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The serious side of plastic surgery
CHITRA RAMASWAMY (Contributor)
24 September 2007
Wound treatment involving plastic and reconstruction (P&R) surgery is integral to rehabilitating a victim of injury who has lost partial mobility of any limb
WHEN MOST people think of plastic surgery, they visualise facelifts, tummy tucks, breast augmentation, liposuction and other cosmetic aspects. However, there is more to Plastic and Reconstruction (P&R) than simply enhancing looks and figure. Wound treatment involving P&R surgery is integral to rehabilitating a victim of injury who has lost partial mobility of any limb or has lost sensation in an area says Dr.Mohan Rangaswamy, P&R Surgeon, Welcare Hospital, Dubai.
So what are the type of wounds that are amenable to P&R surgery? Basically any wound that is potentially problematic should be seen and treated by a plastic surgeon. They include burns especially in children, elderly or hand and face burns, high velocity/high impact injury wounds, wounds where tissue is lost, where tissues are torn irregularly and crush wounds. In these wounds, tissue is de-vitalised and needs gentle and selective handling as well as proactive management to ensure as best a healing as possible. Further wounds that have not healed in a reasonable time of two weeks are better seen by a plastic surgeon.
The goal of such surgery in these instances is to preserve tissues and encourage quick healing, avoid infection, restore anatomy and if not possible replace “like by like” tissues at the earliest opportunity to return the person to normal activity in the quickest possible time and with the least expense.
It is important in several instances that the wounds be treated by P & R surgeon than a general surgeon alone. For instance if an individual has got his fingertip crushed in a door. This may result in irregular cuts in the skin, possibly some skin loss, nail avulsion and bone fracture. The average surgeon may put some stitches on the skin, splint the bone externally and cover with dressings; often the nail-bed injury is not treated or is even missed. The result could be a mis-shapen finger tip with chronic pain and abnormal nail growth which may be accepted as an unavoidable result in such a severe crush. A plastic surgeon on the other hand would clean such an injury, wait one to three days for swelling to subside and then undertake an accurate repair of the nail-bed after aligning the bone. If need be, he may also do some skin grafting for missing skin or nail-bed and use special dressings. The result is often a near normal restoration of form and function.
Further, plastic surgeons make use of magnification and fine delicate techniques to repair highly sensitive and fragile tissues. The timing of repair is also important. Contrary to popular practice, it is not important to close and suture everything on the first day. While it is certainly vital to do thorough cleaning and debridement within six hours of injury, some wounds should not be closed tightly the first day, as for instance war wounds and wounds from disasters. If closed on the first day, much harm can result from such injudicious closure.
It is absolutely important for debriding of wounds. This involves removal of dead and devitalised tissue so as to leave behind only viable tissue. Good washing with warm saline, preferably using jet pressure removes contamination and bacteria. Presence on non-living tissue in a wound increases the risk of infection a thousand fold. The single most important service a surgeon can do for wound healing is doing a good debridement; closure is of secondary importance emphasises Dr.Mohan.
Skin graft may be used in the treatment of wounds when skin cover is lost and an early debridement has been done within 6-12 hours. The process is undertaken immediately to cover the deeper tissues and prevent pain, tissue drying and fluid loss. Skin is the best form of dressing goes an old adage. Sometimes when there is no loss but surgeons expect a lot of swelling, or if the closure is tight, surgeons prefer to close what can possibly be closed easily and cover the rest with a skin graft. If a wound is bad and infected, careful dressings and antibiotic therapy should be done till the wound is clean before skin grafting it.
Is skin grafting associated with any dermatological or other problems? There is no doubt a different look to the area where grafting has been done. The thicker the graft, the more natural it looks. Split grafts have a tendency to shrink and become darker. They need compression garments and massage with moisturisers for six months to get optimum cosmesis. Split grafts do not have hair and do not produce oil, hence always need moisturiser. The donor site also needs care for three to six months to prevent Hypertrophic scar, explains Dr. Mohan.
Skin grafts need to be immobilised for five days for a “take”. Movement prevents “take” and disturbs the ingress of new capillaries. The donor site needs two weeks to heal. They both need three to six months of after care to prevent permanent scarring.
P&R surgery can be done at any age if the person is fit for surgery. The contraindications to the surgery include the presence of invasive uncontrolled local infection or presence of beta haemolytic streptococcus bacteria. Poor general health, steroid usage, local radiation therapy, poor local circulation are adverse factors that must be carefully considered before doing local flap procedures.