Plastic Surgery Prema Dhanraj
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What is Plastic SurgeryChapter 1

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DEFINITION
The term Plastic Surgery was coined by Vongraffe in 1818. The word Plastic is derived from the Greek word “Plastickos” which means to create, to shape, and to mould (The opposite of plastic is elastic). Plastic Surgery is a multifacetted speciality that combines form, function, technique and principle where deformities and defects of the skin and underlying structures are dealt with. It is also known as a problem solving speciality, as every patient presents with a challenging problem requiring a unique solution.
 
Reconstructive Surgery
It is an attempt to restore the individual to near normal.
 
Cosmetic Surgery
It is an attempt to surpass the normal.
Plastic surgeons have to treat patients in a wholistic manner to help them overcome not just their medical problems but also emotional problems to improve self-esteem. Hence, the surgeon should be flexible, creative, innovative, artistic and realistic. Most specialities are limited by the area of the body or by age. Plastic Surgery transcends all these. Plastic surgeons are, therefore, Craniofacial, Maxillofacial, Reconstructive, Microvascular, General plastic, Hand, Cosmetic, Oculoplastic and Burn surgeons. There is no limit to the number of problems solved by the Plastic surgeon, the only limitation being the patient's needs and the surgeon's imagination.
Craniofacial surgery is a discipline where congenital deformities like Crouzon's syndrome (Figs 1.1 and 1.2), Apert's syndrome and syndromes presenting with abnormal shape of the bones of skull and face are corrected by repositioning and reshaping these bones without any visible incisions on the face (Figs 1.3 and 1.4).
Microvascular surgery is a technique where large tissue is taken from one part of the body to another for reconstruction by connecting the vessels. This technique makes it possible even to reimplant amputated parts of the body. The tissue transfer can be only soft tissue (Fig. 1.5) or a composite of soft tissue and bone (Fig. 1.6).3
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FIGURE 1.1: Crouzon's preoperative
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FIGURE 1.2: Crouzon's postoperative
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FIGURE 1.3: Apert's Syndrome
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FIGURE 1.4: Apert's postoperative
Maxillofacial surgery is a discipline where facial bony deformities are corrected. These deformities can be congenital or acquired (Figs 1.7 to 1.9). This type of bony surgery is also performed for aesthetic appearance of the face, where the bones are reshaped to achieve the desired effect.
Reconstructive surgery is a vast field where defects and deformities due to various causes are treated. The different procedures performed can be for congenital, traumatic, infective, malignant (Figs 1.10 to 1.12), burns (Figs 1.13 and 1.14) and aesthetic purposes.
Aesthetic or cosmetic surgery is a discipline where body sculpturing, nose surgery, face lift, breast enlargement and various other surgeries are performed to give a better appearance to improve the patients body image and self-esteem (Figs 1.15 and 1.16).4
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FIGURE 1.5: Radial forearm freeflap
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FIGURE 1.6: Free osteo cutaneous flap
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FIGURE 1.7: Preoperative maxillofacial injury
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FIGURE 1.8: Intraoperative showing displacement of maxilla
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FIGURE 1.9: Postoperative after reduction maxillary fracture
 
