Plastic Surgery - RCP London

Plastic SurgeryMore than bums and tums

Catherine Sedgwick, St George’s University Hospital NHS Foundation Trust

Sylwia Osinska, St George’s University Hospital NHS Foundation Trust

What is Plastic Surgery?

British Association of Plastic, Reconstructive and Aesthetic Surgeons:

“Plastic surgery has two main components: reconstructive plasticsurgery which is all about restoring appearance and function to thehuman body after illness or accident and aesthetic (often called“cosmetic”) plastic surgery which is done to change the appearancefrom choice.”

Plasticus (Latin)

Plastikos (Greek)

A little bit of history3000 BC - 500 AD

Ancient Egypt: Manipulation of nose fracturesIndia: Skin grafts and flapsAncient Greece + Roman Empire: Eyelids - lagophthalmos/ectropion

500 - 1450Arabic/Ottoman: Gynaecomastia; Eyelids - entropion, ectropion

1450 - 1750Europe: Nose/lip/ear reconstruction; pedicled flaps, replacement prosthetics

First Plastic Surgery text book

• By Gasparo (or Gaspare) Tagliacozzi - Houghton Library, Public Domain, https://commons.wikimedia.org/w/index.php?curid=34551848

1750 - 1914

Plastic Surgery in Europe

Indian forehead flap

Anaesthetic agents

Ether; chloroform; cocaine; antiseptic surgery

1914 - 1945

1915 Gillies: Maxiofacial trauma

1938 Airmen and the Guineapig Club

1945 - present

‘Back to basics’ - anatomy/physiology

Microsurgery

1966 Chen - second toe to thumb transfer

1973 Free flaps

Role of Physician Associate within Plastics

Work 37.5 hours a week over 4 week days with 2 week rolling rota.

Week A: Ward cover. Daily MDT handover; ward round; discharge letters; ward related jobs

Week B: Theatre - assisting with operations + documentation; outpatient clinics e.g. hand trauma triage, plastic dressings; assisting on call SHO, 1 day ward cover

Provide link as permanent member of department to staff on surgical rotation

Plastic Surgery department covers:

Acute and elective hand surgery

Melanoma and non-Melanoma skin cancer

Breast reconstruction

Head and neck reconstruction for malignancy

Trauma

Plastic surgery department works with:

Orthopaedics, ENT, ophthalmology, dermatology, oncology, radiotherapy, general surgery, care of the elderly, paediatrics

Common scenarios

Cat bites and a case history

Dog bites

Human fight bites and a case history

Pictures tell 1000 stories - a study on an avocado and more

Pasteurella multocida

50% cat bites become infected - polymicrobial

Bite weaker than a dog bite

Fine, sharp teeth- pierce more deeply than other animal bite

Small puncture wounds seal quickly trapping infection

Abscess formation. Osteomyelitis.

Damage all structures

Exploration and debridement

Course of antibiotics Co-Amoxiclav for 7 days or Doxycycline plus Metronidazole for penicillin allergic

55 y. o female, normally fit and well

5 day history of a cat bite to the right wrist – patient’s cat, bitten in the UK

Presented with ascending lymphangitis extending to the elbow

O/E

Visible 5 x puncture wounds to the volar right wrist discharging pus

Wrist red, hot, swollen

X-ray

Swab sent

Local anaesthetic, debrided and washed dressed: inadine, gauze, wool and crepe

Elevate in Bradford sling

Tetanus

Patient admitted for a following day washout in the theatre

IV antibiotics

Treated as septic joint

Further washout in the theatre

Discharged with 6 weeks course of antibiotics following Micro advice

Dog bite - male aged 27, walking in the park. Attempted to separate his dog from another which was attacking it. Bitten on forearm

Attended A&E with avulsion injury, swelling and pain

What next?

History, thorough examination

X-ray

Tetanus cover

Local anaesthetic, debridement and washout

Dress wound – inadine, gauze, wool, crepe

Elevate

Antibiotics - co-amoxiclav 7/7 or metronidazole plus doxycycline for penicillin allergic

Discussion with senior about damage to underlying structures

Theatre for surgical exploration under anaesthetic +/-repair

Learning points:

Dogs can exert significant amount of pressure with their jaws:

• Devitalise tissues• Crush injuries• Laceration, puncture and avulsion injuries

3-18% dog bites become infected - polymicrobial

Pasteurella, Streptococcus, Staphylococcus - most common

Fight bite - human bite

Commonly due to being attacked or fighting under influence of drugs/alcohol

Otherwise poor history

Open wound over the metacarpal joints

Usually presents few days post fight bite with swollen and painful metacarpal joint

