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Plastics/Breast Surgery Session 1: Plastics

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Summary

In this in-depth session, we cover the core principles of wound management for medical professionals focusing on plastic surgery. Presented by Sammy, a third-year from Newcastle University, the session delves into the specifics of managing wounds, including a detailed examination of reconstructive procedures. From an introductory explanation of what plastic surgery is and its wide-ranging capacity in restorative medicine, the session moves onto providing a list of increasingly complex wound management techniques such as primary closure, skin grafting, flap surgery and more. The nature and treatment of various types of wounds, the importance of dressings, and even specific details like how autografts, allografts, and xenografts work are showcased. This session takes its viewers up the reconstructive ladder (or as is now being coined 'the reconstructive elevator'). Attend this session to elevate your understanding of wound management in plastic surgery.
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Learning objectives

1. Understand the general overview, scope and sub-specialties of plastic surgery, focusing on its function as restoration and structure to affected body parts post illness or trauma. 2. Recognize the surgical procedures involved within each sub-specialty of plastic surgery, such as congenital defect correction, breast reconstruction following cancer, skin condition treatments, trauma management, head, and neck cancer surgeries, hand and upper limb abnormalities and cosmetic surgery. 3. Understand the basic principles and stages in wound management like tissue management, inflammation/infection control, moisture balance, and epithelial or edge advancement, and the different kinds of wounds and wound classifications. 4. Ascertain the components and indications of the reconstructive ladder (or elevator or toolbox), encompassing healing by secondary intention, primary closure and different types of skin grafting. 5. Develop the ability to choose a suitable treatment strategy from the reconstructive ladder and become familiar with each treatment’s pros, cons and specific situations where they may be best employed.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi guys. Um We're just gonna give it five minutes to let uh everyone join, you want to join and then we'll make a start. Ok, guys. Um I think we'll make a start now. It's a couple of minutes past. So, um basically, I just wanna welcome you all to the session. Um We've got Sammy today who's presenting the first part of our plastics and breast session. Um We're from Newcastle University. Um And so we've got a good, a good session coming up and so I'm just gonna leave it. Uh It should last about an hour. Um And at the end, if you have any questions, I'll pass them on to summary. Um So just put them in the chart and in terms of getting your certificate at the end, I'll explain all of that. Good Sammy whenever you're ready. Hi, thanks, Cameron. So, welcome to the session. I'm Sammy. I'm a third year at Newcastle and today we're gonna be talking about plastic surgery. So let's get started. So these are all the various organizations that are involved tonight. So the aims of the talk is to give a general overview of the specialty. Firstly, and then we're gonna cover the learning outcomes which have been given to us this evening. So we'll start with the overview bit. So, what is plastic surgery? Well, um, it's based on this idea of restoring function, um, and structure to affected body parts after illness or trauma. So that might be after someone's had a cancer removed. Um, you know, the plastic surgeons will go in and reconstruct, um, the body part that's had the cancer removed from it or maybe someone's got, you know, um, a congenital defect that needs reconstructing. It's a very wide range. Uh there's lots of different conditions and like I say, on the next point, it's an interesting and varied specialty. So what's interesting about it is there's lots of different techniques, but it's also varied because it's from the head to the foot. So most surgical specialties only deal with one specific part of the body or system. So general surgery is mainly abdominally focused or ent would be focused on the head and neck or orthopedics is on the bones and the joints with plastic surgery. It's, it, it, it's, it's all the, the body that it's focused on. And because of that, there's a wide range of subspecialties which I'm gonna go through now. So these are the subspecialties within plastic surgery. So, firstly, there's congenital, which is fixing cleft lip and palate and other um, facial er, congenital defects, which I'm sure you're familiar with breast surgery, which is um reconstruction following cancer usually. So if someone's had a mastectomy, then the plastic surgeons will come in and reconstruct the breast after that skin. So that's removing, you know, basal cell carcinoma, squamous cell carcinomas, et cetera, which we'll actually be talking on later in the talk. Um, there's trauma, so dealing with open fractures, burns again, which we'll be talking about in more detail and digit replantation, er, cancer. So specifically head and neck cancer is a big thing in plastic surgery. So once head and neck cancers have been removed, uh plastic surgeons will come and reconstruct the face using flaps, which is something that we'll talk about later. Um, hand and upper limb surgery. So dealing with hand abnormalities and cosmetic surgery as well. So things like breast augmentation and rhinoplasty, I think the general public tend