dermatology - gualdi

• Plastic surgery is a surgical branch focused on transposing skin (or other tissues) from one location to another.
• Plastic surgery is used to cover wounds caused by injuries.
• Nasal pyramid reconstruction using a frontal skin flap with its arterial-venous nutritive peduncle originated in ancient Indian medicine around 600 BC.

Plastic Surgery Principles

• Plastic surgery aims to intervene before scar tissue forms.
• Plastic surgeons aim to create the best possible scar by minimizing tension, using proper sutures, and caring for healing.
• Re-epithelialization is a typical aspect of second intention healing.

Healing Intentions

• Primary intention healing occurs in wounds with close dermal edges, like a scalpel incision, and is usually faster than secondary intention.
• Primary intention healing typically results in a complete return to function with minimal scarring and loss of skin appendages.
• Secondary intention healing happens when wound sides aren't close, leading to healing from the bottom upwards.
• Myofibroblasts are crucial in secondary intention, contracting the wound and reducing space between dermal edges.
• Leaving a wound to close naturally with taping might require grafts if primary closure isn't possible.

Plastic Surgery Branches:

• Reconstructive surgery addresses congenital defects such as labiopalatoschisis and malformations.
• Reconstructive surgery addresses acquired conditions such as surgical removal of neoplasm (breast tumor) or traumas, and burns.
• Aesthetic surgery enhances normal forms when patients experience discomfort.

Cutaneous Physiopathology:

• Cutaneous Physiopathology is related to aging.
• Langer’s lines, also called relaxed skin tension lines (RSTL), are determined by the movement of mimic muscles.
• Incisions that follow Langer's lines aid wound healing and result in less scarring.
• Incisions along Langer's lines minimize scar retraction and hypertrophy.
• Surgeons make incisions where there is less resistance to minimize scarring and promote better healing.

Skin Thickness and Healing

• Skin thickness and elasticity vary across different body regions.
• Wound healing depends on the thickness and elasticity of skin, based on body region composition.
• Thin skin tends to heal well with minimal scarring, such as on the upper or lower eyelids.

Skin Aging

• Younger individuals generally experience better healing due to more reactive skin.
• Elastosis causes skin to lose elasticity as people age, and reduces collagen production, which leads to aging.
• Other factors impacting the skin include time, smoking, and sun exposure, and sun protection.
• Healing involves new collagen fibers and fibroblasts depositing.
• A normal scar can form in the absence of tension and with the correct suture choice for the skin.
• Healing is continuous, with the process halting when the suture is removed.

Hypertrophic and Keloid Scars

• Suture type, timing of suture placement and removal, and post-operative care determine the quality of scar and prevent keloidal/hypertrophic scars.
• Hypertrophic scars result from tension and manifest as thick, raised scars within the original incision line.
• Keloid scars extend beyond the surgical incision margins, resembling a cauliflower-like tumor.
• Black people, children, and some body areas (sternum, deltoid) have a higher incidence of pathological scars.
• External factors such as wound infection, tension, and margins contribute to pathological scars.
• Hypertrophic scars are difficult to manage, and are generally treated with cortisone injections or pressure.

Keloid and Hypertrophic Scar Treatment

• Treatment varies according to the patient, beginning by removing the keloidal scar.
• Strategies to reduce the risk of keloid or hypertrophic scars include compression, silicon strips, steroid injections, radiotherapy, and laser therapy.

Dressing and Healing Intentions

• Dressing protects wound site and maintains optimal chemical, and physical conditions (hydration, pH, humidity, etc.).
• Second intention healing forms granulation tissue.
• In second intention, the injury heals through granulation tissue formation and re-epithelialization.
• Healing is influenced by general, local, and external factors.
• General factors include physiology and conditions such as diabetes, local factors involve infection or pressure (decubitus lesions), and external factors relate to sun damage.
• Second intention healing involves granulation of tissue to coat and cover the lesion, however deep tissues should not be stitched alone.

Factors Affecting Healing

• Factors that affect healing include nutritional status, protein balance, blood glucose disorders, clotting disorders, and infections.
• Local factors that affect healing include humidity, temperature, and oxygenation.
• Healing issues in areas with terminal vascularization such as the lower leg, the nose, or the tongue must be considered.
• Oxygen is important for healing, which is supplied by oxygen and high pressure.
• Hypertrophic growth occurs when there is a low level of oxygen available.
• Granulation and second intention healing can be used when healing cannot be managed.
• Wounds should be approximated without tension.
• Tissue needs to stretch properly otherwise the healing will be bad.
• It is important to remove the suture after healing is completed.
• Remove the suture before the healing has grown towards the running of the suture.

