Plastic and Reconstructive Surgery

Plastic and Reconstructive Surgery

PLASTIC SURGERY

“Plastic Surgery (Greek plassein = to Mould) is concerned with the restoration of form and function of the human body”

Plastic and Reconstructive Surgery

1              Soft Tissue Management

2              Trauma

3              Hand Surgery

4              Neoplasia

5              Breast Reconstruction

6              Congenital including Cleft  Surgery

7              Aesthetic Surgery

8              Burns

Patient Examination

Describe wound, shape,  measurements

Haemorrhage, foreign bodies,  surrounding tissue damage

Document Neurovascular  injuries

Radiology

Microbiology

Soft Tissue  Management - Reconstructive Ladder

1. Primary Closure

2. Secondary Intention

3. Skin Graft

• Split thickness
• Full thickness

4. Local Tissue Flaps

5. Distant Tissue Flaps

6. Free Tissue Flaps

TRAUMA

Upper Limb

• Musculoskeletal
• Neurovascular
• Hand Fractures

Lower Limb

Facial Lacerations

Trunk

Burns

2. Trauma

Follow ATLS principles

Treat as Appropiate e.g.

Wound Management - Debridement

< 6 Hours if possible

Second look 48 hours later

Classification of wounds

• Clean  (elective, no GI, GU, Trauma)
• Clean contaminated (Minor breaks of sterility)
• Contaminated (Traumatic, spillage, infected bone or tissue)
• Dirty (abscess, soft tissue infection)

Scar Management

Normal

Hypertrophic

Keloid

Upper Limb

• Vascularity
• Neurology
• Tendons
• Muscle Bellies
• Bones
• Foreign bodies

Flexor Tenosynovitis

Kanavel’s Cardinal Signs

• Fusiform Swelling
• Pain on passive extension
• Tenderness over flexor tendon sheath
• Flexed digital posture

Replantation of Amputated Limbs/Digits

• Mechanism: Sharp/Blunt
• Condition of Amputated Stump
• Timing since Injury
• Indication for Attempted  Replantation

Transportation of Amputated Parts

• Wrap Amputated Part in Moist  Saline Gauze
• Place in Watertight Container
• Place in another Sealed  Container of Iced Water
• Place Patient ID on Container

Facial Lacerations

• Important structures
• Human bites
• Innoculation risk for HIV and Hepatitis
• Difficult reconstructive problem

Lower Limb Trauma

Gustillo and Anderson Classification of Tibial Fractures

I              Soft tissue wound < 1 cm

II              Soft tissue wound > 1 cm,  without extensive soft tissue  damage

III              Soft tissue damage requiring  reconstruction

• A              Adequate soft tissue coverage
• B              Soft tissue loss with periosteal  stripping and bone exposure
• C              Vascular Injury

Hand Surgery

• Trauma
• Reconstructive
• Congenital
• Degenerative

Dupuytrens Disease

Characterised by fibrosis & contracture of the palmar fascia result = digital contracture

Solitary / multiple painless nodules, skin dimpling & flexion contractures

Associations

• Alcoholism
• Diabetes Mellitus
• Epilepsy
• Smoking
• Chronic Pulmonary Disease
• HIV
• ?? Manual labour

Treatment = Surgery

Palmar Fasciectomy

• Partial or Complete
• Care with skin flaps

Dermatofasciectomy- Severe, diathesis, recurrent  disease

Neoplasia

• BCC
• SCC
• Melanoma
• Others

Inspection

Site

Size

Shape

Surface/Edge – sloping, raise  rolled, undermined

Base – slough, granulation  tissue, discharge

Surround

Palpate

Temperature

Tenderness

Consistency

Mobility

Pulsation

Fluctuation

Reducibility

Squamous Cell  Carcinoma

Epidermal keratinocytes

Sun induced

Immunosupression

Marjolin

HPV

70% in head and neck & 15% on upper extremities

2-6% metastatic risk

Characteristically invasive SCC

raised, firm, pink-to-flesh–coloured keratotic papule or plaque arising on sun-exposed skin

Surface changes: ulceration, crusting,cutaneous horn Less commonly, SCC may manifest as a pink cutaneous nodule without overlying surface changes.