to associate er plastic surgery with mainly aesthetic or cosmetic surgery. Um, and that is one part of the specialty, but it's a very small part of the specialty. It's actually only one aspect of a much bigger picture. And today that's hopefully what you'll see from the slides that I'm going to be presenting. So, without further ado, so these are the learning outcomes, I'm not gonna read them all out. You can just have a brief look at them now. So we're gonna be covering these. So to start off with, describe the principles of wound management, specifically explaining all the steps of the reconstructive ladder and providing examples for use. So just sipping my tea. So wound management. So wounds have a wide range of causes. So they might be surgical, it might be due to infection, it might be due to trauma, whatever. Um and these wounds need to be managed to make sure that they heal properly. Um There's lots of different types of wounds so you can have a simple wound, a uncomplicated wound, a large complex wound. There's lots of different classifications of wound, which I won't be going into today. Cos that's a bit beyond the scope of this, this lecture. Um And they've got to be managed, like I say, so generally, the general principles of wound management is that they need to be kept clean with an environment for healing. Um and er the wound needs to be assessed. But so you can find out how you're gonna um treat it. And the way that you assess this wound is um by this mnemonic times. So that's tissue management, inflammation in infection control, moisture balance, an epithelial or edge advancement. And these are all the domains of wound management. So when you're establishing the aims, like I say, you need to take all of these things into account. And then once you've taken these things into account, you can decide how you're going to manage the weight and that brings me onto the reconstructive ladder. So the reconstructed bladder is a tool that's used to help with wound management decisions. And it's essentially a list of increasingly complex er wound management techniques and surgical techniques that can be used. And the idea is that you want to use the least invasive one from the list and you can consider each option before choosing, OK, I'm gonna do a full thickness skin graft, for example, or a free flap. There has been a bit of a change in terms of the terminology around the reconstructive ladder because nowadays, people might refer to it as the reconstructive elevator or the reconstructive toolbox. And the reason for that is because the reconstructed bladder implies that you need to do each of these steps before you can advance onto the next one. When in reality, that's not the case, you can go, for example, straight for a free flap. If that's what is required, you don't have to do primary closure and then full thickness graft, it doesn't have to, you don't have to try each one. You can just go to the one that's going to be appropriate for the specific situation that you're in. And that's why the reconstructive elevator is actually a more appropriate term for this. So I'm gonna go through the different er rungs of the reconstructive ladder if you will. Um and it starts off with er human bse intention. So this is the use of dressings. Um and the idea of a dressing really is to form a physical barrier. Obviously, you need to stop infection from getting into the wound because that's gonna be an issue for healing and also it can advance into something maybe more sinister. Um, and the aim is to maintain a moist environment without exudate. And when we say exudate, we mean, um, fluid that's leaking out of vessels around the wound, you know, pus, et cetera. We don't want that cos it's not good for healing. So this is the idea of um, a dressing and, um, it's mainly used in small wounds, um, because large wounds tend not to um, er, heal spontaneously and like I say, the idea is to er, allow the dressing to heal spontaneously on its own. Um, so yeah, there's lots of different types of dressings. You've got, er, low adherence, semi per ball films, foam, et cetera and they all do different things and there's lots of different adjuncts with dressings. So there, there's a whole world of dressings that you can use on wounds and also you can use dressings on wounds after er, like a surgical incision or something. And after you've done another technique, so the pros of using dressings and healing by secondary intention is that it's not invasive at all and it allows the body to heal um, by itself. And that means that the skin that's gonna grow back is gonna be sensate, it's gonna have it a good nerve supply, a good blood supply and it's gonna be similar in appearance in terms of the pigmentation to the skin around it. In terms of the cons you might get unwanted scarring because, because it's healing spontaneously, you can't control the scarring. So that's gonna cause, you know, potentially scarring that is unsightly or unwanted for the patient. So that's something that you need to consider. So the next step of the er, reconstructive bladder is using er suturing to close wounds. So, it's, this is called primary closure. And the idea behind this is that you're requiring these basic surgical principles of suturing to, um, to close the wound. These er principles being you want a slight, a version of the skin edges, you want minimal tension, a gentle tissue handling when you are suturing and excising dog ears. So dog ears are the edges of the wounds, um, that form when you've sutured, which can, er, lead to adverse scarring. So you have to excise that and so that the, um, the scar becomes flatter. Um, and then, so it's used for surgical w a little bit of a