Discharging wound

Superficial or into the joint capsule

O/E

Usually one wound, approximately 1 cm wide

Over the metacarpals

Isolated red, hot, swollen joint

Affecting range of movement in the digit

Pus

Treatment

Treatment depends on how soon patient presents to A&E

First of all in all cases:

X-ray - foreign bodies, fracture

Send swab

Explore and debride the wound and wash with saline

Treatment with Co-amoxiclav (if penicillin allergy Metronidazole-Clarithromycin)

On presentation:

HIV status, start prophylaxis Hep B and C Tetanus Debride and wash with large

amount of saline, admit on the basis of clinical picture

Normally fit and well 35 y.o presented to A&E 7 days post fight bite

Reports being attacked on the street by unknown individual

Visible swelling, redness and discharge over the wound 3rd metacarpal joint

On admission debrided and washed with 2 L of saline, admitted

Following day EUA, findings 40% of EDP – repaired

Discharged home with 1 week Co-amoxiclav splint , f/u in hand dressing clinic in 1 week

3 days post discharge re-presented to A&E with pain and swelling

Self employed electrician, homeless

Removed splint post discharge, started to work

100% rupture of the EDP repair

Now septic joint with discharging pus, open wound

Underwent two more washouts and debridement

Unable to oppose the edges - flap

2 weeks stay at the hospital for IV antibiotics

Antibiotics are given on Micro advice

Discharged with 4 more weeks of oral antibiotics

Splint

Hand therapy

Fingers and hands

Paronychia

Paronychia - female aged 34 years. Worsening erythema, swelling and pain of right middle fingertip. Had manicure 4 days ago

Attended A&E with purulent discharge from finger

What next?

History, thorough examination

X-ray

Swab of pus only

Admit for incision and drainage plus removal of nail under local anaesthetic and ring block

Dress wound – silicone, gauze, adaptic, elastoplast

Elevate

Antibiotics - Flucloxacillin or clarithromycin 7/7

Review in 24 hours

Learning points:

Staphylococcus aureus most common causation

Nails take between 4-6 months to grow

Risk of osteomyelitis/septic arthritis without aggressive treatment

Check out your manicure salon

From the collection of Dr N.J. Jellineck and Professor C.R. Daniel III

https://bestpractice.bmj.com/topics/en-us/350/images-and-videos

Theatre time: Fingers and hands

Exploration under anaesthetic, debride, washout + repair

Tendon repairs: extensor pollicus longus

extensor digitorum minimi

extensor digitorum communis

extensor carpi ulnaris and

many other tendons

Thumb repairs: ulnar cruciate ligament

Fractures : many and varied

Dislocations: manipulation under anaesthetic

Terminalisation: crush injury

dry gangrene

Lacerations: glass

machinery

self inflictedMedical illustrations by Lena Lyons MA in consultation with Ivanhoe B Higgins, M.D., and Joseph J. Mandiberg, M.D. 1998, 2000 Wolters Kluwer

Importance of hand therapy

Integral part of Plastic Surgery team

Hand - major area of work

Primary aim of repair - function

Post operatively on ward - patient encouraged to mobilise fingers and hand

Hand therapists manage post-surgery patients in outpatient setting

Fundamental to achieving good results

Aim: Restoration of hand/finger function without pain through active/resistance exercises, stretching, splinting and wound care

Infection - moving in from outside

Skin

Cellulitis

Tendon

Flexor sheath infection

Joint

Septic arthritisBone

Osteomyelitis

CellulitisAcute spreading infection of the skin -erythema, oedema, warmth and tenderness

Regional lymphadenopathy can be present

Why?

Breakage of skin barrier allowing micro-organisms into tissue

Treat

IV antibiotics – Flucloxacillin or Clarithromycin

Mark area of erythema

Elevation

Monitor after 24 hours

Learning point:

Increased likelihood of recurrence due to residual damage to proximal lymphatics

Flexor tendon sheath infectionFinger held in slight flexion

Fusiform swelling

Tenderness along flexor tendon sheath

Pain with passive extension of the digit

Why?

Puncture wound, closed space aggressive bacterial infection

Treat

Emergency surgery

Incision and drainage

Irrigation

IV antibiotics + elevation

Learning points:

Vascular compromise

Rapid loss of function of finger

Septic arthritis Acutely inflamed joint

Hot swollen tender joint with restricted movement

Why?

Prosthetic joint

Pre-existing joint disease – especially RA

IV drug use

Diabetes

Treat

Requires prompt and aggressive treatment

Urgent joint fluid aspiration – synovial fluid microscopy and culture

Empirical IV antibiotics for 2/52 followed by oral antibiotics for 2-4 weeks (once back)

Learning point:

Not usually a Plastics patient:

See, initiate treatment and refer to relevant speciality

OsteomyelitisNon specific pain at wound site, erythema, swelling

Decreased range of movement

Soft tissue surrounding dead, infected, and reactive new bone

Why?

