Dr loqman

• Cosmetic surgery


  Surgery that modifies or improves the appearance of a physical feature, irregularity, or defect
• Reconstructive surgery


  Surgery to rebuild a structure for functional or esthetic reasons
• Plastic surgery


  The surgical specialty or procedure concerned with the restoration, construction, reconstruction, or improvement in the form, function, and appearance of body structures that are missing, defective, damaged, or misshapen by injury, disease or anomalous growth and development
• Legal status of cosmetic procedures in Malaysia - Animal Welfare Act 2015 Part V-1(h) - Cruelty offences
• Anatomy of the skin

  • Epidermis
  • Dermis
  • Hypodermis (Subcutis)
  • Skeletal musculature

  
• Wound management


  1. Objectives

  2. Phases in wound healing

  3. Considerations in an open wound assessment

  4. Strategies for the management of wounds
• Surgical wound closure


  1. Placement of sutures

  2. Suture knots

  3. Basic suture patterns

  4. Tension relieving techniques (undermining, tension suture pattern, walking suture pattern, single or multiple relaxing incision)
• Pedicle graft


  A portion of skin and subcutaneous tissue with a vascular attachment moved from one area of the body to another
• Pedicle graft classification


  • Circulation, blood supply (subdermal plexus flap, axial pattern flap)
  • Location relation to the recipient bed (local flaps, rotating flaps, advancement flaps, distant flaps)
• Principles of flap surgery

  1. Plan in advance

  2. Meticulous technique

  3. Large enough & no tension

  4. Keep flap cool & moist

  5. Drain and/ or bandage
• Preparing the recipient bed for pedicle grafts

  1. Free of debris, necrotic tissue, infection

  2. Excision of chronic granulation tissue, healthy granulation bed within 3-5 days

  3. Removing the epithelialized borders on the wound
• Subdermal plexus flaps


  • Advancement, rotational & transposition
  • Delayed SPF
  • Distant flaps
  • Principles (width of the flap should be no greater than the base, gentle tissue handling, no tension on the closure line)
• Subdermal plexus flap techniques

  • Single advancement flap
  • Bipedicle advancement flap
  • Transpositional flap (90°, 45°)
  • Rotational flap
  • Bilateral rotation flaps
  • Tubed pedicle graft (indirect, direct)
• Axial pattern flaps


  • Designed on the basis of the direct cutaneous artery (DCA)
  • Principles (meticulous surgical technique)
  • Indications (major surgical procedures, wide tumour excisions, avascular wound bed, extensive body wounds)
• Skin graft


  A segment of epidermis and dermis that is completely removed from the body and transferred to a recipient site
• Skin graft classification


  • Autografts (autogenous graft)
  • Allografts (homografts)
  • Xenografts (heterografts)
  • Isografts

  
• Skin graft classification by thickness

  • Full thickness
  • Split-thickness

  
• Skin graft classification by shape and size

  • Unmeshed grafts
  • Mesh grafts
  • Seed grafts
  • Strip grafts
• Skin graft acceptance ("graft take")


  • Adherence
  • Plasmatic imbibition
  • Inosculation
  • Penetration and ingrowth of new vessels
• Skin graft technique


  1. Harvesting and donor site

  2. Defatting

  3. Keep moist

  4. Suturing

  5. Bandage
• Complications of skin grafts include fluid accumulation under graft, infection, and necrosis
• Burn wound


  Injuries caused by an extreme of heat or cold or by another physical agent having a similar effect e.g. electricity, caustic agents or radiation
• Types of burns


  • Thermal
  • Chemical
  • Electrical
  • Radiation
• Burn classification


  • First degree (superficial burn)
  • Second degree (deep, partial thickness burns, possible progression to 3rd degree)
  • Third degree (full-thickness burns)
• Burn pathophysiology


  • Cellular destruction (reversible or irreversible)
  • Thrombosis of the blood (ischemia)
  • Vascular permeability changes (fluid volume shift, fluid, electrolyte & plasma protein loss)

  
• Burn shock


  Hypovolemic shock (cardiac output, tissue hypoperfusion, multiorgan failure, hypoxia, death)
• Respiratory distress syndrome in thermal burns

  • Edema of larynx
  • Bronchospasm
  • CO poisoning
  • Bacterial pneumonia
• Burn effects on host defense mechanism

  • Skin as external barrier
  • Specific/non-specific immune response (infection)
• Burn management objectives


  • Tissue loss
  • Hypovolemic shock prevention
  • Prevention of septic complications
  • Removal of dead tissue
  • Reconstruction
• Initial burn evaluation


  1. Assess size and depth of burn wounds

  2. Determine if emergency support therapy/special care is needed based on % total body surface area (TBSA) affected

  
• TBSA (Total Body Surface Area)


  Rule-of-nine: 9% for each forelimb, 18% each hind limb, 9% for head and neck, 18% each dorsal and ventral surface of abdomen and thorax region
• Initial burn treatment


  1. O2 therapy

  2. Tracheostomy

  3. Bronchodilator

  4. Local wound treatment

  5. Cold therapy

  6. Systemic therapy (fluid, diuretic, analgesic, sedative)

  7. Nutritional support
• Burn wound management


  1. Dressing/debridement

  2. Topical & systemic antibiotic therapy

  3. Nutritional support
• Burn wound surgery


  1. Burn eschar removal

  2. Wound closure (reconstructive procedure or 2nd intention healing)

  3. Consideration of healing period and medical/cosmetic result