Head & Neck Cancer

Aggressive

Usually SCC

Excision and Reconstruction can be technically demanding

Breast  Reconstruction

• Implant Only
• Pedicled Flap – LD Flap
• Free Flap
• TRAM

Congenital

• Cleft
• Craniofacial
• Congenital limb
• Skin
• Genito-urinary
• Cleft
• Craniofacial
• Congenital limb

Aesthetic Surgery

Burns

BURNS

Types: Thermal, Chemical,  Electrical.

Significant cause of morbidity  and mortality.

Acute Management

Resuscitation

Lund and Browder Chart

Parkland Formula

Assessment of Depth

Assessment of Extent

Reducing  Morbidity/Mortality

High index of suspicion for the  presence of Inhalational injury.

Maintenance of haemodynamic  normality with volume  resuscitation.

Temperature control.

Removal from injury-provoking  environment.

Primary survey (ATLS)

A - Airway

B - Breathing

C – Circulation

Airway/Breathing	Circulation
Breathing problems: 1) Direct  thermal injury. 2) Inhalation of  toxic fumes. 3) CO poisoning. Pointers to Inhalational injury:  Hx of confinement; Coughing;  Wheeze; SOB; Facial burns;  Carbonaceous sputum. CarboxyHb >10% → CO  poisoning. Consider definitive airway.	H.R, B.P.,Urine output. Burns >20% TBSA needs  circulatory volume support  (>10% in kids/elderly). ATLS guideline: 2-4ml  Hartmanns soln per kg body wt  per % partial/full thickness burn  in the first 24 hrs.

Depth of Burn

Superficial Burns

• E.g. sunburn.  Erythema, pain,  blanches with pressure,  absence of blisters. 3-6 days  healing time. No scarring.

Superficial Partial  Thickness Burn

• E.g. Scald (splash).  Blisters;  moist, red and weeping;  blanches with pressure.  Painful  to air and temp.  7-20 days  healing time. Scarring unusual.

Deep Partial Thickness  Burn

• E.g. Scald (spill).  Blisters  (easily deroofed), wet or dry,  variable colour, does not blanch  with pressure.  Perceptive of  pressure only.  Healing time  >21 days.  High risk of  contracture.

Full Thickness Burn

• E.g. flame, steam, boiling oil,  high voltage electricity.  Waxy  white to leathery grey to  charred and black; dry; does  not blanch with pressure.     Lacks sensation. Generally  never heals.  Severe risk of  contracture.

Extent of Burn

• Expressed as the total % body  surface area (TBSA) affected  by the burn.
• Several methods developed to  estimate the TBSA of burns.
• Rule of Nines (less accurate for  kids).
• Lund and Browder method.
• Very rough guide: Palm of  hand= 1% TBSA.

Additional issues

Analgesia

Dressings: Indicated for all  partial and full thickness burns;  Provide anaesthetic relief, act  as a barrier to infection, keep  wound dry.

Tetanus immunisation:  indicated for burns deeper than  superficial partial thickness.

Antibiotic prophylaxis not  indicated.

Special Burn  Requirements

Chemical burns- e.g. exposure to acids, alkalines, petroleum products.  Removal of chemical essential to good outcome- immediately wash away with large amounts of water for at least 20-30 min.

Electrical burns- Frequently more serious than they appear on surface (eg deep muscle necrosis). Cardiac arrythmias(48 hrs), Rhabdomyolysis (need particularly aggressive fluid therapy).

Who needs  hospitalisation?

• >10% TBSA burn in adult (>5% in young or old).
• >2% full thickness burn.
• High voltage injury.
• Suspected inhalational injury.
• Circumferential burn.
• Comorbidity predisposing to infection.
• Suspected child abuse.