Post trauma or surgery

Open fracture - devitalised bone and soft tissues + delays in providing definitive soft tissue coverage

DM high risk factor

Treat

Thorough surgical debridement of dead tissue/bone and wound irrigation

Muscle-flap/vascularised tissue grafts (fill dead space)

Bone nibbling

6 week antibiotic therapy (OPAT)

Learning points:

High suspicion and prompt treatment necessary

Commonest organism: Staphylococcus aureus

Compartment Syndrome

Haemorrhage within closed compartments; direct trauma to muscle and resulting oedema

The five Ps: pain, paraesthesia, pallor, paralysis, pulselessness

Pain out of proportion to the injury + aggravated by passive stretching of muscle groups within the involved compartment - early sensitive clinical feature

Pressure monitoring: differential pressure within 20-30 mmHg of diastolic pressure - strong indicator for fasciotomy

Early suspicion needs immediate response

Fasciotomy within 6 hours if possible

Plastics involvement – skin grafting post fasciotomy

Complications of unrecognised acute Compartment Syndrome

Muscle scarring, contracture, loss of function

Infection

Permanent nerve damage

Rhabdomyolysis, renal failure

Amputation

Man aged 32 cycling. Hit by car. Rolled over bonnet onto road.

BIBA

No LoC, no open wounds, no fractures

Pain, paraesthesia, rapidly increasing swelling and numbness to left forearm

Theatre for compartment release

Arm elevation

Return to theatre 2 days later for wound closure +/- skin grafting

https://aneskey.com/fasciotomy/ https://images.app.goo.gl/MqUPcYeZYEXY3icQ9

Necrotising Fasciitis

Rare and life threatening bacterial infection

Rapidly progressive inflammatory infection of the fascia with secondary necrosis of subcutaneous tissues

Cellulitis (swiftly expanding) with pain out of all proportion

May present with normal overlying skin - subtle skin changes - leakage of fluid and oedema precede blistering and redness

Underlying induration, greyish discolouration, bullae

Systemic symptoms - hypotension, tachycardia, tachypnoea, nausea, vomiting, delirium

Why?

Chronic skin conditions, lesions, trauma, surgery, IV drug use, varicella, herpes zoster, DM

Treat

Radical debridement of infected tissue

IV antibiotics

Intensive care unit

Learning Points:

Early recognition crucial

Scoring systems – LRINEC; NEWS; SEPSIS 6;

Fournier’s gangrene

Hasham, Matteucci P, Stanley PRW, et al. Necrotising fasciitis. BMJ Apr 9;330(7495);830-3

https://bestpractice.bmj.com/topics/en-gb/821/images-and-videos

Theatre time: Skin

Wide local excisions of

Dysplasic naevus - can run in families. Increased risk of melanoma

Basal cell carcinomas - lateral spread. Bleeding scab ‘not healing’; pink pearly nodules, ulcerated, encrusted, pigmented. Face, neck and ears. Common (>80%)

Squamous cell carcinomas - firm skin tumour. Everted edges with keratotic crust. Actinic keratosis/Bowen’s Disease. Outdoor workers

Malignant melanomas - cancer of pigment cells of skin. ABCDE code. Too much exposure to UV light especially during first 20 years

All excised and followed with

Direct closure - sutures

Split skin graft - allows early detection of recurrence

Full thickness skin graft - small wound site

Local flap - tissue adjacent to the wound, skin subcut tissue + underlying fascia

Regional flap - for small/moderate size defects. Uses tissue with same characteristics as area of defect, with minimal morbidity of donor site

Reconstruction – of the ear

https://doi.org/10.1016/j.jpra.2018.12.006 https://ars.els-cdn.com/content/image/1-s2.0-S2352587818300512-gr1_lrg.jpg

Wound healing - complex

Factors hindering: Nutrition, smoking; infection; foreign body; hypoxia; venous insufficiency; medication; chronic health conditions; immobility; stress; age

https://oaepublishstorage.blob.core.windows.net/f17a320e-cd04-4bd6-8997-d0ed443086ce/1211.fig.1.png

Wound closure - reconstruction pyramid

Skin-muscle free flap - most

complex

Skin-muscle-bone flap

Bone-tendon-nerve flap

Skin-muscle flap

Muscle flap

Skin flap

Skin graft

Linear closure

Secondary healing - least complex

Theatre time: Case study

Adjustment of custom made implant to right buttock and lipofilling to right lateral hip

Donor site liposuction from abdomen

Ewings Sarcoma as child

Atrophy of hip as consequence

Difficulty with underwear/trousers fitting

Breasts

Reconstruction following cancer

Deep inferior epigastric perforator artery running through abdomen.

