Local factors (cid:142)(cid:3) Foreign bodies (cid:142)(cid:3) Infection (cid:142)(cid:3) I schaemia (cid:142)(cid:3) Arterial or venous insufficiency (cid:142)(cid:3) Smoking (cid:14 2)(cid:3) Neoplasia. Systemic factors (cid:142)(cid:3) Nutritional deficiency (cid:142)(cid:3) Diabetes (cid:142 )(cid:3) Ageing (cid:142)(cid:3) Liver disease (cid:142)(cid:3) Alcoholism (cid:142)(cid:3) Medications, particularly steroids and immunosuppessoats (cid:142)(cid:3) Immobility (cid: 142)(cid:3) Cancer (cid:142)(cid:3) Anticancer therapy (X-rays). Techniques to assess wounds (cid:142)(cid:3) Inspection (cid:142)(cid:3) Bacteriology swab (cid:142)(cid:3) Histological biopsy (cid:142)(cid:3) Radiological imaging (cid:142)(cid:3) Biopsy. Types of abnormal healing (cid:142)(cid:3) Delayed (cid:142)(cid:3) Dehiscence (cid:142)(ci d:3) Stretched scar (cid:142)(cid:3) Keloid (cid:142)(cid:3) Hypertrophic scar. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 768 Keloids and hypertrophic scars (cid:142)(cid:3) Keloids and hypertrophic scars are characte rized by excessive accumulation of collagen within the wound. There are abnormalities of cell migration and pr oliferation, inflammation, and the synthesis and secretion of matrix proteins and cytokines . (cid:142)(cid:3) Keloids grow beyond the borders of the original wound, can form some time after a tissue injury and generally do not resolve spontaneously. Hypertrophic sc ars stay within the limit of the original wound, usually develop soon after the tissue inju ry and tend to regress spontaneously. (cid:142)(cid:3) Histologically they differ from normal skin by having a rich blood supply, high cell density and a thick epidermal layer. Hypertrophic scars have collagen fib ers arranged in a loose, wavy pattern. Keloids have irregularly shaped collagen fibers in a disorganized pattern. Predisposing factors That certain patients and conditions may predispose to hypertrophic sc ar formation is well known. Both hypertrophic scars and keloids occur more commonly in dark -skinned individuals. Wounds that cross skin tension lines or wounds that are located on th e ear lobes or presternal and deltoid areas are common sites for these forms of abnormal he aling. Conservative management includes pharmacologic therapy, pressure, laser, and radioth erapy. Each method has varying degrees of reported success. (cid:142)(cid:3) Black, Asian, and Celtic (red hair and freckles) skin. (cid:142)(cid:3) Wounds on the anterior chest, sho ulders and anterior neck as well as wounds that cross skin tension lines. (cid:142)(cid:3) A wound that has healed by secondary intention, especially if the healing time is greater than 3 weeks. (cid:142)(cid:3) Wounds with prolonged inflammation (foreign body, infection, burn). Treatm ent No single, universally successful treatment for hypertrophic scars and keloids exists a nd the recurrence rate is high. Surgical treatment is reserved for cases that are unrespons ive to conservative management. (cid:142)(cid:3) Compression dressings are custom-made for the patient and should be worn 24 hours a day. (cid:142)(cid:3) Corticosteroids injected directly into the lesion act by diminishing colla gen synthesis and decreasing mucinous ground substance. (cid:142)(cid:3) Excision is most e ffective when combined with external radiation, steroid injection, (cid:140) pressure therapy. There is a high risk of recurrence. (cid:142 )(cid:3) Radiation is most effective when used in the immediate postoperative period. (cid:142)(cid:3) Cryosurgery with liquid nitrogen is used to cause cell damage and to affect the microvasculature. (cid:142)(cid:3) Laser therapy. (cid:142)(cid:3) Silicone sheets sometimes in combination w ith compression applied over a scar are reported to reduce the bulk. (cid:142)(cid:3) Massage with aqueous cream ma y be effective. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 770 Reconstructive ladder When a plastic surgeon assesses a wound, or a situation in which a wo und will result from resection, a basic set of rules guides the formula- tion of a treatmen t plan. The least complex methods, such as direct closure, are on the lower rungs whilst th ere is an increase in complexity to the top. The size and nature of the injury as well as factors such as the patient \200\231s general condition will determine which treatment method is used. In general the least complex metho d of achieving the desired result is used. