Plastic Surgery consists of two main components: Reconstructive plastic surgery and aesthetic (cosmetic) plastic surgery. Reconstructive plastic surgery refers to the restoration of forms and functions of the human body mainly after injury, tumour resection or infection. Aesthetic plastic surgery (commonly known as cosmetic surgery) involves procedures performed medically or surgically to enhance a patient's appearance based on the patient's personal choice, and not necessarily to restore forms and functions.
Managing trauma or emergency patients is an integral part of reconstructive plastic surgery. Trauma can range from a simple laceration to complex open wounds that require extensive reconstructive surgical repair. Broadly speaking, the following are the main categories of the trauma that are managed by the plastic surgeons:
Mr. Fuan Chan MD FRCSI(Plast) specialises in trauma and reconstructive surgery. He is the lead consultant for the Acute Plastics Trauma Service at Blackrock Clinic. He is also a certified Advanced Trauma Life Support (ATLS) Provider and certified by The British Burn Association in the Diagnosis and Management of Burns based on the Emergency Management of Severe Burns (ESBM) guidelines and protocols.
The following are a few examples of the broad spectrum of traumas that can be treated by plastic surgeons. Note that any of the treatment principles mentioned here are not a substitute for a visit to the GP or Emergency Department for the appropriate treatment, with subsequent referral to plastic surgeons if indicated.
The face is generally accepted as the most cosmetically sensitive area of the body. Thus, plastic surgeons are routinely called for in the management of such patients. The injury commonly occurs as a result of direct blunt or sharp trauma. More serious facial injury often results due to degloving injury or crush injury leading to severe facial deformity and soft tissue loss. These injuries usually require reconstructive surgery to re-surface the defects.
Specifically, lacerations around the eyes, nose, ears and lips require meticulous surgical apposition and repair to minimise impairment of form and function. Any slight mis-match and failure to repair the underlying deep structures such as the fascia, muscle layers, facial nerves or facial bone fractures can seriously influence the long-term outcome.
Prompt acute management and diagnosis followed by plastic and reconstructive surgery is essential. Thus, patients are strongly advised to seek plastic surgical input when suffering from facial trauma.
This type of trauma usually occurs as a result of motor vehicle accidents whereby a significant amount of impact force is directed against the face and is often associated with facial bone fractures. Head injury and brain injury are also implicated in this type of trauma.
The first line of treatment is based on Advanced Trauma Life Support Protocol* with high index of suspicion for intra-cranial injury, especially in those patients who have altered mental status. Neurosurgical input should be sought as early as possible for these patients.
Radiological investigation such as CT scans with 3D Reconstruction and accurate diagnosis should be performed for precise anatomical facial bone fracture fixation and meticulous soft tissue repair under general anesthesia.
Upper limb trauma is a very common injury referred to plastic surgeons for treatment, in particular the hands. This group of patients can be presented as a direct referral from General Practitional (GP) or from the Emergency department.
Surgical interventions range from suturing of simple lacerations to repair of tendons, digital nerves, reduction and fixation of finger bone fractures or a combination of the above. On rare occasions, replantation of the fingers or thumbs is indicated, which is technically demanding as it requires a plastic surgeon with reconstructive microsurgical skills.
Excellent surgical repair of upper limb trauma only accounts for half of the outcome success, as the other half requires a patient's commitment to regular post-op rehabilitation; whereby the occupational therapists and physiotherapists will actively work together with the patient to achieve the best optimum functional outcome. This is especially important for patients suffering from extensor or flexor tendon injuries to the hand. Digital nerve injury and finger bone fractures will proportionately increase the complexity of the plastic surgery and post-operative rehabilitation. Of note, there is excellent backup available at Blackrock clinic for post-operative rehabilitation.
The most frequent cause of significant infection is a neglected wound and delay in presentation has a significant negative effect upon recovery. Thus, early diagnosis and early intervention with intravenous antibiotic therapy guided by the microbiological analysis are likely to lead to successful outcomes. Unfortunately, some patients still require formal surgical debridement, washout and delayed reconstructive surgery following recovery from the infection.
