Basic plastic surgery and wound management

นพ.โอภาส พณไชย หนวยศลยศาสตรตกแตง

ภาควชาศลยศาสตร คณะแพทยศาสตร มหาวทยาลยเชยงใหม

กภาพนธ 2562

วตถประสงค

• มความเขาใจความรพนฐานทางศลยศาสตรตกแตง

• น ามาประยกตใชใหเกดประโยชนแกผ ปวย

เนอหา

• 1. การแบงประเภทของบาดแผล

• 2. การดแลรกษาบาดแผลและการปดบาดแผล

• 3. การเยบปดบาดแผล

• 4. การท าใหเกดแผลเปนนอย(fine-line scar)

• 5. Skin graft

• 6. Skin flap

• 7. Z-plasty

1.การแบงประเภทของบาดแผล

• Abrasions

• Lacerations

• Incised wound

• Puncture wound

• Penetration wound

• Stab wound

Scratch/Graze

https://www.tshs.eu/en/service/wound-healing/article/treatment-instruction-for-bite-wounds-abrasion-wounds-and-burn-injuries.html

http://www.wound-treatment.jp/english/index_e.htm

Lacerations/Incised wound

https://www.123rf.com/photo_78223406_leg-has-new-incised-wound-.html https://autonomousfx.com/fx-gallery-item/deep-laceration/

Penetration wound/Puncture wound/Stab wound

https://sc0rn3d.wordpress.com/2013/10/01/tending-to-a-puncture-wound/

https://www.drugs.com/cg/puncture-wound.html

https://www.outlanderanatomy.com/fun-fact-penetrating-wound-warning-not-suitable-for-morning-coffee/

2.การดแลรกษาบาดแผลและการปดบาดแผล

• Examination: shape,depth,necrosis, FB, deep structure

injuries

• Preparation: hemostasis,pulsed irrigation,debridement

• Approximation

• Dressing

• Antibiotics: infection

• Follow-up: contaminated wound(24-48h)

Pulsed irrigation

https://www.crbard.com/davol/en-US/products/Simpulse-SOLO-Suction-Irrigator

3.การเยบปดบาดแผล

• Sutures material

• Suturing techniqes

Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014,

Half-buried horizontal mattress suture

https://slideplayer.com/slide/6988158/24/images/27/Suture%20Techniques%20Corner%20stitch%20(half-buried%20mattress%20stitch)%20%E2%80%93%20to%20close%20a%20flap.jpg

https://accessmedicine.mhmedical.com/content.aspx?sectionid=40381509&bookid=348

Fine-line scar

https://plasticandhandsurgery.com.au/plastic-surgery/scar-management-revision/

https://www.nhsdirect.wales.nhs.uk/encyclopaedia/s/article/scars

Suture marks

https://www.laroche-posay.com/article/How-to-optimize-scarring-process-Stitches/a27821.aspx

Factors?

https://areton-ltd.com/microneedling-surgical-scars/

4.การท าใหเกดแผลเปนนอย(fine-line scar)

1. Skin tension

2. Skin eversion

3. Surgical technique or atraumatic technique

4. Skin line

5. Infection

6. Age of the patient

7. Regions of the body

8. Length of scar

9. U-shaped scar

10. Angle of wound to skin surface

11. Type of skin

12. Skin disorders

1.Skin tension

-Sutures tied too tightly -Lateral pull on the wound

https://www.youtube.com/watch?v=BjL1YXXGlDA https://emedicine.medscape.com/article/1824895-technique

2.Skin eversion

https://lacerationrepair.com/wound-blog/eversion/

https://slideplayer.com/slide/7496439/

https://www.bumc.bu.edu/surgery/training/technical-training/suturing-basics/

Simple interrupted suture

Skin eversion?

https://www.youtube.com/watch?v=-IRKgQLDM28

http://www.med.cmu.ac.th/dept/obgyn/2011/index.php?option=com_content&view=article&id=1098%3A2015-03-01-15-10-48&catid=45&Itemid=561&fbclid=IwAR3PtTBF4hkVrWstLNCn14RQCW_DfzcIkM073WXtzDZRydk-NXI7TeJiMhY

Vertical mattress suture/Horizontal mattress suture

https://www.slideshare.net/Maghnani/suture-presentation-by-dr-nabeel-ur-rehman-and-dr-suneel-maghnani

https://geekymedics.com/horizontal-mattress-suture/

3.Surgical technique or atraumatic technique

• Skin necrosis -crushed skin

-dried skin by exposure to the air

-damaged skin from forceps or hemostat

-too much tension by suture

http://www.ijps.org/viewimage.asp?img=ijps_2011_44_3_511_90844_f2.jpg

Scar?

