Plastic surgery and skin

CHAPTER 19 Plastic surgery and skin



Plastic surgery has evolved from the innovation of techniques concerning the movement and reconstruction of soft tissue defects by the movement of autologous, distant and allogeneic tissue. Knowledge of anatomy, vascularity, wound healing and vessel, nerve and tendon reconstructive techniques are applied. Excision of benign and malignant tumours of the skin and soft tissue (sarcoma) with subsequent reconstruction of resulting defects forms a large part of the workload. Breast reconstruction following partial or total mastectomy defects, soft tissue defects due to trauma and burns and congenital hand, urogenital and craniofacial abnormalities such as cleft lip and palate are also addressed using these techniques. Elective and traumatic hand surgery and reconstruction forms a large subspecialty. Plastic surgeons often work with other specialties to reconstruct defects that cannot close directly, e.g. orthopaedics (open lower limb fractures), general surgeons and gynaecologists (perineal defects), cardiothoracic surgeons (sternal dehiscence and chest wall defects), neurosurgeons (craniofacial defects), and head and neck surgeons (facial reconstruction following tumour excision and trauma, facial palsy correction). The importance of aesthetics in these reconstructions has led to the refinement of cosmetic surgery which forms the minority of the workload. However the recent increased numbers of obese patients undergoing bariatric surgery has increased the volume of referrals for body contouring procedures (abdominoplasty, belt lipectomy, thigh lift, breast reduction/mastopexy, brachioplasty).




Providing skin cover





Skin graft


A graft tissue is removed completely from one part of the body and inset onto another site. It is separated from its blood supply and therefore depends on being placed on a healthy vascular bed for its revascularization.






Flaps


A flap is a section of tissue transferred, carrying its own blood supply. They can be defined by their composition, e.g. skin (cutaneous), fasciocutaneous, adipofascial, or muscle with or without skin or bone. They can be local (raised from an area sharing a border with the defect) and move by advancement, rotation or transposition. These can be geometrically designed to rely on the unnamed vasculature from the base of the flap (random pattern → Fig. 19.1) or based on a named or identified vessel – the pedicle, e.g. groin flap, deltopectoral flap or on a vessel perforating from the deeper tissues. These pedicled flaps do not necessarily share a border with the defect (regional), and can be moved into the defect around a pivot point, related to the axis around the pedicle. General indications for flap cover include: avascular areas, e.g. exposed bone or joint surfaces, exposed major blood vessels, irradiated areas or areas to undergo radiotherapy. (For a selection of pedicled flaps, see Figure 19.2.)






‘Surgical’ skin lesions: principles of management (→ Table 19.1)









TABLE 19.1 ‘Surgical’ skin lesions



















































Benign  
Epidermis Pedunculated papilloma, wart, seborrhoeic keratosis, keratoacanthoma
Dermis Pyogenic granuloma, fibrous histiocytoma, keloid
Appendages Furuncle, carbuncle, hidradenitis suppurativa, sebaceous cyst, dermoid cyst, pilonidal sinus
Subcutaneous Lipoma, neurofibroma
Melanotic Intradermal naevus, blue naevus, compound naevus, spitz naevus, congenital naevus
Vascular Campbell de Morgan spots, haemangiomas, capillary/venous/arteriovenous/lymphatic malformations, spider naevi, glomus tumours
Premalignant  
Epidermis Actinic (solar) keratosis, Bowen’s disease, erythroplasia of Queyrat (penis)
Malignant  
Epidermis Basal cell carcinoma, squamous cell carcinoma
Dermis Kaposi’s sarcoma, secondary deposits
Appendages Sebaceous carcinoma (rare), sweat gland carcinoma (rare)
Subcutaneous Liposarcoma, neurofibrosarcoma
Melanotic Malignant melanoma
Vascular Angiosarcoma (rare)


Common benign lesions





Skin appendages









Disorders of the nails



Ingrowing toenail (IGTN)


A common condition, it usually appears on the great toe, particularly the lateral side. Caused by a combination of tight shoes and paring the nail downwards into the nail fold rather than cutting it transversely. The sharp edge of nail then grows into the nail fold producing ulceration, infection, and granulation tissue.





Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on Plastic surgery and skin

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