PLASTIC AND

RECONSTRUCTIVE
SURGERY

By: Natnael Temesgen

PAACS
Wolitta Soddo,SNNP, Ethiopia
June 19,2023
 GENERAL PRINCIPLES
• Relate to technical aspects of:
1. Incision planning
2. Wound repair

• Skin composed of Epidermis and dermis

• Multiple layers of epidermis
 SKIN INCISION
• Incisions placed parallel to Langer’s line often heal with less
conspicuous scar
• Borge’s lines- along tension lines
 SKIN INCISIONS
• The epidermis and superficial dermis should be incised sharply
with a scalpel.

• Then continued through the deep dermis and subdermal plexus of

blood vessels with electrocautery.

• Don’t make multiple pathways, esp subcutaneous

 SKIN INCISIONS
• It is preferable to completely excise the scar
 INCISION REPAIR
• Unfavorable Scar- Excessive Collagen deposition
 INCISION REPAIR
• Most important layer to approximate is dermis
• Optimal wound closure involves placing deep dermal sutures
followed by superficial sutures
• Avoid step off
• Stability is important to avoid motion, hence, reduced
inflammatory phase.
• The timing of suture removal depends on the type of suture placed
in the superficial closure
 RECONSTRUCTIVE
STRATEGIES AND METHODS
• Reconstructive surgery restores normal anatomy and function
using plastic surgery methods of tissue repair, rearrangement, and
replacement

• Aim of wound healing is to achieve a closed wound. There are 3

mechanisms to this
 SKIN GRAFTS

Skin Grafts

Composite
STSG FTSG
tissue graft

Thin STSG Thick STSG

 MESHING
• Maximizes surface area that can be covered by harvested skin
• Enhanced reliability of engraftment since the fenestrations allow
egress of wound fluid and excellent contour matching
Draw backs
• Poor cosmetics
• Secondary contracrures
 DONOR SITE HEALING
STSG
• From basal cells between recesses of dermal papillae
• Keep it moist and Free of bacteria
• Analgesics is important
FTSG
• Primary closure since no skin elements remains
 STAGES OF GRAFT TAKE
1. Imbibition (24-48hrs)
• Fibrin bonds between graft and bed
• Nutrition through osmosis
2. Inosculation(After 48hrs)
• Ingrowth of blood and lymphatic vessels
• High time for graft failure
3. Revascularization (4-5days)
• Strong blood vessels bridging
Tie over bolster
dressing

TOPICAL NEGATIVE PRESSURE DRESSING

 SURGICAL FLAPS
• A surgical flap is a unit of tissue harvested from a donor site and
transferred to another location for reconstructive purposes
• The distinguishing feature of a surgical flap is having a blood
supply independent of the injured area
 Flap
Classification

Tissue Proximity to Blood supply

Contained defect pattern
 TYPES OF TISSUE
CONTAINED
• Cutaneous flap: Skin + Subcutaneous tissue
• Muscle flap: Only muscle
• Musculocutaneous flap:Muscle,skin & intervening tissues
• Osseous flap: Segment of bone
• Osteocutaneous flaps: Bone + Skin
 PROXIMITY TO DEFECT
• Local Flap: Donor adjacent to defect
• Regional Flap: Donor in same anatomic region with the defect
• Distant Flap: Outside anatomic region of the defect
• Pedicled Flap if blood supply not divided from source
• Free Flaps if Donor site exceeds the length of the flap pedicle(Tissue
transmitting blood supply) and reauires division of blood supply
 PATTERN OF BLOOD
SUPPLY
• Random Pattern Flaps
• Axial Pattern Flaps
• Musculocutaneous Flaps
• Fasciocutaneous Flaps
• Direct Cutaneous Flaps
• Perforator Flaps
• Free Flaps
 RANDOM PATTERN
FLAPS
• Blood supply unnamed and depends on subdermal plexus
• For small full thickness defects
• Traditional geometric principles of skin rearrangement dictates
length to width ratio of 3:1
 SUB CLASSIFICATIONS
OF RPF
• Transposition flaps
• Limberg or Rhomboid flaps
• Z plasty
• Rotational Flaps
• Advancement flaps
• V-Y advancement flaps
• Rectangular advancement flaps
• Interpolated flaps
• Head and neck flaps for tumors
EXAMPLES INCLUDE:

Deltopectoral flaps
Groin flap
Posterior thigh flap
TISSUE EXPANSION
CONGENITAL CRANIOFACIAL
ANOMALIES
PRIMARY PALATE- WEEK 4 TO 7 (ANT. TO INCISIVE FORAMEN)
SECONDARY PALATE- WEEK 6-12
 CLEFT LIP/PALATE
• Most common birth defect
• Asians > Caucasians > African Americans
• Males > Females
• Left > Right
• 29% have associated anomalies
• Family Hx is strongest predictive factor
• Extrinsic factors- Maternal smoking, Phenytoin
 ISOLATED CLEFT PALATE
• Females > Males
• No racial preponderance
• Almost 50% has syndromes + Additional anomalies
• Geneticist evaluation always indicated
• Environmental factors- Maternal smoking and alcohol, folate
deficiency, steroids, phenytoin, retinoid excess
 CLEFT LIP
• Unilateral or Bilateral
• Microform- small notch in the vermilion
• Complete-All srtuctures of primary palate
• Incomplete- Requires intact nasal sill
CLEFT PALATE
 CLEFT LIP REPAIR
• Presurgical Infant Orthopedics
• Nasoalveolar Molding
• Lip adhesion procedure-Complete to incomplete
• Cleft Lip Repair
• Millard Rotation Advancement
 CLEFT PALATE REPAIR
• Intravelar Veloplasty
• Furlow double opposing Z plasty
 CRANIOSYNOSTOSIS
• Premature fusion of one or more calvarial sutures
• 85% non syndromic
• sagittal craniosynostosis is the most common, lambdoid less
common
• FGFR and TWIST, half denovo mutation, most aut. Dominant
• No proven environmental risks
• Increased ICP in many patients
• Virchow’s law- patients with craniosynostosis exhibit a
predictable pattern of deformity that results from an arrest of
cranial growth perpendicular to the prematurely fused suture, with
a compensatory increase in growth parallel to the affected suture
 DIAGNOSIS
• Physical exam with 98% accuracy
• Identify the distinct pattern of cranial growth
• Palpable ridges are not pathognomonic
• CT scan in dysmorphic facies, multiple sutures

Treatment
• Strip Craniectomy +/- spring distractors
• Remodelling procedures (> 6 months)
 ATROPHY AND HYPOPLASIA
• Progressive hemifacial Atrophy(Parry-Romberg)
• Idiopathic, Rare atrophy of skin,sc,mss,bone on 1 side of face
• Self limiting in 2 to 10 yrs (burning out)
• Tx: autologous fat grafting vs microvascular transfer
• Robin Sequence- Micrognathia, glossoptosis, Airway obstruction
• Cleft palate in 90%
• Diagnosable syndrome in 50% (eg. Strickler synd.)
• TX: Conservative prone positioning with airway Mx Vs Tongue lip
adhesion or mandibular distraction osteogenesis
• Tracheostomy is last resort
HYPERTROPHY, HYPERPLASIA, AND
NEOPLASIA
Hemangioma
• Most common vascular tumors in children, benign and common
in females, less common in dark skin people
• Are collections of primitive blood vessels from angioblasts
• Tx: Most conservative
Early intervention
• Ulcerated and bleeding
• Periocular hemangiomas
• Beard distribution areas
• Midline lumbosacral
• >4 hemangiomas- Abdominal US to see large hepatic lesion
Medical Tx: Propranolol
 VASCULAR
MALFORMATIONS
CM- Port wine stains
• Pink patches at birth to Dark cobble stoning later
• Look for Sturge-Weber with leptomeningial involvement
• Laser therapy
VM
• Lobulated collection of dilated veins
• Skin, mucosa, subcutaneous, 50% deeper
• Soft, compressible
• Firm, tender- Phlebolith
• Grow in proportion with the patient except at pregnancy and puberty
which will be accelerated
• Tx: Compression, Sclerotherapy, Surgery for small resectable lesions
LM
• Collection of abnormal lymph
channels
• Swelling, pain, bleeding, bone
overgrowth
• Macrocystic, microcystic or
combined
• Tx: Sclerotherapy for all
macrocysts, CO2 laser for
draining cutaneous lesions
 CONGENITAL
MELANOCYTIC NEVI
• Hyperpigmented lesion at birth
• Ectopic rests of melanocytes
• 1% incidence, but giant ones less common
• Involve dermis to muscles unlike acquired one
• Often flat brown and hairless
• Can under go verrucous thickening,
hpertrichosis,erosion,ulceration
• 0.7% to 2.9% risk of melanoma
• >20 satellite lesions, midline or calvaria lesions- Neurocutaneous
melanosis
 ADULT
RECONSTRUCTIVE
SURGERY
 MAXILLO FACIAL
INJURIES
• ATLS always
Facial Skeleton
• Upper 3rd- inferiorly bounded by superior orbital rim
• Middle 3rd- maxilla, nasal bone, zygoma.
• Lower third- Mandible(inferior to oral cavity)
Functional structures of the mid face are system of buttresses
Arrenged vertically and horizontally, and distribute force
Three Paired Vertical buttresses
• Naxomaxillary, Zygomaticomaxillary, Pterygomaxillary
• Horizontal Buttresses
• Superior and inferior orbital rims, hard palate
FACIAL BUTTRESSES
MANDIBULAR
FRACTURES
ANGLE’S CLASSIFICATION
OF MALOCCLUSION

