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Plastic Surgery Sammy Ramadan rd 3 Newcastle UniversityThanks to our partners!Aims of the talk • Cover the learning outcomes • Give a general overview of common the conditions seen in plastic surgeryLearning Outcomes • Describe the principles of wound management, specifically explaining all steps of the reconstructive ladder and providing examples of use. • Describe the burns assessment and management guidelines. • Identifying common skin cancers such as BCC, SCC, and melanoma. Describe each of these conditions and understand their clinical features (signs, symptoms, and risk factors), differential diagnosis, Investigations, Management options, and prognosis. • Describe each of the following infections seen by Plastic surgeons. Understand and describe their clinical features, differential diagnosis, investigations, management options, and complications/prognosis o Necrotising fasciitis o Bite injuries o Hand infections (paronychia, infectious tenosynovitis, felon injuries, deep hand space infections) • Describe common hand trauma presentations. Understand their clinical features, differential diagnosis, investigations, management options, and complications/prognosis. o Flexor tendon injuries o Extensor tendon injuries o Metacarpal and phalangeal fractures o Nail bed injuriesDescribe the principles of wound management, specifically explaining all steps of the reconstructive ladder and providing examples of use .Wound management • Wounds have a wide range of causes • Many of different types • Generally, should be kept clean with an environment for healing • Wound and patient need to be assessed • TIMES • Wound management aims must be establishedReconstructive ladder 1.Secondary intention 2.Primary closure 3.Split thickness graft 4.Full thickness skin graft 5.Tissue expansion 6.Random flap 7.Pedicled flap 8.Free flapSecondary Intention • Use of Dressings • Forms Physical barrier • Aim is to maintain a moist environment without excess exudate • Used in small wounds • Many different types of dressing • Pros- Least invasive most natural • Cons- May cause unwanted scarringPrimary Closure • Closing a wound using suturing • Apply basic surgical principles • Used for surgical wounds or large traumatic wounds • May require delayed closure in dirty/traumatic woundsSkin Grafting • Skin transferred without blood supply • Graft forms fibrin bonds with bed and develops new blood and lymphatic vessels- “taking” • Split thickness or full thickness • Autograft, Allograft, XenograftSplit thickness Skin Graft • Epidermis +/- variable part of dermis • Graft can be taken from anywhere • Commonly taken from thigh • Used in defects that are too large for used of full thickness graft • Harvested with Watson knife or power assisted dermatome • Advantages- Versatile, can be meshed, donor sight heals spontaneously • Disadvantages- Small volume, develops patchy pigmentationFull thickness Skin Graft • Epidermis and entire dermis • Donor site must be close to application site • Commonly used in facial reconstruction and hand surgery • Donor site must be closed directly • Advantages- retain volume and pigmentation, less contraction • Disadvantages- limited size, don’t take as well, hair retainedTissue expansion • Aims to increase area of locally available skin • Uses expander implant under the skin • Multiple saline injections over weeks and months • Expander can be removed once skin has advanced • Used in breast reconstruction • Advantages- similar color, skin remain sensate, donor site unlikely to die • Disadvantages- painful, prolonged, multiple procedures, can’t be used acutelyFlaps • Tissue is transferred from donor site with corresponding blood supply • Provide better cosmetic results than full thickness graft • Classification is based on tissue type, blood supply and location • Many different typesPedicled flap • Flap stays connected to a named vessel which is not detached from donor site • Commonly used in breast reconstructionFree flap • Tissue is removed from the donor site with its blood supplying vessel and then an anastomosis is made at application site with local blood supply • Often taken from the thigh • Commonly used in reconstruction after head and neck surgeryDescribe the burns assessment and management guidelines.Burns • Most burns are minor • Major burns require close monitoring and management • Causes large fluid shifts • Should be particularly vigilant of those with co-morbiditiesBurns assessment • Start with A to E approach • History • Severity of burn is indicated by total body surface area burned (%TBSA) and burn depth • TSBA can be estimated with Wallace’s Rule of nines or Rule of palm • Assessment of burns is done by appearance and sensationInitial Burns Management • IV morphine • Wound dressing • Mitigate hypothermia risk • Fluid resuscitation • Modified Parkland formula • Support for systemic complicationsBurns reconstruction • Local complications of burns often need reconstruction • Effect on structure and function • Excision and grafting • Application of pressure garment • Wide range of techniques used to repair local complications • Non-surgical techniques are also usedIdentifying common skin cancers such as BCC, SCC, and melanoma. Describe each of these conditions and understand their clinical features (signs, symptoms, and risk factors), differential diagnosis, Investigations, Management options, and prognosis.Basal Cell Carcinoma • Slow growing and locally invasive • Most common skin cancer • Least likely to metastasize • Associated with long term UV exposure • Found in sun exposed areas of skin • Slow, raised pearly edges, telangiectasia • Various subtypesBasal Cell Carcinoma Diagnosis and treatment • Various subtypes • Diagnosed clinically • Multiple management options • Surgical management is excision biopsy +/- skin graft • May be managed with Mohs Micrographic Surgery • Generally good prognosisMohs Micrographic surgery • Tissue preserving technique • Surgeon excises 1mm layers of tissue • Each layer is checked under microscope until complete removal • Various indications • Very high cure ratesSquamous cell carcinoma • Second most common skin cancer • Arises from epidermal layer • Can arises from premalignant lesions like Bowen’s disease • Uncommonly metastasizes via