PLASTIC & RECONSTRUCTIVE SURGERY

Question 1

Basic technique in plastic surgery?

Answer 1

Direct repair —> which involves direct sutures meaning no reconstruction is necessary. Primary intention closure involves closing a wound by bringing the edges together while secondary intention closure occurs when the wound is left open to heal naturally due to extensive tissue loss.

Grafts —> are a portion of tissue transferred from one area to another, and their purpose is to restore or replace lost or damaged tissue. They can be classifies based on origin (autograft, isograft, allograft or xenograft), by tissue type (skin, cartilage, bone), by complexity (single tissue type or multiple tissue types). The process of graft healing is long (adhesion, inhibition, revascularization and stabilization).

Flaps —> piece of tissue that is transferred from a site to another while maintaining its own blood supply. Can be classified based on composition (cutaneous, fascia cutaneous, myocutaneos, muscular), donor site (rotation flaps which pivot, advancement flaps which move straight forward and transposition flaps shifter over)

Implants —> artificial materials used in reconstructive procedures to restore or improve morphology. Types include breast implants, bone implants, tissue expanders.

Question 2

Empty point and flap length?

Answer 2

Empty point refers to the area at the distal end of the flap where blood supply might be insufficient, causing tissue death. The goal is to avoid an empty point that’s too large, as it indicates insufficient blood supply to the end of the flap. The longer the flap, the harder it is to keep the entire flap viable.

• Type 1: this is a flap with a single blood supply. There’s only one main vessel.
• Type 2: this has one main vessel with one secondary vessel supplying the flap.
• Type 3: this has two main vessels, and you know exactly where they come from, like with the rectus abdominis or pectoralis minor muscle flaps.
• Type 4: these have multiple segmental vessels supplying the flap. • Type 5: these have one main vessel with multiple segmental vessels branching out.

Question 3

Breast reconstruction?

Answer 3

Breast reconstruction can be:
• Immediate reconstruction occurs simultaneously with the mastectomy, often preferred by patients as it reduces the need for multiple surgeries.
• Delayed reconstruction, on the other hand, is performed after the mastectomy, allowing time for other treatments or recovery before addressing reconstruction.

The extent of breast tissue removed is categorized into levels:
• Level 1: removal of less than 20% of the breast tissue. This is often managed with minor volume displacement techniques.
• Level 2: removal of 20–50% of the breast tissue. Reconstruction may involve reshaping remaining tissue or using flaps.
• Level 3: removal of more than 50% of the breast tissue. Extensive reconstruction is required, often necessitating local or distant flaps to restore volume.

Question 4

Ulcers?

Answer 4

A skin lesion as a result of tissue loss that does not heal spontaneously within 40 days. Can be vascular or non vascular.

Vascular ulcers are chronic wounds caused by poor blood circulation. Grafts can accelerate and improve healing.

Pressure ulcers also known as bedsore are due to the skin and underlying tissue being exposed to prolonged pressure. They are staged from stage I (non blanchable erythema), stage II (partial thickness skin loss), stage III (full thickness skin loss), stage IV (full thickness tissue loss). Can be treated with myocutaneous or fasciocutaneous flaps.

Neoplastic ulcers caused by presence of malignant tumors that infiltrate and erode skin. Typically occur in areas where the tumor is close to the skin like on face, breast, neck and extremities.

Post traumatic ulcer due to trauma to skin and underlying tissue.

Question 5

Burns?

Answer 5

A burn is damage to the skin and/or underlying tissue caused by heat, chemicals, electricity, sunlight or radiation.

Extension —> palmar method (palm of hand represents 1% of TBSA) or rule of nine (body is divided in 9 regions accounting for 9% or multiples of 9%).
To define a 3rd degree burn in adults must be more than 20% in children 10-15%.

Location —> most common locations are face, neck, hands, flexor surfaces, genital area.

Depth —> first grade burns are superficial no blister and no scars. A second degree burn can be partial thickness or deep partial thickness, we have blisters and weeps. Third degree burns are full thickness burns and require skin grafting and will leave scar.
Fourth grade burns involve muscles or bone.

Question 6

Treatment for burns?

Answer 6

In critical burn injuries, we have to use a formula in order to calculate the amount of fluid required to rehydrate the patient and to prevent further damage (fluid resuscitation).
It is called Parkland formula: Total Crystalloid Fluid in the first 2 hours = 4ml x %TBSA (total body surface area burned) x body weight in kg.

This formula is not used in 1st degree burns, as they do not cause significant haemodynamic shifts. It is applicable when:
• Burns involve more than 20% of the TBSA in adults
• Burns involve more than 10% of the TBSA in children or in elderly
• There are deep partial thickness burns (2nd degree) or full thickness burns (4th degree)