Sutures

• Wound margins are approximated using sutures, patches, staples, or adhesive glues to reduce tension until healing.
• Suture types include absorbable, non-absorbable, monofilament, and braided.
• Each suture is composed of a different material and has a different needle type.
• Needles are directly engaged to the stitch and vary depending on where you put the stitch (mucosa, skin).
• Sutures are available in curved, straight, or ski-shaped needles.

Suture Techniques

• Simple interrupted sutures involve maintaining a consistent distance to reduce tissue strain and distribute tension.
• The entry point for sutures should be around three millimeters.
• The suture should be advanced with a consistent distance and not strangle the tissue.

Vertical Matrix Suture

• With a vertical matrix suture, insert the needle, exit, re-enter, and exit on the same side of the incision with the node on same side.
• The matrix suture helps because you apply pressure with each stitch.

Intra-dermal Suture

• Intra-dermal suture is similar to the vertical mattress suture, but in an horizontal way.
• Adapt the intra-dermal suture in cases of varied tissue thickness; bite the dermis and lift towards the incision, also called aesthetic suture.
• Absorbable suture needs additional nodes to stabilize it, and non-absorbable sutures must be removed to prevent reactions.
• Before removal, rapidization of the running is needed to divide it into subcuticular.

Running Locking Suture

• Running locking sutures are ideal for solo use and firm closure.
• This suture requires a locking setup, which manages bleeding via compression and promotes healing.

Suture Techniques Differences

• When you enter the loop before securing it, it's referred to as a locking interlocking suture, a running interlocking.

Liquid Band Aid

• Liquid bad aids are a convenient alternative to sutures, especially for children.
• Application should be precise to avoid sticking edges incorrectly.
• Glue, like threading a needle, must be applied very close to the edge.

Suture Tools

• Plastic surgery tools are more gentle because we respect the tissue.
• When using a scissor, it should stabilized by the third finger, and the fourth finger.
• The needle should enter at 90 degress to the skin.
• Rotate the nedle through the tissue to prevent tissue damage, and only take the dermis, not the fat.
• Bring the suture through the tissue, leaving a short tail, and bring the needle driver in parallel to the wound.
• Cross your hands to the other side, then cross back to make a square knot.
• When performing a vertical mattress suture, the pattern is far far, near near.
• The goal of the horizontal mattress suture is approximation to the tissue, not the strangulation.
• When performing an intradermal suture: after backing out for the final time, create a new loop of suture.
• Aberdeen Knot involves placing a needle dagger, which is used to pull needle through the three limbs of suture.
• The needle drags it underneath the knot, all the way up to the apex of the wound, about a centimeter beyond the apex of the wound.

Common Rules of Plastic Surgery Tools

• Plastic surgery tools are more delicate than the general surgery ones.
• There are many tools designed only for specific acts.

Midface Lift Technique

• During the Midface Lift Technique, a straight needle can be used with a special device.
• A subperiosteal dissection is made with a bloodless space, after elimination of tissue.
• The strengthened stitch is used bind the tissue and fix the flap without closing the one.

Grafts

• Grafts involve transplanting healthy skin, bone, kidney, or other tissue without vascularization from one body part to replace damaged tissue elsewhere.
• Skin grafts cover burn areas; unlike flaps, they need a well-vascularized wound bed for ingrowth.
• Grafts involve removing healthy skin without a blood supply from a donor area and placing it in a recipient area.

Types of Grafts:

• Autogenous grafts (autografts) are from the same organism
• Allogenic grafts are from another individual of the same species (homologous)
• Xenografts are from another species (heterologous).
• Barnard was a South African doctor who performed a heart transplant, as well as the first heterologous transplant using a baboon's heart.
• Pig heart valves are now used but require treatment to remove antigenic components.

Autografts

• Autograft nutrition relies on a fibrin network and exudate.
• A tissue patch is disconnected from its blood supply and placed in the recipient area, relying on a fibrin network
• Endothelial appendages form, followed by capillary buds, and vascular network reconstruction within 5-7 days,
• Autografts can serve as temporary medication but must be removed before blood vessel formation.