mishap there. So it's used for surgical wounds or large traumatic wounds and with large traumatic wounds, often there has to be delayed closure. So you might have to wait 24 hours before closing it because otherwise you, you don't know if the infection's fully cleared or not and that if you close it, it can spread the infection further and perpetuate the infection which is unwanted. So the next bit is skin grafting. So skin grafting, the important thing about skin grafting is you're transferring skin from one part of the body to the other, but you're doing this without a blood supply. Um And how that works is that the, once the graft has been applied, um fibrin bonds form between the graft and the capillary bed of the area that you're applying it to and then new er blood vessels and lymphatic vessels form over time. So you can have a split thickness or a full thickness graft, which I will be talking about in more detail in a second and it can be an autograft, an allo graft or a Xenograft. So, autograph not being something that you get from a celebrity. Um It's when you take it from the patient and apply it to the patient allograft being you're taking it from another human and applying it to a human or same species. So in veterinary practice from the same species and then Xenograft is from a different species. So if you were to use like a um a graft from a pig or something, then that would be a xenograft. So splitt thickness graft is where it's just the epidermis, um and some parts of the, the dermis, but it's unlikely and the graft can be taken from anywhere. It's commonly taken from the thigh cos it's a good area to take it from cos it's a large piece of tissue and they're used in defects that are too large for a full thickness graft, which we'll discuss in a second, you harvest it using a Watson knife or a power assisted dermatome, which are these devices that I've got here on the right. And they're a bit like lawnmowers the way that they work. Um The advantages of these is that they're very versatile and they can be meshed. So by mesh, I mean that they, you put perforations in it so you can stretch it further and increase the volume of the skin graft. And another thing that's good about this is that the donor site heals spontaneously. In other words, you don't have to do anything with the er donor site apart from cover it with um dressing. And then the disadvantage is is that it can develop patchy pigmentation. So when you apply the skin graft, the er pigmentation in that skin graft might not be exactly the same as the area that you've applied it to, which can be, you know, cosmetically, maybe less pleasing. The next is a full thickness graft, which is where you take the epidermis and the entire dermis. Um And for this, the donor site has to be close to the application site because it's gonna the um if you use skin that's from similar parts of the body, the skin's gonna have a similar um what's the word, a similar quality? So they're gonna have um the similar pigmentation, similar thickness, things like that, which is gonna be more um beneficial. So, for example, if you were going to um skin graft onto the face, then you would want to take the graft from the neck, for example, because it's close by, it's gonna have similar pigmentation. It's commonly used in facial reconstruction and hand surgery. Um The, the donor site has to be closed directly. So, wherever you've taken um the skin graft from, you have to suture it up, er cos it's not gonna heal on its own because you're taking a thicker layer of skin. The advantages of this is that it's gonna retain volume and pigmentation more than um the full thickness graft and it won't contract. So it won't all become bunched up and tight the skin, it will be more loose, more natural. The disadvantage is is that it's gonna be limited in terms of size because you're taking a more significant chunk of tissue, they don't take as well. So, because it's a thicker piece of tissue, it's gonna be hard for that capillary bed to um to form new blood vessels with the graft and also hair can be retained. So if you're um a applying a skin graft to the face, then and there's hair on it that obviously could be seen done sightly. And then finally, we not finally, but we have tissue expansion. So um the aim is to increase the area of locally available skin and you use this expander implant under the skin which I've shown here essentially. What you do is you inject saline. So you apply this expander implant and then you inject saline over weeks and months and you put a little bit more in each time. And then once the skin's stretched around this cos the skin needs time to stretch, you can remove it. So it's used commonly in breast reconstruction and I'm sure you can imagine how that would be useful um, Advantages is that the skin's gonna be the same color, it's gonna be remain sensate. So you're gonna be able to feel it when you touch it. Um And the donor site isn't gonna die because it's all vascularized properly. The body has made the skin itself. It's like if you grow your skin will stretch with you, the disadvantage is, is it would be painful as you can imagine, er, prolonged, it takes a while um multiple procedures needed because you've got to keep injecting this saline and you can't use it acutely as well. So if in a trauma case, this wouldn't be a viable option. And then finally, we have flaps. So this is where you um transfer tissue to a donor site and it comes with a blood supply. So it's not like the skin graft where it doesn't have its own blood supply, it's coming with its own blood supply. Um and usually it's done to provide better cosmetic results than a skin graft. And the classification system is