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 772 Primary and secondary intention healing Primary intention (primary closure) This is where t he edges of the wound are in direct contact. This is most appropriate for small and uninfec ted wounds. Methods of skin closure may be: (cid:142)(cid:3) Sutures (cid:142)(cid:3) Stapl es (cid:142)(cid:3) Glue (cyanoacrylate) (cid:142)(cid:3) Adhesive strips. Secondary intention This is where the wound edges are not in contact. Healing takes place b y a combination of wound contracture and granulation/epithelisation. Whilst this generally leads to a wider and less attractive scar it may be appropriate in situations such as: (cid :142)(cid:3) Infection (cid:142)(cid:3) Wound breakdown (cid:142)(cid:3) Poorly vascularise d areas (cid:142)(cid:3) Patient not fit for surgery. Delayed primary and secondary closure Can be used when an open wound is clean and free of i nfection or other underlying pathology. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 774 Skin grafts If a wound is too large for suturing, and healing by secondary intention or sec ondary closure is inappropriate, a skin graft may be suitable. A skin graft consists of the epidermis and a variable amount of the dermis. This is placed on the recipient site where it attains a new blood supply and integrates itself into the recipient site. The bed must b e suitable for grafting and: (cid:142)(cid:3) Be free of friction. (cid:142)(cid:3) Have no contamination. (cid:142)(cid:3) Have no infection. Pseudomonas aeruginosa and group A (cid :168) haemolytic streptococci are both particularly problematic. (cid:142)(cid:3) Have an adequate blood supply. Bare tendon or bone for example are not suitable. Anatomy (Fig. 17.3) In all skin grafts the epidermis is taken but the amount of dermis vari es. If only part of the dermis is taken it is a split thickness skin graft; whereas in a fu ll thickness skin graft the whole of the dermis is taken. SKIN GRAFTS1 775 Hair follicle Sebaceous gland Hair Epidermis Thin Medium Split thickness skin graft Dermis Thick Full thickness skin graft Subcutaneous fat Duct of sweat gland Sweat gland Fig. 17.3 Depth of skin grafts CHAPTER 17 Principles of plastic surgery 776 Split thickness skin graft This includes the epidermis and only part of the dermis. Advantages (cid:142)(cid:3) Donor site heals by epithelisation from remaining dermal elemen ts such as sweat glands and hair follicles (cid:142)(cid:3) Can be re-harvested (cid:142)(cid:3) Larger amounts can be harvested (cid: 142)(cid:3) Can conform to defects as it is thin. Disadvantages (cid:142)(cid:3) Less resilient to trauma (cid:142)(cid:3) Less esthetically acceptable (cid:142)(cid:3) Can contract leading to secondary deformities. Donor site Virtually any part of the body can be used as a donor, including the scalp. Whil st the area does heal it leaves a scar and so a relatively hidden area is preferable. A var iety of dressings have been used (alginate, semi- occlusive or occlusive) but they all aim to protect the healing donor site. It is not necessary to keep checking these sites unless specifically indi- cated such as the suspicion of infection. Healing takes from seven days to several weeks depending on the thickness. Harvesting with hand knife The commonest types of hand-held knife are the Watson or a modif ica- tion of the Humby knife. There is a wide and sharp blade that has a depth guard runnin g its length \200\224this can be varied to cut to different depths. Holding the knife up to the light allows the depth to be seen and judged by experience; the depth is then locked. Making the donor as taut as possible is essential, and an assistant to place traction on th e skin is invaluable. The blade is then placed on the skin and an even reciprocating motion is used to harvest as it is advanced along the donor site. The angle and pressure used is a matter of preference as a correct balance is needed to harvest skin of the desired thickn ess. Harvesting with dermatome (Fig. 17.4) These may be either electric or air powered. The blad e used is narrower than that in a hand knife and the power causes it to vibrate rapidly. Th ere is a depth gauge that is graduated in thousandths of an inch. Again having skin as taut as possible is helpful. The safety catch is released and the dermatome advanced along the donor site harvesting the skin. SPLIT THICKNESS SKIN GRAFT1 777 Fig. 17.4 (A \200\223C) Sequence showing how to use a powered dermatome CHAPTER 17 Principles of plastic surgery 778 Meshing The skin is placed on a carrier board and passed through a hand pow- ered device th at cuts even fenestrations in it. The reasons for this are (cid:142)(cid:3) Expansion is us ually 1.5:1 but can be up to 9:1 (cid:142)(cid:3) Conforming allows the graft to fit irregu lar surfaces better (cid:142)(cid:3) Fenestrations help prevent collection of blood or sero us fluid under graft. Storage It is possible to store a split thickness skin graft for a few weeks. This may be u seful if too much skin was harvested or the wound was not suitable for immediate applicatio n. In the latter case the skin can be applied on the ward with no need for further surgery. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 780 Full thickness skin graft This includes the epidermis and the whole of the dermis. Advantages (cid:142)(cid:3) Better esthetic appearance (cid:142)(cid:3) Less prone to contr acture. Disadvantages (cid:142)(cid:3) Less can be harvested (cid:142)(cid:3) Donor site has no der mal elements remaining and therefore usually needs suturing to close. Technique (cid:142)(cid:3) A pattern of the defect is taken and then transposed onto the do nor site. The graft is then harvested by incising around this pattern and dis- secting the skin at the level of the subcutaneous fat. This is made easier by draping the graft over th e surgeon \200\231s finger. (cid:142)(cid:3) If there is some fat remaining on the harvested graft this is then removed by trimming with scissors. (cid:142)(cid:3) The donor site is then closed by suturing, it is usually necessary to convert the defect into an ellipse. (cid:142)(cid:3) The graft is then sutured onto the recipient around the edges. Occasionally sutures may be placed across the surface attaching it to the bed; this is know n as quilting and may help reduce shearing or haematoma development. The usual dressing is a tie-over which is formed by leaving the ends of the sutures longer than normal and then t ied over a piece of gauze or cotton wool. The reason for this is to ensure there is maximal contact of the graft with the bed as well as reducing shearing, haematomas, and seromas. T he sutures are then left in place for 5 \200\2237 days. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 782 Flaps Whereas a skin graft needs to acquire a new blood supply from the recipient site a fl ap takes its blood supply with it. The term flap originated in the sixteenth century from t he Dutch word flappe, meaning something that hung broad and loose, fastened by one side. To help the understand- ing of flaps a number of classifications have been used based on the blood supply, contents, donor site, and geometry. Blood supply Flaps need an adequate blood supply to survive and the two types in this categ ory are: (cid:142)(cid:3) Random pattern This is where the supply is only from the various plexuses discussed above and not derived from a recognized artery. Many skin flaps fall int o this category. The relative dimensions of the flap are limited by the local blood flow; u sually the base is the same length as the flap but in the face the length may be greater. (cid:142)(cid:3) Axial pattern Here the blood supply is from a recognized artery and as suc h can be relatively much larger. Some skin and most muscle flaps fall into this category. Fasciocutaneous Many skin flaps are random pattern and so a longer flap needs a wider base in order to supply adequate circulation. The ration of width to length may only be 1:1 in t he lower limb but much greater, up to 8:1, in the head and neck because of the much greater inherent vascularity of this area. However, if fascia, as well as skin, is incorporated in to a flap then the potential length of flap is greatly increased. The reason for this is th e excellent blood supply to the fascia from the subfascial plexus. This type of flap is par ticularly useful in lower limb reconstruction. Muscle Because there is much variation in the blood supply to muscles a further classificat ion of this has been formulated (see Table 17.1). Contents The following tissue or combinations of them can be used (cid:142)(cid:3) Skin (ci d:142)(cid:3) Fascia (cid:142)(cid:3) Muscle (cid:142)(cid:3) Bone (cid:142)(cid:3) Viscera l Combinations include fasciocutaneous, myocutaneous, or osseocutaneous. (cutaneous) (fascio \200\223) (myo \200\223) (osseo \200\223) Donor site (cid:142)(cid:3) Local Tissue to be transferred is adjacent to the defect (cid:1 42)(cid:3) Distant Tissue to be transferred is from an incontiguous site to the defect (cid:142)(cid:3) Pedicled Transferred whilst the blood supply is still attached (cid:142)(c id:3) Free The flap is detached from its native blood supply and reattached to the recipient vessels. FLAPS1 783 Configuration (cid:142)(cid:3) Advancement (cid:142)(cid:3) Rotation (cid:142)(cid:3) Trans position (cid:142)(cid:3) Interpolation. Table 17.1 Classification of muscle flaps Flap type Blood supply Example (cid:142)(cid:3) Medial gastrocnemius (cid:142)(cid:3) Lateral gastrocnemius (cid:1 42)(cid:3) Tensor fascie lata (cid:142)(cid:3) Soleus (cid:142)(cid:3) Gracilis (cid:142)(c id:3) Trapezius (cid:142)(cid:3) One vascular pedicle Type I (cid:142)(cid:3) Dominant vascular pedicles and Type II minor vascular pedicle (cid:142)(cid:3) Dominant pedicle is sufficient to sustain the flap (cid:142)(cid:3) Two dominant pedicles from (cid:142)(cid:3) Rectus abdominis (cid:142)(cid:3) Gluteus maximus Type III separate sources (cid:142)(cid:3) Muscle usually survives on one of the pedicles or can be split allowing the use of only part of the muscle (cid:142)(cid:3) Segmental vascular pedicle (cid:142)(cid:3) Division of more than two or t hree of the pedicles usually results in necrosis of part of the