Basic plastic surgery and wound management · Suture fixation Tie – over dressing or bolus...
Transcript of Basic plastic surgery and wound management · Suture fixation Tie – over dressing or bolus...
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Basic plastic surgery and wound management
นพ.โอภาส พณไชย หนวยศลยศาสตรตกแตง
ภาควชาศลยศาสตร คณะแพทยศาสตร มหาวทยาลยเชยงใหม
กภาพนธ 2562
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วตถประสงค
• มความเขาใจความรพนฐานทางศลยศาสตรตกแตง
• น ามาประยกตใชใหเกดประโยชนแกผ ปวย
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เนอหา
• 1. การแบงประเภทของบาดแผล
• 2. การดแลรกษาบาดแผลและการปดบาดแผล
• 3. การเยบปดบาดแผล
• 4. การท าใหเกดแผลเปนนอย(fine-line scar)
• 5. Skin graft
• 6. Skin flap
• 7. Z-plasty
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1.การแบงประเภทของบาดแผล
• Abrasions
• Lacerations
• Incised wound
• Puncture wound
• Penetration wound
• Stab wound
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Scratch/Graze
https://www.tshs.eu/en/service/wound-healing/article/treatment-instruction-for-bite-wounds-abrasion-wounds-and-burn-injuries.html
http://www.wound-treatment.jp/english/index_e.htm
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Lacerations/Incised wound
https://www.123rf.com/photo_78223406_leg-has-new-incised-wound-.html https://autonomousfx.com/fx-gallery-item/deep-laceration/
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Penetration wound/Puncture wound/Stab wound
https://sc0rn3d.wordpress.com/2013/10/01/tending-to-a-puncture-wound/
https://www.drugs.com/cg/puncture-wound.html
https://www.outlanderanatomy.com/fun-fact-penetrating-wound-warning-not-suitable-for-morning-coffee/
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2.การดแลรกษาบาดแผลและการปดบาดแผล
• Examination: shape,depth,necrosis, FB, deep structure
injuries
• Preparation: hemostasis,pulsed irrigation,debridement
• Approximation
• Dressing
• Antibiotics: infection
• Follow-up: contaminated wound(24-48h)
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Pulsed irrigation
https://www.crbard.com/davol/en-US/products/Simpulse-SOLO-Suction-Irrigator
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3.การเยบปดบาดแผล
• Sutures material
• Suturing techniqes
Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014,
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Half-buried horizontal mattress suture
https://slideplayer.com/slide/6988158/24/images/27/Suture%20Techniques%20Corner%20stitch%20(half-buried%20mattress%20stitch)%20%E2%80%93%20to%20close%20a%20flap.jpg
https://accessmedicine.mhmedical.com/content.aspx?sectionid=40381509&bookid=348
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Fine-line scar
https://plasticandhandsurgery.com.au/plastic-surgery/scar-management-revision/
https://www.nhsdirect.wales.nhs.uk/encyclopaedia/s/article/scars
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Suture marks
https://www.laroche-posay.com/article/How-to-optimize-scarring-process-Stitches/a27821.aspx
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Factors?
https://areton-ltd.com/microneedling-surgical-scars/
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4.การท าใหเกดแผลเปนนอย(fine-line scar)
1. Skin tension
2. Skin eversion
3. Surgical technique or atraumatic technique
4. Skin line
5. Infection
6. Age of the patient
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7. Regions of the body
8. Length of scar
9. U-shaped scar
10. Angle of wound to skin surface
11. Type of skin
12. Skin disorders
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1.Skin tension
-Sutures tied too tightly -Lateral pull on the wound
https://www.youtube.com/watch?v=BjL1YXXGlDA https://emedicine.medscape.com/article/1824895-technique
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2.Skin eversion
https://lacerationrepair.com/wound-blog/eversion/
https://slideplayer.com/slide/7496439/
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https://www.bumc.bu.edu/surgery/training/technical-training/suturing-basics/
Simple interrupted suture
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Skin eversion?
https://www.youtube.com/watch?v=-IRKgQLDM28
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http://www.med.cmu.ac.th/dept/obgyn/2011/index.php?option=com_content&view=article&id=1098%3A2015-03-01-15-10-48&catid=45&Itemid=561&fbclid=IwAR3PtTBF4hkVrWstLNCn14RQCW_DfzcIkM073WXtzDZRydk-NXI7TeJiMhY
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Vertical mattress suture/Horizontal mattress suture
https://www.slideshare.net/Maghnani/suture-presentation-by-dr-nabeel-ur-rehman-and-dr-suneel-maghnani
https://geekymedics.com/horizontal-mattress-suture/
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3.Surgical technique or atraumatic technique
• Skin necrosis -crushed skin
-dried skin by exposure to the air
-damaged skin from forceps or hemostat
-too much tension by suture
http://www.ijps.org/viewimage.asp?img=ijps_2011_44_3_511_90844_f2.jpg
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Scar?