Human bites are responsible for 25% to 30% of hand infections. This type of injury is very serious because the human saliva carries 109 bacteria per ml. In the punch bite injury, this high bacteria load can cause severe infection, usually at the knuckle area (metacarpo-pharyngeal joint), which hits the teeth leading to the breach of the knuckle joint capsule (Metacarpal pharyngeal joints). This can result in the introduction of bacteria into the joint space leading to severe joint infection if left untreated. Thus, it is crucial to have a high index of suspicion when managing this group of patients. Patients are invariably admitted and treated as early as possible with high-dose intravenous antibiotic therapy with direct input and regular updates from the microbiologist colleagues. Surgical debridement and joint washout are often required in this group of patients, especially those presenting late.
Cellulitis is an infection that involves the soft tissue. It can occur without an obvious history of trauma but usually has a history of minor cuts or penetrating injury to the hand, which goes unnoticed by the patient. Patients present with painful swelling, redness and decreased movement. The severity of the cellulitis will dictate the use of oral or intravenous antibiotics. Again, some of these patients would have presented to the GP for a course of oral antibiotics prior to the Emergency Department visit and then been referred to a plastic surgeon for definitive treatment.
Osteomyelitis is defined as the infection of the bone. Patients could present acutely or more often with recurrent painful swelling of the thumb or finger with or without discharge of pus. Patients with conditions such as diabetes are at higher risk of developing osteomyelitis. Radiological investigation can reveal the extent of the osteomyelitis. Surgical debridement and intravenous antibiotics are the main treatment for this group of patients.
Injury to a lower limb poses a severe risk of complications if not managed appropriately. Plastic surgeons often work closely with orthopaedic surgeons as recommended by the latest guidelines published by the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS)/British Association of Orthopaedics (BAO) joint committee on the management of lower limb trauma especially in severe lower limb injury with loss of soft tissue associated with open fractures of the bones of the leg.
Pretibial lacerations are another category of lower limb trauma that often involve the input of a plastic surgeon, as direct closure is often difficult or not ideal. Thus reconstruction with a skin graft, local flap or free flap is indicated to achieve healing and maintain a robust coverage of the pretibial laceration.
A good patient history and clinical examination followed by appropriate radiological investigation are the foundation for timely and accurate diagnosis of lower limb trauma.
Lower limb injury with significant soft tissue loss is a challenging wound to manage. This is because the wound needs to be reconstructed with robust tissues and the elimination of the infective process at the wound. Otherwise, the patient is at high risk of losing the injured limb. Thus, a joint care under orthopaedic surgeons and plastic surgeons is of paramount important for a successful outcome.
A burn injury is one of the most painful experiences, both in physical and psychological aspects, for the sufferer. The ordeal extends beyond the initial injury. Patients who suffer severe burns will invariably require prolonged hospital stays and are likely to need multiple surgical procedures. Thus, the burden of care for this group of patients shall not be under-estimated. Burn patients range from the youngest to the eldest in the population and occur in both developed and developing countries. Hence, raising awareness of burn prevention and fire safety is strongly advocated as 90% of burn injuries are preventable.
The skin is the largest organ of the body and has a very challenging physiology in the setting of a burn injury. The body's response to a burn can be local or systemic or both. The systemic response occurs usually in large burns (more than 20% to 30% of total body surface area of burn wounds). Burn injury can be broadly classified into thermal burn, electrical burn, chemical burn or non-accidental injury burn. However, the general treatment principles are the same with some modification of the treatment plan for different type of burns.
Key areas in the management of burn patients are resuscitation, control of infection, support of the hyper-metabolic response and early burn wound closure with skin grafts or skin substitute. It is important to be aware that patients with burns could have other potential associated injuries such as head and neck injury, compartment syndrome and limb injury. It is crucial to identify patients who are at risk of inhalation injury and circumferential burn as early as possible because late diagnosis may lead to devastating outcomes.