Plastic surgery


Tendons are the noble structures that connect the muscles and the bones, allowing for the muscle contraction to turn into movement in the anatomical segments. The hand is the anatomic segment with the most tendons, which are directly involved in finger movements.

Trauma to the tendon can occur in the following circumstances:

accidental cuts (glass, knife, sword etc)
accidents in the household
work injuries while using electric shearing machinery (flex, jointer, circular etc)
important bruises or tears etc.

The hand tendon repair is done depending on the complexity of the injury and the degree of pollution of the wound, with immediate emergency (in the first hours after the accident), in delayed emergency (the first 24-72 hours after the injury) or in secondary delayed emergency (within 2 weeks from the injury).

If more than 3 months have passed after the injury, tendon reconstruction methods are already taken into account. These methods often involve tendon stretching or remodeling (called tenoplasty), tendon release from posttraumatic scars (called tenolysis), or tendon grafts, often being used the long palmar tendon, a tendon from the volar side of the forearm that can be sacrificed without notable pathological implications.

In the case of immediate repair, the techniques differ depending on the location of the injury. Flexor tendons (in the palm of the hand) that are force tendons require a special suture technique in order to hold the stress of finger movements and motions of gripping and lifting of objects of different masses.

In the case of extensor tendons lesions (those on the dorsal hand) sometimes they can heal without suturing, only splint immobilization in a cast beeing necesary for 3 weeks.

Results depend largely on the type of injury, its severity and the time lapsed since its appearance.

The reconstructive surgery of the peripheral nerves addresses patients undergoing trauma involving different peripheral nerves (median, ulnar, radial, sciatic etc). If the nerve has been damaged over 6 months prior to the intervention, the reconstructive surgery can not restore full functionality. The paresis and paralysis that sets in after the peripheral nerve's trauma may be final if the period exceeds 24 months.

Depending on the complexity of the injury, a decision is made for the urgent, delayed urgent (a few days after the injury) or secondary (a variable interval between 2 and 4 months) treatment of all the traumatized elements. Nerve repair is done by microsurgical suture under magnification and requires splint immobilization in a cast for at least 3 weeks in order for the nerve suture to scar.

If the nerve repair is secondary and the damaged nerve ends were anchored in emergency or if there are significant defects of the nerve substance, there is a need of using nerve grafts, namely using fragments of other nerves with lesser importance in the overall economy of the body, in order to restore continuity to the damaged nerve.

The restoration of the nerve path often takes more than three weeks, may last even a few months, as the injured nerve recovers at a rate of 1mm/day.

Common causes of nerve injuries are:

road or rail accidents
accidental cuts (glass, knife, sword etc)
large bone fractures, orthopedic or surgical (radial nerve lesion)
work injuries using electric shearing machinery (flex, jointer, circular etc).
important bruises or tears afecting all structures of the injured segment. In this case there is the increased risk of compartment syndrome, and even if there is no solution of skin continuity, the correct therapeutic attitude is to open all the skin and muscle fascia in order to avoid the internal compression of the noble tissues (muscles, vessels, nerves).

In case of an injury originated more than six months prior, if the lesion is peripheral and relying on electric investigations, we can try to revive the nerv. If this attempt fails, then we can choose a palliative method for partial recovery of the functionality in the affected segment.

Results depend largely on the type of injury, its severity and the time since its appearance.

DEFINITION:
Cutaneous tumor cells are defined as a conglomerate without functionality. The tumors can be benign or malignant.

Benign tumors (BT) are defined as a new unstable cellular formation with a tendency to grow slowly. Tumors may originate in any structure of the skin. They grow slowly and do not metastasize.

Malignant tumors ( MT) are anarchic cell proliferations that are able to invade nearby tissues and also spread to distant areas (metastasis).
The major risk factor for skin cancer is excessive sun exposure, especially in childhood.

Benign skin tumors can be:

Epithelial tumors (seborrheic keratosis, clear cell acantoma, keratoacanthoma, polyp, actinic keratoses)

Tumors of the connective tissue (keloid, histiocytoma, glom tumor, leiomyoma, neurofibromas, xantelasmele, dermatofibroamele, lipomas)
Cystic tumors (epidermoid cyst, trichilemal, milia, dermoid cyst)
Vascular tumors (hemangioma)
Pigmented tumors (pigmented nevi)

Premalignant lesions are defined as benign proliferations of skin structures with increased malignant potential. These are:

actinic keratosis
Bowen 's disease
Eritroplazia 's Queyrat
leukoplakia
keratoacanthoma
dermatitis irradiation
Xeroderma pigmentosum
Chronic ulcerative lesions

The malignant skin tumors are:

Basal cell carcinoma (squamous)
squamous cell carcinoma
Malignant melanoma.
Dermatofibrosarcoma.