HISTORY
Plastic surgery originated in India in 600 BC. Sushrutha is called the “Father of Ancient Plastic Surgery”. In 600 BC Sushruta described operations of the nose and the ear lobes. In India it was a common practice to amputate the nose as a mark of punishment. These patients were operated by a group of people called the koomas or the pot makers. Knowledge of this Indian rhinoplasty reached the west much later in 1794.
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FIGURE 1.10: Neck tumor preop
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FIGURE 1.11: Post excision tumor
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FIGURE 1.12: Postoperative skin graft
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FIGURE 1.13: Preop burn contracture neck
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FIGURE 1.14A: Postoperative release with STSG
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FIGURE 1.14B: Lady with Indian rhinoplasty in Vellore Fort
In the 14th century Italy used similar techniques by using tissue from the arm and named it as Tagliacozzi arm flap for the reconstruction of the nose. In the 20th century Herold Gillies of England described tubed pedicle flaps. “Sir Herold Gilles” an ENT surgeon is called the “Father of Modern Plastic Surgery”.
The first surgeon to publish a book on Principles and Practice of Plastic Surgery is John-Staige Davis in 1924.
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FIGURE 1.15: Depressed nose
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FIGURE 1.16: Postoperative augmentation rhinoplasty
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PRINCIPLES OF PLASTIC SURGERY
  • Interpret the deformity in terms of loss and displacement of tissues and the resulting functional impairment. Assess tissue loss and the type of tissue involved
  • Recreate the defect
  • Plan and reverse plan, have a back up plan and if possible back up of a back up plan
  • The tissue to be transplanted should resemble the original tissue
  • Repair of defect should not produce another visible deformity
  • Always choose the most simplest technique and then progress to complex methods
  • Reconstructive ladder - planning includes the most simplest to the most complicated procedure.
 
INJURIES
Facial injuries tend to be more common because there is no protective covering. A facial injured victim often sustains multiple injuries to other organ systems. Thus, suturing of facial injuries is not an emergency and should be managed as soon as the patient's general condition is stable. Suturing skin lacerations on the face may be complex.
Soft tissue injury of the face includes skin, muscle, nerves, blood vessels and salivary glands.
 
Unique Characteristics of Face
  • No protective cover
  • High incidence of injury
  • Rich blood supply
  • Good lymphatic drainage
  • Venous drainage is excellent as it is above the level of the heart
  • Primary healing of the wound is good
  • Muscles are attached to the skin to give beautiful facial expressions and it deserves special attention due to its unique function and aesthetic significance.
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Challenges of a Surgeon
  • To restore the face to preinjury appearance (Figs 1.17 and 1.18)
  • Restoration of function (Figs 1.19 and 1.20)
  • To return the patient to an active and productive life with minimal aesthetic and functional disability.
 
Cause of Injury
 
Investigations
  • Plain X-ray: Waters' view (PA) in prone position
  • Reverse Waters' view: Mento occipital position (when patient cannot be placed in prone position)
  • Orthopantogram (OPG)
  • CT scan—visualizes both the soft tissue and bone.
 
Life-Threatening Facial Emergencies
  • Respiratory obstruction—broken tooth, dentures, foreign body and blood clots
  • Hemorrhage—control with local pressure, dressing, application of a clamp, ligation or packing
  • Aspiration—oral secretion, gastric contents and blood.
 
Classification
  • Soft tissue injury
  • Soft tissue injury associated with fracture of bone
  • Facial fracture without soft tissue injury
 
TYPES OF SOFT TISSUE INJURY
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FIGURE 1.17: Road traffic accident
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FIGURE 1.18: Postoperative following reconstruction
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FIGURE 1.19: Adherent skin in thyroid carcinoma
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FIGURE 1.20: Intraoral view
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FIGURE 1.20A: Cheek vascular tumor
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FIGURE 1.20B: Post excision
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FIGURE 1.21: Avulsion scalp
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FIGURE 1.22: Postoperative rotation flap
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FIGURE 1.23: Preop assault face
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FIGURE 1.24: Postoperative following suturing
 
MANAGEMENT OF INJURIES
  • Airway to be secured
  • Cervical injury to be checked
  • Hemorrhage to be controlled
  • Shock treated
  • Associated injuries evaluated
  • Facial injuries to be tackled in the end
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FIGURE 1.25: Abrasion
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FIGURE 1.26: Preoperative avulsion face
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FIGURE 1.27: Postoperative avulsion face
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FIGURE 1.28: Scalp avulsion
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FIGURE 1.29: Burn wound
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FIGURE 1.30: Clean laceration of wound
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FIGURE 1.31: Bullgore injury
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FIGURE 1.32: Postoperative suturing
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FIGURE 1.33: Gunshot wound
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FIGURE 1.34: Gunshot wound with shattered mandible
A word of caution—Rule out head injury and cervical spine injuries before facial lacerations are sutured.
 
