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Plastic & Cosmetic Surgery
Plastic surgery is a very wide field has its application in rather every surgical specialty. The word “plastic surgery” has been taken from Greek word “Plastic’s” meaning “fit for molding”. This reflects the theme and basic work of specialty in best possible way. This specialty is concerned with correction of externally apparent deformities and functional deficits. By different techniques we change / mould the size, shape of or from of various tissues or parts of body to give these desired and acceptable look or to restore function e. g. reconstruction of lost nose by using bone or cartilage graft and skin flap cover, reconstruction of lost thumb, restoration of lost hand function (after trauma, never injury, tendon injury, contracture etc. ) or reanimation of paralyzed face. Plastic surgery is largely done for reconstructive or rehabilitative problems. Every procedure has aesthetic aspect as well.

“We restore, repair, make or do aesthetic correction of whole those parts ……. Which nature has given but fortune has taken away, not so much that they may delight the eye but they may buoy up the spirit and help the mind of the affected.” (Text Book of Plastic Surgery, McCarthy)

Purpose of Plastic surgeryis to restore the individual to normal whereas cosmetic surgeryis an attempt to surpass the ‘normal’ e.g. reconstruction of ‘cut’ nose is plastic or reconstructive surgery. Whereas if a person is unsatisfied with the looks of his/ her ‘normal’ nose and wants to get it changed; in that case it’s known as cosmetic surgery. Both types of works are done by same surgeon and basic principles are also the same. Cost of most of the procedures is within the limits of middle class families. Cost of surgery increases only when some implants are to be used. Details about common procedures and problems addressed by it are as follows:
Trauma
Skin Lacerations: All the injuries of face should be treated by using plastic surgery techniques so as to get better cosmetic and functional and early recovery.
Bony Injuries: Fractures of facial bones e.g. mandible, maxilla, zygoma, orbital fractures involving frontal sinus, nasal bone. These fractures tend to get sticky by tenth day so it’s always better to start treatment as early as possible.
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 staged and requires meticulous planning.
Amputation / total or partial loss of parts: Reimplantation by microsurgical techniques or as composite graft may be the modality of treatment in selected acute injuries. Reconstruction however is always in stages.
Avulsion injuries: Scalp or limbs are the usually affected parts. In most of the patients it’s possible to do early wound debridement and skin grafting. Reimplantation of avulsed scalp skin is possible in selected cases and hence it should be preserrrved (as described in microsurgery – reimplantation surgery) and brought to hospital with patient as early as possible.
Avulsion injuries: Scalp or limbs are the usually affected parts. In most of the patients it’s possible to do early wound debridement and skin grafting. Reimplantation of avulsed scalp skin is possible in selected cases and hence it should be preserrrved (as described in microsurgery – reimplantation surgery) and brought to hospital with patient as early as possible. Read More...
Maxillofacial injuries:
  • TM joint alkalosis
  • Surgery for recurrent tmjoint dislocation
  • Management of all facial bone fractures
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Hand injuries:
  • Hand injuries
  • Simple lacerations
  • Finger tip injuries – nail bed injuries
  • Tendon injuries
  • Vascular injuries
  • Nerve injuries
  • Avulsion injuries
  • Crush injuries
  • Firearm / blast injures
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Congenital problems
Clefts: one of the most common congenital deformities is cleft lip. This may be partial or complete or may be associated with cleft palate. Rarely we may see cleft of the other parts of face as well e.g. from lips to eye (oro- ocular) or from lips to ear (oro – aural). Surgical correction of cleft lip is done after the age of ten weeks. In cases of complete clefts (cleft lip & palate) lip, alveolus and part of hard palate is repaired in first stage (after age of ten weeks). Remaining part of palate is repaired at about 15 mouths of age.
Absence, hypoplasia or other deformities of nose, eyelids or other parts; congenital nevi (black spots): small spots may be removed in single stage with local skin flaps but method of tissue expansion is better for larger lesions.
Ear deformities; congenity problem may be mild (e.g. small coloboma) or severe (e.g. microtia i.e. ear is present in from of small skin fold). These can be enumerated as: absence of ear,
  • Hypo plastic ear- with or without atresia of ext. auditory canal
  • Hypoplasia of a part of ear
  • Cup shaped ear
Some of the problems (e.g. cup ear, small colobomas) may be corrected in single sitting. However reconstruction of major part of ear is always in stages. Total ear reconstruction is done after age of 7-8 years. Two important things needed for total ear reconstruction are ear framework and skin cover. Ear framework may be made from autologous costal cartilage or commercially available silicon or porex implants. Absence of ear is part of first bronchial arch syndrome and facial palsy or hyperplasia of ipsilateral facial bones may be associated with it.
  • Facial asymmetry
  • Torticollis
  • Neck folds
  • Low set hairlines
Vascular malformations or he mangiomas: modalities of treatment are sclerosant inj., local steroids in selected cases or surgery. Read More...



