Plastic

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Plastic Reconstructive Surgery

• Gregory D. Pearson, M.D.
• Assistant Professor Clinical
• The Ohio State University

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Plastic Reconstructive Surgery

• From Greek word, plastikos meaning to mold
• History dates back to ancient Egypt and Indian
  texts
• Nasal reconstruction was frequent in India
• Significant advances during World War I and II

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Plastic Reconstructive Surgery

• Definitions
• Reconstructive Surgery
• To take abnormal and return to normal
• Typically covered by insurance
• e.g. breast reconstruction
• Aesthetic Surgery
• To take what is normal and improve upon it
• Typically not covered by insurance
• e.g. breast augmentation

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Wound Healing

• Primary
• Mechanical apposition of the wound edges
• Secondary
• Healing via inflammation, contraction, and
  re-epithelialization
• Delayed Primary
• Leave upon for a couple days to clean up and then
  close primarily

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Wound Healing (cont.)

• Factors that delay wound healing
• Infection
• Poor vascularity
• Radiation
• Diabetes
• Hypertrophic Scars and Keloid
• Hypertrophic scars stay within initial boundaries
  of insult

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Suture techniques

• Goals Minimize tension, appose edges
• Relaxed lines of tension
• Dermal stitches
• Techniques
• Simple
• Horizontal vertical mattress
• Staples
• Tissue glues

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Simple
Vertical Mattress
Subcuticular
Horizontal Mattress
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Soft Tissue Reconstruction

• Reconstructive ladder
• Direct Closure
• Skin graft
• Local flap
• Distal flap
• Thought process from simple to complex
• Sometimes skip rungs

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Skin Grafts

• Split thickness versus full thickness
• Full thickness involves all of the dermis
• Survival depends upon a vascularized bed
• 3 phases of graft survival
• Imbibition
• Inosculation
• Angiogenesis

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Skin Grafts

• Skin contracture
• Primary versus secondary
• Related to amount of dermis
• Getting your graft to take
• Prevent hematoma
• Mesh versus pie crusting
• Prevent Shear
• Immobilize graft

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Flaps

• Think about the blood supply
• Classified by blood supply and/or components
• Skin, fasciocutaneous, myocutaneous, muscle
• Random versus axial
• Random relies upon subdermal plexus, no named
  vessel
• Axial has defined vessel (e.g. radial forearm
  flap)

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Skin and Fasciocutaneous Flaps

• Multiple descriptors of flaps
• Z-plasty
• All limbs must be equal
• Gains length at expense of width
• Scar revision, move tissue to desired location
• V-Y advancement
• Recruitment technique for tissue deficiency
• Rotational
• Need wide arch of rotation to fill small defect
• Back cut increases arc of rotation (decreases
  vascularity)

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Skin and Fasciocutaneous Flaps

• Advancement
• Transposition
• Need to close the wake
• Scalp flap
• Rhomboid
• Bi-lobed
• Make first flap 2/3 defect and second 1/2 of first

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Flap types
Z-plasty
Rotation
Transposition
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V-Y Flap
Rhomboid Flap
Bi-lobed Flap
Advancement Flap
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Muscle and Myocutaneous Flaps

• Mathes Classification
• Classified by blood supply
• Angiosome
• Descriptor of anatomic area supplied by a given
  vessel
• Excellent for complex reconstructive issues
  (infection, radiation)
• Fill space, provide antibiotic delivery, can
  restore function

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Tissue Expansion

• Placing an expandable device to recruit new
  tissue
• Creep
• Stretch on skin causes mitosis and formation of
  new skin

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Microsurgery/Free Tissue Transfer

• Technically demanding (pre-operative planning and
  intra-operative technique)
• Takes tissue from one anatomic region to new
  anatomic region with a new arterial and venous
  anastomosis
• E.g. breast reconstruction with abdominal tissue
  free TRAM
• Arterial insufficiency and venous congestion need
  to be monitored for in post-operative period

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Sub-specialties (and other areas of interest)

• Peripheral Nerve/Hand Surgery
• Craniofacial and Pediatric Surgery
• Head/Neck Reconstruction
• Breast Reconstruction
• Trunk and lower extremity reconstruction
• Wound Management