General Treatment
  • Injection tetanus toxoid 0.5 ml IM
  • Tetanus immunoglobulin 250 units
  • Systemic antibiotics
  • Analgesics
  • Anti-inflammatory drugs
 
Local Treatment
  • Local anesthetic agent used is Lidocaine, maximum dose which can be used is 5 mg/kg body weight of plain lidocaine or 7 mg/kg with adrenaline
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FIGURE 1.35: Mid face degloving
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FIGURE 1.36: Sutured wound
  • Clean the surrounding area with antiseptic solution
  • Irrigate the wound with copious saline using syringe/asepto syringe
  • Debridement of the wound or freshening of the edges
  • Closure of the wound in layers
  • Oppose skin edges with a dermal suture to reduce tension
  • Sutures are placed 1–3 mm apart and 1–2 mm from the edge of the wound
  • Skin edges should be everted for better dermal opposition
  • Avulsion injuries should be thoroughly cleaned and sutured for good approximation (Figs 1.35 and 1.36).
 
SUTURE LINE CARE
  • Sutured wound should be washed with soap and water daily
  • Anti-microbial cream to be applied locally
  • Sutures to be removed on 5th day
  • Adhesive tapes or steri strips applied on the skin to give support
  • Long-term care - Moisturizing cream or oil to be applied along the line of sutured wound to avoid hypertrophy of scar
  • If the patient has the tendency for scarring, precautions are taken to give pressure garments, silicone gel sheet and moisturizing creams.
 
Suture Materials
  • Natural or synthetic
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  • Absorbable or non-absorbable
  • Braided or monofilament
 
Natural Material
  • Catgut—Submucosal layer of sheep intestine
  • Tensile strength lost in 7–10 days
  • Moderate tissue reaction
  • Absorbed in 60 days
 
Synthetic Material
  • Vicryl
    • Braided, has tissue reaction
    • Absorbed in 90 days
    • Tensile strength is 75% at 2 weeks
  • Monocryl—is a monofilament synthetic suture, less prone to infection
  • Polydioxanone (PDS): A synthetic monofilament, absorbs in 6 months
 
Absorbable
  • Catgut
  • Polydioxanone (PDS)
  • Polyglycolic acid (Dexon)
  • Polyglactin (Vicryl)
 
Non-absorbable
  • Nylon-monofilament
  • Silk-braided
  • Prolene
  • Steel
 
Other Closure Materials
  • Skin staplers
  • Steri strips
  • Simple adhesive tapes
  • Glue-like cyanoacrylates
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Transplantation
It means removal of a colony of living cells from donor area to recipient site
  • Autograft—This is transplantation of tissue from one location to another in the same individual
  • Allograft (Homograft)—This is transplantation of tissue between different individuals of the same species
  • Xenograft (Heterograft)—This is transplantation of tissue between individuals of different species
  • Isograft (identical twins)—This is transplantation of tissue between genetically identical individuals.
 
Replantation
Surgical procedure where by tissue is replaced into its original site.
 
Implantation
Insertion of a foreign body into the tissue.
 
Barter Principle
Robbing Peter to pay Paul (skin borrowed from one area to another).
 
SUN BLOCKING AGENT (SUNSCREEN)
A sunscreen is a photo protective agent designed to reduce the effects of UV radiation from the sun. It acts by absorption, reflection or scattering of solar rays. Upon application, sunscreen acts as filters and inhibits the penetration of UV rays to the cells of epidermis and dermis and thereby reduce pigmentation changes. The other photo protecting measures are clothing and sun avoidance. A commonly used sunscreen is para-amino benzoic acid (PABA). The most common measure of sunscreen effectiveness is sun protecting factor (SPF) of 15 or greater (SPF of normal skin is 13.4). Sunscreen should be applied 15–30 minutes before actual solar exposure and applied repeatedly.16
Direct effects of sunlight has both acute and chronic changes on the skin:
  • Acute changes are—sunburn and tanning
  • Chronic changes are:
    • Premature aging
    • Premalignant skin lesion
    • Malignant skin lesion.
 