RECONSTRUCTION LADDER

To reconstruct

• Skin loss
• Fascia loss
• Muscle loss
• Bone loss

Types

Secondary intention healing

• Healing through contraction  and epithelialization

Primary Closure :  approximation of edges

• Think of typical surgical  wound
• Decreased scar
• Less granulation tissue

Delayed Primary Closure

• Surgical closure within days
• Usually occurs if wound is  contaminated

• Wound is initially debrided  and rigourous on table  washout
• Closed usually after 4 days
• Eg: dog or human bite

Basic Techniques

Defect analysis

• Volume and type of tissue  missing
• Start with earliest rung on  the ladder

Reconstruction  Ladder

The reconstructive ladder is a term coined by reconstructive plastic surgeons to describe levels of increasingly complex management of wounds

Rung 1: healing by secondary intention
Rung 2: primary closure
Rung 3: delayed primary closure
Rung 4: split thickness graft
Rung 5: full thickness skin graft
Rung 6: tissue expansion
Rung 7: random pattern flap
Rung 8: pedicled flap
Rung 9: free flap

The Ladder : Skin  Grafts

SSG

• Epidermis and variable  dermis
• Taken from buttock or thigh
• Cover large areas: often  meshed 1: 1.5
• Donor site heals excellently
• Graft contracts+++: poor  scar
• Takes under less favourable  conditions than FTG
• Skin Grafts

FTGs

• All epidermis and dermis
• Donor site must be closed  primarily = scar
• Cover less area
• Useful for face: better  cosmesis
• Less contracture

Skin Grafts : Basic  Principles

• WILL NOT TAKE ONTO EXPOSED:
  • Bone (except membranous orbital bone)
  • Cartilage
  • Tendon
• WILL TAKE ONTO:
  • Periostium
  • Perichondrium
  • Paratenon

• Graft inspection: Day 5-7
• Donor site inspection: Day 10-12

Local Tissue Transfer

AKA  Flaps

• Have their own blood  supply
• Constituents:
  • Skin, fascia, muscle, bone
  • Proximity to defect: local,  regional, distant
  • Movement: rotation,  advancement, transposition

Rotation Flaps

Transposition Flap

Distant tissue  Transfer

Flap still attached to its pedicle. Eg:

• LD for breast recon
• TRAM for breast recon

Free Flaps

• Flap separated from its  blood supply
• Transferred to defect and  vein and artery are  anastomosed to vessels  near site of defect
• Most complicated rung of  ladder
• Needs microscope or Loupe  magnification
• Examples
  • LD
  • TRAM
  • DIEP
  • RFF

LD Flap

Possible Questions

• Covering defects: bone,  tendon, cartilage
• Factors that stop grafts  taking
• Flap monitoring
• Possible anaerobes
• Graft and donor site  inspection

Free Flap monitoring

Can fail due to venous or  arterial insufficiency

Venous congestion signs

• Brisk refill
• Congested, dark
• Bleeds black blood

Arterial insufficiency signs: Pale, cold, no pulse on  doppler, CRT slow

BASAL CELL CARCINOMA

Most common cutaneous  malignancy

Almost NEVER metastasizes

Often leads to local destruction

Usually arise from epidermis or  outer root sheath of hair follicle

Epidemiology

Most common in fair skin

Fitzpatrick types : I and II

Males > Females

Rarely found before age 40

Fitzpatrick Skin Types

Type 1	Type 2	Type 3	Type 4	Type 5	Type 6
Pale skin Blond, red hair Never tans	Burns easily Tans poorly	Darker white skin Tans after burning first	Light brown skin Burns minimally Tans easily	Brown skin Tans easily Rarely burns	Black skin Never burns

Aetiology

Sunlight: mainly UVB

Artificial UVB: Tanning salons

Ionizing radiation

For acne treatment

Immunosuppression

Renal transplants etc

Xeroderma Pigmentosa

Autosomal recessive: inability to repair UV damaged DNA,increased risk of all skin Ca.

Other features: corneal deposits, blindness

Gorlin syndrome

Autosomal Dominant

Odontogenic keratocysts, palmoplantar pitting, intracranial calcs, rib anomalies

Aetiology

Bazex Syndrome

Features:

   -follicular atrophoderma : “ice pick hands”

   -local anhydrosis

   -multiple BCCs

Hx of previous non-melanoma skin Ca

Types of BCC

Nodular-ulcerative

• Most common type
• Raised, round pearly lesion
• As it enlarges : telangiectasia  and central ulceration
• Mainly on face

Cystic

• Uncommon variant of nodular
• Polypoid appearance
• Typically blue-grey cyst

Pigmented

• Brown - black macules in some  areas
• Difficult to distinguish from MM

Sclerosing

• White-yellow, waxy sclerotic  plaque
• Increased collagen deposit  from fibroblasts- thus  resembling a scar
• Margins are difficult to see

