Basic plastic surgery and wound management · Suture fixation Tie – over dressing or bolus...
Transcript of Basic plastic surgery and wound management · Suture fixation Tie – over dressing or bolus...
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.