muscle (cid:142)(cid:3) One large dominant and several (cid:142)(cid:3) EHL (cid:142)(cid:3) FHL (cid:142)(cid:3) Tibialis anterior Type IV (cid:142)(cid:3) Latissimus dorsi (cid:142)(cid:3) Pectoralis major Type V segmental pedicles (cid:142)(cid:3) Either is sufficient to sustain the muscle CHAPTER 17 Principles of plastic surgery 784 Types of local skin flap Advancement flap (Fig. 17.5) The tissue adjacent to the primary de fect is mobilized and stretched to cover the defect. In its simplest form two parallel cuts are made along the sides of a defect and the intervening tissue undermined and advanced. U ndermining around the defect minimizes tension and pro- motes better scarring along the inc isions. If there is wrinkling at the base of the flap it may be necessary to excise a small amount of tissue (B row \200\231s triangle). A variation is the V-Y advancement flap where a triangular piece of skin is mobilized and t hen advanced to cover the defect. The donor area is then closed as a straight line. Rotation flap (Fig. 17.6) This rotates about a pivot point and is semicircular in shape. Th e steps to creating a flap are: (cid:142)(cid:3) Triangulation of defect (cid:142)(cid:3) E xtend lower limb (cid:142)(cid:3) Draw semicircular line from the other edge of the defect to meet the above line (cid:142)(cid:3) Incision of the semicircular line (cid:142)(cid:3) Undermine the flap and advance it (cid:142)(cid:3) To reduce it is important to keep the arc of rotation as large as possi- ble under tension; if this is too great a backcut or excision of B row \200\231s triangle may be necessary. Transposition flap (Fig. 17.7) In this type a flap is transferred laterally to cover the de fect. For the basic transposition flap a defect is changed into a triangular shape. A recta ngu- lar flap is raised adjacent to the defect and transferred laterally. As the pivot poin t is at the base of the flap distal to the defect, then it is necessary to make the flap lo nger than the edge of the defect to allow adequate movement. The donor defect is usually co vered with a skin graft. Limberg flap (Fig. 17.8) This is a form of transposition flap used to close a rhomboid defe ct, with no need to skin graft the donor as it can be closed. The markings are very precise and the steps are: (cid:142)(cid:3) Convert the defect into a rhomboid with angles of 60(c id:13) and 120(cid:13) (cid:142)(cid:3) Extend the short axis into an area of loose skin (c id:142)(cid:3) The length of this line is equal to the short axis of the defect (cid:142)(c id:3) The third limb of the flap is drawn parallel and equal in length to the edge of the defect. (cid:142)(cid:3) The flap is undermined and then transposed into the defect. There are four possible flaps for each defect and which one is chosen depends on the orientation of the r elaxed skin tension lines. TYPES OF LOCAL SKIN FLAP1 785 (A) (B) Fig. 17.7 Advancement flap Fig. 17.8 Rotation flap Fig. 17.9 Transposition flap CHAPTER 17 Principles of plastic surgery 786 Z-plasty flaps (Fig. 17.9) These are opposed transposition flaps that fill each other \200 \231s defects. They are used to either lengthen a contracted scar or alter the orientation of a scar. The basic flap consists of central axis, along the line that needs lengthening, and two limbs orientated at 60(cid:13) to it. All three parts of the flap are of the same l ength. The flaps are then undermined and transposed. Whilst the classic Z-plasty has flaps of 60(cid:13) they can vary from 30(cid:13) to 90(cid :13). The theoretical gain in length of the tissue depends on the angle of the flap as outl ined in Table 17.2. TYPES OF LOCAL SKIN FLAP1 787 B 120 A 80 C B1 C1 A1 B B1 C A1 A C1 Fig. 17.10 Limberg flap 1 6 A B B AA 2 A 5 B B A B B 3 A 4 A Fig. 17.11 Z-plasty flap Table 17.2 Angles of Z-plasty Theoretical gain in length (%) 30(cid:13) 25 45(cid:13) 50 60(cid:13) 75 75(cid:13) 100 90(cid:13) 120 CHAPTER 17 Principles of plastic surgery 788 Free flaps and microsurgery Microsurgery may used for both vessels and nerves; either in th e trauma setting or for free flap surgery as part of reconstruction. It is time con- suming , tiring and requires the utmost attention to detail and surgical technique. Requirements (cid:142)(cid:3) Magnification using either a microscope or loupes (cid:142)(c id:3) Microinstruments consisting of forceps, scissors, needle holder, microvascular clamps, and vessel dilator (cid:142)(cid:3) Microsutures monofilament ranging from 8/0 to 11/0. Vascular anastomosis (cid:142)(cid:3) Support of the arms so that the hand muscles allowed fine movement (cid:142)(cid:3) Vascular clamp is applied to allow accurate matching of the ends. Different types are available (cid:142)(cid:3) Vessel ends should be cleanly transected (cid:142)(cid:3) Adventitia is di ssected free from the vessel (cid:142)(cid:3) Intima should be undamaged and free of clot o r atheroma (cid:142)(cid:3) Arterial flow is checked by releasing the microvascular clamp ( cid:142)(cid:3) Anastomosis may be end-to-end or end-to-side. If there is a dis- crepancy i n diameters one vessel may be cut obliquely to give a better match (cid:142)(cid:3) Suturing is usually by single interrupted sutures taking care not to pass the needle through the back wall causing a stenosis (cid:142)(cid:3) Patency is checked after release of the clamps. Vascular problems (cid:142)(cid:3) No-reflow phenomena is where there is reperfusion in the distal tissue despite an adequate anastomosis. This is due to capillary occlusion, with pl atelets and clot, resulting in shunting. The lack of perfusion leads to flap or replantatio n death. (cid:142)(cid:3) Vasospasm can be prevented by minimizing the handling of vessels and keepi ng the patient warm and pain free (reduces circulating catechola- mines). It can be tempora rily reversed by mechanical dilatation with vessel dilators or pharmacological agents (papa verine, verapamil, lignocaine) (cid:142)(cid:3) Thrombosis at the anastomosis may develop if there has been damage to the intima. Microneural surgery This may be necessary to repair divided nerves, for an innervated free flap or if a nerve graft is used (cross facial re-animation of facial palsy). A nerve consi sts of 3 layers: (cid:142)(cid:3) Endoneurium is between the axons (cid:142)(cid:3) Perineu rium surrounds fascicles (cid:142)(cid:3) Epineurium surrounds the nerve. FREE FLAPS AND MICROSURGERY1 789 The types of nerve repair are: (cid:142)(cid:3) Epineural is the most commonly performed. I t may be used for all types of nerve but particularly for smaller ones (cid:142)(cid:3) Perineural (fascicular) is more challenging and whilst theoretically advantageous this has not been proven (cid:142)(cid:3) Grouped fascicular is undertaken when specific branches can be identified such as in the median nerve. Replantation The decision to replant a severed body partly depends on a number of factors s uch as co-existing injury, time since injury, likelihood of future functional recovery, typ e of injury (guillotine better than avulsion) and body part. (cid:142)(cid:3) Arm/digits re plantation is indicated if involving children, thumb, multi- ple digits, midpalm or more proximal. (cid:142)(cid:3) Leg replantation is rarely indicated because of the poor functional outcome. (cid:142)(cid:3) Head/neck scalp avulsions or amputated ears may be replanted as there is e xcellent vascularity and the late reconstructive options do not give a good esthetic result . Postoperative care (cid:142)(cid:3) Access should be easy to allow monitoring. (cid:142)(ci d:3) Dressings should not compress the pedicle. (cid:142)(cid:3) Visual observations should be performed regularly noting color, capillary refill, tissue turgor. A pale flap with poor turgor may indicate an arterial prob lem whereas a tense, cyanosed flap with brisk refill may indicate a venous problem. (cid:142)(cid:3) Pain should be minimal to reduce circulating catecholamine \200\224may cause vasospasm and shunting leading to ischaemia and anastomotic problems. (cid:142)(cid:3) Hydration should be kept high to reduce blood viscosity and therefore the chances of thrombus formation. (cid:142)(cid:3) Heat either by keeping the room warm, or warming blankets maintains a hyperdynamic state and reduces circulating catecholamines. (cid:142)(cid:3) Monitoring with temperature probes or Doppler assessment of the anastomosis are useful adjuncts. Ultimately there is no replacement for regular visual assessment by an experienced observer and senior advice should be sought if there is any doubt. If there are worries concerning the patency of the anastomosis then timely re-exploration in theater is indicated. CHAPTER 17 Principles of plastic surgery 790 Management plan Risk factors A number of factors may lead to an unfavorable result and may influence any plan of treatment. (cid:142)(cid:3) Unrealistic expectations (cid:142)(cid:3) Poor compliance (cid:142)(cid:3) Poor communication (cid:142)(cid:3) Child patients (cid:1 42)(cid:3) Surgeon \200\231s preconceptions (cid:142)(cid:3) Male esthetic patients (cid:14 2)(cid:3) Psychiatric/psychological pathology. Intrinsic factors (cid:142)(cid:3) Endocrine disorders particularly diabetes. (cid:142)(cid :3) Nutrition may lead to inadequate healing. Consider nutritional supplements or even naso gastric feeding (particularly in burns). (cid:142)(cid:3) Mobility may be poor and physioth erapy is vital to rehabilitation. (cid:142)(cid:3) Cardiovascular compromise can cause woun ds in the lower leg to heal poorly. Extrinsic factors (cid:142)(cid:3) Infection Chronic wounds should have a swab taken preope ratively and antimicrobial therapy (topical antiseptics (cid:140) IV/O antibiotics) given if appropr iate. (cid:142)(cid:3) Wheelchair etc. Poorly fitted surgical appliances may be