actually quite complicated. You can classify it in many different ways based on the tissue type or the um vessel that the tissues come from, et cetera. But there's two types that we'll go through now. Um Yeah. OK. So pedicle flap, so that's when the flap stays connected to its original blood supply. Um um So it's a named vessel. Um and then it's brought to it's transferred to another area. So, for example, in reconstruction, as you can see it here, this is a common technique where you take part of uh it's called an lb flap. You take part of the latissimus dorsi and it remains attached to its um blood supply in the back and then you can bring the tissue round and reconstruct the breast. And then the second type I wanted to go through is a free flap, which is where the tissue is removed from the donor site and with its blood supply and vessels, so it's totally removed. It's free as you can see in image D and then it's applied to the site that you're applying it to an an, an an anastomosis is made um with the blood supply that's local to that site. So for example, you can take a flap from the thigh, totally disconnect it, keep the vessel attached to it. But it's, you've detached it from its original blood supply and then put it on the face and plumb it into the vessels in the neck for example. And it's commonly used in head and neck surgery. So that was, um, the reconstructive bladder. Let's get onto burns. I am. Ok. So burnt. So most burns are minor. I think most people that are attending this talk will have burned themselves at some point in their lives. I think I burnt myself yesterday when I was making my tea. So it, it's, they're common and most of them are minor. But the problem is that major burns do require close um monitoring. Um because you get these large fluid shifts in major burns which can cause hypovolemia which can be fatal. So you have to be vigilant and you've gotta be particularly vigilant of people with certain uh comorbidities. So I've just put this slide here and it's got all the different types of burns. I'm not gonna go through all of them, but you can just keep this in mind because these are relevant to the treatment options. Ok? So, um in terms of burns assessment, you need to start with the A to E approach. Um I'm sure you're all familiar with that. So, airways, breathing circulation, disability exposure. The reason why you start with an AY is cos if it's a burn injury, there are very serious injuries, but there might be something more acute because it's an acute situation. So you need to fix that before you fix the burns and then once you've established that the patient's stable, then you can move on to taking a history and trying to figure out what the mechanism is. The reason why this is relevant is because it will give a hint of what type of burn it is as you can see here, but also the thickness of the burn. Ok. And then for further assessment, you need to er, calculate the severity of the burn by calculating the total body surface area that's been burned and burned out. for the er, total body surface area that's been burned on the T BSA. There's loads of different ways you can do it. There's the rule of nines, which is, for example, like the arm is worth 9% of the, the body surface area, the torso is worth 9%. There's all the rules or the other one is the, the er, where are we here? The, the rule of palm. So you can use the patient's palm and then one palm is worth 1% of the total body area. And then there's also um, like the lung Browder charts that you can use, which are more accurate. But depending on the situation, you can use different things. And then in terms of um, the burn thickness, it's done by appearance and sensation. And there's a chart here showing that. So different burns have different appearances. So for example, superficial burns will have this dry blanching, erythema and the sensation will also be different depending on different burns because with deeper burns, they tend to have decreased sensation or be painless because they're going so deep that the nerve endings have been burned and damaged. Whereas with the more superficial burns, they tend to be more painful and more sensing. And then you can see that I mentioned this um this l browser chart that I've included here. So um in terms of burns management, you can do this during your A to E you start off with IV morphine. You can also do an E CG and a chest X ray. Uh cos for chest x-ray, it's more for inhalation injuries which come under burns. But E CG is good for a baseline to see if that's changing from a hypovolemia point of view and then also start a fluid balance chart for the wound dressing. Um They recommend using cling film. The reason for that is so that you can still assess the appearance of the burns, but it's gonna stop um water from leaking out for burns. And then in terms of the fluid resuscitation, which is kind of the important step, um you can calculate how you're gonna resuscitate them with this part formula. So you can see that here. So you do the calculation with the TB SA that you calculated earlier and then you give the first half of fluids in the first eight hours and the next half of fluids over 16 hours. And you also need to support for any systemic um complications which can occur commonly. Um SS can occur. Um also AK is can occur and acute lung injuries can also occur. And these are things that patients might need extra support for. So, the goal of the fluid resuscitation is to achieve adequate end organ perfusion. Um to make sure, obviously, there's no organ failure. That's, that's the end goal. Ok. In terms of burns, reconstruction, this is the more surgical part of it. Um So local complications can require