Plastic and Reconstructive surgery
Plastic surgery
•Plastic surgery is a surgical speciality that concentrates on the restoration of functions and form the body structures damaged by trauma, transformed by aging process, change by disease process (skin cancer) or malformed as a result of congenital defects.
Two types/ major areas
1.Aesthetic (cosmetic) and
§Improves physical features that are already within the normal range.
2.Reconstructive
§It attempts to restore a more normal appearance / function in a person who has an abnormal body parts or in whom a body part is missing.
COSMETIC PROCEDURES
•The vast array of cosmetic procedures is almost limitless. Cosmetic procedures can include chemical peels, toxin injections, collagen fillers, laser surgery, breast enlargement and reduction, laser surgery, face-lift, eyelid-lift, and liposuction.
Aesthetic / cosmetic
1.Face Rejuvenating procedure
A.Facial resurfacing
ØSkin peels
ØLaser resurfacing
ØDermabrasion
ØDermal filler
ØBotulinum injection
B.Rhytidectomy (Face lift)
C.Blepharoplasty(Eye lids)
D.Rhinoplasty
2.Body Conturing Surgery
A.Liposuction
B.Abdominoplasty and Penniculectomy
1. Face Rejuvenating procedure
A.Facial resurfacing
•Skin peel
•Various products can be used to lift superficial layers.
•Alpha Hydroxy Acids, glycolic acid, lactic acid, trichloroacetic acid.
•Best candidate is client with fair skin & fine wrinkles.
•Trained nurses perform the peel procedure.
•Care include application of skin moisturizers, use of hydrocortisone to reduce edema, gentle cleaning, use of sun screen.
Elective Surgery
•Laser Surgery.
•When a laser beam enters the skin, the light can affect skin structures by scattering, absorbing, or passing through different layers. The spectrum of clinical application for each laser depends on the depth of the wavelength emitted and the operator technique.
•Tretinoin (Retin-A, Renova)
•Chemical Peels
•Microdermabrasion
•Alpha Hydroxy Acids (e.g., glycolic acid, lactic acid)
Indications of Laser surgery
•Improves appearance of aged and photodamaged skin, especially fine wrinkling and the reduction of actinic keratoses
•Improves appearance of aged and photodamaged skin, acne scarring, freckles, actinic and seborrheic keratoses
•Smoother appearance of photodamaged and wrinkled skin
Patient teaching
•Apply emollients (e.g., petroleum jelly) and sunscreen (SPF 15 or higher), use sunavoidance measures, avoid use of abrasive or drying facial cleansers for severe sensitivity (e.g., excess blistering, peeling); notify health care provider of severe sensitivity
Common Cosmetic Injection
•Neurotoxin
•Fillers
•Type
•Botulinum toxin (Botox)
•Collagen (e.g., Zyplast, CosmoDerm)
•Hyaluronic acid (Restylane)
Indications
•Decreases wrinkles caused by repetitive facial expressions; also used to shape eyebrows into an arch and correct facial asymmetry
•Reduces depth and visibility of facial lines and creases (e.g., nasolabial crease, lips)
Patient teaching
•Most people do not notice any unpleasant effects
•Ice to relieve discomfort
Face-Lift / Rhytidectomy
•A face-lift (rhytidectomy) is the lifting and repositioning of the lower two thirds of the face and neck to improve appearance.
•Indications
•1. Redundant (overabundant) soft tissue resulting from disease (e.g., acne scarring)
•2. Asymmetric redundancy of soft tissues (e.g., facial palsy)
•3. Redundant soft tissue resulting from trauma
•4. Preauricular lesions
•5. Restoration of body image
•The surgical approach and lines of incisions vary according to the nature of the desired correction and the position of the hairline. Eyelid-lifts (blepharoplasty) with similar indications are performed to remove redundant tissue and possibly improve the field of vision.
•Application of ice packs is usually used the first 24 to 48 hours to reduce swelling and decrease the possibility of hematoma formation.