DERMABRASION
Dermabrasion or surgical planing consists of removal of the epidermis and superficial dermis retaining the skin appendages to allow for spontaneous re-epithelialization with minimal scarring. This is a useful technique for surface irregularities following acne scars. The goal is to sand down the normal elevated areas so that the pits look less deep. Here the superficial layers of the skin, down to the interface between the papillary and reticular dermis are removed with a rapidly rotating dermabrader. The dermal papillae are noted as fine sites of bleeding. Postoperatively the dermabraded areas are treated with ointments.
Indicated commonly in acne scarring, best suited for fair skinned people. It acts by leveling the edges of crater and thus a good blending with surrounding tissue.
Dermabrasion is also done for over grafting on burn wounds. The advantage is that the graft laid on the dermabraded surface has less chance of contraction. The most simplest technique is to use sand paper also known as emery paper which is autoclaved, rolled on a bottle and gently scrapped to remove the most superficial burned skin (Figs 1.37 and 1.38). Emery paper is available in cream and black color. The best type of emery paper to use is cream color with coarse granules (Fig. 1.39).
 
Complications
Hyperpigmentation, scarring and infection.17
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FIGURE 1.37: Post burn hypopigmented patch
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FIGURE 1.38: Postoperative dermabration and sheet graft
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FIGURE 1.39: Emery paper foruse as dermabrader
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FIGURE 1.39A: Dermabrasion
 
TATTOOING
 
Definition
Tattoos are permanent colors introduced in the skin by multiple small needles dipped in coloring matter.
 
Types of Tattoo
  • Cosmetic
  • Traumatic
  • Iatrogenic (placed for radiation)
  • Camouflage
  • Decorative
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FIGURE 1.40: Blast injury face with traumatic tattoo
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FIGURE 1.41: Postoperative scrubbing and suturing
 
Traumatic Tattoo
Traumatic tattoo seen after road traffic accidents and blast injuries should be treated as early as possible as the particles get embedded in the dermis. Delay in removal will result in permanent scarring (Figs 1.40 and 1.41).
 
Cosmetic Tattoo
Cosmetic tattoo is performed using the pigment iron oxide in glycerol and alcohol base. The pigment penetrates to the level of the dermis, maximum fading occurs within 6 weeks. This can be repeated after few months. Most commonly used for coloring nipple area after breast reconstruction (Figs 1.42 and 1.43). It is also used for tattooing the lip, both for lip lining and for vermillion filling.
 
Decorative Tattoo
Decorative tottoo can be removed using Q-switched lasers. Various colors can be removed by using different types of lasers (Fig. 1.44).19
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FIGURE 1.42: Loss of nipple areola region
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FIGURE 1.43: Postop cosmetic areola region tattoo to the nipple areola region
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FIGURE 1.44: Decorative tattoo after removal
 
Camouflage Tattoo
Camouflage tattoo are used to treat portwine stain, burn scars, and hypopigmented patches on the body (Figs. 1.45 and 1.46).
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FIGURE 1.45: Preoperative camouflage for hypopigmented patch lip
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FIGURE 1.46: Postoperative tattooing for hypopigmented lip
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Tattoo is very effective for pigments deposited in the superficial dermis. Those involving the epidermis cannot be masked by tattooing for they have no healthy skin surface where pigments can be deposited.
Basic pigments are inorganic—White pigment (titanium oxide) Red pigment (ferric oxide)
 
TISSUE EXPANSION
Tissue expansion is a mechanical process that increases the surface area of local tissue available for reconstructive procedures. In 1957, Neuman described tissue expansion. Tissue expansion is an effective reconstructive modality and is ideal for reconstruction of scalp defects allowing development of hair bearing tissue to cover areas of alopecia (Figs 1.47 to 1.49).
 
