieffenback (1845) 5. World War I Facial injuries were very common; facial plastic surgery was developed Early facial plastic surgeons: Gillies, Kazanjian and Blair
Surgeons who started fixing head and neck injuries became the first plastic surgeons

4. Post extirpative surgery 5. Burns care 6. Hand surgery orthopedic subspecialty and plastic surgery 7. Microvascular/reinplantation surgery 8. Aesthetic or cosmetic surgery III. PRINCIPLES OF PLASTIC SURGERY Patient Doctor Relationship Based on integrity, is fundamental (honesty between doctor and patient) Doctor should understand patients concerns Doctor should know what patients want
ask patient why the patient wants to undergo surgery; best answer is doing for myself and not for others.

Patient and doctor should have similar goals

The story of a wife wanting to have big breasts to gain her husband back because the husband wants big breasts, wife feels her breasts are still small because the husband did not return to her.

Elective Surgery
Most surgeries are elective

Patients elect enthusiastically and rationally to have surgery as opposed to general surgery This is surgery that can be postponed, should not be in a hurry A positive and optimistic attitude tempered with some degree of anxiety or apprehension; patient should want the surgery. TRADE OFF risk vs benefits (always weigh the two and always think of the patient)
Treatment should not be worse than the problem

cost
Scars are like diamonds, they live forever.

6. Post-WWI Period
Birth of cosmetic surgery People wanted to be pretty before as much as today

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TRUE VS APPARENT DEFECT Surgeons should determine the true extent of the deformity

FACE Other body areas of the

3-5 days no longer than 7days

JOINTS EYELIDS

7 days remove on the 2 day

nd

Figure 1. Contracture. You might think that this is the defect but you find out that the true defect is quite long.

If you cannot do primary closure, the next step is to cover it with skin graft where tissues are harvested from one area and transfer it to another. They depend on vascular bed for vascularity and viability. If defect is bone do local flaps which are adjacent to the defect. If local flaps still will not suffice, do distant flaps which are away or far from the defect. If this still cannot be done, do a microvascular flap where you harvest artery or vein.

Skin grafts For large defects or defects in the vascular bed.

Part of epidermis and dermis are harvested, used to cover large area because the donor site can regenerate again, for large defects or defects in the vascular bed. For full thickness burns After the dead skin and scars are removed, you apply the full thickness skin graft. It is dry and usually the skin grows. Eventually the wound is covered. Figure 2. A burn patient who did not consult a physician. The wound became a contracture. Burn patients require a very long procedure.

Local flaps If the bed does not support the graft use, local flaps which are those adjacent to the defect and carries their blood supply. Distant flaps Harvested away from the defected area. B. Reconstructive Elevator: Microvascular free flaps For full loss of soft tissues in nonvascular bone grafts, go directly to a microvascular skin graft.
From Sabiston: As a rule, the surgeon applies the concept of a reconstructive ladder when assessing possibilities for wound closure. The reconstructive ladder is followed so that simple options are used before complex solutions are considered. A secondary plan needs to be available in case the primary plan fails. This ensures that the surgeon does not compromise a future option while performing an initial closure. Ascending the reconstructive ladder, skin grafts follow only linear closure in complexity. Skin grafts can be divided based on thickness: full-thickness and splitthickness grafts. Full-thickness grafts include epidermis with the entirety of the dermis; the donor site must be closed separately. Split-thickness grafts vary in the amount of dermis included in the graft. For split-thickness grafts, the donor site is most often closed with an occlusive or medication impregnated meshed gauze. The donor site reepithelializes spontaneously. Because of this healing ability of the donor site, split-thickness grafts are especially valuable to close larger wounds. Because split-thickness donor sites can be re-harvested after reepithelialization, this method of wound closure is the workhorse for burn injuries. Thin split-thickness grafts contract to a greater extent than thick splitthickness or full-thickness grafts. Full-thickness grafts resist deformation more than thinner splitthickness grafts and are therefore more suitable for reconstruction when late contracture is expected to compromise the functional or aesthetic outcome.

