Craniofacial surgery is surgery to the head or face to correct a birth defect or restore normal appearance after an accident or cancer treatment. In some cases, surgeons will move soft tissue and bone from one part of the body to restore symmetry and normal appearance in the head or face. In other cases cheek or chin implants, are used.
Surgery has risks, but you can help minimize complications by carefully following your physician's instructions both before and after surgery. Discuss with your plastic surgeon the potential risks and complications.
After craniofacial reconstruction, a patient can expect to have some swelling for up to three months while the wound heals.
Cleft Lip & Palate
Facial clefts are birth defects in which the tissues of the mouth or lip don't form properly during fetal development. When the tissues that form the upper lip fail to join up in the middle of the face, a gap occurs in the lip either one side or both sides known as unilateral cleft lip or bilateral cleft lip respectively. When the palate fails to join up, a gap is left in the roof of the mouth up into the nose known as cleft palate.
Surgery to close the gap in the lip is usually first performed three months after the baby is born. Surgery to close the gap in the palate is usually done at about six- eight months old. Both operations are done with the baby asleep under general anaesthetic and involve a hospital stay of three to five days.
As the child grows older further surgery may be needed to improve the appearance of the lip and nose and the function of the palate. If there is a gap in the gum, a bone graft may be use to fill it.
Speech and language therapy may be used to monitor and develop speech. Orthodontic treatment (braces, for example) may be used to ensure that the permanent teeth come through straight and in the right place. Detailed protocol for the management of the child with cleft lip & palate will be discussed at the time of presentation prior to surgery.
Facial Bone fractures
High velocity injuries can cause fracture of the facial bones, a patient can sustain severe facial fractures with very little soft tissue injury. However, vital structures such as the brain, eyes and airway may be involved. The combined resources of a craniofacial team provide coordinated fracture management which often involves surgery under anaesthesia.
Unlike other fractures of the body, facial fractures rarely require urgent surgery, often it is performed after the swelling has subsided or more urgent issues are dealt with, that could be upto 2 weeks.
The principle is to replace the bones in its place and fix it with specially designed titanium miniplates & screws.
Chin & Cheek Augmentation are required if there is lack of definition of chin & or malar bones (cheek bones) due to either congenital cause or because of trauma. Augmentation can be performed either using a patients own bone as a graft (autologous bone graft) or moving the jaw bones forward eg genioplasty or using an implant to augment the bone (eg chin implant, malar implants). Chin implants can be done under local anaesthetic however other procedure usually involves general aneasthetic.
Jaw Surgery
During jaw surgery, a doctor surgically cuts the jaw bone and then permanently repositions it with titanium plates and screws. The procedure dramatically impacts a person’s appearance, and is usually performed through incisions inside the mouth. Distraction is a technique where the surgeon cuts the bone and then inserts a small metal spacer. After the surgery, a small metal key is used to gradually expand the spacer twice a day.
A two-centimeter expansion can take up to two weeks to achieve. After the jaw has reached its final position, the spacer is either left in place until the jaw heals naturally or the jaw is permanently set in place with titanium plates and screws.
Jaw surgery is to correct an over bite or under bite, developmental problem, or final surgery in reconstructing a cleft lip/palate. Patients typically require six months to one year of orthodontia before having jaw surgery. Additional care may be required after the surgery as well.
Cancer reconstruction
Reconstructive plastic surgeons are an integral part of the cancer treatment team. After cancer surgery, plastic surgeons are able to restore form and function in many instances. Often the plastic surgeons will do their work during the surgery to remove the cancer, though sometimes a second operation is necessary for reconstruction.
Surgery has risks, but you can help prevent complications by carefully following your physician's instructions both before and after surgery.
Because patients recuperating from cancer reconstruction surgery are also healing from surgery to remove cancer, the road to recovery can be long. Your doctor will talk with you about what to expect after the procedure.
Facial paralysis surgery
The aim of Plastic surgeon is to restore function, symmetry and appearance for those with facial paralysis, or weakness on one side of the face. They are not only treating the peripheral effects of facial nerve damage but also repairing the facial nerve itself.
Bells palsy is the most common cause of facial paralysis. The condition can impair speech, keep eyelids from closing completely, cause drooling and leave facial features drooping. Treatment may or may not be amenable to surgical treatment.
Every form of facial paralysis is different, as is every patient. Talk with your reconstructive plastic surgeon about what results you can realistically expect after your surgery. Many patients can have significant movement restored to their face, though subtle expressions may not be recoverable.
Discuss with your plastic surgeon to be sure you understand the potential risks and After the wound from your surgery has healed, your doctor may prescribe physical or occupational therapy to help regain further.
Skin cancer
Skin cancer is the most common form of cancer. Though we are all at risk for skin cancer, you are at greater risk if you are fair skinned, have a family history of skin cancer or spend a lot of time outdoors. Risk also increases with age.
There are three major types of skin cancer:
Basal cell carcinoma – This is the least dangerous form of skin cancer. It grows slowly and rarely spreads.
Squamous cell carcinoma – This form is more likely to spread and become life threatening if not treated.
Malignant melanoma – Melanoma commonly spreads and can be deadly. A new mole or a change in existing mole can be a warning sign for melanoma.
Early diagnosis is important for long-term health.
Prevention
You can lower your chances of developing skin cancer by protecting yourself from the sun. Ultraviolet rays are dangerous, whether from the sun or the artificial lights of tanning beds and sunlamp. Doctors recommend applying SPF 15 every day, wearing protective clothing, staying away from tanning beds and doing your best to avoid blistering sunburns.