a cause of the problem and will need correcting. (cid:142)(cid:3) Social Burns in particular may be the first sign of inability to cope at home. (cid:142)(cid:3) Surgical technique This is a major cause of poor results. Have a back-up plan It is imperative that the pros and cons of each surgical option are con - sidered. The reconstructive ladder is essential \200\224formulate a plan and usually the simplest option is the safest. However, the simplest is not necessarily the one that will g ive the best result. Whatever plan is de- cided upon it is equally important to have an alt ernative should the origi- nal fail \200\224Sir Harold Gillies described this as a \200 \230lifeboat \200\231. Consider the donor Steal from Peter to pay Paul only if Peter can afford it \200\224 i.e. t issue from one part of the body is used to reconstruct another only if the resultant donor is acceptable either cosmetically or functionally. Body units The body can be divided into units and each has still further subunits. It has b een said that the most important aspects of a regional unit are its borders, which are dema rcated by creases, margins, angles and hair liners \200\231. It may be best to convert a pa rtial defect of a unit to one that encompasses the whole unit. MANAGEMENT PLAN1 791 Replace like with like Skin from different parts of the body has different qualities \200 \224e.g. compare eyelid skin to palm skin. It is best to use as similar tissue for the reco n- struction as was originally in the defect. Postoperative care Treatment does not finish with surgery and postoperative care may be mor e important. This may involve physiotherapy, occupational therapy, psychology and psychiatr ic help. CHAPTER 17 Principles of plastic surgery 792 Plastic surgical technique Factors (cid:142)(cid:3) Body region The sternal and shoulder re gion are particularly prone to poor quality scars. (cid:142)(cid:3) Anatomical landmarks Wounds close to landmarks such as the eye- brow or li ps will produce a particularly noticeable scar if not sutured meticulously. (cid:142)(cid:3) RSTL The closer the line of a wound to these the better the cosmetic result. (cid:142)(cid:3) Shape of incision Curved or U-shaped incisions can cause unsightly scars called trapdoor deformity \200\224the scar contracts causing a curved groove with the central area bulging. (cid:142)(cid:3) Race Black skin is more likely to develop keloids. (cid:142)(cid:3) Age Ol der skin is less elastic and so under less tension which can give a better quality scar. Incision The proposed incision is usually marked with ink prior to surgery. The skin is hel d taut and the incision itself should be perpendicular to the skin edge in the line of the RSTL. Methods of skin closure (cid:142)(cid:3) Sutures (cid:142)(cid:3) Staples (cid:142)(cid:3) Glue (cid:142)(cid:3) Adhesive strips. Suture material There are so many types of suture \200\224braided, monofilament, absorbable , non-absorbable that it is impossible to give definitive guidance. Indeed for most situati ons there are a number of equally acceptable alternatives that the choice is usually dictat ed by personal preference. General suture technique (cid:142)(cid:3) Ensure that an elective incision runs along a RST L (cid:142)(cid:3) Debride the wound, remove any foreign bodies, and irrigate it (cid:142)( cid:3) Ensure the wound edges are not under tension (cid:142)(cid:3) Ensure that the wound edges are well apposed (not inverted) (cid:142)(cid:3) Ensure that the forces acting on the wound only act in one direction, and minimize distracting forces (cid:142)(cid:3) Minimize tissue trauma when suturing (cid:142)(cid:3) Suture neatly with a gently everting wound edge (cid:142)(cid:3) Avoid materials that cause a bad tissue reacti on e.g. silk on the face (cid:142)(cid:3) Make sure you immobilize the wound with Steri-str ips, tapes, and even thermoplastic splints and plaster casts where necessary. PLASTIC SURGICAL TECHNIQUE1 793 Simple interrupted suture (cid:142)(cid:3) A skin hook placed at either end of the wound ca n aid in suturing (cid:142)(cid:3) The thread should enter the skin at a distance from the wound border equal to the thickness of the skin (cid:142)(cid:3) It then passes through the skin slightly obliquely taking a larger bite more deeply (everts skin) (cid:142)(cid:3) The knot is tied with sufficient tension to evert the wound (cid:142)(cid: 3) Enough sutures are used to satisfactorily approximate the wound edges Mattress sutures (cid:142)(cid:3) Horizontal These complement the simple suture and help to achieve wound eversion (cid:142)(cid:3) Vertical Are used when there is extensive undermining or when the surgeon does not want to place deeper sutures. They should not be tied too tightly and may not actu ally coapt the wound edges in which case they will need to be alternated with simple suture s. Continuous sutures The continuous buried