Reconstructive and cosmetic surgeries [Auto-saved].pptx

VHD

1. Reconstructive and cosmetic surgeries

2. Definition- It is a medical specialty concerned with the correction or restoration and functions of the body structures damaged by trauma transformed by ageing process changed by disease process and malformed as a result of congenital defects. Plastic surgery

3. The word plastic derives from the greek word plastikos (to mould or to shape). Plastic surgeon typically mold and reshape (the tissues of body,bone,cartilage,muscles,fat and skin).

4. plastic surgery involves

5. Aesthetic surgical procedures (to improve the appearances). Reconstructive surgeries (to correct abnormalities).

6. Goals of plastic surgery

7. BENEFITS OF PLASTIC SURGERY: Correction of congenital or acquired deformity. Correction of perceived physical impaction. Psychological benefits.

8. Basic principles of plastic surgery

9. Incision Excision Microsurgery: transplanting patient’s own tissue Chemosurgery: removes samples of he cancerous tissue in sections and tests each sample before removing more. Electrosurgery : to control bleeding. Laser surgery Dermabrasion : Dermabrasion is a type of surgical skin planing , generally with the goal of removing acne, scarring, and other skin or tissue irregularities. liposuction Common techniques in plastic surgery

10. Performed to correct the functional impairment(burns/traumatic injuries). Reconstructive surgery

11. Common reconstructive surgical procedures are for: Breast reconstruction Face injury Contracture surgery for burns Hand and finger injury Cleft lip and palate Injuries to limbs. Craniofacial defects Pressure sores Hand anomalies Spinal cord defects Congenital cardiac defects repair

12. Reconstructive modalities Skin grafting- it involves transplantation of the skin. It is a technique in which the section of the skin is detached from its own blood supply and transferred as free tissue to a distant recipient site.

13. Removal of excess tissue in the area needed. Timing of reconstructive surgery should be individualized. Early reconstruction does not retard or influence further treatment or adversely affect predicted survival. The extent of reconstruction depends on the type of surgery done. Flaps are mostly taken from back or abdomen An implant may be used in addition to the flap, if flap does not provide cosmetic results. Principles of reconstructive surgery

14. The natural response to the presence of foreign substance is the formation of a fibrous capsule around the implant. The indication of the surgery is to improve self image or therapeutic purposes or palliative. Tissue expanders may be necessary before implants are inserted.

15. Indications Excision of skin tumors Burns(to cover wound in which insufficient skin is available to permit wound closure). Skin damage due to serious injuries Extensive wound or trauma Extensive skin loss due to some infection

16. Purposes of skin grafting Reduce the course of treatment Can improve the function and appearance of the area of the body which receives the skingraft. Provides protection to the underlying structures.

17. Classification Autograft (patient’s own skin). Allograft (obtained from a donor of the same species). xenograft /heterograft (donor of different species).

18. TYPES OF SKIN GRAFTS Classification by thickness: split skin thickness- used to cover large wounds. Shaving the surface layers of the skin with dermatome. It involves removing the top layer of the skin- the epidermis as well as a portion of the deeper layer of the skin called dermis. *Dermatome: is an area of skin in which sensory nerves derives from a single spinal nerve root

19. The surgeon removes these layers from the donor site. Split thickness skin grafts often comes from the front or outer thigh, abdomen, buttock or back. Surgeon uses this skin to cover larger areas of damaged skin. These grafts have a shiny or smooth appearance .

20. Full thickness skin grafts- consists of dermis and epidermis with out the underlying fat. It involves removing all of the epidermis and dermis from the donor site. Usually take healthy skin from the abdomen, groin, forearm. Removing layers of the skin with a scalpel(wolf graft). The piece of the skin is cut in to correct shape, the applied to the wound. It can be used to cover large wounds that needs to be closed directly.

21. Composite graft - combination of skin and fat, skin and cartilage or dermis and fat. Used in patients with injuries who require three dimensional reconstruction. Eg . A wedge of ear containing skin and cartilage can be used to repair the nose.

22. Donor sites. Dressing present in the donor site will remain for 7-14 days. Re-pad if incase of oozing or bleeding. Donor site will be painful than grafted area. (analgesics can be provided). The dressings present at the donor site will often become stiff or dry or the dressings will be fall of earlier than 7- 14 days, contact with healthcare professionals.