Figure 3. In electrical burn patients, the true extent of injury is not apparent. Later on the skin becomes necrotic; deeper tissues are injured since heat comes from the bone. So if you have an electrical burn patient, admit, then observe. Most burned injuries seem superficial so you have to admit and you will observe that tissues around the bone will be injured as heat comes from bone.

MULTIDISCIPLINARY TEAM In dealing with patients, reconstructive surgeries are usually multi-disciplinary. An example would be a patient with cleft palate who would need experts like craniofacial surgeon, dentist, plastic surgeon, speech pathologist in management
Know how to prioritize the problems.

RECONSTRUCTIVE LADDER VS RECONSTRUCTIVE ELEVATOR Simple procedures are chosen before complex ones. A. Reconstructive Ladder: Primary closure The defect is very small that you can approximate the edges together.
Approximation of skin edges without tension Tension both of sides of skin pulling one another Deeper wounds are closed in layers Everybody uses sutures to close the wound. Wound adhesives, staples and tapes (even Mighty Bond). For wounds involving the epidermis and dermis, you can use tapes. Suturing techniques Right suturing techniques produces right results. Suture Selection Select the smallest suture required to hold the wound together. You have to remove the suture early:

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LESS IS MORE Avoid over aggressive surgery/treatment.

Avoid doing a lot of procedures in one sitting.

that with tissues at the same time. The best donor site would be the lower lip. With all the components, surgeon has to create new commissure.

CONCEPT OF AESTHETIC UNITS Face is also divided into units. AUTOGENOUS (implants) (from the patients) vs ALLOPLASTIC

Best filler is fat harvested from patient itself.

3D RECONSTRUCTION OF DEFECTS
Should look the defect at 3D and not just covering defect but restoring volume as well. Figure 4. Patient had too much fillers and developed foreign body reaction. The pectoralis major myocutaneous flap (skin component attched to braest) uses tunnelling to cover a defect. If bone graft is needed, rib harvests are often used. The ear is very vascular and can recover fast.

TIMING OF SURGERY Age young patients would usually produce hypertrophic scars Psychological status Patients who have lived with the deformity for sometime are more appreciative of the outcome
Figure 5. Patient underwent alar plasty. Patient could not breathe anymore; even a tiny finger could not fit in there. Example: Cleft lip deformity can be fixed using Rules of 10. 10 months- wants parents to see that there is a defect so they would be more appreciative after the surgery

REPLACE LIKE WITH LIKE (same texture and color matching)

Good color and texture matching is achieved when graft is harvested at the same level of the body.

SKIN LINES Lines of minimal tension (LMT) Cut along these lines and you produce the best scar possible; make patients do a horse smile to see the lines. Other terms: Relaxed skin tension lines (RSTL) Lines of habitual expression Lines of skin relaxation
Skin lines are usually prominent in older patients, when you make an incision, always do it along these skin lines because they produce the best scars.

THE Z-PLASTY Used to lengthen the scar. Break up the scar

From one straight line scar, divide it to several lines/scars like a Z to produce a good scar where you exchange flap A with flap B.

Figure 6. Patient with Basal Cell carcinoma of the lower lid. After incision, there was a defect that is so hard to close. Physicians decided to cover it with a full thickness skin graft because of better texture and color match. You usually get skin from almost the same level of the body. So for face defects, best donor site is the back of the head. The skin there is thin with almost the same color and texture. After 6 months or 1 year, this will be unnoticeable. It is very different when you have a small defect on the nose. The skin of the nose is so oily and full of sebaceous glands. If you put a skin graft there, it will be very obvious. So use simple transposition flaps.

Reorient the scar along lines of minimal tension Applied to revise and redirect existing scars Involves the transposition of two triangular flaps resulting in reorienting the scar, releasing of contracture and scar lengthening.

REPLACE KIND WITH KIND know what was lost!