DIEP flap - fat, skin and blood vessels cut from wall of lower abdomen and moved up to chest to rebuild breast

Silicone implant - problems - capsule formation/non symmetry

Reduction

Mammoplasty – females

BMI </= 26 maintained for at least 12 months

Bra cup size G or more

Gender affirmation

Bilateral mastectomy

Overnight stay in hospital

Chest binder for 6 weeks post op

No heavy lifting

Paediatrics

Lip lacerations

eyebrow lacerations

Nailbed injuries - crush

Sports and finger fractures

Dog bites

Extravasation injuries

Tongue tie - frenotomy (treat when difficulty with suckling, lifting tongue up/side to side, sticking tongue out, may be notched on protusion)

Polydactly + removal of nubbins

Syndactylyhttps://radiopaedia.org/cases/syndactyly-of-the-3rd-and-4th-digits?lang=us

Extravasation injuries

Extravasation - accidental leakage of any fluids or medicines from a vein into the surrounding tissues

Chemotherapy drugs most potent - may cause tissue damage and necrosis

Vesicants - drugs causing pain, inflammation and blistering of the local skin and underlying structures

Irritants - drugs capable of causing inflammation, irritation or pain at site of extravasation but rarely cause tissue breakdown

Non-Vesicants - inert or neutral compounds not causing inflammation or damage. Cause pain at, and around injection site, and along vein

Early symptoms: Oedema + erythema

Later symptoms: Inflammation, induration, blistering

Intervention: Flush out with saline - puncture points and dressing

Elevation of affected area and analgesics

https://images.app.goo.gl/ir2g6xcm9WdvbvkX8

Thank you

Any questions?

References:

Nakhdjevani, A., Baker, R., Ahmadi, H., Plastic Surgery Survival Guide to Trauma

Davidson’s Principles & Practice of Medicine

DermNet NZ

https://portal.e-lfh.org.uk/LearningContent/Launch/331853

British Association of Plastic, Reconstructive and Aesthetic Surgeons 2011

https://www.nhs.uk/news/medical-practice/inaccurate-reporting-of-cat-bite-dangers/

https://vcahospitals.com/know-your-pet/wounds-cat-bite-injuries-to-humans

https://cks.nice.org.uk/bites-human-and-animal

https://bestpractice.bmj.com/topics/en-gb/280/epidemiology

https://cks.nice.org.uk/paronychia-acute

https://cks.nice.org.uk/cellulitis-acute

Image Cellulitis: By James Heilman, MD - File:CellulitisJmh649.JPG, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=56635080

https://www.handsurgeryresource.com/infection-flexor-tendon

Fernández-Calderón M, Casado-Sánchez C, Cabrera-Sánchez E, Casado-Pérez C. Versatilidad de colgajos en hacha en defectos del cuero cabelludo. Actas Dermosifiliogr.2012;103:629-631.

https://bestpractice.bmj.com/topics/en-gb/354?q=Osteomyelitis&c=suggested

https://www.nhs.uk/conditions/necrotising-fasciitis/

https://bestpractice.bmj.com/topics/en-gb/821?q=Necrotising%20fasciitis&c=suggested

https://emedicine.medscape.com/article/2051157-overview

Cone J, Inaba K Lower extremity compartment syndromeTrauma Surgery & Acute Care Open 2017;2:e000094. doi: 10.1136/tsaco-2017-000094

Stone, Christopher. Case Presentations in Plastic Surgery

https://bestpractice.bmj.com/topics/en-gb/502?q=Compartment%20syndrome%20of%20extremities&c=suggested

https://www.bssh.ac.uk/default.aspx

https://bnf.nice.org.uk/treatment-summary/soft-tissue-disorders.html

https://www.england.nhs.uk/midlands/wp-content/uploads/sites/46/2019/05/management-extravasation-of-a-systemic-anti-cancer-therapy-including-cytotoxic-agents.pdf

References

https://cks.nice.org.uk/bites-human-and-animal#!backgroundSub:1

https://emedicine.medscape.com/article/218901-overview#a3

https://www.uptodate.com/contents/human-bites-evaluation-and-management

https://cks.nice.org.uk/bites-human-and-animal#!scenario:1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3122494/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776367/

Images

By Homeguides Getty Images/iStockphoto

By Unknown - https://web.archive.org/web/20060515202557/http://www.nass.usda.gov/fl/apfp.htm (Original link: http://www.nass.usda.gov/fl/apfp.htm), Public Domain, https://commons.wikimedia.org/w/index.php?curid=51323

By Shiretoko-Shari Tourist Association, Attribution, https://commons.wikimedia.org/w/index.php?curid=361

By Beautiful Buildings Pics - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=82566087

By http://www.marines.mil/unit/mcasmiramar/PublishingImages/2005/habitat4148.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=23052387

By KennethHan - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=21925277