RECONSTRUCTIVE SURGERIES & Cosmetic surgeries.pptx

Reconstructive surgeries- types

1. RECONSTRUCTIVE AND COSMETIC SURGERIES

2. The word "plastic derived from the Greek plastikos meaning to mould or to shape. Plastic surgeon typically mold and reshape the following tissues of the body; bone, cartilage, muscles, fat and skin. Plastic surgery is a medical specialty concerned with the correction or restoration of form and function of the body structures damaged by trauma, transformed by aging process, changed by disease process and malformed as a result of congenital defects.

3. In plastic surgery the transfer of skin tissue (skin grafting) is one of the most common procedures . Plastic surgery include closure of wounds, removal of skin tumors, repair of soft tissue injuries or burns, correction of deformities and repair of cosmetic defects.

4. During plastic surgery the following procedures are common: tissue may be removed to fill depression to cover a wound or to improve appearance and tissue may be completely removed to alter the shape. Plastic surgery is divided into two major areas: Reconstructive surgery and Cosmetic (aesthetic) surgery.

5. GOALS The basic goals of the plastic surgery include following: Correction of perceived disfigurement Restoration of impaired function Improvement of physical appearance

6. BENEFITS The benefits of plastic surgery may include : Correction of a congenital or acquired deformity Correction of a perceived physical imperfection Psychological benefits

7. Basic principles of plastic surgery : Achieving minimal scarring Careful planning of incisions Appropriate choice of wound closure Use of best available suture materials Early removal of exposed sutures Documentation through photography

8. RECONSTRUCTIVE SURGERY Reconstructive surgery is the use of surgery to restore the form and function of the body. It is performed to correct functional impairments caused by: burns, traumatic injuries such as facial bone fractures, congenital abnormalities such as cleft lip or palate, developmental abnormalities, infection or disease and removal of cancers or tumors such as mastectomy.

9. Common Reconstructive Surgical Procedures There are several operative and non-operative procedures available to improve the shape and enhance the beauty of various body parts . Most commonly performed procedures for various body parts are as follows : Breast Reconstruction Cleft Lip and Palate Ptosis/Drooping of Eyelid Face Injury

10. Injuries to Limbs Defects of e ars Burn Contracture Surgery Cranio -facial Defects Pressure Sores Hand and finger Injuries Amputations Spinal cord defects

11. RECONSTRUCTIVE MODALITIES 1. Skin grafting - split skin graft - full thickness skin graft - composite graft 2. Skin flap a)Local flap - rotational flap - advancement flap - transposition flap - interpolation flap b)Distant flap - direct flap - tubed flap - microvascular free flap

12. Reconstructive Modalities Skin Grafting Skin grafting is a type of medical grafting involving the transplantation of skin. Here a section of skin is detached from its own blood supply and transferred to a distant site . Skin grafts are commonly used to repair defects result from excision of skin tumors, burn and to cover the wound in which insufficient skin is available to permit wound closure.

13. The grafting has two purposes: it can reduce course of treatment needed it can improve the function and appearance of the area of the body which receives the skin graft . Indications Extensive wounds or trauma Burns Specific surgeries

14. Classification 1.Autografts : An autografts is tissue obtained from the patient's own skin . 2 . Allografts : An allograft is tissue obtained from a donor of the same species ; these grafts are also called allogenic or homografts . 3 . Xenografts : A xenografts or heterograft is tissue from a donor of a different species

15. Types of Skin Grafts Split Skin Grafts A split-thickness graft can be cut at various thicknesses and is commonly used to cover large wounds. It is taken by shaving the surface layers (epidermis and dermis) of the skin with a large knife called a dermatome The shaved piece of skin is then applied to the wound. This type of skin graft is often taken from the leg . It is often used after excision of a lesion on the lower leg .

16. Full Thickness Skin Grafts: Full-thickness graft consists of epi dermis and the entire dermis without the underlying fat This type of skin graft is taken by removing all the layers of skin . It is done in a similar way to skin excision. The piece of skin is cut into the correct shape, and then applied to the wound. This type of skin graft is often taken from the arm, neck or behind the ear. It is often used after excisions on the hand or face.

17. Composite Graft: A composite skin graft is a combinations of skin and fat, skin and cartilage . It is used in patients whose injuries require three-dimensional reconstruction For example, a wedge of ear containing skin and cartilage can be used to repair the nose .