Macroscopic Response
Progressive inflation of an expander increases the overlying tissue.
 
Microscopic Response
  • Epidermis thickens by cellular hyperplasia with narrowed intracellular spaces
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FIGURE 1.47: Postelectrical burn scalp with alopecia
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FIGURE 1.48: Tissue expanded flap
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FIGURE 1.49: Final result
  • Dermis and subcutaneous tissue becomes thinner
  • Muscles are pressed and stretched eventually becoming thin
  • Vascularity increases dramatically.
 
Advantages
  • Tissues of similar color and texture to that of donor site
  • Sensate skin can be got for reconstruction
  • Donor site deformity is less.
 
Complication
  • Hematoma
  • Infection
  • Implant extrusion
  • Implant exposure
  • Discomfort
  • Pain
  • Pressure effects.
 
TISSUE ENGINEERING
 
Definition
It is the application of principles and methods of engineering and the life sciences towards the development of biological substitutes to restore, maintain or improve tissue function. It provides living 22substitutes for medical and biologic application. It is the development and manipulation of artificial implant, laboratory grown tissue and cells, to replace or support the function of defective or injured parts of the body.
It is a new field that seeks to provide a different solution to tissue loss or deficiency.
Skin is the first tissue engineered organ for clinical use.
 
LASER (LIGHT AMPLIFICATION BY STIMULATED EMISSION OF RADIATION)
 
History
Einstein thought that light could be generated via stimulation of energy.
Maiman discovered Ruby crystals, and in 1965 CO2 and Argon laser were developed.
 
Action
Light in contact with a surface can be:
  • Reflected
  • Absorbed
  • Transmitted
  • Scattered
Laser affects tissue via absorption and it is the absorbed portion of light that has clinical use. Depth of penetration depends on wave length, color, consistency of tissue, duration of exposure and spot size of beam (distance measured from peak to peak).
Shortest wavelength has more scattering and less penetration.
 
Clinical Application
  1. Vascular anomalies—Flashlamp pumped pulsed dye targets selective absorption by blood vessels. Transmission occurs through epidermis and dermis. Red blood cells undergo rapid lysis. Ideal for portwine stain in infants and children. Darker lesions in older children contain more deoxyhemoglobin resulting in less absorption and thus less effective.
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  2. Cutaneous pigment—can be epidermal and dermal pig-mentation. The targeted chromophore is melanin.
    Q-switched ruby laser—can treat both epidermal and dermal lesions
    Nd:YAG and pulsed dye are also used.
  3. Tattoo—melanocytes are destroyed
    Q-switched laser penetrates to the level of upper papillary dermis and targets ink particles based on their color
    Nd:YAG Laser either green or infrared (effective for tattoo at different wavelength)
    Ruby laser—blue black
    Alexandrite— Green
  4. Hair removal—Melanin is the main chromophore targeted in laser hair removal. Hypopigmentation is a side effect. Ten percent regrows months after treatment.
  5. Skin resurfacing (CO2 laser)—The targeted chromophore is water. The direct effect for skin resurfacing is tissue vapo-rization. It is useful in photoaged skin resulting in improvement of fine wrinkles with a lasting result. Here, it causes thermal ablation of epidermis and superficial dermis. Erbium laser—Known as lunch time peel. It reduces fine superficial wrinkles and gives much better results.
  6. Acne scarring—Erbium YAG is specific for collagen and scar.
 
Complications of Laser
  • Erythema
  • Thermal burns
  • Scarring
  • Hypopigmentation and hyperpigmentation
  • Infection
  • Hypersensitive reaction to ointments.
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