•Complications can occur if the person smokes or is involved in vigorous exercise.
Laser Treatment of Cutaneous Lesions
•Lasers are devices that amplify or generate highly specialized light energy.
•The argon laser, carbon dioxide (CO2) laser, and tunable pulsedye laser are used in dermatologic surgery.
Argon Laser
•The argon laser produces a visible blue-green light that is absorbed by vascular tissue and is therefore useful in treating vascular lesions: port-wine stains, telangiectases, vascular tumors, and pigmented lesions.
•CARBON DIOXIDE LASER
•The CO2 laser emits invisible light in the infrared spectrum that is absorbed at the skin surface because of the high water content of the skin and the long wavelength of the CO2 light. As the laser beam strikes tissue, it is absorbed by the intracellular and extracellular water, which vaporizes, destroying the tissue.
•It is useful for removing epidermal nevi, tattoos, certain warts, skin cancer, ingrown toenails, and keloids.
PULSE-DYE LASER
The tunable pulse-dye laser with various wavelengths is the latest laser available for dermatologic surgery. It is especially useful in treating cutaneous vascular lesions such as port-wine stains and telangiectasia.
Liposuction.
•Liposuction is a technique for removing subcutaneous fat to improve facial and body contours.
•Possible contraindications for the procedure include use of anticoagulants, uncontrolled hypertension, diabetes mellitus, and poor cardiovascular status.
•Persons under 40 years of age with good skin elasticity are the best candidates.
•The procedure is usually performed on an outpatient basis with the aid of local anesthesia. One or more sessions may be necessary, depending on the size of the area to be treated.
•A blunt-tipped cannula is inserted through a 0.5-inch incision and pushed into the fat to break it loose from the fibrous stroma. Multiple repeated thrusts disrupt the fat and create tunnels. The loosened fat is removed with a powerful suction.
SKIN GRAFTS
•Uses
•Skin grafts may be necessary to provide protection to underlying structures or to reconstruct areas for cosmetic or functional purposes.
•Improved surgical techniques make it possible to graft skin, bone, cartilage, fat, fascia, muscles, and nerves.
•For cosmetically pleasing results, the color, thickness, texture, and hair-growing nature of skin used for grafting must be chosen to match the recipient site.
•The three categories of temporary dressings are:
A) Allograft (skin grafts from human tissue donors).
B) Xenograft (treated animal products).
C) Synthetic skin coverings.
Types
•The two types of skin grafts are
§free grafts and
§skin flaps.
•Free grafts are further classified according to the method of providing a blood supply to the grafted skin. One method is to transfer the graft to the recipient site from the donor site.
üIf the graft is an autograft (from the patient's own body)
üor an isograft / allograft (from an identical twin), These grafts are also called allogeneic or homograft.
üA xenograft or heterograft is tissue from another species.
•Another method of free skin grafting is by reconstructive microsurgery. With the use of an operating microscope, circulation is immediately established in the free flap by anastomosis of the blood vessels from the skin flap to the vessels in the recipient site.
•Skin flaps involve moving a section of skin and subcutaneous tissue from one part of the body to another without terminating the vascular attachment. The vascular attachment is called a pedicle. Skin flaps are used to cover wounds with a poor vascular bed, when padding is needed, and to cover wounds over cartilage and bone.
•Donor skin is taken from the patient for grafting by means of a dermatome, which removes a thin (split-thickness) layer of skin from an unburned site.
•dermatome pics
•The donor site now becomes a new open wound. For the thin-skinned elderly patient, healing of the donor site may be a difficult task and requires vigilant care by the health care team.
Soft tissue expansion
•Soft tissue expansion is a technique for providing skin for resurfacing a defect, such as a burn scar; for removing a disfiguring mark, such as a tattoo; or as a preliminary step in breast reconstruction.
•A subcutaneous tissue expander of an appropriate size and shape is placed under the skin, usually as an outpatient procedure.