18. Donor Site The common areas which are used as donor sites are buttocks, Thighs upper arms the dressing will usually be left in place for 7-14 days R e- pad the dressing as the area often oozes/ bleeds after the operation Donor site area is usually more painful than the grafted area as the top layers of the skin are removed exposing nerve endings . Regular painkillers will need to be given to ease discomfort All dressing need to be kept dry

19. The donor site is selected with several criteria The donor site is selected with several criteria :- Achieving the closest possible color match Matching the texture and hair bearing qualities Obtaining the thickest possible skin grafts without affecting the healing of donor site

20. Graft Application W ound preparation. The wound is cleaned and measured, and then a pattern is traced for transfer over to the donor site . Anesthesia is administered. Depending on the size, severity, and location of the wound, as well as the type of graft, the procedure may require local anesthesia, regional anesthesia, iv sedation, general anesthesia, or a combination.

21. The donor skin is harvested and prepared. The skin is either removed with a scalpel, skin grafting knives or with the help of a special harvesting machine called a dermatome. The graft may also be "meshed," a process by which multiple controlled incisions are placed in the graft. This technique allows fluid to leak out from the underlying tissue and the donor skin to spread out over a much larger area .

22. With full thickness or composite graft, the donor site is then closed with sutures. With a split- thickness graft, sutures are not needed at the donor site . The skin graft is taken from the donor or host site and applied to the desired site called the recipient site or graft bed. It is held in place by a few small stitches or surgical staples. A pressure bandage is applied over the graft recipient site. A special vacuum apparatus called a wound VAC may be placed over the area for the first 3 to 5 days to control drainage and increase the graft's chances of survival .

23. Healing begins. At first, the graft uses oxygen and nutrients from the tissue at the recipient site to survive. The graft is initially nourished by plasma. ( plasmatic imbibitions ) New blood vessels begin to grow within the first 36 hours by a process called capillary inosculation , followed by new skin cells which then begin to grow from the graft to cover the recipient area with new skin.

24. The process of revascularization and reattachment of skin graft to a recipient bed takesplace . After a skin graft is put in place, it may be left exposed or covered with a light dressing or a pressure dressing depending on the area. Post-Op Care: Both the donor and recipient sites should be kept moist and well- protected . Physician will instruct patient on the proper use of medications and bandaging

25. For a graft to survive and be effective, certain conditions must be met: The recipient site must have an adequate blood supply so that normal physiologic function can resume . The graft must be in close contact with its bed to avoid accumulation of blood or fluid . The area must be free of infection The graft must be fixed firmly (immobilized) so that it remain in place on the recipient sites.

26. Complications of Skin Grafts and Donor Areas 1.Infection Smelly discharge from dressing High temperature Increased pain Redness and swelling around the skin graft and donor area 2.Bleeding through dressing due to trauma or infection which may cause clots and lift graftt

27. 3. Inadequate excision of the wound bed 4. Inadequate vascular supply to the wound bed 5. Hematomas and seromas 6.Graft rejection Rejection may occur in heterologous graft. To prevent this, the patient usually must be treated with long term immunosuppressant drugs .

28. Graft Care Clean and free from infection. Avoid stretching or moving around the graft area or the affected limb unless advised. The graft have firm dressing in place to help stop any movement and friction. Patient might also need a plaster to prevent extra movement near joints. The pressure of the dressing will help to stop fluid collecting under the new skin . Dressing is usually kept over the skin graft for 2-7 days

29. After Care Once a skin graft has been put in place, it must be maintained carefully even after it has healed . Patients who have grafts on their legs should remain in bed for 7 to 10 days with their legs elevated . For several months, the patient should support the graft with bandage or stocking .

30. Grafted skin does not contain sweat or oil glands, and should be lubricated daily for two to three months with mineral oil to prevent drying and cracking

31. Try to avoid scratching the wounds Administer anti-histamine . Antibiotics is given to fight or prevent an infection caused by bacteria C lean and wash regularly on areas where there are no dressings . Make sure patient wears cotton clothes to help stop getting too hot.

32. Keep wounds clean and dry When allowed to bathe, carefully wash the graft and donor sites with soap and water. Dry the area and put on clean, new bandages as (Change bandages every time when they get wet or dirty . When the wounds have healed patient will need to apply cream on to them, gently massaging them 2-3 times a day, to prevent them getting dry and flaky.