Basal Cell Carcinoma

Basal cell carcinoma is the most common form of skin cancer (65-80 %). It originates in the basal cells of the epidermis, slowly invading the area. It rarely metastasizes. It occurs more frequently in subjects that are:

white skin, European race
males
adults
location: foto-exposed areas: most commonly the cephalic extremity (head and neck - 85%)

It commonly occurs on the face (nose, lips, forehead, ear flag), chest and appears at first as small, round, translucent nodules, covered with thin telangiectasia epidermis. Subsequently it evolves into ulcers of different sizes, covered or not with crust.

The prophylactic treatment consists in avoiding sun exposure and using sunscreen creams.

The curative treatment is represented by:

surgical excision, recurrence being common.
Mohs surgery:
ensures the extemporaneous microscopic control of the excision's margins, thus eliminating the risk of recurrence.
the cure rate is above 99% for primary lapses and 96 % for relapses, but it is a costly method.

The excision of skin tumors creates defects. These, depending on the size, depth and location can be:

primary sutured
grafted with PLD
covered with local or neighborhood flaps
covered by distance flaps or microsurgical free transfer

Squamous Cell Carcinoma

Squamous cell carcinoma is a more aggressive skin cancer. It originates in the keratinocytes. Characteristic of squamous cell carcinoma is that it has a rapid growth rate, invading the area, and that it has an increased metastatic capacity. It predominates in men, especially in smokers and immunosuppressed. It usually locates in modified skin (actinic radiation, scarring, trauma).

Predisposing factors:

genetic - skin type I, II;
X radiation,
trauma,
degenerative and inflammatory changes
chemical factors (keratosis, tar, arsenic)
inf virus (papillomavirus)
immunosuppression

From a clinical point of view, there are two types:

slow-growing: squamous papillary nodular corneum (cutaneous horn)
fast-growing: node endured, red-purple, firm ulceration that occurs early, combined with a local invasion

The treatment is surgical and consists of the aggressive excision with higher limits both in surface and in depth.

Mohs technique is beneficial in this type of lesion. Defects should be sutured directly if possible or closes by using grafts, or locoregional or free transferred flaps.
Malignant Melanoma

It is defined as an extremely aggressive malignant melanocytic, which appears in any cell capable of forming melanin. Represents 1-2% of the total number of malignant tumors and 2-5% of all cutaneous malignant tumors. Occurs more frequently in 35-50 years old men, especially on the chest, and in women especially on the legs.

The etiology is unknown. The predisposing factors are:

genetic phenotype I, II (very rare in people with dark colored skin)
preexisting melanoma lesions (30 % )
local trauma
UV radiation
immunosuppression

Clinically, the malignant melanoma appears as a hyper lesion, slightly inflamed, with poor demarcation and irregular edges, itchy and full color (from dark brown to light, erythematous). The treatment consists of a complete surgical excision which is a fundamental therapeutic approach . If the tumor is

< 1 mm – the excision around the tumor must be 1 cm
1 – 4 mm – the excision around the tumor must be 2 cm
> 4 mm – the excision around the tumor should be 3 cm

The Mohs Excision

The slow Mohs excision allows for the cancer margins to be verified, being widely accepted as an extremely valuable method in this type of lesions. Undergoing an elective lymphadenectomy is not recommended, but the biopsy of the sentinel node is performed in patients with malignant melanoma > 1 mm. If micrometastases are detected, then the complete neck dissection is performed.

Results depend largely on the type of injury, its severity and the time since its appearance.

The Cubital Tunnel Syndrome is caused by compression of the ulnar nerve at the elbow, in a defined area of bone and fibrous structures. It is wrapped in a fibrous extension of the elbow joint that gives support and stability to the joints. ( see figure 1)

If the neuritis cubits the decompression is done at the elbow and the ulnar nerve is transpositional at this level in order to prevent recurrences. The causes of neuritis cubits are most often traumatic, but can also be obesity, pregnancy and menopause, chronic arthritis etc. The scar in this case will be positioned at the anterior of the elbow, at the ulnar boundary.

Symptomatology is superimposable to that of Guyon Tunnel Syndrome, more pronounced and with implications at the deep flexors of the fingers 4 and 5. In severe cases atrophy of the interosseous space 1 may develop (between the thumb and forefinger). Coupling strength decreases.

The treatment is conservative in moderate cases, consisting of elbow immobilization and local corticosteroids. The surgical treatment is for severe cases and consists of techniques for transposition of the ulnar nerve associated with the neurolysis.

Results depend largely on the type of injury, its severity and the time since its appearance.

