Plastic surgery
Definition: is branch of surgery that is concerned with remold, repair and
restore body parts especially by transfer of tissues.
Plastic as adjective mean capable of being shaped or formed.
Divided into 2 parts:
1. Aesthetic or cosmetic surgery: which performed to reshape
normal structure of body to improve the patient appearance
e.g.rhinoplasty, face lift.
2. Reconstructive surgery: which is done for these who have
congenital deformities e.g. cleft lip and palate, or those who have
acquired deformities as result f infection, accident, burn.
Anatomy of skin: skin is largest organ in body ranging from 0.22 m² in
new born to more than 2m² in the adult.
It provided barrier to invasion by microorganism, regulate the exchange of
heat with environment, provided surface for vitamin D synthesis by U.V.
light.
It consists of epidermis and dermis.
Epidermis: is the outer layer composed of keratinized stratified squamous
epithelium, it divided into:
 Stratum germinatirum: which rest on dermis and generate the cell of
stratum corneum.
 Stratum corneum: This is the desquamating dead superficial layer.
Dermis: which is 20 times thicker than epidermis, it consists of non-cellular
connective tissues (collagen and elastic fibers) and ground substances. It
divided into:
 Upper papillary dermis (thin).
 Lower reticular dermis (thick) which extended form papillary dermis
to subcutaneous tissues.
Dermis contained sweat gland, blood vessels, lymphatics and pilosebaceous
units.
Subcutaneous layer: the skin is connected to the underlying bone and deep
fascia by layer of areolar tissues that varies in thickness, it prominent in
palm and sole, and absent in eyelid.
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Blood supply:
1. Major vessels: deep to muscle (musculocutaneous) perforators which
pass perpendicular through the muscle and deep fascia
dermosubdermal plexus which supply the skin.
2. Direct cutaneous artery: superficial to muscles then dermosubdermal plexus.
Wounds: is the disruption of unity or breech in surface epithelium. In
primitive animals respond to this by mitosis, selected part in our body still
have this ability e.g. liver, intestinal mucosa.
Phases of wound healing:
1. inflammatory phases: begin at time of injury and last 2-3 days, begin
with vasoconstriction to achieved hemostasis ,then vasodilatation with
infiltration of neutrophils,monocytes and limited number of
lymphocytes
2. Proliferative phase: begin around day 3 and last through week during
which collagen synthesis and epithelization occur.
3. Remolding phase: during which increase in collagen production and
breakdown, continuous for 6 month-1 year. Wound strength increase
as collagen reorganized and vascularity decrease.
Ladder of reconstruction:
By secondary intention→direct closure→skin graft→local flap→distance
Flap→free flap.
Secondary intention: mostly used for small wound, by leaving wound
heal by itself without surgical intervention, apart from local wound care. It
depends on epithelization an contraction provided by myoblast.
Direct closure: most preferable method, because it use the same skin of
area with same colour and quality. it involved approximating the two end of
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the wound by suturing. Usually done to wound with straight, clean edge,
such as simple cut.
Closing in such method depends on area of defect and availability of
surrounding tissues.
Principles of wound closure:
1. When the wound is clean, incised wound as seen in surgical wound or
clear cut wound, direct closure achieved y approximation its edge
without tension.
2. When the wound is lacerated, with irregular edge and contaminated,
direct approximation should not done unless the wound is irrigated
and debrided.
Debridment: involves the excision of all devitalized, contaminated
tissues and foreign body.
Irrigation: involves washing the wound by copious amount of saline
and ringer lactate.
Method of debridment:
 Mechanical: This involved sharp or blunt excision of dead tissues.
 Gauze: repetitive application of moistened gauze which desiccates
and gradually removed necrotic debris from the wound.
 Chemical: topical enzyme application which digests devitalized
tissues.
3. When handling the tissues during closure we should avoiding
excessive retraction and pressure on wound, irrigation and moist pack
should be used to prevent wound desiccation.
4. aseptic technique: by strict using aseptic measurement such as hand
scrubbing, using of sterile instrument, and clean operative site, and
hair shaving
5. hemostasis: as bleeding can cause ischemia and hematoma formation
which can lead to infection which affect normal wound
healing.hemostasis can achieved by:
 Topical application of adrenaline.
 Electrocautery.
 Large vessels can be clamped or suture.
 Topical hemostatic e.g. fibrin glue.
6. antibiotics: which indicated for the fallowing:
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 Acute wound with surrounding cellulitis with gross
contaminated.
 Human or animal bit.
 Immunosuppressed or diabetic patient.
 Vulvular heart disease to prevent endocarditis.
Most soft tissues infection caused by gram (+) organism e.g. (staph.,
strept.).Usually we begin with broad spectrum antibiotics such as
cephalosporin, and more specific therapy directed by bacterial culture and
sensivity.
Closure methods:
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Simple interrupted suture.
Horizontal and vertical mattress.
Subcuticular continuous suture.
Continuous running suture.
Closure materials:
1. Suture materials: This divided to natural and synthetic materials or
to absorbable or non-absorbable.
2. Staples: which more rapid than sutures and create minimum reaction.
3. Surgical tapes: either alone or with other suture materials e.g. steristrip.
4. Biological or synthetic materials e.g. Cynoacrylate.
Direct wound closure either:
 Primary closure which mean wound closed surgically soon
after creation.
 Delayed primary closures which mean wound remain open for
days before closure to reduce risk of infection in contamination
wound.
Flap:
Segment of tissue contained network of blood vessels at the base of flap.
Flap can classify according to the fallowing:
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1. according to blood supply:
 Axial flap: which has direct cutaneous vessels lying above the
muscle, it could be:
a-peninsular axial flap which keep both skin and vessels intact.
b-island flap in which the skin cut and keeps vessels.
 Random flap: which depend on musculocutaneous artery pass
deep to the muscle and send perforator to base of flap.
2. According to method of transfer:
 Rotational flap: flap that rotate around pivot point, its
semicircular flap.
 Transposition flap: triangular flap that rotate on pivot point,
the donor site can be either closed directly or if not possible
covered by skin graft.
 Advancement flap: it moved primarily in straight line from
donor site to recipient site. There are various advancement flap
like single pedicle advancement flap, bipedicle advancement
flap and V-Y advancement flap.
 Interpolation flap: in which the donor site is separated from
recipient site by pedicle of flap, so should pass above or
beneath tissue to reach the recipient area.
3. According to its contents:
 Cutaneous
 Fasciocutaneous.
 Musculocutaneous.
 Osteomusculocutaneous.
 Omental.
4. According to proximity to defect.
 Local flap: flap has side of defect.
 Regional flap: flap not immediate adjacent to defect e.g.
paramedian forehead flaps.
 Distance flap: not near to defect e.g. groin flap.
 Free flap: which mean free tissue transfer with its own blood
supply and anastomosis is done with recipient site by
microvascular surgery.
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5. According to site of donation:
 Groin flap which supply by superficial circumflex iliac artery.
 Deltopectoral flap which supply by internal mammary artery.
Indication of skin flap:
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Wound with poor vascularity.
Full thickness defect of ear, check,nose.
Padding of body prominence e.g. patient with bed sore.
Muscle flap as motor unit.
Control of infection since have good blood supply.
Factors which lead to flap necrosis:
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Hematoma collection under flap.
Tight dressing.
Tight sutures.
Pressure from position.
Kinking of flap or pedicle.
Cool ambient.
Nicotine ,caffeine or other vsconstrictive agents
Technical error especially from free tissue transfer.
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