Plastic surgery

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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18 Plastic surgery

Introduction

There is no part of the body that is the specific territory of the plastic surgeon; plastic surgeons treat a great variety of problems in many different sites. The development of fibre-optics and microsurgery has also increased the capability of the plastic surgeon to restore form and function. Nevertheless there are several subspecialities:

• oncoplastics

• cranio-facial

• burns

• cosmetic

• hands

• trauma.

Spontaneous wound healing

This is the natural phenomenon comprising the basic events of blood clotting, fibrin deposition, organisation and collagen synthesis. Many wounds will heal completely without intervention, but the pattern of wound healing may be affected by endocrine, pharmacological and physical manipulation or by the surgery itself. Numerous dressings and topical agents are commercially available that aim to accelerate wound healing although they have not been proven superior – the aim being to provide the optimum environment for re-epithelialisation. The application of negative topical pressure (‘vacuum assisted closure’ or ‘VAC’ dressing) has also become increasingly popular.

Vacuum assisted closure

Topical application of negative pressure (see Fig. 18.1) is achieved with:

• suction pump (1)

• tubing

• impermeable film layer (2)

• foam ± interpositional layer (3).

image

Figure 18.1 Topical application of negative pressure.

This achieves:

• reduced bacterial load

• reduced exudate

• maintenance of moist environment

• may encourage angiogenesis

• provides protected wound environment (secure dressing).

Disadvantages:

• cumbersome for patient

• noisy

• relatively frequent attention to maintain function

• expensive.

Direct surgical wound closure

The first choice for wound repair is direct closure by suture, incision of which should be along the same axis line as the local skin creases (Langer lines – see Fig. 23.1, p. 339. Attention to detail is important with minimal handling of the skin edges, meticulous haemostasis and the wound sutured so that the edges are exactly matched but slightly everted. Hopefully hypertrophic scars can be avoided in this way (although true Keloid scarring is unpredictable and often difficult to manage, see Box 18.1)

Box 18.1 Keloid scarring

A benign overgrowth of connective tissue at the site of skin injury, beyond the usual confines of the wound (cf. hypertrophic scarring). They are raised, rubbery and nodular and can grow from seemingly innocuous wounds. There is a preponderance among those of African origin. Management is ideally preventative (i.e. avoidance of surgery in those predisposed), ablative (laser, sharp excision – with a >50% chance of recurrence), radiotherapy or intra-lesional steroid therapy.

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