reconstruction. In terms of local complications, there might be adverse scarring. So, keloid scarring or hypertrophy scarring and also contractures which I've included in the image of on the right, um which can cause problems with mobility of joints. So all the skin becomes bunched up and tight and it means that patients have reduced range of motion. Um As you can imagine, these complications can have um an effect on the structure and function. So you need to do excision and grafting to remove these contractures or the the scars and then put a graft on there to um stop the scarring from happening again. Um You can apply a pressure garment. Um And like I say, there's a wide range of techniques that you can use. There's loads of other ones that I haven't mentioned and you can also use non surgical techniques. So things like corticosteroid injections, cryotherapies, laser treatment, and um uh like chemical radiotherapy, like um five fluorouracil. So that brings us to the end of burns and now we're gonna move on to skin cancers. So this is uh the learning outcome. Listen, expert. Ok, let's go. So, er, we're gonna start off with, so we're doing basal cell carcinoma, squamous cell carcinoma and Melanoma, and we're gonna start off with P CCS. So they're slow growing and locally invasive. So they have a very low propensity to metastasize to other parts of the body. They're fairly low risk generally. Um, And it's the most common type of skin cancer and basal cell carcinoma. Um So, like I say, it's the least likely to metastasize. Um It's associated with long term UV. Exposure is the main risk factor. Um So high prevalence in um places like Australia and also Caucasians also have a higher prevalence of um basal cell carcinoma because of the um of uh just the way their skin is. Um So it's found in sun exposed areas of skin. Um So for example, the face, the neck, uh et cetera. And in terms of the features of them, it the classical kind of features is the pearly edges and the telangiectasia. So that's when you've got the visible capillaries. And there's various subtypes of um basal cell carcinomas such as nodular superficial and basosquamous. And you can see all of these here pigmented as well. So in terms of the diagnosis and treatment, like I said, there's various subtypes, uh they're diagnosed clinically by their appearance and there's multiple management options. So I'm gonna talk about the surgical management, but you can also manage them medically. Um So with things like cryotherapy, so freezing it off ridge electrodissection, burning it off and topical chemotherapy as well. With five fluorouracil surgical management is excision biopsy. So that's removing it and then sending it for biopsy to make sure that it's been removed fully. And you, the way that you ensure that it's been removed fully is by er adhering to the correct margins. So areas of skin around the lesion, uh the amount of skin that should be there. So it might be like five millimeters. For example, it depends on the type of uh basal cell carcinoma that you have. It may be managed with Moore's micrographic surgery, which I'll talk about a bit in a second and they generally have a good prognosis because of the fact that they don't metastasize as readily as other things. So Moore's micrographic surgery is a tissue preserving technique. To be honest, this wasn't a learning outcome. I just thought it was quite cool. So I included it. Um, and essentially what happens is the surgeon excises little craters of, they're about one millimeter thick tissue and then that'll get sent to someone with a microscope in, in the theater and they'll look at er, the rate of tissue, the, the microscope, sorry that the surgeon has, er, excised. Um, and see if they can see any cancer cells on it as the surgery is going on. Um And they keep going until they've removed the whole tumor. So there's various indications for that. So for example, if someone's got a recurring tumor, if it's cosmetically better or functionally better. So for example, if you've got a tumor that's very close to the eye or a lesion that's very close to the eye, then you like on the eyelid, you don't want to take a lot of the eyelid, so you want to get away with taking the least bit of eyelid possible. So you could use more micrographic surgeries for that. Um And then also if it's the site of previous surgery or radiotherapy because you don't want to um you know, increase scar tissue and things like that. Um There's va so yeah, various indications and they have very high cure rates because you pretty much know straight away whether it's been complete removal or not. So that was just a little aside on was micrographic surgery. Now we'll continue with squamous cell carcinoma. So it's the second most common skin cancer and they, it arise from the epidermal layer. Um mm let's bone it. Um They can, so they can arise from premalignant lesions like bones disease, for example, um also actinic keratosis as well and they uncommonly metastasize by the lymphatic system, but it's quite rare for that to happen. Um If he believes them, this can happen, um it's associated again with long term UV exposure and there's other risk factors as well. So things like um, chronic, chronic wounds, inflammation, immunosuppression and smoking are other risk factors. And it's found in sun exposed areas of the skin, like I said, with the neck and the head and they can be categorized into nodular indurated and keratinized in terms of the diagnosis, it comes from the biopsy after removal. But you clinically, you would have a good idea from the appearance that it was a squamous cell carcinoma. Um The classifications based on the number of undifferentiated cells in the