What types of wounds are amenable to plastic and reconstructive surgery?
Basically any wound that is potentially problematic should be seen and treated by a plastic surgeon. Some examples: 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 or avulsed, crush wounds etc. The reason is that in these wounds, tissue is de-vitalized 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.
What is the goal of P & R surgery in treating wounds?
The goal 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.
We try to understand the wound at the tissue level and try to save or salvage as much as possible and make an accurate repair. Further, P&R surgeons try to optimize all factors influencing wound healing – right from the choice of suture material used, amount of tightness in the stitches applied and even simple things like omitting a few stitches at critical areas and type of dressing; these factors can make a difference in whether the wound heals or gets infected/complicated. Being treated by a plastic surgeon, the patient gets the advantage that missing tissue can be filled in at the same time or at the earliest opportunity rather than suffering for some time before going for plastic surgery.
How precisely does P & R work in the treatment of wounds?
This can best be understood by an example. Let us take a situation where a finger-tip got crushed in a door resulting 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 would clean such an injury, wait 1-3 days for swelling to subside and then undertake an accurate repair of the nail-bed after aligning the bone, possibly 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. So, the difference is in the level of understanding of minute tissue trauma, devising a special program for it and basically taking such a “small” trauma seriously enough to take it to the ultimate level of care and restoration. We are used to ‘much ado about small things’.
Are there different techniques of surgery used in treating different wound kinds?
Basic principle are the same, however specialized tissues like tendon, cartilage, ligaments, nail-bed are treated as per specific requirements. All elements are attended to in the primary repair as much as possible so as to give the best restoration. If tissue is missing and bone or tendon gets exposed, then tissue cover must be provided. 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; certainly it is vital to do thorough cleaning and debridement within 6 hours. Some wounds should not be closed tightly the first day. War wounds and wounds from disasters are not to be closed on the first day, much harm can result from such injudicious closure.
What is debriding and when is it used in the treatment of wounds?
Debriding basically refers to removal of dead and devitalized tissue so as to leave behind only viable tissue. Good washing [wound irrigation 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!
When, in which areas and under what circumstances is skin graft used?
When skin cover is lost and an early debridement has been done within 6-12 hours, we like to do skin grafting 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 we expect a lot of swelling or if the closure is tight, we prefer to close what we can close 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 [granulating well and looks strawberry red] before skin grafting it.
What are split-thickness, full thickness and composite grafts and when is the one used vis-à-vis the other?
Skin consists of epidermis and dermis. The epidermis is the renewable outer layer of skin and does not have blood supply. The dermis is the thicker deeper layer made of complex tissues and has blood and nerve supply; it is non-renewable. A split thickness graft consists of the epidermis and variable thickness of dermis included. A full thickness graft consists of full thickness of skin i.e all layers. The donor site of split graft heals itself by epithelial regeneration while the donor area of full thickness graft has to be stitched close. Composite grafts consist of multiple different tissues for example skin and fat or skin and cartilage – these may be needed for specialized indications such as missing rim of nose/ear. Split skin grafts are the commonest in use.
Are there any dermatological or other problems that may crop up on account of skin grafting? If yes, how are these dealt with?
The grafted skin does not look exactly like normal skin there is always a difference. The thicker the graft, the more natural it looks i.e a full thickness graft is superior in cosmesis to a split graft. Split grafts have a tendency to shrink and become darker. They need compression garments and massage with moisturizers for 6 months to get optimum cosmesis. Split grafts do not have hair and do not produce oil, hence always need moisturizer. The donor site also needs care for 3-6 months to prevent Hypertrophic scar.
What is the healing or recovery time from such treatment? What about scars in the treated areas? Will they be lifelong?
Skin grafts need to be immobilized for 5 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 3-6 months of after-care [see above].
What is microsurgery and when precisely is it used?
Microsurgery means surgery carried out under high magnification usually provided by an operating microscope. This is used by different surgical specialties. In plastic surgery for wounds it is used in two indications: 1. to repair fine structures like nerves or important vessels in the initial injury wound and 2. To move tissue form a distant location to the wound area for reconstruction of lost tissue especially when locally available tissue is not enough or appropriate or local flaps have failed.
What is free flap procedure and how is it different from muscle and skin flap and bone/soft tissue flap and what are the respective merits of these procedures?
Flaps transferred by microsurgery to a distant location are called free flaps. The flap may consist of different tissues such as skin, fat, fascia, muscle or bone. Accordingly it is called a free skin flap, free muscle flap and so on. The same tissues can also be moved from adjacent locations in non-microsurgical way. Usually microsurgery is more risky, more skill and time is needed and is kept reserved for special indications.
What is tissue expansion and when is this used in the treatment of wounds?
There are situations where a wound has “healed” but the local skin quality is not optimal, the scar is tight or new specialized tissue [ex: hair bearing scalp] is needed then one can use tissue expanders. These are balloons that are implanted under the adjacent donor area and progressively blown up by injecting saline every week. Once sufficient expansion is achieved, the balloon is removed and the excess tissue thus generated can be moved into the defect. Tissue expansion is thus a very useful technique to generate larger quantities of tissue that matches the requirement in quality. This is especially used in breast reconstruction and in face/scalp reconstruction
What are the points to be considered prior to undertaking P & R surgery?
This is a general question and I shall limit the reply to the patient with an acute wound.
In case of an acute wound, the patient’s general status is very important. In cases of multiple trauma, other life threatening situations take precedence over plastic surgery but a quick effective wound debridement is still important to prevent sepsis. One can always come back for detailed wound repair. Aspirin usage will increase bleeding and should be stopped, diabetes should be controlled and in the meantime detailed planning is done and the patient and relatives are involved in the discussions to get an informed consent.
Once surgery is done, how do you ensure proper circulation in the treated area?
We keep the operated part warm to promote circulation and the patient well hydrated. Sometimes drugs are also used to promote circulation but most important factors are the planning and correct execution of flap /graft procedures and proper preparation of the recipient wound to accept the graft or heal the flap without infection.
What are the signs and symptoms to look for, post treatment, for infection or other problems that may have occurred on account of the procedure?
Fever, Redness, increasing pain, smell and discharge indicate infection. Monitoring the flap color and warmth lets us know about flap circulation.
In what ages of people can P & R surgery be done? Is there an absolute minimum age?
Can be done at any age if the person is fit for surgery.
What are the contra-indication to the surgery?
Invasive uncontrolled local infection or presence of beta haemolytic streptococcus bacteria is an absolute contraindication. Poor general health, steroid usage, local radiation therapy, poor local circulation etc are adverse factors that must be carefully considered before doing local flap procedures.
What are the Do’s and Donts following surgery?
The graft and flap need time to become stronger and should not be stressed too soon. It may not have sensation and this is especially important to consider in flaps on the foot. Proper local hygiene is a must. It is most important to follow-up with physiotherapy and use proper compression garments / orthotic devices to get the best outcome. It is important to see your plastic surgeon at periodic intervals since further refinements are possible and quite often necessary at a later date.
Should there be an injury at a later date at the site of the surgical area, would it create major problems and how easy is it to treat this new injury?
Often a good flap will heal after incidental trauma. Grafts can also heal. However one must see the plastic surgeon without delay or at least consult over phone so that further trouble is avoided.