The Guyon's Canal Syndrome is a condition that occurs in the wrist and fingers 4 and 5 and it is caused by the compression of the ulnar nerve at the wrist ( see figure 1).

The syndrome may occur due to the development of a synovial cyst or posttraumatic. Symptoms are represented by tingling and numbness in the fingers 4 and 5. Same symptoms are present in the case of the cubital tunnel syndrome (the cubital neuritis) which is a compression of the ulnar nerve at the elbow.

Therefore it is important that the correct diagnosis is made ​​based on clinical examination, laboratory and electrical investigations.
The treatment of choice for the Guyon's Canal Syndrome is surgical and requires relieving the ulnar nerve from the Guyon tunnel. The outstanding scar has the same location as in the surgery for the carpal tunnel syndrome.


Anatomical explanation:

The Guyon's Canal is located in the wrist, around the same location as the carpal tunnel, medial to it, being limited by pisiform bone and hamate bone (bone hook). ( see figure 2 ) Above it is bounded by fibrous structures. It contains the ulnar nerve and ulnar artery.

Results depend largely on the type of injury, its severity and the time since its appearance.

Carpal tunnel is a condition that occurs in the wrist. It is caused by compression of the median nerve at this level. Symptoms are represented by tingling and numbness in the palm and fingers 1, 2 and 3, especially at night. (see Drawing 1)

The causes are unknown. It was observed that intense use of the computer (mouse) can cause this condition. Occurs more frequently in pregnant women and those entering menopause. The therapeutic solution is injections of cortisone products to alleviate the symptoms. If the patient does not respond to the treatment, than surgical relief of the median nerve in the carpal tunnel is the other solution. The hand will be immobilized in a cast splint for several days until the wound heals. The outstanding scar is located on the volar face of the hand and will have a trajectory in the longitudinal axis of the hand and forearm, about 7-12 cm long. Anatomical explanation ( see figure 2 )

The carpal tunnel is a delimited osteofibroase structure and contains most of the finger tendons and the median nerve. Any inflammation that occurs in the constituent structures can cause compression. This explains the compression of the median nerve in carpal tunnel syndrome.

Results depend largely on the type of injury, its severity and the time since its appearance.

Dupuytren Disease is a condition that occurs in the hands and fingers and consists of the retraction of the palmar aponeurosis (palmar fascia) with the appearance of fibrous strings that cause tension that will pull fix the fingers to the palm. It occurs more frequently in men than in women and usually affects both hands.

The first signs of the disease are the appearance of nodules in the palm, which evolve to the formation of retractile cable ties. The hand and finger joints (metacarpophalangeal and interphalangeal) will block at various degrees of flexion. The most commonly affected fingers are IV and V (ring and ear). Hand movements are hampered, especially in terms of grip and supporting items on your hands.


Factors favoring the occurrence and recurrence of the disease are:
alcohol
smoking
diabetes
drug treatment for epilepsy
belonging to the northern European populations

The stages of the disease are caused by the appearance of following formations:

A node may be visible or can be felt, at the base of the fingers or hands. Sometimes, it may be sensitive to touch and gradually thins and starts to pull one or more fingers toward the palm.
A hollow depression occurs on the palm, when the affected fascia (the tissue between the skin and tendons) starts pulling the skin.
As the disease progresses, one or more fibrous cords develop in the fascia that will retract the fingers toward the palm, forming what is called Dupuytren's contracture.

TREATMENT

Dupuytren Disease is a chronic progressive disorder, with frequent recurrences. In the early stages of the diseas, physiotherapy is important so the patient can maintain functionality of the hand for a longer period of time. Injections of cortisone products may relieve the symptoms but do not treat the disease, nor slows its progress. If you experience pain local anesthetics like lidocaine, Marcain etc can be administered.

The classical method of treatment is the surgery of the contractile clips. A series of long palmar incision are imagined and drawn along the volar side of the affected finger which are designed to relax the contracture and also create enough skin reserves to cover the palm defects. If the skin reserves are not enough the graft method can be used (skin harvested and transplanted on the palms or fingers).

After the surgery, exercise must be practiced in order to restore hand function.

The disease recurs after surgery in variable proportions, so it often requires a new surgery for maintaining hand function. When a new intervention is done skin reserves may be shorter. The new surgery requires other incisions and other flaps to vover the defects resulting from a new intervention.

There are alternative treatments such as strength exercises which can be associated with the surgical treatment.

The AN (aponeurotomy needle) treatment or needle aponeurosis sectioning technique consists, as its name says, the use of a needle with which the affected palmar fascia in incided. The technique is done with local anesthesia and lasts for about 20-30 minutes.
The procedure can be done in the consulting room, this method being minimally invasive. After applying the surgical treatment on the fibrous cords, the stress is relieved immediately, without the need for incisions or palmar skin grafts. Mobility labor can be resumed immediately without the need for immobilization splints or suture materials. The technique can be applied an indefinite number of times, the local skin resources remaining intact after each intervention. The tendency to relapse is somewhat higher than in the case of surgery.