biopsy, but I don't think that's er within the scope of this talk. Um Sorry, just go back. Um So yeah, standard management is um excision biopsy. Um and plus or minus skin graft. So the plus or minus is if it's a big removal, then you're gonna need to use a skin graft so that it's covered properly. But if not, you can close it directly just with suturing. Um it may be managed with mos micrographic surgery and the prognosis depends on the risk. So, some have very good prognosis, some less. So, depending on how advanced it is and other patient factors. And then finally, for skin cancer, we have melanoma. So, er, it's a malignant tumor of the melanocytes and it arises from the um stratum bizarre which is the fifth and final layer of the skin, uh the deepest one, um there's many histological subtypes um and they metastasize early. So as soon as someone for example, someone in primary care or GP spots, um A melanoma, they should refer it straight away to dermatology for it to be looked at and diagnosed and hopefully, um managed because they can metastasize very quickly and they can be very dangerous. Um It's associated with long term UV exposure like the other skin cancers. Um And there's many other risk factors as well, which I mentioned before, it's similar to sec in terms of risk factors. Um it can present as a new skin lesion. Um So people will come and they'll say I've got this new lesion on my arm and I don't really know what it is and it could also be a change in appearance of an existing mole. So it might start bleeding or become less well differentiated in which case, that could also be another um presentation of melanoma and like I say, they can be bleed and they can be itchy as well. So in terms of diagnosis and management, you can diagnose it with the ABCD E rule, not like ABC that we talked about earlier, it's different and I've got it on the right here. So asymmetry border irregularity, if the color is uneven, er if there's a diameter of more than six millimeters and if it's er evolving as a lesion, so if it's changing, then it's likely to be a Melanoma. So it's a good rule of reference, they can be mistaken for other benign conditions like for example, it could just look like a mole. Um So diagnosis is made through biopsy after it's been removed, you can say if it's for definite, it's a Melanoma. It might not have been. Um The standard management is surgical with a wide local excision. The margins for Melanoma excision are quite wide. So they range from 0.5 centimeters to three millimeters, sorry, three centimeters, sorry. Whereas with, for example, B CCS, it will be in the millimeters. So it's a lot wider. Um and you can also do a sentinel lymph node biopsy as well. So if um the primary lymph node of that area looks like it's been infested with Melanoma, then you can take that away as well. Um The prognosis, it depends on staging like um sec and prevention is the best management. So the best thing that people can do is use sun cream, you know, um be careful how they are in the sun and all that kind of stuff. So we got through your skin cancer. Um Now let's move on to infections. Er a bit of a trigger warning with this one, there are some pretty gruesome images. So if that's not your thing, then just be aware. So let's start off with bite injuries. And as you can see here, there's a after the bite and then after a couple of days where it's become infected. So, b injuries are very common. Um It's a very common presentation to A&E, um, and they can be human or animal. So the, the three most common ones are human, then there's dog and then the cat. So they're the three most common ones. And, er, as you can imagine, bacterial infection is a huge risk because the mouth is obviously full of bacteria. So it can get infected because that bacteria is gonna be transferred from the mouth to the wound. There's a risk of tetanus, there's also a risk of rabies specifically with dogs. And then I just wanted to talk about this fight bite, which is a common presentation. So if someone's been fighting and they punch someone else in the face, um they can end up punching someone in the teeth and the tooth of the person that they've punched can go into the knuckle and can potentially injure the joints in the knuckle and cause this septic arthritis, which can be um joint threatening investigation is with uh an X ray to rule out um you know, fracture or any foreign bodies in the wound. Um And then you can also do bloods as well, er like routine bloods. So FBC S and C RP would be sensible bloods to do in that scenario. So in terms of bite injuries, it can be medical or surgical depending on the severity of the bite. So in terms of medical management, um removement of foreign bodies is the first one and washing it out. So just with saline or um, sterile water, you can give a prophylactic antibiotics for three days as per the trust guidelines. Um And then if you suspect that the wounds already infected, you can give antibiotic treatment, um, uh for five days instead of three. And again, that would be down to trust guidelines. You need to set, um, you need to seek advice from infectious diseases, um, and consider rabies or tetanus prophylaxis. So if it's in an area of the country where there's a high rabies or tetanus risk or if someone's been bitten by. So like a dog that has known rabies, then obviously, you'd have to give the prophylaxis for that on the treatment. Um And then you need to admit patients who have worsening signs of infection. So all the classic systemic symptoms, like increased temperature down to shock, whatever you should admit these patients. And then surgical is debridement of nonviable tissue. So that's where you um cut out any tissue