Superficial

• Erythematous patch or plaque
• Multicentric

-normal skin interspersed with  malignant patches

Investigations

Biopsy

• Punch
• Shave
• Incisional
• Excisional
• Deep-wedge

Imaging- Not required as very little risk of  metastasis < 0.01%

Treatment

Medical

5-FU cream (Efudex)

   -T bd x 2/52

   -cure in 93% in some trials

   -surgery is preferred

Surgery

Excision

   -direct closure

   -local flap

   -FTSG ie PAWG (Wolf)

Mohs Micrographically  controlled surgery

Mohs Surgery

Tumour excised and 1mm of  surrounding tissue is examined  under microscope

Additional pieces of tumour are  removed in the persisting area

Highest cure rate: 99%

Time consuming, LA top ups  required

Recurrence

Risk factors:

• BCC in NL fold
• Recurrent tumours
• Large tumours >2cm
• Deeply infiltrating tumours
• Young females

SQUAMOUS CELL CARCINOMA

2nd most common skin Ca

Malignant tumour of epidermal  keratinocytes

Can Metastasize

Strongly related to sun  exposure

70% occur on head and neck

Epidemiology

Age > 50

Fitzpatrick I and II

Males

Closer to equator

Aetiology

Sunlight: UVB

Sunbeds

Ionizing Radiation

Arsenic

Xeroderma Pigmentosa

Transplants: greatest in heart

HPV: 5,6,8,11,16

Chronic Ulcers: Marjolins

Burns

Necrobiotic Lipoidica

Hidradenitis

Actinic Keratosis

Bowens Disease

Intra-epidermal form of SCC

SCC in situ: BM not invaded

Well demarcated erythematous  plaque

Irregular border

Surface crusting or scaling

Rx: Photodynamic therapy,  Cryotherapy or topical 5-FU.

SCC Types

Typical: most common

Periungual

Perioral

Marjolins

Anogenital

Verrucous

Typical SCC

A raised, firm, pink-to-flesh –coloured keratotic papule or plaque arising on sun-exposed skin

70% occur on head and neck

Surface changes may include:

• Scaling
• Ulceration
• Crusting

SCC Pathophysiology

malignant tumour of epidermal keratinocytes

De novo or from actinic keratoses

Capable of:

Local infiltration

Spread to regional nodes

Distant mets

Investigations

• Biopsy
• Incisional
• Excisional
• Punch- Must reach level of mid dermis  to see if invasion has occurred

If a patient has  lymphadenopathy:

• Imaging studies: CT
• LN biopsy or FNA
• May require lympadenectomy  of the draining basin

Staging: AJCC

Use TNM guidelines

Most SCC are not metastatic at  time of presentation

Staging: AJCC

Classification of primary tumour:

T0: no evidence of primary

Tis: Ca in situ

T1: <2cm in greatest diameter

T2: 2-5cm in greatest diameter

T3: >5cm in greatest diameter

T4: deep invasion; bone,cartilage, muscle

Medical Care

Topical therapy

• For premalignant and in-situ  lesions
• Efudex (5 FU)

Topical immune response modifier

• enhances cell-mediated immune responses via the induction of proinflammatory cytokines
• e.g. imidazoquinoline (Imiquimod)

Radiotherapy

Indications:

   -patients refusing/not fit for  surgery

   -metastatic disease

Radiotherapy problems:

• Expensive and time consuming
• Irritation at site: erythema, erosions
• Pain: requiring narcotic analgesia
• Poor long term cosmesis: cutaneous atrophy, dyspigmentation, telangiectasia
• Increased risk of further cutaneous malignancy

Surgery

Cryotherapy

• Liquid nitrogen
• For selective SCCs: AKs or Cis
• Complications:
  • transient pain
  • oedema
  • blistering

Electrodessication and  Curettage

• Indications; AK and Cis
• Tumour margins are delineated  with a curette and scraped out:  tumour is far more friable than  normal tissue
• Main disadvantage is loss of  margin
• Cure rates of 96-99% have  been quoted
• Surgery

Excision with conventional  margins

• 4mm margin for low risk  lesions:<2cm, well differentiated,  without fat invasion
• 6mm margin for higher risk  lesions:>2cm, fat invasion, high risk  areas- central face, ears,  genitalia