The sooner on the disease's progression scale the intervention is applied, the better the results.

Although often not needed, it is usually better that after the needle aponeurotomy the patient undergoes 2 weeks of physiokinetotherapy in order to fully recover hand functionality.

The major advantages of this technique are:

can be repeated whenever needed, no matter how fast the disease recurs
can be applied even in the same segment that has been previously treated
does not require incisions, skin grafts or sutures and does not leave scars
it is not an open method, so the risk of infection is minimal
it can be successfully applied to diabetic patients
it does not require restraining the hand on a cast splint for 2 weeks in order to heal
does not cause mutilations, denervation, amputations of fingers etc., no matter how advanced the aponeurotic contracture is
it does not require an operator block
it is applicable at any age, regardless of superimposed flaws.

Results depend largely on the type of injury, its severity and the time passed since its appearance.

Whenever the skin comes into contact with objects and it is injured, smaller or larger cellular destructions occur, which will heal without a trace or will leave a scar.

Scars vary in shape, color, size, appearance, texture, elasticity etc. The healing process is the sequence of steps that through which the skin goes from injury to definitive scar formation. This time varies depending on many factors, among which the most important are genetic factors and modes of production and wound healing.

Usually, after the acute phase that lasts up to 2 weeks, during which usually the suture material is extracted, up to six months following is a period in which the newly formed scar evolves continuously. It is the period in which the scar is called "young " or "immature" or "evolving".
It has a reddish coloration and appearance is usually uneven. It is also the only time it can be influenced by creams, ointments, patches, especially silicon, massage etc.

After about 6 months a normal scar stops evolving and it will turn into a "mature" or "final" scar . The scar turns white and becomes uniform.
Described above is the physiological healing process. There are cases when scarring does not follow the physiological path and pathological scarring can occur:

Hypertrophic (greater volume) retractile (retractable clamps produce the natural flexion creases)
depression (lack of volume)
hyperchromic (colored in excess hyperpigmented)
keloid (very bulky pathological scars appear like tumors) etc.

Methods of scar treatment are:

nonsurgical (for immature scars) - endermologic massage, special applications of creams or ointments, applying patches with silicone, chemical peeling, medical tatooing, subscision etc.
surgical (for final scars) - reexcizia and direct scar suture, serial excision, use of various folded flaps for retractile scars etc.

A special category is composed by the mature hypertrophic scars for which a reactivation of the remodeling process is desired. This can be achieved by injecting cortisone products such as triamcinolone acetonide.

The scar is reactivated and it becomes reddish and increased in volume again. During this time non-surgical therapies can be applied for a better healing result in terms of aesthetics.
Surgical methods:

reexcision and direct scar suture applies to those who do not meet their aesthetic criteria and for whom their specialist can guarantee a better aesthetic result. Not all scars may benefit from such a treatment. It must be specified again that the appearance of a scar depends to a great extent on the accuracy of the cuts, the way the suture is done, the type of yarn used and the surgeons skill, but it depends also a lot on the way each of us "scars".

The appearance of a scar depends also on the path of the cuts. The cuts must follow the physiological force lines that are at various levels of the skin. Any scar disposed perpendicular to these lines of force will heal poorly and will grow wider in time.

2. The serial excision is the method by which a large scar covering a large area of skin is excised at intervals of a few months a portion so it shrinks with each step. It must be mentioned that there is no method to completely removal the scar. Even if these serial excisions can not excise the scar permanently, the overall look will greatly improve.
3. In the case of retractile scars that occur espacially after severe burns, special “tricks” are required in terms of their incisions and excision, namely the creation of folded flaps, so that we can get a retractable seating for these clamps. It is the prerogative of plastic reconstructive surgery and it brings major benefits, especially functional and aesthetic.

4. Using this method by means of tissue expansion requires using silicone implants (swelling) that are inserted under the healthy skin in the immediate vicinity of the scar area and left in place for a few weeks, up to three months. These implants will filled weekly with saline, thus obtaining "excess skin". When the specialist decides that he has enough skin to cover the scar, the second intervention takes place and the expander is removed, as well as the scar tissue and the excess skin is used to cover the postexcizional defect. The results can be very good especially if before the surgery the best areas for implants insertion are chosen, so that all lines minimize scarring. It takes sometimes several smaller implant insertions in order to “push” the scar line to a less visible area.

Although these treatments are very effective, 1% of the patients do not achieve the desired results!
Suna Acum
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