Most important role of plastic surgery is in injuries involving skin, muscle, tendons, nerves, vessels, facial bones. Reconstruction of damaged or lost structures is better done by principles & techniques of plastic surgery. Plastic surgeons are an important part of a trauma management team. Role/services of plastic surgeon are essential in restoration of form or function of different parts, especially of face, hand, neuro-vascular injuries, injuries of lower limb associated with skin loss and burn injuries. Plastic surgeons are better trained for management of skin, nerve, vascular, tendon and muscle injuries. Plastic surgery is basically reconstructive surgery that may be related to any part of body from head to toe; be it loss of scalp, cranium, facial fracture, hand injuries, avulsion injuries or compound fractures. Aim in trauma management is early healing.
Aim is to achieve healing by primary intention so as to minimize scaring. Healing by primary intention means that after injury, wound is repaired by surgical means so as to close the gap between damaged tissue margins. 1a, 2a, 3a, 4b, 4c, 14a, 15a 16a, 17a, 18a, 78, 78(2) etc.
If a wound is treated by dressings only, the body’s own defence mechanisms gradually clean the wound and this gap between tissue margins slowly gets filled with granulation tissue (red vascular tissue) 3b, 3i (Deep burn wound where few area have been cleaned and covered with red granulation tissue where as in some areas there is still dead skin (white areas) present). With the passage of time this granulation tissue shrinks thus reducing the wound size. Together with this process, skin cells from the periphery of wound margin migrate toward center of wound to cover the granulation tissue (3j). Ultimately both these mechanisms together are responsible for healing of wound. This is known as healing by secondary intention. In smaller wounds this will lead to ugly scar 84 but may not produce noticeable deformity. However in larger wounds or wounds across joint surface contraction will hamper movement of the affected joint (3j, 3jj)
Physical trauma may lead to –
Abraision – may be superficial skin loss (that heals with dressings only without leaving any scar) or deep skin loss that may need some surgical intervention depending on situation.- photo
Laceration – of skin only or may affect underlying structures to variable extent, photo
Tissue loss – skin or underlying structures, photo
Bony injuries – Fractures of face and hand bonews are treated by plastic surgeons. phot<
Facial injuries: 3e, 3f
Face is our most important means of identity and interaction in society; also it houses all the five sense organs of body. Goal of management is restoration of
  • Appearance and
  • Function
that is so much important for any person. Patient’s sagging self-esteem and his faith in treating doctor gets restored only after his acceptance in social life without any adverse remark that many times comes from his/her family members only. There may be injuries to soft tissue only, facial bones only or both. Apart from good management of injuries psychological support of patient and at times his/her immediate relatives is must. They must have patience and must realize that treatment is not like magic. Recovery and scar maturation take time.
A small cut may later turn out to be a cosmetic blemish. Suturing of simple facial wounds is not a job to be done in outdoor clinics with relatives holding a crying child and doctor putting stitches with local or even only vocal anesthesia. In cases of polytrauma priority of management depends on general condition of patient and other associated injuries. Maintenance of airway, control of bleeding and management of shock always take precedence. Most common cause of major facial injuries is motor vehicle accidents. Minor injuries are usually result of outdoor sports, domestic accidents or altercation. Injuries may be in form of abrasions, lacerations, contusions, incised wounds, maxillofacial fractures, partial or total loss of parts of face (nose, ear, lip, eyelid) or burns. Deep lacerations may be associated with facial nerve, salivary duct or even salivary gland injury 7a. A black eye 7b nd subconjuctival haemorragea photo 1 must arouse suspicion of fracture zygoma or orbit similarly as a nasal bleed indicates injury inside nose that may be any laceration inside or nasal bone fracture or even fracture of upper jaw bone (maxilla). Numbness of upper lip is usually seen in fracture zygoma and maxilla, as that of lower lip is associated with fracture of body of mandible. Improper dental occlusion 7c is hallmark of fracture of jawbones ie maxilla and mandible. Trismus (difficulty in mouth opening) is associated with fracture of zygoma, maxilla or mandible. Diagnosis of facial bones fracture is always clinical. X-rays of face AP view or lateral view are usually not helpful; rather x-rays in other special positions (Water’s view, Panoramic view, oblique views of mandible) are needed for confirmation and treatment planning.