suture should leave no suture marks and gives good dermal approximation. However, there is little resistance to stretching, can be time consu ming and is more difficult to achieve a satisfactory result. Suture removal An incised wound is epithelialised in 3 \200\2235 days and the strength of i t for most of that time is due to the sutures. Sutures should be removed as soon as it is p racticably safe to do so and the timing primarily depends on the anatomical site. In the fa ce sutures should be left no longer than 5 days, in the hand this is usually 10 \200\22314 days and in the lower limb or back 14 days. If sutures are left too long and were tied too tight then stitch marks may remain. CHAPTER 17 Principles of plastic surgery 794 Lower limb trauma Lower limb trauma, particularly when high energy is involved, has a com- bination of bone and soft tissue injuries. Optimum treatment requires collaboration between plastic and orthopedic surgeons from the start. The first crucial step is the recognition of a potential problem prior to surgery and to formulate a plan for the first few days afte r the injury. It is not adequate to realize a problem during or after bony fixation; the fi rst call to a plastic surgeon should not be when the patient is on the way to theater for b ony fixation. It is generally accepted that by the end of the 5th day all wounds should be covered; the s uccess of microvascular free flaps is diminished after this time. Even if an operation for definitive soft tissue cover will be some- time after bony fixation then it may still be ve ry useful for a plastic surgeon to be involved in the first procedure (or second look at 48 hours); either to advise on debridement or the placement of incisions/fixators so they do not compromise subsequent flap surgery. History There are some features that should alert a surgeon to the potential for problems ( cid:142)(cid:3) Road traffic collisions (cid:142)(cid:3) Falls from a height (cid:142)(cid: 3) Bullet/missile wounds (cid:142)(cid:3) Crushing mechanisms. Examination (cid:142)(cid:3) ABC (airway, breathing, circulation) (cid:142)(cid:3) Coexisti ng injuries (cervical spine, pelvis) (cid:142)(cid:3) Skin (large wounds, degloving, crushi ng) (cid:142)(cid:3) Compartment syndrome (cid:142)(cid:3) Vascular compromise (cid:142)(ci d:3) Nerve injury (cid:142)(cid:3) X-ray (comminution, segmental fractures, air in tissue). LOWER LIMB TRAUMA1 795 Classification The classification formulated by Gustillo is the most widely used and useful when discussing an injury. (cid:142)(cid:3) Grade I Low energy Skin opening of \211 1cm Quite clean Mostly from inside to outside Minimal musc le contusion Simple transverse or oblique fractures Moderate injury Laceration more than >1 cm long Moderate crushing component Simple transverse or oblique fractures with minimal com minution High energy Extensive soft tissue damage including muscle, skin, neurovascular str uctures Adequate bone coverage Extensive soft tissue injury with periosteal stripping and b one exposure Vascular injury requiring repair (cid:142)(cid:3) Grade II (cid:142)(cid:3) Grade III (cid:142)(cid:3) IIIA (cid:142)(cid:3) IIIB (cid:142)(cid:3) IIIC Preoperative management (cid:142)(cid:3) ABC (cid:142)(cid:3) Wound Bacteriology swab, teta nus prophylaxis. (cid:142)(cid:3) Antibiotics Broad spectrum but consider adding penicillin (against clostridia). (cid:142)(cid:3) Plan An initial one should be made at this stage. Initial surgical management (cid:142)(cid:3) Skin extension should be longitudinal (less li kely to compromise subsequent flaps). All devitalised tissue must be removed but it may be possible to harvest skin grafts from degloved areas. (cid:142)(cid:3) Muscle can be difficult to accurately assess as it is very sensitive to tr auma. Obviously dead muscle should be removed but a further inspection at 48 hours may be n eeded. (cid:142)(cid:3) Fasciotomies must be adequate and decompress all compartments (in lower limb; anterior, peroneal, posterior, and deep). (cid:142)(cid:3) Closure should not be attempted if there is any suggestion of skin tension \200\224subsequent oedema will only worsen this. Reconstruction (see Table 17.3) Using the reconstructive ladder the 3 methods are (cid:142) (cid:3) Skin grafting (cid:142)(cid:3) Local flaps (cid:142)(cid:3) Free flaps. CHAPTER 17 Principles of plastic surgery 796 Skin grafts These must be applied only if there is a vascularised bed with no infec- tion. If the bed is not vascularised then the next step up the reconstruc- tive ladder is a local flap, either skin (fasciocutaneous) or muscle. Fasciocutaneous flaps These may be based on the medial or lateral aspects of the leg and ei ther proximally or distally based. Muscle flaps (cid:142)(cid:3) Proximal third Medial or lateral bellies of gastrocnemius. (c id:142)(cid:3) Middle third Anterior compartment muscles or soleus. Free