Transcript 34-plastic_FINAL.ppt

Presentation &
Management of Common
Problems in Plastic
Surgery
Presented by
Anas Albarrak
Ali Alsaleemi
Hasan Alomaish
Notes with blue color mean doc’s notes
Plastic surgery includes many types:
Reconstructive surgery,
Craniofacial surgery
Hand surgery,
Microsurgery,
and the treatment of burns.
Reconstructive plastic
surgery
Reconstructive surgery is performed on
abnormal structures of the body, caused by
birth defects, developmental abnormalities,
trauma , injury, infection, tumors, or disease.
It is generally performed to improve function, 
but may also be done to approximate a
normal appearance.
Reconstructive Ladder IMP.
a range of techniques of managing wounds and
repairing defects.
The surgeon should start on the lowest rung
and move up until a suitable technique is
arrived at.
secondary intention
primary intention
skin graft
skin flap
secondary intention: do nothing
leave it to heal by secondary intention e.g. abrasion.
Primary intention: also called primary closure or first
step
You can use sutures, staples, wound glue, and adhesive
strips to close the edges of the wound directly and
splint the wound in the position that will give the
best cosmetic result.
skin grafts
If there is skin loss, with a healthy bed of tissue
underneath - for example, an uncomplicated
burn—
A skin graft is an autologous (material is taken
from one part of a patient to another anatomical
site on the same patient)
The graft is a sheet of living cells without a blood
supply
Skin grafts provide a source of cells to grow over
the damaged area and act as biological dressings
to protect the wound.
Grafts may be full thickness or split •
thickness.
1- A full thickness graft is including the whole
dermis, from the donor site.(better but more
difficult to survive )
2- Split thickness grafts are the epidermis and
only part of the dermis.
NOTE: the bed must be vascularized . DON’t
put a graft on bone or cartilage
A skin graft used to help heal a leg ulcer 
Meshing
To increase the size of the graft
When we have limited area of donor
Skin flaps:
A skin flap consists of skin and subcutaneous
tissue that survives based on its own blood
supply.
Use a skin flap for wound coverage when
inadequate vascularity of the wound bed
prevents skin graft survival.
Local flap:
Use local flaps for defects that are adjacent to
the donor site.
Free flap:
"Free" implies that the tissue, along with its
blood supply, is detached from the original
location ("donor site") and then transferred to
another location ("recipient site").
Tissue expansion (we use it to take a flap or
agraft)
insert the inflatable expander beneath the skin
and periodically, over weeks or months,
injects a saline solution to slowly stretch the
overlaying skin.
excess skin is grown purposely by expansion
remove it and transplant it to another site
where skin was lost.
Craniofacial surgery
Craniofacial surgery is divided into pediatric and
adult craniofacial surgery.
Pediatric craniofacial surgery involves around
the treatment of congenital anomalies of the
craniofacial skeleton and soft tissues, such as
cleft lip and palate, craniosynostosis, and
pediatric fractures.
Adult craniofacial surgery deals mostly with
fractures.
CLEFT LIP AND PALATE:
Cleft lip and palate:
Congenital deformity caused by abnormal facial development
during gestation:
Types:
Types of cleft lip :
1- INCOMPLETE
a small gap or an indentation in the lip .
2- COMPLETE
Continues into the nose
Lip cleft can occur as one sided (unilateral) or two sided
(bilateral). It is due to the failure of fusion of the maxillary and
medial nasal processes (formation of the primary palate).
Cleft palate:
Less common than cleft lip
In most cases, cleft lip is also present.
Usually affect soft palate and posterior third of hard palate.
Palate cleft can occur
complete (soft and hard palate)
incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate).
When cleft palate occurs, the uvula is usually split.
The hole in the roof of the mouth caused by a cleft connects the mouth directly
to the nasal cavity.
Symptoms & signs: 
cleft lip is obvious at birth
Cleft palate is discovered after routine
inspection
Feeding difficulties
If not treated: may have speech and hearing
problems
V.Imp slide
peirre-robin sequence 
.micrognathia, glossoptosis and cleft palate 
(MCQ)
Treatment of cleft lip/palate •
Cleft lip treatment: operation at 10 weeks. •
Cleft palate treatment :
.The operation is done at 9-12 months
Craniosynostosis
Craniosynostosis 
a condition in which the sutures (soft spots)
in the skull of an infant close too early,
causing problems with normal brain and skull
growth. Premature closure of the sutures
may also cause the pressure inside of the
head to increase and the skull or facial bones
to change from a normal, symmetrical
appearance.
Hand surgery
Hand surgery
is concerned with acute injuries and chronic
diseases of the hand and wrist, correction of
congenital malformations of the upper
extremities, and peripheral nerve problems
(such as brachial plexus injuries or carpal
tunnel syndrome).
* Congenital anomalies present at birth:
1-problems in development of the parts:
Radial clubhand:
involves all of the tissues on the radial side
(thumb side) of the forearm and hand.
There may be shortening of the bone, a small
thumb, or absence of the thumb.
operated on around 6 months of age.
ulnar clubhand: 
less common than a radial clubhand.
involve underdevelopment of the ulnar bone
or complete absence of the bone.
Ulner clubhand
clubhand
Radial
Preoperation
Postoperation
( Ulnarization procedure )
Know the names
2-failure of parts of the hand to separate:
Syndactyly is the most common congenital hand
deformity
There is a familial tendency to develop this deformity.
