Key notes on plastic surgery/Adrian M. Richards

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1 30 GENERAL PRINCIPLES • Avascular necrosis (AVN) • Shortening • Damage to adjacent structures. Bone graft healing Bone grafts heal by the following mechanisms. Incorporation • This is adherence of the graft to the host tissue. • Incorporation is maximized in immobilized, well-vascularized tissue. Osseoconduction • The bone graft acts as a scaffold along which vessels and osteoprogenitor cells travel. • Old bone is absorbed as new is deposited. • This process is also known as creeping substitution. Osseoinduction • This is the differentiation of mesenchymal cells within the local tissue into osteocytes. • Osteoclasts, osteoblasts and osteocytes within the bone graft are not capable of mitosis. • The increased numbers of these cells within the bone graft are derived from the mesenchymal tissue of the recipient site. • Osseoinduction is controlled by bone morphogenic proteins (BMPs). Osteogenesis • This is the formation of new bone by surviving cells within the bone graft. • It is the predominant mechanism by which new bone is formed in vascularized bone grafts. • Osteogenesis does not occur to a significant degree in non-vascularized bone grafts. Survival of bone grafts Factors influencing the survival of bone grafts can be divided into three groups: (i) systemic factors; (ii) intrinsic graft factors; and (iii) factors relating to the placement of the graft. Systemic factors These are similar to those affecting wound healing and include: • Age • Nutrition • Immunosuppression • Drugs • Diabetes • Obesity.
Intrinsic graft factors NERVE HEALING AND NERVE GRAFTS 31 • Bone grafts with intact periosteum undergo less absorption than those stripped of this covering. • Membranous bone undergoes less absorption than endochondral bone when used as an onlay graft in the facial skeleton. Graft placement factors Orthotopic or heterotopic placement • Orthotopicagraft is placed into a position normally occupied by bone. • Heterotopicagraft is placed into a position not normally occupied by bone. • Grafts placed into an orthotopic position are less prone to absorption. Quality of the recipient bed • Radiotherapy, scarring and infection adversely affect graft survival. Graft fixation • Rigidly fixed grafts survive better than those that are mobile. Site of graft placement • Grafts survive better in areas in which bone is normally laid down (depository sites). • These sites include areas such as the zygoma and mandible in the child. Nerve healing and nerve grafts Nerve anatomy and function • Nerve cells (neurons) consist of a cell body from which nerve fibres project. • Efferent nerve fibres are called axons. • Afferent nerve fibres are called dendrites. • The endoneurium surrounds individual nerve fibres or axons. • The perineurium surrounds groups of nerve fibres (fascicles). • The epineurium surrounds a group of fascicles to form a peripheral somatic nerve. • Schwann cells produce a multilaminated myelin sheath in myelinated nerves. • Unmyelinated nerves are surrounded by a double layer of basement membrane. • In myelinated nerves, adjacent Schwann cells abut at the nodes of Ranvier. • Nerve conduction involves the passage of an action potential along a nerve. • In myelinated nerves, this is via saltatory conduction between adjacent nodes of Ranvier. Nerve fibres are subdivided into the following groups. • Group A • Group A-alpha fibres conduct motor and proprioceptive impulses. • Group A-beta fibres transmit pressure and proprioceptive impulses. • Group A-gamma fibres conduct motor impulses to the muscle spindles. • Group A-delta fibres transmit touch, pain and temperature impulses. 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 and 14: 1 General principles Structure and
Page 15 and 16: Collagen fibres STRUCTURE AND FUNCT
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: • Cortical bone consists of: BONE
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
Page 73 and 74: BENIGN PIGMENTED SKIN LESIONS 61
Page 75 and 76: Junctional naevi BENIGN PIGMENTED S
Page 77 and 78: Naevus of Ito MALIGNANT NON- PIGMEN
Page 79 and 80: • Infiltrative MALIGNANT NON- PIG
Page 81 and 82: MALIGNANT MELANOMA 69 • These tum
Page 83 and 84: MALIGNANT MELANOMA 71 Clark’s lev
Page 85 and 86: 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
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Cleft 4 • This is also known as t
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CRANIOFACIAL SURGERY 85 • The loc
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Apert’s syndrome CRANIOFACIAL SUR
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CRANIOFACIAL SURGERY 89 • Median
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Orbit CRANIOFACIAL SURGERY 91 • P
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3 Free-tissue transfer 4 Osteotomie
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CLEFT LIP 95 • Failure of mesench
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Schweckendiek technique CLEFT LIP 9
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• Advantages: • The technique i
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CLEFT PALATE 101 • The muscle bun
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• 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
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Comprehensive neck dissection HEAD
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• Of these, the complications may
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• Larynx • Trachea and upper br
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Mucoepidermoid carcinoma HEAD AND N
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HEAD AND NECK CANCER 117 • The co
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Treatment HEAD AND NECK CANCER 119
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HEAD AND NECK CANCER 121 • Bony r
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FACIAL FRACTURES AND SOFT- TISSUE I
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• Malocclusion FACIAL FRACTURES A
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• CT scanning FACIAL FRACTURES AN
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Page 149 and 150:
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OCULOPLASTIC SURGERY 139 • The up