flaps These are very flexible and can be applied to almost any situation. They may be either muscle \200\224latissimus dorsi, rectus abdominis, gracilis or skin \200\224antero-l ateral thigh. LOWER LIMB TRAUMA1 797 Table 17.3 Summary of treatment options for lower limb trauma Region of defect Flap (cid:142)(cid:3) Gastrocnemius (cid:142)(cid:3) Proximal fasciocutaneous (cid:142)(cid:3) F ree flap (cid:142)(cid:3) Soleus (cid:142)(cid:3) Anterior compartment muscles (cid:142)(ci d:3) Proximal fasciocutaneous (cid:142)(cid:3) Free flap (cid:142)(cid:3) Distally based fa sciocutaneous (cid:142)(cid:3) Free flap (cid:142)(cid:3) Distally based fasciocutaneous (c id:142)(cid:3) Free flap (cid:142)(cid:3) Proximal third (cid:142)(cid:3) Middle third (cid:142)(cid:3) Distal third (cid:142)(cid:3) Ankle CHAPTER 17 Principles of plastic surgery 798 Neoplasia Basal cell carcinoma Basal cell carcinoma (BCC) is the most common skin tumor enc oun- tered in practice and is almost entirely, but not exclusively, confined to white cauca sian individuals. Etiology (cid:142)(cid:3) Sun exposure (cid:142)(cid:3) Scars (cid:142)(cid:3) Irradiation (cid:142)(cid:3) Genetic syndromes \200\224Gorlin \200\231s syndrome (cid:142)(cid:3) Autosomal dominant (chromosome 9q) (cid:142)(cid:3) Palmar pits (cid:142)( cid:3) Jaw cysts (cid:142)(cid:3) Parafalcine calcification. Xeroderma pigmentosa Presentation (cid:142)(cid:3) Nodulo-ulcerative (cid:142)(cid:3) Cysti c (cid:142)(cid:3) Morphoeic (cid:142)(cid:3) Superficial (cid:142)(cid:3) Pigmented. Treat ment (cid:142)(cid:3) Curettage (cid:142)(cid:3) Cryotherapy (cid:142)(cid:3) Radiation (ci d:142)(cid:3) Surgery (cid:142)(cid:3) Conventional (cid:142)(cid:3) Moh \200\231s microsur gery Squamous cell cancer Squamous cell cancer (SCC) is the second most common skin malignancy. Classified into: (cid:142)(cid:3) Well differentiated through to poorly differentiated. (ci d:142)(cid:3) Kerato acanthoma \200\224difficult to differentiate even pathologically and i s considered a form of well differentiated SCC. It is self limiting. Etiology (cid:142)(cid:3) Sun exposure (cid:142)(cid:3) Human papilloma virus (cid:142)(cid :3) Exogenous carcinogens (cid:142)(cid:3) Tobacco/pipe smoking (cid:142)(cid:3) Petrochemical exposure (cid:142)(cid :3) Radiation (cid:142)(cid:3) Genetic syndromes \200\224xeroderma pigmentosa (cid:142)(cid:3) Marjolin \200\231s ulcer NEOPLASIA1 799 Treatment (cid:142)(cid:3) Surgical excision with adequate margins is the treatment of choi ce (cid:142)(cid:3) Lymph node dissection should be considered in poorly differentiated or large cancers or if clinically enlarged lymph nodes (cid:142)(cid:3) Radiation therapy has been advocated in small cancers in anatomically impo rtant areas such as eyelids or in cases to control and palliate. Melanoma Melanoma is classified by description. Essentially all melanomas present pathologi cally as the same, but they are described by appearance (cid:142)(cid:3) Superficial spread ing (cid:142)(cid:3) Nodular (cid:142)(cid:3) Lentigo maligna (cid:142)(cid:3) Acral lentig inous (cid:142)(cid:3) Amelanotic and unclassifiable. Etiology (cid:142)(cid:3) Sunlight (c id:142)(cid:3) Genetic (cid:142)(cid:3) Pre-existing naevus. Staging (cid:142)(cid:3) Micro staging (cid:142)(cid:3) Breslow \200\224based on depth in millimeters (cid:142)(cid:3) Clarke \200 \231s level \200\223 I \200\224within epidermis \200\223 II \200\224within papillary dermis \200\223 III \200\224within reticular dermis \200\223 IV \200\224fills reticular dermis \200\223 V \200\224into subcutaneous fat (cid:142)(cid:3) AJCC classification 2002 Treatment (cid:142)(cid:3) Surgical (cid:142)(cid:3) Primary excision (cid:142)(cid:3) Marg ins (cid:142)(cid:3) Less than 1mm Breslow depth \200\2241cm margin (cid:142)(cid:3) Greater th an 1mm Breslow depth \200\2242cm margin Sentinel node WHO recognize sentinel node as being the standard of care in mela- noma great er than 1mm Breslow depth. In the UK it is still not accepted that sentinel node is the acc epted standard of care. Prognosis: lymph node status is the most important factor in assess ing prognosis. The AJCC Classification groups different aspects of melanoma, such as: (cid: 142)(cid:3) Breslow depth (cid:142)(cid:3) Ulceration (cid:142)(cid:3) Mitoses per high pow er field (cid:142)(cid:3) Sentinel node positivity (cid:142)(cid:3) Number of nodes positiv e, and gives a prognostic figure. CHAPTER 17 Principles of plastic surgery 800 The risk of recurrence may be stated approximately as: Breslow 1mm Breslow 2mm Breslow 3mm Breslow 4mm Breslow 5mm or greater 10% risk of recurrence 20% risk of recurrence 30% risk of recurrence 40 % risk of recurrenc e 50% risk of recurrence. Pressure sores Pressure sores (bedsores and decubitus ulcers) are areas of tissue loss resu lting from pressure. These areas are usually, but not exclusively, over bony prominences.