An Introduction to Reconstructive Plastic Surgery Hannah Dobson

What is Plastic Surgery  From the Greek ‘plastikos’  Reshaping the tissues of the body to restore form and function  Encompasses both cosmetic (aesthetic) and reconstructive surgery

Ancient Plastic Surgery  First performed by Indian potters ~3000 BCE  Ritual amputation of the nose as punishment to thieves and adulterers  Flap of tissue turned down from the forehead to cover the defect  Indian physicians used skin grafts ~800 BCE

Modern Plastic Surgery Cosmetic Surgery Reconstructive Surgery  Facelifts  Injectable fillers  Nose surgery  Hair replacement surgery  Breast augmentation / lift  Arm lift  Tummy tuck  Sclerotherapy  Body contouring  Liposuction  Chemical peel  Cancer  Skin, head & neck, breast and soft tissue sarcoma  Congenital  Craniofacial surgery  Cleft lip & Palate  Skin, giant naevi, vascular malformations  Urogenital  Hand and limb malformations  Trauma  Soft-tissue loss (skin, tendons, nerves, muscle)  Hand and lower limb injury  Faciomaxillary  Burns  Breast reconstruction / reduction

Primary Wound Closure  Clean the wound  Anaestheic  Injectable lignocaine or bupivacaine  Adrenaline to decrease bleeding  Do not use on the fingers, nose, toes or penis  Allow 5-10 minutes for the anaesthetic to take effect  Suture the wound  Face: 5/0 or 6/0  Other areas: 4/0 or 4/0  Non-absorbable sutures cause less noticeable scarring

Key principles  Optimise wound by adequate debridement or resection  Wound or flap must have a good blood supply to heal  Place scars carefully – lines of minimal tension  Replace defect with similar tissue – ‘like with like’  Observe meticulous surgical technique  Remember donor site ‘cost’

Split-thickness Skin Grafts  Epidermis and part of the dermis  Commonly from anterior or lateral aspect of the thigh  Graft obtained with a Zimmer dermatome or Humby knife

Split-thickness Skin Graft

Full-thickness Skin Graft  Epidermis and entire dermis  Palmar surface of hand  Commonly from above the inguinal crease

Full-thickness Skin Graft

Flaps Transposition flap Advancement flap

Bilobed flap Intraop and at 6-weeks post-transfer

Pedicled Myocutaneous Flap

Myocutaneous free flap

Common causes of flap failure  Poor anatomical knowledge when raising the flap (such that the blood supply is deficient from the start)  Flap inset with too much tension;  Local sepsis or a septicaemic patient;  Dressing applied too tightly around the pedicle;  Microsurgical failure in free flap surgery (usually caused by problems with surgical technique).

Sagittal Craniosynostosis

Apert Syndrome  Mutation in FGFR2 on chromosome 10  Classic features  Complex, symmetrical syndactyly of hands & feet  Multi-suture synostosis  Small mid-face  Relative exorbitism

Indications for fronto-orbital advancement  To release the synostosed suture and decompress the cranial vault  To reshape the cranial vault and advance the frontal bone  To advance the retruded supraorbital bar, providing improved globe protection and an improved aesthetic appearance

Scalp is retracted

Frontal Advacement

Calvarial remodel

Postoperative results

Post-operative Results

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