Mohs Micrographic Surgery

• Excellent option if tissue  preservation is required
• Almost 100% of histologic  margin is examined (compared  to 1% in conventional excision)
• Best cure rates for SCC (94- 99%)
• Local recurrences are fewer

Chemotherapy

Useful for metastatic disease

Capecitabine (Xeloda) ang IFN alpha

Prognosis

Variable:

Tumor- and patient-related risk factors associated with higher rates of recurrence and metastasis are as follows:

Tumor-related factors in high-risk SCC:

• Location: lips, ears, scar
• Tumour size > 2cm
• Poorly diff tumour
• Recurrent tumour
• Perineural involvement

Patient-related factors in high-risk SCC

• Organ transplant recipient
• Haematological malignancy ie CLL
• Chronic immunosuppression
• HIV infection

Prognosis: Overall

• The 3-year disease-specific survival rate is 85%
• Almost 100% if none of previous risk factors
• 70% if 1 risk factor present

The Future?

NSAIDS:

• May protect against SCC  development
• COX 2 often overexpressed in  SCC
• Studies are ongoing

MALIGNANT MELANOMA

A malignancy of pigment  producing melanocytes

Predominantly skin

Also: eyes, ears, GI tract, and  oral and genital mucous  membranes

Accounts for 4% of skin  cancers

Responsible for 74% of all skin  cancer deaths

Frequency

6th  most common cancer in U.S.

1 in 60 lifetime risk of  developing melanoma in  Caucasians

Highest incidence in Australia  and NZ

Incidence increasing worldwide.

Epidemiology

Primarily disease of whites

Whites: African-Americans  =  20:1

MR far higher in darker skin  types

Incidence greatest in females

Mortality highest in males

Median age at Dx = 53

Aetiology/Risk factors

Changing mole

Atypical naevus

Large numbers of common naevi >100

Naevus >20cm

Previous melanoma

Sun exposure

1st degree relative

BCC/SCC

Male

>50

XP

Fitzpatrick I and II

Immunosuppression

Pathophysiology

Tumour progression: 5 stages

Benign melanocytic naevus

Dysplastic naevus: cytolological  atypia

Primary MM: radial growth  phase

Primary MM: vertical growth  phase

Metastatic MM

Classification

Superficial Spreading  Melanoma

• Most common, accounts for  70%
• Usually > 6mm in diameter
• Occurs most commonly:
  • On trunk in men
  • On legs in women

• Irregular, asymmetric borders  are characteristic
• Histologically, characterized by  “buckshot scatter “(pagetoid) of  atypical melanocytes within the  epidermis

Nodular Melanoma

• Second most common : 25%
• Legs and trunk are most  common sites
• Raised dark brown-black  papule or nodule
• Usually lacks the ABCDE  warning signs
• Lacks radial growth phase

Lentigo Maligna  Melanoma

• Accounts for 4-10%
• Most common on head, neck  and arms
• Precursor lesion = lentigo  maligna
  • Usually present for 10-15yrs
  • Dark brown macule or patch
• Dermal invasion characterized  by raised blue-black lesions  within precursor
• In Australia
  • More common in men on RHS
  • More common in women on  LHS

Acral Lentiginous  Melanoma

• Accounts for 2-4%
• Accounts for 55% in dark skinned individuals
• Usually occurs in glabrous skin or beneath the nail plate (subungual variant)
• Pigment spread to the proximal or lateral nail folds is termed the Hutchinson sign
• Characteristic features:
  • Irregular pigmentation
  • Large size > 3cm
  • Plantar location

Amelanotic Melanoma

• Non pigmented
• Pink or flesh coloured – often  mimicking BCC or SCC

Rare Sub-Types

• Desmoplastic Melanoma
• Mucosal Melanoma
• Malignant Blue Naevus
• Melanoma of Soft Parts (clear  cell sarcoma)

Assessment

History

Exam

• Inspection alone can diagnose  65%
• Nodes: axillary, cervical and  groin

MacKies 7 point checklist

• Major (2 points each)
  • Change in size
  • Irregular pigmentation
  • Irregular outline
  • Diameter > 6mm
• Minor (1 point each)
  • Inflammation
  • Oozing
  • Itch or altered sensation
• Needs further evaluation in  presence of one major or if  score = 3