•Weekly expansion with saline solution can be done in a health care setting or by the patient at home. This expansion procedure is repeated until the skin reaches the size needed for the repair. This may take from several weeks to 3 to 4 months. Once sufficient skin is available, the old incision is opened, the expander is removed, and the soft tissue is ready to be used as an advancement flap.
•This is accomplished by implanting a tissue expander, which is a balloon-like device, beneath healthy skin. The expander is gradually inflated with injections of saline fluid over a period of several weeks.
Cultured Epithelial Autografts.
•Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting.
•CEA is grown from biopsy specimens obtained from the patient's own unburned skin. This procedure is performed in burn units as soon as possible after admission on patients who have been identified as suitable candidates.
•The specimens are sent to a commercial laboratory, where the biopsied keratinocytes are grown in a culture medium containing epidermal growth factor. After approximately 18 to 25 days, the keratinocytes have expanded up to 10,000 times and form confluent sheets that can be used as skin grafts.
•CEA grafts generally form a seamless, smooth replacement skin tissue.
•Problems related to CEA include a poor graft take due to thin epidermal skin graft loss, and contracture development.
Artificial Skin.
•Integra artificial skin has a bilayer membrane composed of acellular dermis and silicone. In the operating room, the wound is debrided, the bilayer membrane is placed dermal layer down, and the wound is wrapped with dressings.
•The dermal layer functions as a biodegradable template that induces organized regeneration of new dermis by the body.
•The silicone layer remains intact for 3 weeks as the dermal layer degrades and epidermal autografts become available.
•At this point, the silicone is removed during a second surgical procedure and replaced by the patient's own epidermal autografts. In some situations, burn units use CEA as the source of epidermis.
BIOSYNTHETIC AND SYNTHETIC DRESSINGS
•Currently the most widely used synthetic dressing is Biobrane, which is composed of a nylon, Silastic membrane combined with a collagen derivative. The material is semitransparent and sterile.
•It has an indefinite shelf life and is less costly than homograft or pigskin.
•Biobrane adheres to the wound fibrin, which binds to the nylon–collagen material. Within 5 days, cells migrate into the nylon mesh. Generally, adherence to the wound surface correlates directly with low bacterial counts. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks.
•Biobrane is a temporary synthetic skin substitutes.
It is made from:
- A silicone thin layer that has small holes in it. Through these tiny pinprick holes, wound secretions find their way out. This layer protects the burn from the environment.
- Underneath the silicone layer there is a nylon mesh upon which is bonded proteins extracted from pigs. These substances bond strongly with the surface of superficial burns. After about 2 weeks, the skin is healed and the Biobrane may be peeled off. Biobrane is used frequently in children who have sustained scald injuries providing good wound cover and excellent pain relief.
•Transcyte is another temporary skin substitute. It has a bi-layer structure similar to that of Biobrane:
– The outer layer is a silicone thin layer that mimics the skin properties and has tiny pinprick holes.
– The inner layer is a knitted nylon scaffold which is layered with human skin cells group in culture in the laboratory. These cells will produce substances that facilitate the healing of burn wounds.
•After 2 weeks, the skin underneath heals and Transcyte is peeled off. Transcyte is used frequently in children that have sustained scald injuries and provides excellent pain relief. Transcyte needs to be stored in the freezer prior to use.
Others types
•Several other products are currently being evaluated in burn units throughout North America, including AlloDerm, a nonimmunogenic dermal transplant, and LifeSkin, a cultured composite autograft.
DISORDERS OF WOUND HEALING
•Scars- One of the most devastating sequelae of a burn injury is the formation of hypertrophic scars.
•Keloids- A large, heaped-up mass of scar tissue, a keloid, may develop and extend beyond the wound surface.
•Failure to Heal- A serum albumin level of less than 2 g/dL is usually a factor in impaired healing in the burn patient.
•Contractures- The burn wound tissue shortens because of the force exerted by the fibroblasts and the flexion of muscles in natural wound healing.