23. Achieving closest possible color match. Matching the texture and hair bearing qualities. Obtain thickest possible skin graft. Criteria for selecting donor site

24. Infection, Smell from discharge, High temperature and increased pain, Redness and swelling around the area Bleeding Loss of grafted skin Rejection Risk of skin graft

25. Recepient site Wound should be cleaned and anesthesia to be given depending the wound size. The graft spread over the bare area Held in place by few stitches or surgical staples. The graft is frequently meshed in order to prevent fluid accumulation under the graft. Pressure bandage is applied over the grafted area. Special vacuum apparatus placed over the area for 3-5 days. Healing begins by Plasmatic imbibition( initial stage of graft healing within 24-48 hrs ) Capillary inosculation( new blood vessels begin growing from the recipient area into transplanted skin within 36 hrs ). Revascularization and reattachment of skin graft to the recipient site is referred to as ‘take’.

26. Most skin grafts are successful. but in some cases they need repeat grafting. prognosis

27. Clean and free from infection Avoid stretching or moving around the graft. Firm dressings is to be in place. Caring the graft

28. Adequate bed rest is to be provided. Patient should support the graft with bandage. Grafted skin needs to be lubricated. Try to avoid scratching the wound. Administration of medications. Cotton clothes needs to be provided to avoid too hot. Massage gently 2-3 times in a day with the cream. The graft and donor site need to be protected from the sun.(it will burn more than rest of the skin). aftercare

29. The graft should be protected from trauma or significant stretching for 2-3 weeks. Exercise to be avoided for 3-4 weeks. Dressings necessary for 1-2 weeks.

30. Flap Surgery Flap surgery involves transporting healthy, live tissue from one location of the body to another - often to areas that have lost skin, fat, muscle movement, and/or skeletal support. There are several different types of flap surgery methods that may be utilized, depending upon the location of the flap and the structures that need to be repaired.

31. Flap surgery   is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is distinct from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels. This is done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures such as breast or jaw.

32. Flaps can be fundamentally classified by their level of complexity, the types of tissues present, or by their blood supply. Classification

33. Local flaps Local flaps are created by freeing a layer of tissue and then stretching the freed layer to fill a defect.

34. B) Rotational flaps- It is a semicircular flaps that rotates about a pivot point to fill the defect. In design, it is critical that the flap should extend beyond the defect. To ensure primary closure ,it is essential that the flap be quite large, often with a circumference 5-8 times width of the defect.

35. C) Transposition flaps- moves laterally about a pivot point in to an adjacent defect. Design the flap longer than the defect. Since the transposition decreases the length. The donor site can be closed directly or closed with a skingraft or skin flap.

36. 1. Z plasty - It is a type of transposition flap in which two triangular flaps, designed with limbs of equal length, are interposed to exchange width and length.Classically,it is designed with 60 degree angles, which yield maximum length.

37. 2.Rhomboid flap – it is designed in a rhomboid shape with 60 degree and 120 degree angles. Designed by Limberg.4 flaps can be designed surrounding a rhomboid-shaped defect.

38. A) Advancement skin flaps Moves directly forward in to a defect without lateral movement. A triangle of skin can be excised from the base of the flap to aid in closure. Thus gaining advancement. It is otherwise popularized as rectangular sliding flaps.

39. Regional flaps Regional or interpolation flaps are not immediately adjacent to the defect. The freed tissue "island" is moved over or underneath normal tissue to reach the defect to be filled, with the blood supply still connected to the donor site via a pedicle.  This pedicle can be removed later on after new blood supply has formed .

40. Cutaneous flaps contain the full thickness of the skin and superficial fascia and are used to fill small defects. Fascia-cutaneous flaps add subcutaneous tissue and deep fascia, resulting in a more strong blood supply and ability to fill a larger defect. Musculo -cutaneous flaps further add a layer of muscle to provide bulk that can fill a deeper defect. Muscle flaps can provide bulk or functional muscle. If skin cover is needed, a skin graft can be placed over it. Bone flaps are used to replace bone, such as in jaw reconstruction. Based on Tissue type

41. Random-pattern flap. The blood supply for the flap is not derived from a recognized artery but, rather, comes from many little unnamed vessels. Many local cutaneous flaps fall into this category. Axial-pattern flap The blood supply for the flap comes from a recognized artery. Most muscle flaps have axial blood supplies. vascular

42. Free flap. Free flap is defined as the vascular detachment of an isolated tissue, followed by transfer to another region of the body with reattachment of the divided artery and vein to separate artery and vein. Perforator flap. The vessels that supply blood to the flap are isolated perforators derived from a deep vascular system through the underlying muscle or intermuscular septa.

43. AXIAL FLAPS

44. Distant flaps Distant flaps are used when the donor site is far from the defect. These are the most complex class of flap. Direct or tubed flaps involve having the flap connected to both the donor and recipient sites simultaneously, forming a bridge. This allows blood to be supplied by the donor site while a new blood supply from the recipient site is formed.

