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INTRODUCTION TO PLASTICS Dr RishiTrivedi QUESTION 1 • A 44-year-old male is admitted with a deep laceration to his forearm after an accident in the garden.Within the first few minutes of the injury,what is the most predominant type of cell seen in the hemostasis phase of wound healing? 1. Neutrophils 2. Fibroblasts 3. Myofibroblasts 4. Macrophages 5. Platelets WOUND HEALING • Surgical wounds – either incisional,excisional,clean, contaminated • Main stages of wound healing: 1. Haemostasis (seconds-minutes) 2. Inflammation (1-7 days) 3. Regeneration (7-56 days) 4. Remodeling (6 weeks-1 year) • Drugs that impair wound healing: • NSAIDs,steroids,immunosuppressive agents,anti-neoplastic drugs SURGICAL MANAGEMENT OF WOUNDS • Key principles of wound management: • Comprehensive assessment • Systematic assessment –TIMES • Establish wound management aims • Most wounds can be managed with secondary intention healing or primary closure • When wounds are larger or more complex,reconstructive surgery may be required: • Skin grafting • Skin flaps SKIN GRAFTING • When a piece of skin is transplanted to a new site on a patient’s body • Used when wound cannot be closed primarily,and delayed healing is not appropriate • 2 types: • Split-skin thickness skin graft – does not contain whole dermis • Full-thickness skin graft – contains whole dermis SKIN FLAPS • Skin flaps bring their own blood supply (unlike skin grafts) • Thought to provide better cosmetic results with a reduced chance of failure • Classified via their tissue type,blood supply or location • Tissue type is based on the compositions that are used • Blood supply: • Axial flap • Random flap • Pedicled • Location: • Local,regional or free flaps QUESTION 2 • A 22-year-old male is admitted toA+E having suffered from a thermal burn.On examination,his skin blanches and appears pale and dry.The likely layers affected include the epidermis and part of the papillary dermis.What type of burn has this man suffered from? 1. Superficial 2. Superficial partial thickness 3. Deep partial thickness 4. Full thickness • May be thermal,chemical or electrical • Alkaline burns often result in deeper,more severe burns,due to protein denaturation and fat saponification • Complications of electrical burns include arrythmias and rhabdomyolysis • Pathology/physiology: 1. Progressive tissue loss and release of inflammatory cytokines 2. Systemic response 3. Catabolic response BURNS 4. Immunosuppression 5. Sepsis ASSESSING BURN SEVERITY • Defined by %TBSA burned and burn depth. • %TBSA –Wallace’s Rule of Nines,the‘Rule of Palm’ or Lund & Browder Chart (used in pediatrics) • Burn depth is an approximation – deeper burns carry an increased risk of complications • Fluid resuscitation should NOT be delayed in favour of accurate burn depth evaluation • If >15% of body surface area burns in adults needs urgent burn fluid resusCLASSIFICATION OF BURNS FLUID RESUSCITATION BURNS • The main aim of resuscitation is to prevent burn deepening • Current guidelines state that fluid resuscitation should begin at 2ml of Hartman’s x patient’s body weight in kg x %TBSA • One-half of the total fluid provided in first 8 hours.Second half administered during subsequent 16 hours • Efficacy of fluid replacement determined by urine output: • Aim for 0.5ml/kg/hour in adults and 1ml/kg/hour in children <30kg • If electrical injury,4ml of Hartmann’s should be used ONGOING MANAGEMENT OF BURNS • patient aim is to stop the burning process and resuscitate the • Conservative management appropriate for superficial burns that will heal in 2 weeks • Complex burns may require excision and skin grafting • Excision and primary closure avoided due to high risk of infection • NO evidence to use prophylactic antibiotics in burn patients • Escharotomies indicated in: • Circumferential full thickness burns to torso or limbs • Involves division of band of burn tissue to improve ventilation or the relief of compartment syndrome and oedema COMPLICATIONS OF BURNS • Transfer to burns centre if: • Need burn shock resuscitation • Face/hands/genitals affected • Deep partial thickness or full thickness burns • Significant electrical/chemical burns • Systemic complications typically in patients with burns >25%TBSA • Specific organ injuries: • ARDS • AKI • Endocrine complications • GI complications – including Curling’s ulcer QUESTION 3 • A 51-year-old diabetic woman presents toA+E with severe pain and sepsis.On examination of her thigh, there is significant cellulitis,oedema,blistering and bullae.A photo is taken: • What is the most likely diagnosis? 