33. The graft and donor site will need to be protected from the sun as they will burn more easily than rest of patient's skin. As the wound heals scarring may occur. Patient may be given pressure garments to wear, or a dressing or gel to be put on the scar(help flatten the scarring)

34. Nursing Care 1.Circulation : Assess the graft area for signs of adequate blood supply Inspects the color of the graft area. M ake sure the graft area is warm(indicates sufficient blood supply to the area) 2 . Drainage : C hecks the patency of drains placed in the graft area . Makes sure they are not blocked, so drainage can flow out of the graft site instead of accumulating in it and potentially causing an infection

35. 3.Positioning: The nurse ensures blood circulation to the graft area by positioning the patient off the graft Taking pressure off the graft and skin surrounding it reduces the risk of decreased blood supply to the area.

36. 4. Low Pressure : P lace the patient on a low pressure bed when lying down or low pressure cushion for sitting down.(adequate perfusion) 5. Trapeze : P rovide an over the bed trapeze M akes sure that the patient is aware of how to use it for moving around in bed. This reduces the amount of shearing and friction that could occur during movement and possibly displace the graft

37. Skin Flaps It is a segment of tissue that remains attached at one end ( base or pedicle) while the other end is moved to a recipient area. Its survival depends on functioning arterial and venous blood supplies and lymphatic drainage in its pedicle or base . A flap differs from a graft in that a portion of the tissue is attached to its original site and retains its blood supply

38. Flaps may consist of skin, mucosa, muscle, adipose tissue, omentum and bone based on its own blood supply. They are used for wound coverage and provide bulk, especially when bone, tendon, blood vessels or nerve tissue is exposed . Flap offer an aesthetic solution because a flap retains the color and textures of the donor area. The major complication is necrosis of the pedicle or base as a result of failure of the blood supply.

39. Indications T o repair defects caused by congenital deformity, trauma, or tumor ablation in an adjacent part of the body . To heal extensive wounds from pressure ulcers. For functional and cosmetic requirements for wound coverage on the face, particularly around the eye, nose and mouth.

40. FREE FLAP A striking advance in reconstructive surgery is the use of free flaps or free tissue transfer achieved by microvascular techniques . Free flaps are harvested from one area of the body to reconstruct a defect in a distant area.

41. The donor tissue (skin, muscle, bone or a combination of these) is detached from its blood supply at the donor site and reattached by microvascular anastomosis to arteries and veins at the recipient site. Microvascular surgery - uses a variety of donor sites for tissue reconstruction

42. Methods of Flap Movement Skin flaps can be moved to a local or distant site. Local Flaps: Used for defects that are adjacent to the donor site. There are 4 major types of local flaps based on the predominant type of movement

43. 1 . ADVANCEMENT FLAP An advancement flap moves directly forward without lateral movement. A triangle of skin is excised from the base of the flap to aid in closure .

44. 2.ROTATIONAL FLAP A rotational flap is a semicircular flap that rotates about a pivot point into an adjacent defect.

45. 3. TRANSPOSITION FLAP A transposition flap moves laterally about a pivot point into an adjacent defect. Usually , it is designed as a rectangle. Design the flap to be longer than defect, since transposition decreases the length. The donor site can be closed directly or closed with a skin graft or second skin flap.

46. 4.INTERPOLATION FLAP The interpolation flap rotates about a pivot point into a nearby defect , with the pedicle passing skin bridge.

47. Distant Flaps: Use distant flaps to cover nonadjacent defects. They may be transferred directly or transferred by microvascular techniques .

48. DIRECT FLAP A direct flap is transferred to a distant site directly so that the donor site and recipient sites are approximated

49. TUBED FLAP The tubed flap 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. MICROVASCULAR FREE FLAP A microvascular free flap is a type of distant flap in which the flap, with its vascular pedicle , is detached completely from its donor vessels and anastomosed to the recipient vessels at the recipient site using a microvascular surgical technique.

51. Pre-Operative Management History and physical examination should be done for (latex sensitivity, cardiovascular problems requiring endocarditis antibiotics prophylaxis, bleeding problems and high BP) To enhance wound healing instruct to avoid smoking, alcoholism and proper nutrition to be encouraged. .

52. Aspirin, NSAID and vitamin E are discontinued 14 days before the procedure Prothrombin time and international normalized ratio should be measured before the procedure The operative site should be free of makeup.

53. Post-Operative Management Initial pressure dressing will be left in place for 24 to 48 hours. If wound begins to ooze apply firm pressure for 10-15 minutes . Do not give aspirin or aspirin-containing medication . Clean site and apply ointment to the surrounding area of the dressing. Keep the graft edges moist with antibiotic ointment

54. Protect the graft from the sun. The sun will cause pigmentation changes in the graft Inspect the dressing daily. Report unusual drainage or signs of any inflammatory reaction Avoid strenuous exercise.Anything that causes face to flush raise BP and impair healing