Key notes on plastic surgery/Adrian M. Richards

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1 2 GENERAL PRINCIPLES • This is the only actively proliferating layer of skin. • The stratum germinativum contains melanocytes. 2 Stratum spinosum • The stratum spinosum is also known as the prickle cell layer. • This layer contains large keratinocytes which produce keratin. • The cells within this layer are joined to each other by tonofibrils (prickles). 3 Stratum granulosum • The stratum granulosum contains mature keratinocytes, which possess cytoplasmic granules of keratohyalin. • This layer is called the stratum granulosum because of these granules. • The stratum granulosum is the predominant site of protein synthesis. 4 Stratum lucidum • This is a clear layer. • The stratum lucidum is only present in the thick skin of the palms and feet. 5 Stratum corneum • The stratum corneum contains non-viable keratinized cells. • The thick cells of this layer protect against trauma. • The stratum corneum: • Insulates against fluid loss • Protects against bacterial invasion. • Sebum produced by the sebaceous glands of the stratum corneum is bactericidal to both streptococci and staphylococci. Cellular composition of the epidermis • Keratinocytes are the predominant cell type in the epidermis. • Langerhans cells form part of the immune system and function as antigenpresenting cells. • Merkel cells are mechanoreceptors of neural crest origin. • Melanocytes: • Are neural crest derivatives • Are usually located in the stratum germinativum • Produce melanin, which protects the surrounding skin by absorbing UV light. The dermis • The dermis accounts for 95% of the thickness of the skin. • The papillary dermis is superficial and contains more cells and finer collagen fibres. • The reticular dermis is deeper and contains fewer cells and coarser collagen fibres. The dermis is composed of the following.
Collagen fibres STRUCTURE AND FUNCTION OF THE SKIN 3 • These fibres are produced by fibroblasts. • They are responsible for much of the strength of the skin. • The normal ratio of type 1 to type 3 collagen is 5 : 1. Elastin fibres • These are secreted by fibroblasts. • They are responsible for the elastic recoil of the skin. Ground substance • This consists of the glycosaminoglycans (GAGs), hyaluronic acid, dermatan sulfate and chondroitin sulfate. • GAGs are secreted by fibroblasts and become ground substance when hydrated. Vascular plexus • This separates the denser reticular dermis from the overlying papillary dermis. Skin appendages The skin contains the following appendages. Hair follicles • Each hair is composed of a medulla, cortex and outer cuticle. • The hair follicle consists of an inner root sheath, derived from the epidermis, and an outer root sheath, derived from the dermis. • Several sebaceous glands drain into each follicle. Discharge from these glands is aided by the contraction of erector pili muscles. • Velus hairs are fine and downy. • Terminal hairs are coarse. • Hairs are in either the telogen or the anogen phase. • 75% of hairs are in the anogen (growth) phase at any one time. • The remaining 25% of hairs are in the telogen (resting) phase. Eccrine glands • These sweat glands secrete an odourless hypotonic fluid. • They are present in all sites of the body. • Eccrine glands occur more frequently in the eyelids, palms, feet and axilla. Apocrine glands • These are located in the axilla and groin. • They emit a thicker secretion than eccrine glands. • They are responsible for body odour. • Hidradenitis suppurativa is an infection of the apocrine glands. Sebaceous glands • These are holocrine glands that usually drain into the pilosebaceous unit. 1
Page 1: KEY NOTES ON Plastic Surgery ADRIAN
Page 4 and 5: © 2002 by Blackwell Science Ltd a
Page 7 and 8: Foreword I am particularly critical
Page 9 and 10: Abbreviations ABPI ankle brachial p
Page 11 and 12: ABBREVIATIONS ix LME line of maximu
Page 13: 1 General principles Structure and
Page 17 and 18: BLOOD SUPPLY TO THE SKIN 5 Vascular
Page 19 and 20: Neural innervation BLOOD SUPPLY TO