Engraftment Factors:

• Engraftment challenges are more common in debilitated or older patients with preexisting conditions.
• Areas treated with radiotherapy or necrotic areas are unsuitable for grafts because they cause vascularization problems.
• Exudates or hematomas can impair fibrin network formation.

Allografts

• Allografts involve donors and recipients of the same species, either isogenic (genetically identical, e.g., twins) or allogenic (genetically similar but not identical).
• Allogenic grafts taken from surgeries or autopsies typically face rejection in 5-7 days as capillaries form, necessitating removal.
• Xenografts, from different species, may trigger anaphylaxis and require removal in 2-3 days.

Graft Material

• Graft materials include epidermis, muscle, cartilage, mucosa, nerves, dermis, adipose tissue, vessels, tendons, fasciae, bones, or composite tissues.

Graft Thickness

• Grafts are classified by thickness, including full-thickness skin grafts (FTSG) and split-thickness skin grafts (STSG).
• FTSG includes the full dermis and epidermis and is typically used for small wounds.
• FTSG donor sites, like upper eyelids, can be easily closed with minimal scarring.
• STSG, used for large areas, includes epidermis and part of the dermis, allowing easier donor site healing.
• Subcutaneous tissue removal allows STSG grafts to attach directly to lesions and facilitates fibrin network formation.
• Dermatomes help harvest large STSG sections and control skin thickness, minimizing donor site damage.
• Skin grafting transfers cutaneous tissue from one body area to another to cover large wounds, healing the donor site while the graft covers the affected area.
• STSG grafts contain epidermis and a portion of the dermis, unlike FTSG, and require a well-vascularized bed, since they lack an intrinsic blood supply.

STSG Types

• Thin (Thiersch-Ollier)
• Intermediate (Blair-Brown)
• Thick (Padgett)
• FTSG, also known as Wolfe-Krause, includes the full thickness of both the epidermis and dermis.
• Grafts are removed from donor sites without involving blood supply; donor sites undergo second intention healing.
• Grafts require a blood supply, which starts from the fibrin network, endothelial appendages, and vascular network.

Flaps in Plastic Surgery

• Flaps maintain a vascular autonomy via their pedicle (containing veins and arteries).
• Flaps are units of tissue transferred from one site (donor) to another (recipient) while maintaining their blood supply.
• The key difference between flaps and grafts: flaps have a pedicle.
• Small grafts are better for addressing necrosis after breast reconstruction near the nipple or areola.
• Flaps are needed for removing mammary tissue.

Types of Flaps:

• Cutaneous flaps: full thickness of skin
• Fasciocutaneous flaps: skin + subcutaneous tissue and deep fascia
• Musculocutaneous flaps: skin + subcutaneous tissue + deep fascia + layer of muscle
• Muscle flaps: muscle layer
• Other: cartilage, mucosa, periosteum, etc.; for mandible and cheek reconstruction, fibula flaps including bone are used.

Cutaneous Flap Classification:

• Local flaps involve freeing and stretching a tissue layer to fill a defect and include advancement, rotation, and transposition flaps (from least to most complex).
• Regional flaps use a freed tissue island moved over or under normal tissue to reach a defect while maintaining blood supply via a pedicle; an example is the TRAM flap for breast reconstruction.
• Distant flaps: divided into direct or indirect, are transferred immediately or later when the donor site is far from the defect. Direct flaps connect to both the donor and recipient sites simultaneously.

Flap Classification by Vascularization:

• Axial flaps have known artery and vein supplies, allowing a larger area to be freed while preserving a small vessel-containing pedicle.
• Random flaps are supplied by unnamed arteries and veins from general vascular networks, requiring the peduncle's amplitude to ensure flap viability (max amplitude: length ratio is 3:1); local flaps are generally random.
• Creating a flap when stitching a wound involves lifting tissue, resulting in a random flap.
• Advancement flaps recruit adjacent tissue to close a defect linearly along the peduncle's axis and are usually random.
• Rotation flaps pivot adjacent tissue around an axis to close a primary defect, rotating the skin.
• Transposition flaps incorporate noncontiguous skin into a primary defect by lifting the flap over normal skin; this involves rotating an adjacent tissue piece, creating a new secondary defect.
• During melanoma removal, resection is performed, and the resulting skin defect is closed using flaps and suturing techniques.