Maxillofacial Surgery:
  • TM joint alkalosis
  • Surgery for recurrent tmjoint dislocation
  • Management of all facial bone fractures
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Hand Surgery
Congenital deformities: Syndactyly, polydactyty, absence of thumb, constriction, and constriction rings, cleft hand, macrodactyly hypoplasia etc.
Age for surgery: as far as possible all major surgical reconstructions shout be complete before school going age so that maximum possible function can be achieved during development period.
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Micro surgery
Incised orlacerated wounds on wrist or forearm are associated with tendon or neuron- vascular injuries. These neuron- vascular injures need to be repaired under magnification. Results of primary repair are always better. With the help of microsurgery we can not only do reimplantation but also we can transfer certain body tissues (free flap ) along with their blood and nerve supply (optional) to other parts of the body according to requirement. This method is used for transfer of vascularized skin or muscle flaps.
  • Peripheral nerve injuries
  • Vascular injuries
  • Recanalization of fallopian tube or vas
Reimplantation surgery: amputated part should be cleaned, wrapped in moist saline gauge and put in a dry polythene bag. This bag should be put in another bag containing ice. Ice should never come in direct contact of amputated part. Amputated part should neither be frozen nor water logged. Patient must be sent to a referral center as soon possible. Bleeding from major vessels should be controlled by local pressure. As far as possible, hemostat, ligature or proximal tourniquet should not be applied. Re- implantation is usually not possible in cases of crush injuries. However it’s better to refer a non- candidate then to miss a deserving candidate.
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Urogenital surgery
Congenital:
Hypospadias:it may have other associated anomalies also. Surgical reconstruction should be complete before school going age. Single stage repair is possible in distal penile or selected cases of mid penile varieties.
  • Epispadies
Vaginal agenesis: in most of these patients uterus is rudimentary or absent vaginoplasty is preferably done approximately one to two years before marriage is planned.
  • Ambiguous genitalia
  • Chorded without hypospadias
  • Acquired
  • Urethral stricture
  • Fistula
  • Penile or vaginal reconstruction
  • Lymph edema (scrotal & penile).
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Burn injuries

May be due to fire, contact with hot objects, chemicals or electric.

Fire Burns with more than 15% body surface area or deep burns need hospitalisation.

Minor burns may be treated on out patient basis.