Nasal bones, mandible and zygoma are the most commonly affected bones followed by maxilla and frontal bones in decreasing order of incidence. History of any impact on chin / chin laceration with tenderness in preauricular region may be associated with fracture of mandibular condyle or temporo-mandibular joint injury. If not treated this may lead to ankylosis of the joint 7k, 7m.
Over the past years there has been tremendous change in management of facial bone fractures. CT scan especially 3D CT gives a very good view of facial skeleton and is the best tool to map out bony injuries. Open reduction and fixation of facial bones by miniplates and screws obviates the need of keeping
mouth closed by inter maxillary fixation in majority of cases. Facial fractures tend to get sticky in about ten days time and so should be tackled early.
One must remember that no surgery is 100% free from scars. Once there is breach in continuity of skin it will unite only by scarring. The job of plastic surgeon is to minimize and camouflage the scars as much as possible. Scarring depends on many factors such as magnitude of trauma, type of wound, type of skin, age of patient, genetic predisposition of person for scaring etc. Restoration of facial bony framework is always given priority over treatment of facial wounds. Facial scars can be managed at a later date but it’s difficult to treat a malunited fracture.
Skin lacerations: All lacerations of face should be treated by using plastic surgery techniques so as to get better cosmetic and functional results and early recovery 3g, 3h, 1a, 2a, 2b, 2c. If these lacerations are left to heal by dressings only, scar will be like a wide line as in photo 3a. If laceration is repaired by ordinary suturing there may develop cross hatch marks of sutures as shown in photo 4a, 4aa. Surgical repair by plastic surgery techniques usually gives results as in photos 2a and 3h.
Management of wounds especially facial and hand is no longer governed by rule of 6 hours though earlier the repair better it is. At times in badly contaminated wounds, repair may need a stage of debridement before final skin cover. Correction of lacerations may be simple straight line closure or may need some plastic surgery procedure like Z – plasty, W – plasty etc so as to give final scar line parallel to skin creases.
At times there is skin loss associated with laceration. In cases of road accidents, wounds are usually contaminated with gravels, dust etc. In a contaminated wound, first stage surgery is debridement only (as early as possible). Second stage surgery is performed after some time, usually 24 or 48 hours later, with relook debridement and skin replacement. Photo 2d, 2d 2, 5a, 6a, photo of ssg on chin, ….
Bony injuries: Gross facial swelling and bruising 7b after injury usually means underlying fractures of facial bones e.g. mandible (lower jaw), maxilla (upper jaw), zygoma (cheek bone), orbital fractures, fractures involving frontal sinus (sinus in middle of forehead), nasal bone. Facial bone fractures lead to facial contour irregularities and disfigurement.
Jaw bone fractures (upper as well as lower) are associated with malocclusion (loss of appropriate relationship between upper & lower teeth <7c).
Nasal bone fracture is the cause of bleeding from nose and depression 7f or deviation of the nose.
Cheek bone (Zygoma) fracture leads to depression 1 (deformity is very obvious), loss of sensation (numbness or feeling of heavyness) on upper lip and difficulty in opening of mouth
These fractures tend to get sticky by tenth day so it’s always better to start treatment as early as possible.
Forehead fracture 7f usually involves underlying sinus and must be treated in time otherwise this may in future be a cause of osteomyelitis (infection of bone) 7g, 7h, 7j. Untreated forehead fracture (if not infected) will lead to odd looking depressed forehead 7e.
Firearm or blast injuries: These injuries are always associated with extensive tissue loss (soft tissue as well as bony) and wound contamination. Reconstruction in such injuries is always in stages.
Amputation / total or partial loss of parts: Reconstruction of lost parts is always staged procedure 7o, 7p, 7q 7r 7s, 7u, 7uu. Reimplantation by microsurgical techniques or as composite graft may be the modality of treatment in selected acute injuries.
Avulsion injuries: Scalp or limbs 78, 78 (2) are the usually affected parts. In most of the patients it’s possible to do early wound debridement and early replacement of skin (skin grafting). Wound debridement is done as early as possible after resuscitation. After 24 or 48 hours, again relook debridement and skin grafting is done.
Reimplantation of avulsed scalp skin is possible in selected cases and hence it should be preserved (as described in Microsurgery- reimplantation surgery) and brought to hospital with patient as early as possible.
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