Z-Plasty

• Z-plasty, a plastic surgery base, improves scar function and appearance by transposing two equal-dimension triangular flaps.
• Z-plasty addresses scar retraction by removing scar tissue or shifting flap movement to elongate tissue.
• The Z-plasty technique involves scalping a Z, making incisions, lifting the skin, excising scar tissue, positioning flaps in an "S" shape, and closing.

V-Y and Y-V Plasty

• V-Y and Y-V advanced flaps are sliding plasties that provide additional tissue for areas with a deficiency.
• The lengthening effect on the scar is similar to a Z-plasty, but instead of transposing, the skin is advanced.
• The skin is incised in a V shape in V-Y plasty, a skin triangle is displaced, and closure forms a Y shape, advancing the point.
• In Y-V plasty, the skin is incised in a Y shape, and the triangular flap is advanced.

H-Plasty

• “H” plasty closes large, round surgery sites/wounds by converting a round hole to a rectangular/square area for suturing.

Bilobed Flaps

• Incision around Defects require removing the entire area near a defect, cutting one centimeter from the lesion, and cutting the skin in a square shape to close it.
• A bilobed flap (double transposition flaps) reconstructs facial skin defects, removes skin on the nose.
• When you use skin for closing a wound on the nose, if there isn't enough of it, you either place a graft, or make this kind of rotation flap using geometric elasticity skin and moving the random blood supply to cover the hole.

Musculocutaneous flaps

• Musculocutaneous flaps: vascularization is not random, a vascular pedicle is needed, since this is an axial flap.

Classification of Musculocutaneous Flaps

• Type I (ONE Vascular pedicle) means you draw the skin part, and the pedicle and save it.
• Type II (ONE dominant pedicle and MINOR pedicles)
• Type III (TWO dominant pedicles)
• Type V (ONE dominant and SECONDARY SEGMENTAL pedicles)
• In breast reconstruction comfort matters mainly, and is preferred over healing.
• In picture 4 (below) the tissue is taken from the gluteus. We can see a necrosis due to a compression of vessels (the lack of blood supply causes the tissue's death). It's important to bring some new tissue but not with grafts which can't work in this case because there is no blood supply and the patch can survive. A new flap is needed to cover the lesion and help the tissue to heal

MUSCULOCUTANEOUS FLAPS:

• Temporal muscle: Type III
• Platysma: Type II
• Sternocleidomastoid muscle: Type II
• Trapezius muscle: Type II
• Rectus abdomen: Type III
• Pectoralis major: Type V
• Latissimus dorsi: Type V

Facial Procedures

• Fat Transplant: fat is injected.
• V-Y plasty: below there are two V-flaps that close into two Y shapes.
• Absence of hyaluronic acid can create poor results during surgery.
• Present when frenulum attachment is too low, the upper lip does not move so we need to release it/ Low attached frenulum.
• Gummy smile: the gingiva are showing when smiling, treated by lowering the mucosa fornix. Fluid silicon has been illegal to use in Italy for about 30 years (sausage lips).
• The only way to reverse its effect is to remove the silicon, which is not easy to do. in order to protect and prevent the function of the muscle it's crucial to remove the scar.
• It's safer to use hyaluronic acid because, unlike silicon, it has an antidote which dissolves it and reverses the effect.

Introduction to Surgery

Patient Preparation

• Patients should sign a written declaration of informed consent and preoperative photographs to avoid legal issues
• Before anesthesia and incisions, ask patients if they are feeling any pain.
• Reassure the patient, and ask for feedback concerning expected results.

Skin Preparation

• Glabrous Skin: remove dirt and makeup and disinfect with Hibiscrub (4% Chlorhexidine) or Betadine (10% iodine-Povidone solution) for 1-3 minutes to reduce resident flora.
• Avoid alcoholic solutions due to fire risk if using diathermocoagulation.
• Scalp: avoid shaving unless strictly necessary, as it increases infection risk; instead, clean with aqueous detergent and secure hair with bobby pins, tape, or clips.

Surgical Hand Wash

• Surgical hand wash involves removing visible dirt, especially under the nails, and should be performed twice.
• Perform the hand wash with running water and Hibiscrub (4% Chlorhexidine) or Betadine (10% Povidone-Iodine), to release an antiseptic film.