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OCULOPLASTIC SURGERY 141 Alternativ
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OCULOPLASTIC SURGERY 143 Excision o
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• They occur in: • Patients wit
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5 Cervical branch FACIAL PALSY 147
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FACIAL PALSY 149 • A strip of spe
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• Nerve transfers FACIAL PALSY 15
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ABNORMALITIES OF THE EAR 153 • Th
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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
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VASCULAR ABNORMALITIES 163 • They
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• It is associated with: • Meni
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FURTHER READING 167 Spauwen PH, Goo
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BREAST REDUCTION 169 • The anteri
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• This technique has the followin
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• Herniation of the NAC • Stret
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Excisional techniques BREAST AUGMEN
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BREAST AUGMENTATION 177 • This te
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• Non-invasive tumours • Ductal
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Surgical treatment BREAST CANCER 18
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BREAST RECONSTRUCTION 183 • Lesio
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BREAST RECONSTRUCTION 185 • Varia
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Superior gluteal perforator flaps B
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CHEST WALL RECONSTRUCTING 189 • E
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FURTHER READING 191 Pectoralis majo
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Embryology 5 The upper limb Embryol
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1 Failure of formation • Transver
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CONGENITAL DEFORMITIES 197 Classifi
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CONGENITAL DEFORMITIES 199 • Ulna
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Camptodactyly CONGENITAL DEFORMITIE
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CONGENITAL DEFORMITIES 203 • Clin
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• Type 2: duplicated distal phala
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• Microvascular free joint or bon
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• Abnormalities of the scalene mu
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NERVE COMPRESSION 211 • Tinel’s
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NERVE COMPRESSION 213 1 Neurolysis
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• Sensory signs include: • A po
Page 229 and 230:
TENDON TRANSFERS 217 Symptoms Pain
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• The ideal tension varies betwee
Page 233 and 234:
DUPUYTREN’ S DISEASE 221 • ECRB
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3 The lateral digital sheet 4 Grays
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Fat • Lipoma • Angiolipoma •
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Carpometacarpal boss TUMOURS 227
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TUMOURS 229 Giant cell tumours of t
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• Pseudogout • Systemic lupus e
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1 Proliferationasynovial swelling a
Page 247 and 248:
• Findings on examination include
Page 249 and 250:
ARTHRITIS 237 • The resultant imb
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Chronic tophaceous gout HAND INFECT
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4 Pain on passive extension. HAND I
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6 The lower limb Leg ulcers, 243 Lo
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• It is normally in the region of
Page 259 and 260:
Mangled extremity severity score LO
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LOWER- LIMB TRAUMA 249 4 This fasci
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The lymphatic system Anatomy LYMPHO
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2Infection LYMPHOEDEMA 253 • The
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LYMPHOEDEMA 255 • Phase twoaconse
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4 Heel 5 Malleolus 6 Occiput. PRESS
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• Pressure dispersion PRESSURE SO
Page 273 and 274:
FURTHER READING 261 Eshima I, Mathe
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Embryology of the sexual organs Int
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HYPOSPADIAS 265 • The tunica albu
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HYPOSPADIAS 267 The Mathieu procedu
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• The dorsal surface of the penis
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VAGINAL AGENESIS 271 • Patients w
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Thermal burns 8 Burns Thermal burns
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• A high respiratory rate • Con
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THERMAL BURNS 277 • Adults with b
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THERMAL BURNS 279 • Full-thicknes
Page 293 and 294:
6Disability CHEMICAL BURNS 281 •
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FURTHER READING 283 • Lightning s
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PATHOPHYSIOLOGY OF VESSEL HEALING 2
Page 299 and 300:
TECHNIQUE 287 Equipment Successful
Page 301 and 302:
POST- OPERATIVE MANAGEMENT 289 Post
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FURTHER READING 291 Further reading
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BLEPHAROPLASTY 293 • This is asse
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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
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• 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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