45. Congenital abnormalities Trauma Tumor ablation in an adjacent part of the body Extensive wounds due to pressure sores. Functional and cosmetic requirements(wound coverage on the face/around the eyes, nose and mouth. Indications

46. Types of transposition flap Z plasty flap Rhomboid flap

47. Donor site is far from the defect. It used to cover nonadjacent defects. They may be transferred directly, tubed or transferred by micro-vascular techniques. Distant flaps

48. Direct flap- It is transferred to a distant site directly so that the donor site and recipient sites are approximated. The flap is later divided after 1-3 weeks and inset.

49. Tubed flap-it is transferred to a recipient site with the lateral flap edges sewn together, while the new blood supply is incorporated from the distant end of the flap. Sewing the edges together result in decreased risk of infection and contraction of the flap.

50. Micro-vascular free flaps – is a type of distant flap in which the flap ,with its vascular pedicle, is divided completely from its donor vessels and anastomosed to the recipient vessels at the recipient site using a micro-vascular surgical technique( his is done by reconnecting the small blood vessels.)

51. Preoperaive Poor flap design Premorbid conditions of patient Underestimation of recipient requirements Intraoperative Technical errors Design errors Poor choice of recipient vessels Causes of flap complications

52. Post operative Extrinsic – pedicle kinking, infection, vascular thrombosis. Intrinsic –distal ischemia

53. Pre-operative management Proper history collection and physical examination(latex sensitivity, cardiovascular problems, bleeding problems, high blood pressure. Encourage to take proper nutrition and advise to avoid smoking, alcoholism in order to enhance healing. All needed blood investigation reports need to be collected(especially PT-INR). Advise to discontinue aspirin, NSAID and vitamin E Operative site should be free of make-up.

54. Initial dressings need to be in place for 24-48 hours. If oozing, apply firm pressure for 10-15 min. Do not give aspirin or aspirin containing drugs Clean site and apply ointment. Keep the graft edges moist with antibiotic treatment. Protect from the sun Check for any complications Avoid strenuous exercise. Post operative management

55. It is a sub- speciality of medicine and surgery Concerned with maintaining and restoring normal appearance. Its directed to all areas of head ,neck and body COSMETIC SURGERY

56. BODY RESHAPING PROCEDURES Liposuction Tummy tuck Brachioplasty Thighplasty Butt augmentation/implant Male breast reduction Aesthetic genital surgery A)SURGICAL PROCEDURES

57. Liposuction Break up or sucks fat from the body. Abdomen,thighs,buttoks,neck,chin,upper and back of arms Tummy tuck This surgery flattens the abdomen by removing extra fat and skin, and tightening muscles in abdominal wall. brachioplasty It is a surgical procedure to reshape and provide improved contour to the upper arms and connecting area of chest wall. A brachioplasty is  a surgery that reshapes the back part of your upper arm, from your arm to your elbow . It's also called an arm lift. It removes extra skin and tissue. It makes your upper arm look smoother. When a person gains a lot of weight, his or her skin slowly stretches over time.

58. Thighplasty - It is a cosmetic surgical procedure to tighten and improve the appearance of your thighs due to excess skin on the thighs that can be a result of aging, pregnancy, or a significant weight loss.

59. Buttock augmentation/ gluteal augmentation, It is used to improve the contour, size and/or shape of the buttocks. This is done through the use of buttock implants, fat grafting or sometimes a combination of the two. Male breast reduction It reduces breast size in men, flattening and enhancing the chest contours.

60. Aesthetic genital surgery There is a variety of aesthetic genital plastic surgery procedures that may enhance appearance and reduce discomfort. These procedures include labiaplasty , clitoral hood reduction, labia majoraplasty , monsplasty ( is a type of cosmetic surgery where excess skin and fatty tissue are removed from the fatty pad over the pubic bone) and vaginoplasty .

61. Blepharoplasty Endoscopic forehead and browlift Rhytidectomy Liposculpture Rhinoplasty Chin and cheek enhancement Dermabrasion Facial cosmetic procedures

62. It is the removal of bulging fat and excess skin around the eyes. Eg . Repairs droopy eyelids Procedure Can be done under local or general anaesthesia Marking the excess skin and fat in standing position Excess skin is removed and fat is excised and the incision is closed by sutures. Blepharoplasty

63. Risk - it can cause ectropion ( eyelid turns outward) Post –operative care: Ice application Local antibiotic creams Eye drops Sun glasses Sutures can be removed within 5 days Lubricants Proper wound care Advice to avoid exercise Elevate the head end of the bed

64. Browlift / foreheadlift It is a cosmetic procedure to raise the brows. A brow lift improves the appearance of the forehead, the brow and the area around the eyes by raising the soft tissue and skin of the forehead and brow. Recovery phase: Antibiotics Ice compress and eye exercises Sutures can be removed within one week