Page 21 and 22: CLASSIFICATION OF FLAPS 9 Circulati
Page 23 and 24: CLASSIFICATION OF FLAPS 11 • Exam
Page 25 and 26: GEOMETRY OF LOCAL FLAPS 13 • Borg
Page 27 and 28: The five-flap plasty GEOMETRY OF LO
Page 29 and 30: V-Y GEOMETRY OF LOCAL FLAPS 17 •
Page 31 and 32: The rhomboid flap The rhomboid flap
Page 33 and 34: WOUND HEALING AND SKIN GRAFTS 21 Wo
Page 35 and 36: Collagen WOUND HEALING AND SKIN GRA
Page 37 and 38: WOUND HEALING AND SKIN GRAFTS 25
Page 39 and 40: WOUND HEALING AND SKIN GRAFTS 27
Page 41 and 42: • Cortical bone consists of: BONE
Page 43 and 44: Intrinsic graft factors NERVE HEALI
Page 45 and 46: • First-degree injury NERVE HEALI
Page 47 and 48: TENDON HEALING 35 • Graft lengths
Page 49 and 50: Inflammation TENDON HEALING 37 •
Page 51 and 52: Active flexion • This results in
Page 53 and 54: ALLOPLASTIC IMPLANTATION 41 • Dis
Page 55 and 56: ALLOPLASTIC IMPLANTATION 43 • It
Page 57 and 58: Methylmethacrylate ALLOPLASTIC IMPL
Page 59 and 60: SUTURES AND SUTURING 47 • They ar
Page 61 and 62: Intradermal skin suturing SUTURES A
Page 63 and 64: Polydioxanone TISSUE EXPANSION 51
Page 65 and 66:
• In the vicinity of an immature
Page 67 and 68:
FURTHER READING 55 Jackson IT. Loca
Page 69 and 70:
Actinic keratosis BENIGN NON- PIGME
Page 71 and 72:
BENIGN NON- PIGMENTED SKIN LESIONS
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BENIGN PIGMENTED SKIN LESIONS 61
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Junctional naevi BENIGN PIGMENTED S
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Naevus of Ito MALIGNANT NON- PIGMEN
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• Infiltrative MALIGNANT NON- PIG
Page 81 and 82:
MALIGNANT MELANOMA 69 • These tum
Page 83 and 84:
MALIGNANT MELANOMA 71 Clark’s lev
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MALIGNANT MELANOMA 73 • Excision
Page 87 and 88:
Koops et al. • J Clin Oncol 1998;
Page 89 and 90:
Deep sarcomas Presentation SARCOMA
Page 91 and 92:
3 The head and neck Embryology, 79
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CRANIOFACIAL SURGERY 81 • The lat
Page 95 and 96:
Cleft 4 • This is also known as t
Page 97 and 98:
CRANIOFACIAL SURGERY 85 • The loc
Page 99 and 100:
Apert’s syndrome CRANIOFACIAL SUR
Page 101 and 102:
CRANIOFACIAL SURGERY 89 • Median
Page 103 and 104:
Orbit CRANIOFACIAL SURGERY 91 • P
Page 105 and 106:
3 Free-tissue transfer 4 Osteotomie
Page 107 and 108:
CLEFT LIP 95 • Failure of mesench
Page 109 and 110:
Schweckendiek technique CLEFT LIP 9
Page 111 and 112:
• Advantages: • The technique i
Page 113 and 114:
CLEFT PALATE 101 • The muscle bun
Page 115 and 116:
• A: abnormal face • T: thymic
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CLEFT PALATE 105 • The muscle sli
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HEAD AND NECK CANCER 107 • N3: a
Page 121 and 122:
Comprehensive neck dissection HEAD
Page 123 and 124:
• Of these, the complications may
Page 125 and 126:
• Larynx • Trachea and upper br
Page 127 and 128:
Mucoepidermoid carcinoma HEAD AND N
Page 129 and 130:
HEAD AND NECK CANCER 117 • The co
Page 131 and 132:
Treatment HEAD AND NECK CANCER 119
Page 133 and 134:
HEAD AND NECK CANCER 121 • Bony r
Page 135 and 136:
FACIAL FRACTURES AND SOFT- TISSUE I
Page 137 and 138:
Page 139 and 140:
• Malocclusion FACIAL FRACTURES A
Page 141 and 142:
Page 143 and 144:
• CT scanning FACIAL FRACTURES AN
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
OCULOPLASTIC SURGERY 139 • The up
Page 153 and 154:
OCULOPLASTIC SURGERY 141 Alternativ
Page 155 and 156:
OCULOPLASTIC SURGERY 143 Excision o
Page 157 and 158:
• They occur in: • Patients wit
Page 159 and 160:
5 Cervical branch FACIAL PALSY 147
Page 161 and 162:
FACIAL PALSY 149 • A strip of spe
Page 163 and 164:
• Nerve transfers FACIAL PALSY 15
Page 165 and 166:
ABNORMALITIES OF THE EAR 153 • Th
Page 167 and 168:
ABNORMALITIES OF THE EAR 155 • Th
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ABNORMALITIES OF THE EAR 157 Specif
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VASCULAR ABNORMALITIES 159 • The
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Non-invasive treatments VASCULAR AB