4. Skin line

• relaxed skin tension lines (RSTL)

From Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014, part 1, ch1, p .2

RSTL

5. Infection

6. Age of the patient

7. Regions of the body

8. Length of scar

Dog ear deformity

Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014, part 1, ch1 p .4.

9. U-shaped scar

10. Angle of wound to skin surface

11. Type of skin

12. Skin disorders

https://slideplayer.com/slide/8771853/

Windshield injury

5.Skin Grafts

https://www.youtube.com/watch?v=yYLxfXsLqBU http://owensborohealthse3.adam.com/content.aspx?productId=117&pid=1&gid=002982

Classification of Skin Grafts

• STSG

-thin

-intermediate

-thick

• FTSG

https://www.carehospitals.com/blog/think-tank/do-you-know-what-skin-grafts-are/

Cutting the skin graft

STSG FTSG

Fixation/Dressing

Tie – over dressing or bolus dressing Suture fixation

Postoperative care of skin graft

1.การเอา hematomas หรอ seromas ออกจากใต skin graft

2.การดแลเมอมการอกเสบตดเชอของแผล

3.Hyperbaric oxygen

4. การหามเคลอนไหว ( Immobilization)

Requirement for Survival of a Skin Graft

• vascular recipient bed

• contact of the skin graft and the recipient bed

• proper preparation of the open wound

Characteristic of Grafted skin

1. Contraction -primary -secondary 2. Color 3. Accessory skin structure -hair growth, sebaceous secretion, sweating 4. Sensation 4. Durability 5. Growth of grafted skin

Primary contraction

https://www.sciencedirect.com/topics/medicine-and-dentistry/split-thickness-skin-graft

Secondary contraction

Composite graft

STSG/FTSG?

Graft/Flap

6.Skin Flaps

https://openi.nlm.nih.gov/detailedresult.php?img=PMC5288546_IPRS-06-01-g-001&req=4

McCarthy, J.G. (ed), Plastic Surgery. Philadephia , WB Sauders, 1990. Vol 1, Ch 9,p 282

Free flap

Direct flap from the groin

Postoperative care of skin flap

1.Flap ตงเกนไป(tension)

2. บรเวณขวของ flap มการบดงอ (kinking)

3. flap แนนเกนไป (pressure)

4.Hematoma ใต flap

5..การอกเสบตดเชอ (infection)

Uses of flap

1. Avascular/poor bed

2. Important structure

3 Bulk

4. Padding

5. Re-operation

6. Sensation

7. Composite tissue reconstruction

7. Z – Plasty

• Surgical technique

https://www.saintlukeskc.org/health-library/scar-revision-z-plasty

Charles H. Thorne, eds : Grabb and Smith’s Plastic Surgery,7th edition.

ประโยชนของ Z - plasty

1. Increasing the length of the desired direction

Angles of Z – plasty(degree) Theoretical gain in length(%) 30 – 30 25 45 – 45 50 60 – 60 75 75 – 75 100 90 – 90 120

https://link.springer.com/chapter/10.1007/978-4-431-56045-6_6

2.Change direction of the scar

U-shape scar

3.rotate axis of tissue

Conclusion

1. การแบงประเภทของบาดแผล

2. การดแลรกษาบาดแผลและการปดบาดแผล

3. การเยบปดบาดแผล

4. การท าใหเกดแผลเปนนอย(fine-line scar)

5. Skin graft

6. Skin flap

7. Z-plasty

References

• Smith,J.W. , Aston,S.J., (eds) , Grabb and Smith’s Plastic Surgery, 4th ed.Boston,Little Brown, 1991.

• Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014.

• McCarthy, J.G. (ed), Plastic Surgery. Philadephia , WB Sauders, 1990.