that looks like it's infected or it doesn't have a blood supply. And then if it's a massive bite where there's a lot of tissue that's been lost, you can reconstruct it with the reconstructive techniques that we mentioned before. Nex is necr necrotizing fasciitis, which is a big topic. Um It's life threatening. So it can be an up to 40% mortality rate. It's a surgical emergency and it's classified into type one, type two and gas gangrene as well. So type one is the more common type and that's where there's a mixture of anaerobes in it. And type two is um where it's just one type of anaerobe. Usually uh strep pyogens um is causing that and then gas gangrene is um with the clostridium er bacteria and it causes gas bubbles under the skin. I've got an image of it here. So yeah, you can see it here. It's not pleasant and yeah, there's certain patients that are more at risk. So for example, type one is more common in the elderly and comorbid. So yeah, gas gangrene uh in terms of the clinical features, the main one is that it's rapidly progressing. So it progresses very quickly and you've got a mark on the skin where the infection's got up to and then keep track with that to see if it's progressed further. Um It follows a precipitating event of skin breach. So some kind of trauma, for example, um severe pain disproportional to the clinical signs. So you they're in basically in agony. If they're jumping off the bed, then it might be macro fasciitis. It's also characterized by hemodynamic instability and signs of multiorgan failure. And like I've put this list of clinical features um on the right side that you can have a look at just now, I'll just give you two seconds while I drink my tea. Ok? So necrotizing fasciitis investigations. So you start off with blood tests. So you would have increased um white cell count and C IP. Uh you would do a blood gas and find raises lactate and metabolic acidosis. So, these are all classic signs of infection and you also see worsening renal function on G FR S hyponatremia, impaired liver function, coagulopathy and blood cultures. Um yeah, would be like blood cultures might, you know, come back growing something. Um, imaging is discouraged cos the, it's not really relevant in most cases and it might delay treatment and treatment needs to be offered as soon as. And er you can score the risk using this system here in ec. Um So in terms of management, the definitive management is urgent surgical debridement. So you can excise the necrotic tissue. So the tissue that doesn't, that's dying um until it's not bleeding. So only, only the bleeding Bible tissue would be present and there would be no non bleeding tissue and that's how you'd know that you'd removed it all. After surgery, they need to go to ICU to make sure that they're stable and you might also need to reconstruct after the initial debridement. An important point on the reconstruction is that would usually be done after a day or two because you should never close um a wound that was recently infected or that's infected at the time. Um So, and then finally, we've got hand infections. So it's a common presentation to emergency department requiring surgical intervention. It's most often a result of trauma is commonly caused by staph aureus or strep. Um it can cause damage to important structures. Obviously, the hands are very important, a part of your body for daily functioning, uh fine motor skills, et cetera. So they need to be taken seriously and these are the different types um of hand infections. So, hand infections investigations. So you can do ACR P um A white blood cell count and your rate levels. You can uh do an X ray wound swabs and pus culture are all the investigations that we do. So, first is Paronychia is the first um, hand infection we're gonna cover. Um, it's the most common infection of the hand. Um, and it's uh an infection of the soft tissue fold around the nail plate, you can see it on the right here. Um, it can occur co occur commonly, er, secondary to contamination with oral flora. Um, so if someone's been, I don't know, I, if, if someone's been s like sucking their thumb or something like that, um, the fingertip er, is swollen and inflamed as you can see on the right. Um, and it can cause necrosis of the nail bed and even osteomyelitis or infection of the bones in terms of the treatment, er, you treat it with antibiotics, incision and drainage. So, if it's an abscess, you've gotta to drain the abscess to make sure it doesn't come back and throw a wash out with sterilized water or saline. Um, there's also infectious um, synovitis So, um inflammation of the tendon sheath is the most common type of um infection for the flexor sheath and it's a surgical emergency. Um and it can lead to tendon rupture and necrosis. There's also felon injuries. Oh, let's go back. So, um where the actual pulp of the finger tip is infected. Um As you can see on the right, it's um common in the thumb and the index finger, it's caused by staph aureus presents with swelling and most cases resolve spontaneously and then finally deep hand space infection. So, infection of the deep spaces of the hand, like the hypothenar space, mid palmar space and thenar space. Um, the respective part of the hand can become tendon and swollen and that limits hand movements. So, in terms of hand infection management, antibiotic treatment and then in specific conditions like infectious and you know, sinusitis, flexor sheath infection and deep space infections, they might require wash out in fair so they open whatever's infected and they'll use um sterile water to wash it out and then close it again. And then finally we have um hand trauma, um, and we're gonna be covering the following