65. Lifting and repositioning of the lower two thirds of the face and neck to improve appearance Can remove facial wrinkle and sagging skin Involves tightening of the facial and neck muscles. Indications Asymmetric redundancy of soft tissue Periauricular lesions Redundant soft tissue from trauma Rhytidectomy /facelift

66. It can be done in under LA or moderate sedation in out patient department. Complications Sloughing of the skin Partial facial paralysis Infection Bleeding numbness

67. Management Rest Head end to be elevated Advice to avoid neck flexion Analgesics Liquid diet Topical ointment Advice not to bend for 7-10 days

68. More advanced cosmetic surgery reshapes larger amount of fat Can use local anesthesia Procedure Fat is removed with the use of small needle attached with syringe. This fat is processed to remove excess fluid,and then reinject by using another needle,which is placed under the skin beneath the area that requires fat. It can be repeated until the desired correction has been achieved. Liposculpture

69. Love handles ” are areas of skin that extend outward from the hips. They indicate excess fat accumulation around the hips and abdominal area.

70. Removal of excess cartilage and tissue from the nose with the correction of septal defect. Indication Deviated nasal septum Reducing or enlarging certain areas in the nose Procedure Under GA Incisions made inside the nose Skin of nose is raised and necessary changes are made to the bones, cartilages , and soft tissues. Nose is packed for 48 hours Recovery-takes couple of weeks. Rhinoplasty

71. After care: Proper dressing Reduce activities Head to be elevated Avoid bending and heavy lifting Ice application.

72. It is a surgical procedure to minimize the appearance of scars, restore function and correct disfigurement resulting from an injury. Smoothens the surface of the scar by shaving or scrapping off the top layers of skin Performed by dermatological surgeon. Dermabrasion

73. Shaping of chin and improves chin contours. It involves the placement of an implant around the patient’s existing chin to augment the size and shape of the chin and achieve natural attractive facial features. facial dressing (7 days). Chin and cheek enhancement/ Genioplasty

74. NON SURGICAL PROCEDURES FILLERS CHEMICAL PEEL BOTULINUM TOXIN INJECTION-LIPOLYSIS

75. FILLERS Helps to fill out deep facial wrinkles CHEMICAL PEEL: A technique used to improve the appearance of the skin on the face, neck and hands. A chemical solution is applied to the skin and it causes to exfoliate and eventually peel.

76. BOTULINUM TOXIN: It is produced by the bacterium Clostridium botulinum and can be used as a treatment to reduce the appearance of wrinkles in the upper areas of the face and other cosmetic surgeries. Neurotoxin temporarily interfere with neuromuscular transmission, paralysing the fine muscles especially in the forehead and around the eyes.

77. INJ.LIPOLYSIS: It is an FDA approved non surgical procedure that reduces the number of fat cells in the targeted area. It is minimally invasive aesthetic surgery treatment that uses a chemicals called deoxycholic acid or phosphatidylcholine to damage and kill fat cells. Process of permanent fat removal. Anesthesia not required Full effect can be seen after 4-6 weeks.

78. Mammoplasty Breast reduction Breast lift Nipple areolar reconstruction Breast reshaping procedures

79. It an artificial reshaping or augmenting a breast for cosmetic reasons. It can be done after breast development. It can be done under local anesthesia’. An implant(prosthesis) is placed through an incision, under the breast tissue or under the muscle. the incision can be made under the breast, around the nipple . The entire procedure will take nearly 2-3 hours. Mammoplasty

80. Saline breast implants It is a pouch made of silicone rubber or elastomer. This is surgically inserted under the chest tissue or muscle and then filled with saline water through a valve. Silicone gel breast implants These implants have multiple layers of silicone elastomer around the implant and these are prefilled.it can produce firmer and softer effect than saline implants. * Most saline and silicon implants are FDA approved for 10-20 yrs , but it does not mean that it should be changed every 10-20 yrs. Types of breast implants

81. Infra mammary crease approach A fine 5 cm incision is made beneath the breast Circum areolar approach Incision is made in the lower half circle of the areola. Incision for breast augmentation

82. Procedure: Locations Below the gland(sub glandular) Below the muscle(sub muscular) Dual plane(upper half below the muscle) (lower half below the gland) The pocket for the Implant

83. Minor discomfort Feeling of stretch Swelling Bruising Decreased sensation over the breast Post breast implant surgery

84. Collection of serous fluid or blood Sensory changes Infection Implant malposition Capsular contracture (late): Capsular contracture is a local complication thought to occur due to an excessive fibrotic foreign body reaction to the implant. It is thought to be an inflammatory reaction which causes fibrosis through the production of collagen. Complications associated with breast augmentation