Page 175 and 176:
VASCULAR ABNORMALITIES 163 • They
Page 177 and 178:
• It is associated with: • Meni
Page 179 and 180:
FURTHER READING 167 Spauwen PH, Goo
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BREAST REDUCTION 169 • The anteri
Page 183 and 184:
• This technique has the followin
Page 185 and 186:
• Herniation of the NAC • Stret
Page 187 and 188:
Excisional techniques BREAST AUGMEN
Page 189 and 190:
BREAST AUGMENTATION 177 • This te
Page 191 and 192:
• Non-invasive tumours • Ductal
Page 193 and 194:
Surgical treatment BREAST CANCER 18
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BREAST RECONSTRUCTION 183 • Lesio
Page 197 and 198:
BREAST RECONSTRUCTION 185 • Varia
Page 199 and 200:
Superior gluteal perforator flaps B
Page 201 and 202:
CHEST WALL RECONSTRUCTING 189 • E
Page 203 and 204:
FURTHER READING 191 Pectoralis majo
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Embryology 5 The upper limb Embryol
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1 Failure of formation • Transver
Page 209 and 210:
CONGENITAL DEFORMITIES 197 Classifi
Page 211 and 212:
CONGENITAL DEFORMITIES 199 • Ulna
Page 213 and 214:
Camptodactyly CONGENITAL DEFORMITIE
Page 215 and 216:
CONGENITAL DEFORMITIES 203 • Clin
Page 217 and 218:
• Type 2: duplicated distal phala
Page 219 and 220:
• Microvascular free joint or bon
Page 221 and 222:
• Abnormalities of the scalene mu
Page 223 and 224:
NERVE COMPRESSION 211 • Tinel’s
Page 225 and 226:
NERVE COMPRESSION 213 1 Neurolysis
Page 227 and 228:
• Sensory signs include: • A po
Page 229 and 230:
TENDON TRANSFERS 217 Symptoms Pain
Page 231 and 232:
• The ideal tension varies betwee
Page 233 and 234:
DUPUYTREN’ S DISEASE 221 • ECRB
Page 235 and 236:
3 The lateral digital sheet 4 Grays
Page 237 and 238:
Fat • Lipoma • Angiolipoma •
Page 239 and 240:
Carpometacarpal boss TUMOURS 227
Page 241 and 242:
TUMOURS 229 Giant cell tumours of t
Page 243 and 244:
• Pseudogout • Systemic lupus e
Page 245 and 246:
1 Proliferationasynovial swelling a
Page 247 and 248:
• Findings on examination include
Page 249 and 250:
ARTHRITIS 237 • The resultant imb
Page 251 and 252:
Chronic tophaceous gout HAND INFECT
Page 253 and 254:
4 Pain on passive extension. HAND I
Page 255 and 256:
6 The lower limb Leg ulcers, 243 Lo
Page 257 and 258:
• It is normally in the region of
Page 259 and 260:
Mangled extremity severity score LO
Page 261 and 262:
LOWER- LIMB TRAUMA 249 4 This fasci
Page 263 and 264:
The lymphatic system Anatomy LYMPHO
Page 265 and 266:
2Infection LYMPHOEDEMA 253 • The
Page 267 and 268:
LYMPHOEDEMA 255 • Phase twoaconse
Page 269 and 270:
4 Heel 5 Malleolus 6 Occiput. PRESS
Page 271 and 272:
• Pressure dispersion PRESSURE SO
Page 273 and 274:
FURTHER READING 261 Eshima I, Mathe
Page 275 and 276:
Embryology of the sexual organs Int
Page 277 and 278:
HYPOSPADIAS 265 • The tunica albu
Page 279 and 280:
HYPOSPADIAS 267 The Mathieu procedu
Page 281 and 282:
• The dorsal surface of the penis
Page 283 and 284:
VAGINAL AGENESIS 271 • Patients w
Page 285 and 286:
Thermal burns 8 Burns Thermal burns
Page 287 and 288:
• A high respiratory rate • Con
Page 289 and 290:
THERMAL BURNS 277 • Adults with b
Page 291 and 292:
THERMAL BURNS 279 • Full-thicknes
Page 293 and 294:
6Disability CHEMICAL BURNS 281 •
Page 295 and 296:
FURTHER READING 283 • Lightning s
Page 297 and 298:
PATHOPHYSIOLOGY OF VESSEL HEALING 2
Page 299 and 300:
TECHNIQUE 287 Equipment Successful
Page 301 and 302:
POST- OPERATIVE MANAGEMENT 289 Post
Page 303 and 304:
FURTHER READING 291 Further reading
Page 305 and 306:
BLEPHAROPLASTY 293 • This is asse
Page 307 and 308:
BLEPHAROPLASTY 295 • The fat pads
Page 309 and 310:
The greater auricular nerve • Thi
Page 311 and 312:
Rhinoplasty Anatomy Skeleton The sk
Page 313 and 314:
Techniques RHINOPLASTY 301 • Some
Page 315 and 316:
• Sutures can be placed: LIPOSUCT
Page 317:
FURTHER READING 305 Hamra ST. The d
Page 320 and 321:
308 INDEX breast (cont.) screening
Page 322 and 323:
310 INDEX interpolation flaps—19
Page 324 and 325:
312 INDEX skin grafts—26-8 follow
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