Acute burns:
Indications of hospitalization:
  • 15% total body burns,
  • 10% burns in children or old adults
  • 5% full thickness burns
  • Burns of hands, feet, face, eyes, ears or perineum
  • Suspected inhalation injury
  • All electric and chemical burns
  • Any associated injury
  • Any pre- existing illness.
First- aid:
  • Remove the person from further danger.
  • Neutralize chemicals- water in copious amounts is good.
  • Specific agents:
  • For acid – 3% sodium bicarbonate.
  • For alkali – 1% acetic acid (vinegar).
  • Phosphorous burns – keep wet at all times, irrigate with 1% copper sulphate.
  • Hydrofluoric acid – apply calcium gluconate get.
  • Wound – cover with a clean wet towel.
  • Fluids – major burns – nil by mouth; start an i/v line by 18 g cannula.
  • Analgesia – narcotic analgesics best suited for burn patients.
Evaluation of the abs’s:
Airway – breathing – circulation
Indication for referral to a burn specialist:
  • 20% second degree burns,
  • All deep burn
  • Respiratory burn
  • Electric burn
  • Chemical burns
  • Associated injuries.
Aims of treatment:
  • Prevention & treatment of shock
  • Prevention of complications
  • Closure of wounds
Other important considerations:
  • aintain and preserve body function and appearance as far as possible
  • Healing in least possible time with minimal scarring
  • Mental and emotional stability of patient and family members.
In the field of burn management focus has been on development of techniques so as to achieve complete healing of injuries and return of the patient to his/her schedule in possible time so as to save the valuable time &money and to avoid the psychological trauma and agony to patient and his/her family members. All this has been possible because of the better understanding of –
  • Avoidable causes of infections
  • Factors responsible for delay in wound healing
  • Factors leading to fibrosis & scarring
  • Importance of early provision of healthy skin cover &
  • Importance of early mobilization.
Trend now a day is of management of deep burn injuries by
    early excision of burn wound and skin grafting
wherever possible. The superficial burns almost always (unless infected) heal without any significant scarring in two to three weeks time. Deep burns need specialized management so as to treat the deep burns by dressing & dressings & dressings … until the granulation tissue is fit to accept skin graft. Granulation tissue gradually matures into fibrous tissue that is the precursor of the most of the ill effects of burns. This can largely be avoided by early excision of deep burn areas and at the same time by providing cover by split skin graft. This should always be considered for deep burns on hands, neck, and face& across flexor aspect of joint surfaces.
Post burn scars, contractures, other deformities and disfigurements
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Cosmetic surgery
At times people are dissatisfied from their looks or body shape that may be changed by means of cosmetic surgery. These problems may be congenital or acquired with aging e.g. depressed or parrot beak shaped nose, facial wrinkles, sagging breasts, disproportionate fat deposits etc. one of the main aims of cosmetic surgery is to restore the mental health of the person thus permitting return to social participation.
Rhinoplasty (change in shape of nose): for broad, depressed, deviated nose, parrot beak shaped nose, acquired defects or other unsightly problem. Incision/ scar is almost always inside the nose and doesn’t show up. Hospitalization is usually needed for a day.
Genioplasty (change in shape, size of chin): for disproportionately protruding or recessed chin. Incision/ scar is almost always inside the mouth and doesn’t show up. Hospitalization is usually needed for a day.
Otoplasty (change in shape, size of ear): for large, prominent or cup shaped folded ears. Scar is usually behind the ear.hospitalisation is needed for a day only.
Facelift, browlift and necklift: for aging face – to correct wrinkles & sagging skin of face, neck and sagging eyebrows.
Blepharoplasty: for correction of sagging eyelids or wrinkles on eyelids.
Mammoplasty (change in size shape of breast):
Breast augmentation -
For underdeveloped and small breasts that may be a cause of lack of self – confidence and depression. It’s done by silicon prosthesis and it doesn’t interfere withbreast – feeding at all.
Breast augmentation – for underdeveloped and small breasts that may be a cause of lack of self – confidence and depression. It’s done by silicon prosthesis and it doesn’t interfere with breast – feeding at all.
Brest reduction –for hyper plastic, large, poetic breasts, which not only look awkward, but are also a cause of shoulder, neck and back – ache.
Breast reconstruction- it’s neededinpatients of breast cancer whose disease has been cured or in some girls with congenital absence or hypo plastic breast. Reconstruction is done by flap from abdomen or back with silicon prosthesis.
Gummy smile (exposure of gums while smiling): in few persons upper teeth and gums are excessively visible while smiling. This can be corrected by a day care surgery.
Congenital black spots (nevus), moles: excision of small nevi or the area. Tissue expander is an useful device for better results in these situations.
Change in size of lips:
Reduction –for overly thick, unsightly lips. It’s an outdoor procedure and scar is always inside the lips.
Augmentation- usually done by lip filling and is a day – care surgery.
Scar revision: revision of most of the facial scars is an outdoor procedure and hospitalization is usually not needed. However in case of large scars which can’t be removed under local anesthesia, hospitalization for a day may be needed. We should remember that “once scar, always scar; it’s quality can definitely be improved “. At times it may be possible to vanish a scar but it’s not the usual story.
Post acne scars: these scars need correction by dermabraision. Sun exposure has to be avoided for 3-4 months after surgery.
Post burn scars: deep burns if left to heal by secondary intention always leave scars. Modalities of treatment vary according to size, sight and nature of scar. Lange scars on face are best managed by tissue expansion.
Baldness: surgical options for correction of baldness are hair grafting, scalp flaps or tissue expansion.
Vitiligo / leucoderma: surgical option is adopted only in cases where lesion has been stationary in size for at least last two years. Small facial sport may be excised and defect repaired by suitable plastic surgery procedure. Larger lesions elsewhere on body are managed by excision and skin grafting. Tattooing is good alternative and gives satisfactory results in experienced hands.
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