1. Fournier gangrene 2. Meleneys gangrene 3. Gas gangrene 4. Necrotising fasciitis 5. Myositis NECROTISING FASCIITIS • An advancing soft tissue infection associated with fascial necrosis • Two types: • Type 1 – polymicrobial infection.More common in elderly or co-morbid patients • Type 2 - monomicrobial infection.More common in healthy individuals with a history of trauma • Risk factors: • Diabetes • CKD • Alcohol • Age • Metastatic cancer • Immunosuppression CLINICAL FEATURES • Early clinical features: • Fever • Pain • Cellulitis • Oedema • Late findings: • Purple/black skin discoloration • Blistering • Hemorrhagic bullae • Dirty dishwater fluid discharge • Sepsis DIFFERENTIAL DIAGNOSIS AND INVESTIGATION • DD: • Gas gangrene – a form of necrotizing fasciitis caused by clostridium species gas being produced within the tissue • Produce alpha and beta toxins • Tissue crepitus a classical sign • Meleneys gangrene – a more superficially sited infection than necrotising fasciitis and often confined to the trunk • Fournier gangrene – necrotising fasciitis affecting the perineum • Polymicrobial • Ix – blood gas will show raised lactate with metabolic acidosis.Bloods may show worsening renal function,hyponatremia and coagulopathy • Blood cultures should be taken • NO use of routine imaging • LRINEC score MANAGEMENT • Immediate resuscitation and debridement • Urgent broad-spectrum antibiotics • Resuscitation IV fluids • The only definitive management for necrotising fasciitis is urgent surgical debridement • All cases should be packed following debridement • Reconstructive surgery may be required using skin grafts or flaps once infection has been controlled QUESTION 4 • A 34-year-old male presents with a large,flat and irregularly pigmented lesion on his torso.Over the past month,the diameter of the lesion has become more irregular and so too has it’s colour. The doctor suspects a diagnosis of melanoma.What type of melanoma does this man likely have? 1. Superficial spreading 2. Nodular 3. Lentigo maligna 4. Acral lentiginous MELANOMA • A tumour of melanocytes that have the potential to metastasize early • 4 main histological subtypes • Main contributor is UV radiation exposure • Other risk factors: • Mnemonic PARENTS CLINICAL FEATURES AND INVESTIGATION • History should focus on risk factors and theABCDE rule: • Asymmetry • Border irregularity • Colour uneven • Diameter >6mm • Evolving lesion • Main differential diagnosis are melanocytic naevi • Ix – diagnosis is made through excision biopsy • Sentinel lymph node biopsy aims to identify whether there is any melanoma in the primary draining lymph nodeMELANOMA VS. SIMPLE NAEVI MANAGEMENT • The biopsied area should undergo a wide local excision • Peripheral margins guided by Breslow thickness and deep margins should always be down to the deep fascia • Wide local excision performed at the same time as sentinel node biopsy • Any confirmed lymph node metastasis is treated by completion lymphadenectomy • Prevention is best achieved through education and reducing exposure to UV light QUESTION 5 • A 22-year-old female presents toA+E with a red/purple bruise-like appearance to her thumb and nail bed.She was in the gym when a large weight was dropped onto the right thumb.What part of the nail bed is responsible for 90% of nail plate growth? 1. Cuticle 2. Sterile matrix 3. Germinal matrix 4. Hypochondrium 5. Lunula NAIL BED INJURIES • The nail acts to protect the fingertip and provides counterforce to the pulp • Nail bed injuries are common – crush injuries are the most frequent presentation • Pathophysiology: • Nail bed made up of soft tissue bound to underlying periosteum of distal phalanx • Consists of germinal and sterile matrix TYPES OF INJURY • Subungual hematoma forms when blood collects between the nail and nail bed • Gives it a bruise-like appearance • Occurs following a door crush injury or heavy weight falling on the finger • Nail bed laceration is compression of the nail bed between the distal phalanx laceration • Presents with an intact nail and subungual hematoma >50% of nail SA • Nail bed avulsion when the nail and part of the nail bed are pulled away from the rest of the finger • Follows higher energy injuries,most commonly affecting the ring finger DIFFERENTIAL DIAGNOSIS AND INVESTIGATION • DD: • Distal phalanx fracture • Fingertip infection • Neuroma • Phalangeal dislocation • Investigations: • X-ray MANAGEMENT • Simple nail bed injuries may be managed conservatively • Most will require removal of the nail plate,nail bed repair and splinting of the eponychial fold • The plate is separated from the underlying matrix and soaked in betadine solution • Nail bed repairs undertaken with a 6-0 absorbable suture • Prognosis – usually a full recovery • Complications – scarring,infection,hook nail and split nail (caused by scarring of the matrix) FINAL QUESTION • A 22-year-old male presents toA+E having suffered from an electrical injury. Initial fluid resuscitation must be commenced.What fluid rate should be started in this patient? 1. 2ml Hartmans x kg x %TBSA 2. 3ml Hartmans x kg x %TBSA 3. 4ml Hartmans x kg x %TBSA 4. 3ml normal saline x kg x %TBSA 5. 4ml normal saline x kg x %TBSATHANK YOU – ANY QUESTIONS?