conditions. So, first is flexor tendon injuries which are fairly rare, they usually result from a traumatic injury. Um, and they can occur in sports like um rock climbing and rugby is, is somewhere where they might commonly present. So, rock climbers and rugby players, you can bear this in mind. Er, they're classified based on burden zones, as you can see on the right, they present with reduced flexion in the finger weakness and pain. Um, diagnosis is typically clinical but you can ultrasound it to confirm the diagnosis and it's treated with expiration. So, open it up and see what it looks like from the inside and tend to repair and wash out. Then there's um extension tendon injury, which is very common because of how superficial the extensor tendons are anatomically. Um And it can result in permanent loss of function. So it's important to take them seriously. Um They can be caused by a traumatic injury primarily and they present with loss of extension. So not being able to deal with that um loss of strength and loss of motion range of motion. Um So when you're treating these, you can ask about hand dominance and occupation cos it might have um a bearing on the treatment. For example, if someone's right handed and they've damaged their left hand, then you can maybe go for a less invasive treatment that will preserve less function as compared to if someone was right handed. Um then you might have to go for something different. Um And an important point about that as well is with the occupation as well. So different patients will have different preferences for treatment based on if they're very manually focused. So for example, if it was a piano player, they might want a more advanced treatment than someone who has a less manual job. Um So you need to establish the uh the the mechanism of injury cause. That's also gonna have an effect on the techniques used in the treatment. Examine with a look for your move structure as you would with any M SK complaint. The diagnosis is usually clinical. Um you can do an ultrasound or an X ray to confirm it and to make sure you've not missed anything else like a fracture. Um And then treatment with exploration and tendon repair, like the flexor, um tendon injuries, metacarpal fractures, um a very common um and they er result from traumatic injury usually and they usually present with like nonspecific features. So things like pain and swelling, there's a lot of different types of them. So you've got like um the boxer fracture, which is um a fracture of the fifth metacarpal neck or you've got the Bennett's fracture and the Ronaldo fracture, which are the first um metacarpal uh fractures. So, um there's lots of different types. Um again, ask about hand dominance and occupation cos that was gonna have a bearing on the treatment. Um You can assess for an open fracture cos that's gonna need soft tissue repair as well. Look for your new structure, you need to do an X ray to see what type of fracture it is mostly it's managed conservatively with immobilization. So a cast or a splint and a hand rehabilitation. So, physiotherapy but surgery might also be indicated. So you can do, for example, a closed reduction with K wires, um, plus percutaneous fixation or you can also do an open reduction with internal fixation. It is another surgical um option for metacarpal fractures. And finally, we have nail bed injuries. So, um with no injuries, they're very common and they usually occur from crush injuries. So I don't know if someone's, you know, dropped something on someone else's thumb. Um So different parts of the nail can be damaged and it can cause different presentations. So you've got the subungual hematoma where you get bleeding under the nail, the nail bed laceration where the nail bed itself becomes cut or the nail bed avulsion where the nail is pulled away from the nail bed um and can cause pain, soft tissue swelling. It's clinical diagnosis. So based on the appearance and reinfection and other complications are very common. So things like ingrown toenails er, happen quite commonly after these. So, yeah, that's nail bed injuries. So that brings us to the end of the presentation. So what I've covered, so I did a bit of an inter reduction to plastic surgery. We covered the techniques used by plastic surgeons as part of the reconstructive bladder. We discuss burns assessment and management. We discuss skin cancer diagnosis and management. We discussed infections in plastic surgery and we also discussed common hand trauma presentations. So, thank you very much for listening and um over to Cameron. Nice. Thank you so much for that summary. Um It's a really good presentation. Um Like I said, we've got our socials on there at the end. Um Please feel free to follow. Uh We have another session tomorrow which will be focused on the breast aspect of this kind of um double uh presentations, basically. Uh We've got two more people presenting that tomorrow. Um If you do have any questions for either me or Sammy, um, we'll stick around at the end and we can answer those if you want to put them in the chart. Um In terms of the slides, they'll be on once this session finishes. Um So they'll be automatically uploaded and so we'll be recording this session as well. Um And in terms of getting a certificate for you guys attending, um if you fill out the feedback link, um which you should have when you register for the session, but if not, I'll put it in the chart as well. Um Then um you'll get your certificate automatically. Sure. Thank you very much guys for, for coming. And thanks again, Samy for a great presentation. No worries. Ok. If nobody has any uh questions, I'll finish the session there. I think so. Thanks again, everyone.