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Peripheral Nerve/Hand Surgery

• Involves congenital brachial plexus injures
• Congenital hand anomalies
• Syndactyly, Polydactyly
• Acquired upper extremity conditions
• Carpal tunnel, wrist/hand arthritis
• Traumatic upper extremity issues
• Hand/wrist/forearm fractures
• Frequently involves microsurgical techniques

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Craniofacial and Pediatric Surgery

• Treatment of congenital and acquired bony and
  soft tissue defects
• Congenital Craniofacial Areas
• Cleft lip palate, craniosynostosis, microtia,
  facial clefting (Treacher-Collins)
• Acquired Craniofacial Areas
• Maxillofacial trauma
• Cancer reconstruction

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Maxillofacial Trauma

• Common secondary to assault and MVC
• Treat as trauma
• 50-70 have other injuries
• 33 mandible fractures have c-spine issues
• Ask about occlusion, vision issues
• Physical examination
• Lacerations, bony step-offs, oral bleeding,
  EOMI?, gross sensation, mid-face mobility, look
  at teeth

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Maxillofacial Trauma

• Radiograph
• Panorex for mandible fractures
• Maxillofacial CT for upper facial injuries
• Axial, coronal, and sagittal images
• Head CT is suggestive but not detailed enough

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Maxillofacial Trauma

• Mandible fracture
• 2nd most common fractured facial bone
• Ask about occlusion
• Panorex
• Evaluate the teeth
• Goal is to restore pre-traumatic occlusion
• Maxillo-mandibular fixation (MMF)wiring mouth
  shut

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Maxillofacial Trauma

• Nasal fractures
• Most common facial boney fracture
• No imaging needed, clinical examination
• Inspect septum r/o hematoma
• Fixed within 7 days

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Maxillofacial Trauma

• Orbital and Zygomaticomaxillary Fractures
• Check vision (grossly)
• Ophthalmology consult to evaluate globe
• Check Extra-ocular muscles
• Not urgent unless muscle is entrapped
• Maxillofacial CT required

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Maxillofacial Trauma

• Mid-face fractures
• High velocity/force fractures
• Mid-face mobility and malocclusion
• Maxillofacial CT
• LeForte Classification
• Can require emergent tracheostomy/cricoidotomy
• Avoid nasal intubation

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Head/Neck Reconstruction

• Typically post-cancer reconstruction
• Local flaps and microsurgical techniques
  typically employed
• Areas reconstructed
• Lip, cheek, ear, nose, mandible, eyelid, scalp

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Breast Reconstruction

• Autologous versus alloplastic
• Autologous generally provides improved symmetry,
  tissue quality and aesthetics
• Transverse rectus abdominis myocutaneous (TRAM)
  flap is workhorse of autologous reconstruction
• Free tissue transfer versus pedicled transfer
• FTT allows larger transfer of tissue and more
  versatility in patient selection

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Breast Reconstruction

• Autologous options
• TRAM
• Latissimus Dorsi implant
• DIEP, SGAP
• Gluteal
• Autologous is especially useful in radiation
  reconstruction

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Breast Reconstruction

• Alloplastic
• Tissue expander followed by implant placement
• Less morbid than autologous
• Less operative time
• Less aesthetic
• Breast Reconstruction is mandated to be covered
  by insurance

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Trunk and lower extremity reconstruction

• Trunk lower extremity reconstruction
• Trauma, infection, oncologic ablation
• Sternal wounds
• Pectoralis muscle, rectus abdominis utilized
• May require bony reconstruction
• Combination of local muscle flaps or FTT
  depending on level of lower extremity injury
• Separation components invented by P/S

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Wound Management

• Pressure sores
• Need complete work-up to determine underlying
  etiology of sore
• Nutrition work-up
• Rarely emergent
• May need fecal diversion

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Aesthetic Surgery

• Face lift/Neck lift
• Blepharoplasty/Brow lift
• Liposuction
• Body contouring (abdominoplasty)
• Rhinoplasty
• Breast augmentation