American ABCDE

• A: asymmetry
• B: border is irregular
• C: colour variation
• D: diameter >6mm
• E: examine other lesions

Biopsy

• Types
  • Incisional
  • Excisional
  • Punch
• NB not shave
• Information gained from biopsy:
  • Tumour depth
  • Anatomical level
  • Ulceration
  • Presence of mitoses
  • LVI
  • Host response (tumour infiltrating lymphocytes)
  • Regression
  • Immunohistochemical staining  for lineage: (S-100) or for  proliferation markers (Ki67)

• Excisional biopsy
  • 1-3mm of normal skin should  be removed with the lesion as  more than this could disrupt  lymphatic drainage and  compromise subsequent LN  mapping

Clarkes Level

Classifies level of invasion

• Level 1: only epidermis  involved
• Level 2: invades part of  papillary dermis
• Level 3: invasion fills papillary  dermis
• Level 4: invades reticular  dermis
• Level 5: invades subcutaneous  tissue

Breslows Thickness

• Most important histological  determinant of prognosis
• Measured vertically in mm
  • From top of granular layer  (base of superficial ulceration)
  • To deepest point of tumour  invasion

                                               5yr  survival

0.76mm – 1.5mm                    80%

1.5mm – 4mm                         65%

>/= 4mm                                  35%

• Gives better indication of  prognosis: As depth (Clarkes) of papillary  and reticular dermis vary  throughout the body

Staging

AJCC- Incorporates TNM with Clarkes  and Breslow

Spread

Locally, in LN basins or distally:

• Remote skin
• Remote nodes
• Viscera
• Skeleton
• CNS

Surgery

Excision margins;

• 0.5 cm for melanoma in situ
• 1cm with Breslow thickness  <2mm
• 2cm with Breslow thickness >/=  2mm

Melanomas near vital structures  may require a reduced margin

Aggressive histological features  may necessitate a wider margin

Mohs surgery may have certain  "niche" indications- MM of face,  neck or hands

Sentinel Node Mapping

• Growing in popularity
• Isosulfan blue dye and  lymphoscintigraphy
• Is it as useful as mapping in  breast Ca?
• Sentinel Node Mapping
• Advantages
  • If node –ve, no need for nodal  clearance
  • More thorough pathological  assessment of nodes
  • Psychological relief to patient if  node negative
  • Disadvantages
  • Poor mapping in head and neck  tumours
  • Tumour may skip SN
• Indications: controversial
  • Patients in whom the estimated  risk of LN metastasis is at least  10%
  • Clinically node –ve patients with  tumours >/= 1mm
• Not indicated in tumours  <0.75mm
• 0.76-0.9mm: nebulous area

Elective LN Dissection

• Lymphadenectomy when nodes  are clinically negative
• Rationale is that MM spreads to  nodal basin first – so clearing  the LNs reduces risk of spread
• Controversial: studies have  conflicting results
• Nodal Dissection
• Patients with palpable, clinically  +ve nodes should undergo  complete nodal dissection

Adjuvant Therapy

Interferon  α  2b

• For high risk resected MM:
  • >4mm depth
  • Regional nodal metastases
• Diminishes occurrence of mets
• Prolongs disease free survival

Chemotherapy

For unresectable regional mets  or distant mets

Dacarbazine is the most active  chemotherapeutic agent

Biological Therapy

Interleukin 2

• Useful for metastatic melanoma
• In one study, 7% had complete  response with patients  remaining disease free for up to  8yrs

Monoclonal antibody therapy

• Experimental but very  promising

Vaccines

• Undergoing trials currently

Perfusion Chemo

Isolated Limb Perfusion (ILP)

• Tourniquet applied
• Artery and vein cannulated
• Agent infused and removed  from circulation
• Most effective method of Rx for  local recurrence or in-transit  metastases
• Agents used: TNF α , melphalan

Radiotherapy

For palliation

Specific indications:

• Brain metastases
• Pain with bony mets
• Superficial subcutaneous mets

Prevention

Public education- Australia: “slip, slop, slap”  campaign

Adequate clothing

Avoid UV rays

Systemic carotenoids : retinol- Useful in preventing malignant  transformation