Figure 8. Z-plasty Do not use skin forceps but skin probes, because forceps kills the tissues when you grab them. Do not cauterize as much because burnt tissues also produce scars Edges should be everted so when it heals and the scar softens, it will become flat. Remember: everted sutures produce very good scars. *Remember that scars contract along its axis. One long scar will have more contractions than if you break it. Figure 7. Patient with Basal carcinoma on the upper lip. Lip-switch flap was done. No more skin/muscle/ mucosa cover the mouth, so replace

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The W-plasty Reorient the scar along lines of minimal tension and break up the scar. V-Y ADVANCEMENT FLAP Very good for fingertip injuries and amputations. Limited to minimal tissue involvement.
Make a v-shaped incision and close it into a y-shape. From Schwartz: There are situations in which the direction of the incision has been pre-established, as in acute lacerations, burns, or old contracted and distorting scars. In these circumstances the principles of proper incision placement can be combined with simple surgical techniques to reorient the scar and lessen the deformity. The Z-plasty technique uses the transposition of random skin flaps both to break up a linear scar and to release a scar contracture through lengthening. W-plasty is the technique of scar excision and reconstruction in zigzag fashion to camouflage the resulting scar.

V. THE PRINCIPLES OF SKIN FLAPS

Figure 10.Skin Flaps Skin flap Like a flag wherein you excise it and move it around the area to cover the defect Cutaneous flap Mustarde flap: Basal Cell Carcinoma patient with a wide defect which cannot be closed primarily and so you create a flap from the lower cheek and raise it up to the defect. Subcutaneous flap

IV. THE PRINCIPLES OF SKIN GRAFTING Standard option for closing defects that cannot be closed primarily. Skin Graft types: 1. Split thickness skin graft (STSG) Contains small amount of dermis Produces secondary contracture, less primary contracture Has a better take -heals much better Primary contracture contracture from the graft itself Secondary contracture contracture in the bed 2. Full thickness skin graft (FTSG) Contains all dermis Produces primary contracture, less secondary contracture Elastic fibers are still present Greater sensory return Better color disparity From the shoulder up- full thickness graft For the nose- get full thickness graft from the back of the ear. The donor site is closed primarily.

Types of Flap According to Location of Source: 1. Local Advancement Rotation/transposition flaps just rotated on an axis to cover a defect Interpolation wherein it has its own blood suppy; there is normal akin and tissue 2. Distant Pedicle Microvascular free flap

Figure 11. You can cut it along tension line. If defect is small, you can close the defect primarily. Distribute tension to underlying tissues. *Handle the tissues in an atraumatic way. Bring the edges together (everted NOT flat). W hen the skin heals, it will become flat. If you suture it flat, the skin will become depressed later on. Types of Flaps According to Blood Supply Pattern: (not discussed during the lecture) Random Pattern Flap has blood supply, no specific vessel; subdermal plexuses; with the following types: 1. Transposition 2. Advancement 3. Rotation Axial Pattern Flap has own artery and vein 1. Groin 2. Scapular 3. Temporal 4. Deltopectoral Fasciacutaneous flap subcutaneous with flap Musculocutaneous flap- if with muscle Osteomyocutaneous Flap contains the muscle and bone Composite flap bone muscle fascia and skin; used to repair nasal, oral lining and mandibular deformities It has its own blood supply

Figure 9. Layers involved in skin grafting. Requirements for survival of a skin graft: Imbibition Lasts 24 to 48 hours from the time of placement Absorption of nutrients into the graft occurs by capillary diffusion Inosculation Alignment of donor and recipient capillaries occur Revascularization Presence of kissing capillaries Angiogenesis abundant in sustaining the graft Contraction and remodeling May last up to 2 years Final take and end phase of grafting

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 Required for covering recipient beds that have poor vascularity, covering of vital structures, reconstructing aesthetic body parts Requires good planning Required Margins for the following lesions: Basal Cell Carcinoma = 5mm margin Squamous Cell Carcinoma = 1cm margin Melanomas = 3cm margin From Schwartz: A flap is a vascularized block of tissue that is mobilized from its donor site and transferred to another location, adjacent or remote, for reconstructive purposes. The difference between a graft and a flap is that a graft brings no vascular pedicle and derives its blood flow from recipient site revascularization, whereas a flap arrives with its blood supply intact.

..end.
From the checker: Legend: - Transers notes/Recording. Font size 8- Checkers notes; 2012 trans notes that were not discussed during the lecture. Box- From the book. Sources: 2012 Trans.Recording/Notes. Sabiston.Schwartz

http://search.4shared.com/postDownload/zmbERdsk/SURGERY_TR ANS_CHECKEDPlastic_S.html

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