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4. Skin line
• relaxed skin tension lines (RSTL)
From Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014, part 1, ch1, p .2
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RSTL
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5. Infection
6. Age of the patient
7. Regions of the body
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8. Length of scar
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Dog ear deformity
Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014, part 1, ch1 p .4.
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9. U-shaped scar
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10. Angle of wound to skin surface
11. Type of skin
12. Skin disorders
https://slideplayer.com/slide/8771853/
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Windshield injury
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5.Skin Grafts
https://www.youtube.com/watch?v=yYLxfXsLqBU http://owensborohealthse3.adam.com/content.aspx?productId=117&pid=1&gid=002982
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Classification of Skin Grafts
• STSG
-thin
-intermediate
-thick
• FTSG
https://www.carehospitals.com/blog/think-tank/do-you-know-what-skin-grafts-are/
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Cutting the skin graft
STSG FTSG
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Fixation/Dressing
Tie – over dressing or bolus dressing Suture fixation
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Postoperative care of skin graft
1.การเอา hematomas หรอ seromas ออกจากใต skin graft
2.การดแลเมอมการอกเสบตดเชอของแผล
3.Hyperbaric oxygen
4. การหามเคลอนไหว ( Immobilization)
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Requirement for Survival of a Skin Graft
• vascular recipient bed
• contact of the skin graft and the recipient bed
• proper preparation of the open wound
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Characteristic of Grafted skin
1. Contraction -primary -secondary 2. Color 3. Accessory skin structure -hair growth, sebaceous secretion, sweating 4. Sensation 4. Durability 5. Growth of grafted skin
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Primary contraction
https://www.sciencedirect.com/topics/medicine-and-dentistry/split-thickness-skin-graft
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Secondary contraction
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Composite graft
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STSG/FTSG?
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Graft/Flap
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6.Skin Flaps
https://openi.nlm.nih.gov/detailedresult.php?img=PMC5288546_IPRS-06-01-g-001&req=4
McCarthy, J.G. (ed), Plastic Surgery. Philadephia , WB Sauders, 1990. Vol 1, Ch 9,p 282
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Free flap
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Direct flap from the groin
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Postoperative care of skin flap
1.Flap ตงเกนไป(tension)
2. บรเวณขวของ flap มการบดงอ (kinking)
3. flap แนนเกนไป (pressure)
4.Hematoma ใต flap
5..การอกเสบตดเชอ (infection)
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Uses of flap
1. Avascular/poor bed
2. Important structure
3 Bulk
4. Padding
5. Re-operation
6. Sensation
7. Composite tissue reconstruction
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7. Z – Plasty
• Surgical technique
https://www.saintlukeskc.org/health-library/scar-revision-z-plasty
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Charles H. Thorne, eds : Grabb and Smith’s Plastic Surgery,7th edition.
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ประโยชนของ Z - plasty
1. Increasing the length of the desired direction
Angles of Z – plasty(degree) Theoretical gain in length(%) 30 – 30 25 45 – 45 50 60 – 60 75 75 – 75 100 90 – 90 120
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https://link.springer.com/chapter/10.1007/978-4-431-56045-6_6
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2.Change direction of the scar
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U-shape scar
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3.rotate axis of tissue
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Conclusion
1. การแบงประเภทของบาดแผล
2. การดแลรกษาบาดแผลและการปดบาดแผล
3. การเยบปดบาดแผล
4. การท าใหเกดแผลเปนนอย(fine-line scar)
5. Skin graft
6. Skin flap
7. Z-plasty
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References
• Smith,J.W. , Aston,S.J., (eds) , Grabb and Smith’s Plastic Surgery, 4th ed.Boston,Little Brown, 1991.
• Charles H. Thorne,(ed), Grabb and Smith’s Plastic Surgery, 7th ed, Philadelphia, Lippincott Williams & Wilkins, a Wolters Kluwer, 2014.
• McCarthy, J.G. (ed), Plastic Surgery. Philadephia , WB Sauders, 1990.