Gloves

• Initially, surgeons operated barehanded, relying on caustic soda and antiseptics for cleaning.
• Gloves protect both the patient and the surgeon.
• Gloves are typically latex, with variants available.
• Double gloves can be used for high-risk patients, like those with HIV.
• If a needle punctures the first glove, a second glove is beneficial.
• Exercise caution and gentle movements with sharp instruments during procedures.

Masks and Goggles

• Surgical preparations start with washing hands and scrubbing.
• Masks and goggles protect the eyes and mucous membranes from saliva and blood spatter.

Sterile Gowns

• Sterile gowns protect the surgeon’s clothes and prevent contamination.
• Gown colors vary but are now mostly blue, which helps identify clean vs. dirty gowns.
• Sterile materials should be opened and contents given to someone else prior to donning sterile gowns, glasses, and gloves.
• Cover all areas, such as covering the table before placing instruments, and only touching sterile items after putting on the sterile gown.

Gown Donning

• Step 1: Grasp the sterile gown and step into an area where it can be opened without contamination; put both hands into armholes, holding gown away from body to unfold.
• Step 2: Slip both hands and forearms into armholes and sleeves; keep hands at shoulder level and away from the body.
• Step 3: A circulating nurse pulls the gown over shoulders, touching only the inside.
• Step 4: A circulating nurse arranges hook and loop fixation and ties the inner belt.
• Step 5: Don gloves. Grasp the belt card with both hands, separate the left outer belt from the card, and keep the belt in the left hand.
• Step 6: Hand the belt card to the circulating nurse, make a three-fourth turn to the left while the nurse extends the outer belt, retrieve the outer belt from the nurse, and tie it together with the other belt on the left side.

Sterile Gloves

• Remove the outer packaging of the sterile gloves.
• Open the inner packaging as directed without touching anything inside.
• Using the non-dominant hand, pick up the glove for the other hand by the cuff.
• Slide the dominant hand into the glove with the palm facing up and fingers open taking care not to touch the package.
• Use the gloved hand to slide fingers under the cuff of the second glove touching only the outside of the glove.
• Slide the hand into the glove with the palm up and the fingers open.
• Adjust both gloves until they fit properly, touching only sterile gloved areas.

Breast Augmentation

• Breast implants are made of silicone, including the surface and shell.
• Implants can be placed behind the glands or behind the muscle.
• If there’s insufficient tissue to cover the implant, it is placed behind the pectoralis major muscle.
• Incision location depends on surgeon preference and patient anatomy.
• Common approaches include the inframammary fold, periareolar access, and transaxillary access.
• The inframammary fold is easiest, while transaxillary access is interesting but further from the site.

Breast Reduction

• Large breasts can cause sagging, leading to problems like infections or back pain.
• There are many different techniques and approaches to breast reduction.

Abdominoplasty

• Abdominoplasty removes excess skin and tissue after bariatric surgery, without touching the muscles.
• The procedure involves advancing the flap, making an incision around the umbilicus, shifting the skin caudally, and removing excess skin.

Liposuction

• Liposuction uses a cannula to suction out excess fat, requiring a safe OR environment.
• Adrenaline and local anesthetic are used to induce vasoconstriction.
• The goal is to break up and extract fat while taking care of the skin, asymmetry, reshaping, and redraping.

Liposuction Indications

• Liposuction is not a weight loss method rather achieve a good BMI first and then remove extra skin or fat.
• It's important to exercise, live a healthy lifestyle, and eat properly.

Otoplasty

• The goal is to model cartilage and remove skin, addressing prominent ears due to excess concha or auricular fold issues.

Rhinoplasty

• Rhinoplasty requires achieving a good balance because the nose is the center of the face and good work looks natural.

Blepharoplasty

• Blepharoplasty removes excess skin from the upper eyelids and addresses bags under the eyes.
• A transconjunctival approach removes fat and excess skin in the lower eyelids, followed by stitching to close.

Peeling

• For acne scars, a peeling procedure lasts 3 minutes but healing takes 6 months.
• Peeling procedures cannot be done in the summer.
• Lasers, which are more expensive, can be used to be more precise.

Fillers

• Hyaluronic acid is used for fillers because it can be removed with hyaluronidase.

Botox

• Botox can relieve migraines when injected at specific sites.