Tx:
- Establish dental occlusion-
Arch bars
- Definitive fixation commonly
with plate
• Rigid fixation
• Les rigid but stable
 Early range of motion
FRONTAL SINUS
FRACTURE
 ORBITAL FRACTURES
• Commonest is orbital floor- Blow out fracture
Surgery
• Large fracture
• Enophtalmous (globe retrusion)
• Restriction of upward gaze
• Entrapement of inferior orbital tissue or diplopia > 2 wks
• Late Complications- diplopia, enophtalmous, Entropion,
ectropion
• Superior Orbital Fissure Syndrome (SOFS)
• Direct fractures of posterior orbit, edema
• Ptosis, protrusion, Paralysis of extraocular muscles
• Orbital Apex Syndrome
• SOFS plus Optic nerve entrapement
• Can lead to blindness
• Medical emergency
 ZYGOMATICOMAXILLAR
Y COMPLEX
• Zygomatic fractures Involve zygomatic arch with/without any of
it’s articulating bones
• Displaced and communited fractures can be surgically elevated and
stablized- Gilles approach
• Zygomaticomaxillary complex fractures involve
• Zygomatic arch, inferior orbital rim, ZM buttress, ZF buttress and
lateral orbital wall
• Upper eyelid approach, transconjuctival or inferior eyelid, maxillary
gingivobuccal incision (all for displaced fractures)
 NASOORBITALETHYMOI
D AND PANFACIAL #
• Involves
• Medial orbit
• Nasal bones
• Nasal process of frontal bone
• Frontal process of maxillary bone
• Complications- Nasal airway collapse, Telecanthus, Medial orbital
disruption, Nasolacrimal dysfunction
• If associated with multiple facial bones and intracranial injuries-
Panfacial
• Tx: ORIF +/- bone graft, Synthetic materials
 BREAST
RECONSTRUCTION
• After Mastectomy, reconstruction involves
• Preoperative counseling
• Delayed reconstruction 3 to 6 months
• Immediate reconstruction- at time of ablative surgery
• Stage 1 and 2 disease, good general health
 ONCOPLASTIC BREAST
RECONSTRUCTION
• For women who underwent breast conservative therapy
• Abnormal breast countour correction
• Elevation of skin from gland, nipple mobilization on vascular
pedicle, rearrangement of glanduar tissue, closure and after
adjuvant treatment, breast reduction of contralateral for symmetry
 IMPLANT BASED
RECONSTRUCTION
• Use implant devices
• Tissue expanders usually necessary which continues for 6 to 8
weeks then implant exchange after 3 months
Advantages
• Minimal additional surgeries at time of mastectomy
• Same recovery as mastectomy alone
• Good for slender small breasted woman
Disadvantage
• Long process upto 1 yr
• Requires minimum of 2 operations
• Less predictable cosmetic result
 TISSUE FLAPS AND
BREAST IMPLANTS
• Lattissimus dorsi musculocutaneous flap with breast implants
Advantages
• Immediate replacement of soft tissue and skin
• Implant allows accurate volume reproduction of contralateral breast
• Implant protected by abundant tissue
• Tissue expansion avoided
Disadvantage
• Additional scarring
• Long recovery period
 AUTOLOGOUS TISSUE
CONSTRUCTION
• Most durable and Natural appearing
• TRAM (transverse rectus abdominis mc flap)
• Pedicled is Superior epigastric vessels
• Free- Inferior epigastric with DIE perforators
• With axillary artery if no prior radiotherapy
• Internal mammary for recurrence surgery
Advantages
• Complete restoration of breast mound in 1 stage
• Implant is avoided
• Superior cosmetic result

Disadvantage
• Magnitude of surgery
• More scarring
• Abdominal bulges
 PRESSURE SORES
• Tissue injury caused by external physical pressure exceeding
capillary perfusion pressure
• Treat underlying causes, use padding
• Investigate for infection
• Debride infected areas
• Stage 1 and 2 are treated non surgically
• STSG rarely used in areas where pressure can be avoided
• MC flaps in areas of heavy contamination and complex contour
stracture
• Durability requires ability to offload (7 to 10 days)
• Fasciocutaneous flap if off loading is difficult
• Sacral Pressures- FC or MC flap based on gluteal vessels
• Ischial pressure- Gluteal flaps or posterior thigh flap based on
inferior gluteal artery
• Trochanteric pressures- Tensor fascia, Rectus femoris or vastus
lateralis(lateral circumflex femoral)
THANK YOU