- Additional information
- Reviews (1)
1. The Structure of the skin and wound healing
2. The Management of a wound
3. Reconstruction of large wounds and tissue defects
5. Acute Burns
6. Burn Reconstruction
7. Pressure Sores
8. Skin Lesions
9. Cranio-Facial Surgery
10. Reconstruction of Individual Facial Structures
Plastic surgery is a specialised branch of surgery devoted to the treatment of deformities of the face and other areas of the body and hands. Plastic surgery is mainly concerned with the skin and is largely concerned with form, as implied in the term Plastic. A large part of the specialty is involved with the restoration of function but the concomitant cosmetic appearance must always be taken into account. This booklet describes some of the basic techniques used to repair damaged or absent tissue and shows where these principals are used in situations where the Plastic Surgeon is required.
Prof LA Chait MBBCh (Rand), FRCS (Edin), FCS (PLAST) SA Consultant Surgeon to the Plastic Surgery Department Witwatersrand University and The Johannesburg Group of Teaching Hospitals PARKLANE CLINIC JOHANNESBURG
A major factor in determining the rate of healing is the initial care of the wound. Accurate assessment of the injury avoiding the factors that cause delayed wound healing and early meticulous closure will reduce the deformity and increase the functional results. This evaluation will include the type of injury, the amount of tissue that has been lost and the extent of the injury to deeper structures. Treatment of the wound begins after the patient is evaluated and stabilised. After all dead material has been removed and haemostasis has been obtained the injury pattern and tissue deficit are assessed before the reconstructive technique can be selected. The steps involved are as follows: Initially haemostasis must be secured. The wound can then be gently irrigated with a physiological solution such as normal saline.When the wound is cleaned the viability of the tissues at the wound margins can be assessed. Clean lacerations have minimal surrounding tissue injury and in general can be irrigated and sutured directly. Contused contaminated wounds have a crush component of the surrounding tissue. In these crush contaminated wounds areas of tissue injury and devitalisation will require removal before closure can be attempted. In these cases delayed closure or even use of skin grafts or flaps to resurface the injured area may be required. Types of Wounds and their treatment Different wounds have specific causes and treatment guidelines. Lacerations Lacerations consist of cut or torn tissue. The treatment includes the gentle handling of tissues, wounds should be cleaned of blood clots and foreign material and irrigated with a physiological solution. Once cleaned the lacerations are closed with a traumatic suture technique. Types of suturing which can be used are shown in figures. (Fig 8). Careful closure of the wound edges will give the best scars. Sterile dressings and immobilisation of the affected part will help with healing. (Fig 9). Fig 9. Good scar following management of a wound with sutures Abrasions These are injuries in which the superficial skin layer is removed and may be of variable depth. Initially the abrasion should be gently cleaned of any foreign material and then cared for by dressings that will keep it clean and moist. With the use of a topical anti-bioticointments surgery is often not needed. Avulsions Avulsions are injuries in which the tissue is torn off either partially or totally. In a partial avulsion the tissue is elevated but still attached to the body. If the raised portion is still viable it can be cleaned, irrigated and reattached in its anatomical position. If the tissue is not viable but is still attached the best approach is usually to excise the tissue and use an alternative form of closure, e.g. a skin graft, local flap which will be discussed later. Major avulsions or amputations of extremities such as fingers, ears, nose etc can sometimes be replanted using micro-vascular surgery. In these cases the amputated part should be preserved on ice and referred to a re-plant team for assessment. (Fig 10a&b) Fig 10 a&b.Microvascular replant of amputated hand The Contaminated Wound This is a wound that has been exposed to bacteria from the body or the local environment. The management of acute significantly contaminated wounds consists of debridement, irrigation and healing by secondary or tertiary intention. Occasionally this type of wound can be closed directly once it is cleaned provided there is enough available surrounding tissue present. This must be done cautiously and depends on the location and degree of contamination. Deep sutures should be kept to a minimum. If direct closure is not possible a skin graft or flap may be required. Bites from animals and humans are major problems because they are heavily contaminated with bacteria. Dog bites if handled appropriately can be closed and healed without infection. Due to the much heavier bacterial contamination however, human bites should be irrigated, debrided and left open, anti biotics should be instituted and healing should be either with secondary or tertiary intention. The Chronic Wound A chronic wound is defined as a wound that has not healed within 3 months. Chronic wounds often have a significant amount of scar tissue, proteinaceous debris and necrotic tissue that inhibits healing. They are usually contaminated or infected and should be treated with appropriate dressings. As desiccation is a common factor contributing to poor wound healing and poor epithelisation in chronic wounds the dressings should be designed to keep the wound moist. Dressings may also be used to debride, deliver topical antimicrobials, absorb wound exudates or whatever is appropriate for the particular wound. Treatment of local and systemic factors causing impaired wound healing should be seen to and this includes vascular disease, oedema, diabetes, malnutrition and pressure. A wound bed preparation guideline chart is shown on Page 13. Long healing chronic wounds may require cover in the form of a skin graft or a skin flap.