This deformity usually involves both hands.
two types of syndactyly:
simple syndactyly - involves fusion between only the
tissues of the fingers.
complex syndactyly - involves fusion between the
bones.
Treatment: surgical separation
Others:
duplications of digits: (polydactyly) more in ulnar
side , but more difficult to repair in radial side
-undergrowth of digits
overgrowth of digits >> macrodactyly
. clinodactyly radial or ulnar deviation of the
digit.
.camptodactyly flexion deformity .
duplications of digits
macrodactyly
Camptodactyly
Carpal Tunnel Syndrome
Compression of the median nerve in the carpal tunnel.
compression causes impaired nerve conduction and
paraesthesia and pain
Related Conditions:
Pregnancy
RA
OA
Amyloidosis
Hypothyroidism
Diabetes mellitus
Use of corticosteroids and estrogens
Repetitive activities of the hand and wrist
Symptoms:
Pain, paraesthesia in the thumb index and middle
finger.(median nerve distribution)
Worse at night.
Signs:
Tinel’s sign >> symptoms with percussion over the
median nerve.
Phalen’s test >> symptoms with flexion of wrists.
Thenar atrophy >> late sign.
Investigation:
Nerve conducting study
Treatment
Initially: night wrist splint, vitamin B6, NSAIDs, steroid
injections
Indication for surgery: refractory symptom, thenar
atrophy, thenar weakness
Surgery: release transverse carpal ligament
Trigger finger
Trigger finger is the popular name of stenosing
tenosynovitis, a painful condition in which a
finger or thumb locks when it is bent (flexed)
or straightened (extended).
Due to narrowing of the sheath that surrounds
the tendon in the affected finger, or a nodule
forms on the tendon.
It is called trigger finger because when the
finger unlocks, it pops back suddenly, as if
releasing a trigger on a gun.
Causes:
Overuse, repetitive or frequent movement of the fingers .
Trauma
Accident
Clinical Picture:
Affected digits may become painful to straighten once
bent
Soft crackling sound when moved.
Props back suddenly when straightened
Usually worse in the morning and improve during the
day
Treatment:
local steroid injections and splinting (weeks to months)
70% will respond
Surgery: cut the sheath that is restricting the tendon.
Tumors of the hand
Most of them are benign and amenable for 
surgery.
Classification of the hand’s tumors:
Skin. 
Soft tissue. 
Bone. 
Metastatic. 
Skin Tumors
Squamous cell carcinoma (the commonest)
Basal cell carcinoma rare
Malignant Melanoma
Soft Tissue Tumors
Ganglions >>the most common tumer in the hand
MCQ
Giant Cell Tumor Of Tendon Sheath
Glomus Tumor
Peripheral Nerve Tumors
Ulnar Artery Aneurysm
Epidermal Inclusion Cysts
Sarcomas
Ganglions
70 % of all hand tumors
Caused by mucoid degeneration of fibrous connective tissue in
joint capsules or tendon sheaths
Women > Men (2-3X)
Presents as mass +/- pain
Types of Ganglia
Dorsal Wrist Ganglion most common site
Volar Wrist GanglionII.
Flexor Tendon Sheath Ganglion III.
Carpal Bosses V. IV.
Mucous Cysts
Ganglions Treatment
Observation
Rupture
Aspiration
Injection
Surgical Excision
Bone tumors: just read it
Ewing’s Sarcoma
Osteosarcoma
Chondrosarcoma
Enchondromas
Osteochondromas
Chondroblastomas
Bone Cysts
Osteoid Osteoma
Osteoblastomas
Giant Cell Tumor of Bone
Metastatic Tumors of the hand:
Uncommon 
Associated with primary lung, kidney 
Distal phalanges 
Amputation recommended if life expectancy 
compatible
Cosmetic plastic surgery
concerned with maintaining normal appearance,
restoring it, or enhancing it beyond the average
level toward some aesthetic ideal.
It’s include :
Facial plastic :
Rhinoplasty ,facelift ,Collagen / Fat Injectable
Fillers
Body contouring :
Abdominoplasty, liposuction, breast
augmentation, Breast reduction.
Rhinoplasty
The procedure can;
Closed rhinoplasty
open rhinoplasty
complications;
1-repetitive surgery:
a second procedure may be required to correct a
minor deformity that occurs as a result of the initial
rhinoplast
2- Nosebleed
3-burst blood vessels:
tiny red spots on the nose to surface
4-scarring
With the "open" procedure
Abdominoplasty
is a cosmetic surgery procedure used to make the •
abdomen more firm.
This type of surgery is usually sought by patients •
with loose tissues after pregnancy or individuals
with sagging after major weight loss.
Types:
1-complete, or full abdominoplasty •
2-A partial, or mini abdominoplasty •
3- extended abdominoplasty •
is a complete abdominoplasty that extends to the •
fronts of the thighs and flanks (sides).
•
Contraindications
1-Obesity
2-Likely or planned future pregnancy
Complication
1-Bleeding / Hematoma
2-Infection
3-Wound dehiscence
4-Abnormal scars
5-Umbilical deformity
liposuction
Liposuction is a procedure that removes excess fat
through a suctioning process.
Although it is not a substitute for weight loss, it is a
way of changing the body's shape and contour.
Site of liposuction;
the chin, on the hips, thighs, and stomach, and in
the under arm and breast areas.
complications :
1-injury to the skin or deeper tissue
2-irregular skin surface
3-greater risks if large areas are treated
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