lymphatic system • Associated with long term UV exposure • Many other risk factors • Found in sun exposed areas of skin • Can be nodular, indurated or keratinizedSquamous cell carcinoma Diagnosis and Management • Diagnosis comes from biopsy • Classification is based on number of undifferentiated cells in biopsy • Standard management is surgical with excision biopsy +/- skin graft • May be managed with Mohs Micrographic Surgery • Prognosis depends on riskMelanoma • Malignant tumor of melanocytes • Arises from stratum Basale • Many histological subtypes • They metastasize early • Associated with long term UV exposure • Many other risk factors • Presents as new skin lesion, or change in appearance of existing mole • Can bleed and be itchyMelanoma Diagnosis and Management • ABCDE rule for examination • Can be mistaken for other benign conditions •Asymmetry • Diagnosis is made through •Border irregularity biopsy • Standard management is •Colour uneven surgical •Diameter >6mm • Wide local excision • Sentinel lymph Node biopsy •Evolving lesion • Prognosis depends stage • Prevention is the best management Describe each of the following infections seen by Plastic surgeons. Understand and describe their clinical features, differential diagnosis, investigations, management: Necrotising fasciitis Bite injuries Hand InfectionsBite injuryBite Injuries • VERY COMMON • Human or animal? • Bacterial infection is a risk • Tetanus • Rabies • Fight bite- septic arthritis • Plain radiograph film of affected region- rule out foreign material and fracture • BloodsBite Injuries: Management Medical • Removal or foreign bodies from wound • Encouraging wound to bleed • Irrigation • Prophylactic antibiotic for 3 days • 5 days of antibiotic treatment for clinically infected wounds • Seek advice from infectious diseases • Consider rabies/tetanus prophylaxis • Admission for patients with worsening signs of infection Surgical • Debridement of non-viable tissue • Reconstruction if there is effect of structure and functionNecrotising Fasciitis • LIFE THREATING- up to 40% mortality • Surgical emergency • Classified into Type 1 and Type 2 • Gas Gangrene • Certain patients are more at riskNecrotising Fasciitis: clinical features • RAPIDLY PROGRESSING • Precipitating event of skin breech • Severe pain disproportional to clinical signsNecrotising Fasciitis: investigations • Blood tests- increase WCC and CRP • Blood gas- raised lactate +/- metabolic acidosis • Worsening renal function, hyponatraemia, impaired liver function, coagulopathy, blood cultures • Imaging does not have a routine role as it will delay management • Risk scoring system LRINECNecrotising Fasciitis: Management • Urgent surgical debridement is the definitive management • Necrotic tissue is excised until bleeding viable tissue is present • ICU after surgery • Reconstruction might be needed after initial debridement and infection clearanceHand Infections • Common presentation to ED requiring surgical intervention • Often result of trauma • Common in people with pre-existing comorbidities • Most commonly caused by S.aureus and Streptococci • Can result in damage to local structures and subsequent loss of functionTypes of Hand infections • Paronychia • Infection tenosynovitis • Felon infections • Deep space infectionsHand Infections Investigation • Routine blood tests- CRP , WCC, urate levels • Plain film radiograph • Wound swabs • Pus cultureParonychia • Most common infection of the hand • Infection of the perionychium (soft tissue fold around nail plate) • May occur secondary to contamination with oral flora • Fingertip will be swollen and very inflamed • Can causes necrosis of nail bed and osteomyelitis Treatment • Antibiotics • Incision and drainage • Thorough washoutInfectious enosynovitis • Inflammation of the tendon sheath • Most common type is Flexor sheath infection- Surgical emergency • Can leader to tendon necrosis and ruptureFelon Injuries • Subcutaneous infection of fingertip pulp • Most commonly occur in the thumb or index finger • Caused by S. Aureus • Present with swelling • Most cases resolve spontaneouslyHand Infections Management • Antibiotic Treatment • Infectious tenosynovitis, flexor sheath infection and deep space infections require thorough wash-out in theatreDeep hand space infections • Infection of deep spaces of the hand • When infected the respective space of the hand becomes swollen and tender • Limit hand movements Describe common hand trauma presentations. Understand their clinical features, differential diagnosis, investigations, management options, and complications/prognosis. o Flexor tendon injuries o Extensor tendon injuries o Metacarpal and phalangeal fractures o Nail bed injuriesFlexor tendon Injuries • Rare • Results from traumatic injury • Can occur in sports like rock climbing or rugby • Classified based on Verdan’s Zones • Present with reduced flexion of finger, weakness and pain • Diagnosis is typically clinical, but ultrasound can be used to confirm it • Treated with exploration +/- tendon repair with washoutExtensor T endon Injury • Very common- superficial anatomy • Can result in permanent loss of function • Caused by traumatic injury • Loss of flexion, strength or motion • Classified based on compartment • Ask about hand dominance and occupation • Establish place time and mechanism of injury • Look, feel, move structure • Diagnosis is clinical • Treated with exploration +/- tendon repairMetacarpal Fractures • Very common • Result from traumatic injury • Present with non-specific features • Ask about hand dominance and occupation • Assess for open fracture • Look, feel, move • Plain film radiograph • Mostly managed with immobilisation and hand rehabilitation • Surgery may be indicatedNail Bed Injuries • Common • Crush injuries are a common cause • Damage to different parts of the nail bed can cause different characteristic presentations • Subungual Haematoma • Nail bed laceration • Nail bed avulsion • Pain, soft tissue swelling • Clinical diagnosis • Plain film • Complications are commonWhat I have covered: • Techniques used by plastic surgeons as part of the reconstructive ladder • Burns assessment and management • Skin cancer diagnosis and management • Common plastic surgery infections • Common hand trauma presentationsThank You@supta_uk @SUPTAUK www.supta.uk