The treatment involves surgical removal of the lesion with closure of the wound using surrounding skin or distant skin depending on the extent of defect.
Depending on the size and depth of the skin cancer, your doctor may able to remove the spot in the office using only local anesthesia. In some cases, more extensive surgery and chemotherapy or radiation therapy can be necessary.
Talk to your doctor about what to expect during your recovery and about what steps you can take to prevent a recurrence.
Dramatic advances have been made in recent years in treating patients with hand injuries, degenerative disorders, and birth defects of the hand. At the forefront of these advances have been plastic surgeons-specialists whose major interest is improving both function and appearance.
Hand Injuries
The most common procedures in hand surgery are those done to repair injured hands, including injuries to the tendons, nerves, blood vessels, and joints; fractured bones; and burns, cuts, and other injuries to the skin.
Among the techniques now used by plastic surgeons:
Skin/Tendon/Nerve repair
Grafting - the transfer of skin, bone, nerves, or other tissue from a healthy part of the body to repair the injured part
Flap surgery - moving the skin along with its underlying fat, blood vessels, and muscle from a healthy part of the body to the injured site
Replantation or Transplantation - restoring accidentally amputated fingers or hands using microsurgery, an extremely precise and delicate surgery performed under magnification. Some injuries may require several operations over an extended period of time.
In many cases, surgery can restore a significant degree of feeling and function to injured hands. However, recovery may take months, and a period of hand therapy will most often be needed (see Recovery and rehabilitation below.)
Carpal Tunnel Syndrome
The carpal tunnel is a passageway through the wrist carrying tendons and one of the hand's major nerves. Pressure may build up within the tunnel because of disease (such as rheumatoid arthritis), injury, fluid retention during pregnancy, overuse, or repetitive motions. The resulting pressure on the nerve within the tunnel causes a tingling sensation in the hand, often accompanied by numbness, aching, and impaired hand function. This is known as carpal tunnel syndrome.
In some cases, splinting of the hand and anti-inflammatory medications will relieve the problem. If this doesn't work, however, surgery may be required.
In the operation, the surgeon makes an incision from the middle of the palm to the wrist. He or she will then cut the tissue that's pressing on the nerve, in order to release the pressure. A large dressing and splint are used after surgery to restrict motion and promote healing. The scar will gradually fade and become barely visible.
The results of the surgery will depend in part on how long the condition has existed and how much damage has been done to the nerve. For that reason, it's a good idea to see a doctor early if you think you may have carpal tunnel syndrome.
Dupuytren's Contracture
Dupuytren's contracture is a disorder of the skin and underlying tissue on the palm side of the hand. Thick, scar-like tissue forms under the skin of the palm and may extend into the fingers, pulling them toward the palm and restricting motion. The condition usually develops in mid-life and has no known cause (though it has a tendency to run in families).
Surgery is the only treatment for Dupuytren's contracture. The surgeon will cut and separate the bands of thickened tissue, freeing the tendons and allowing better finger movement. The operation must be done very precisely, since the nerves that supply the hand and fingers are often tightly bound up in the abnormal tissue. In some cases, skin grafts are also needed to replace tightened and puckered skin.
The results of the surgery will depend on the severity of the condition. You can usually expect significant improvement in function, particularly after physical therapy (see Recovery and rehabilitation.), and a thin, fairly inconspicuous scar.
Congenital Deformities
Congenital deformities of the hand-that is, deformities a child is born with-can interfere with proper hand growth and cause significant problems in the use of the hand. Fortunately, with modern surgical techniques most defects can be corrected at a very early age-in some cases during infancy, in others at two or three years-allowing normal development and functioning of the hand.
One of the most common congenital defects is syndactyly, in which two or more fingers are fused together. Surgical correction involves cutting the tissue that connects the fingers, then grafting skin from another part of the body. (The procedure is more complicated if bones are also fused.) Surgery can usually provide a full range of motion and a fairly normal appearance, although the color of the grafted skin may be slightly different from the rest of the hand.
Other common congenital defects include short, missing, or deformed fingers, immobile tendons, and abnormal nerves or blood vessels. In most cases, these defects can be treated surgically and significant improvement can be expected.
Hand Tumours
Ganglia
Inclusion cysts
Granuloma
Soft tissue tumours
Tendon Transfer Surgery
What is Tendon Transfer Surgery?
Tendon transfer surgery is a type of hand surgery that is performed in order to improve lost hand function. A functioning tendon is shifted from its original attachment to a new one to restore the action that has been lost.
Who needs Tendon Transfer Surgery?
Many different conditions can be treated by tendon transfer surgery. Tendon transfer surgery is necessary when a certain muscle function is lost because of a nerve injury or when a muscle has ruptured or in disorders of the nervous system or in congenital absence of muscles in children.
Common nerve injuries that are treated with tendon transfer surgery are spinal cord, radial nerve, ulnar nerve, or median nerve injury.
Common nervous system disorders treated with tendon transfer surgery are cerebral palsy, stroke, traumatic brain injuries, and spinal muscle atrophy.
Common congenital conditions treated this way include hypoplastic thumbs and birth brachial plexopathy.
What happens during Tendon Transfer Surgery?
Below the elbow, there are over forty muscles. Each different muscle has a different function. For example, there are 9 muscles that move the thumb.
Each muscle has a starting point (origin), and tapers down from its muscle belly into a tendon that then attaches onto bone (insertion) in a specific place; when the muscle fires (contracts), it causes a certain motion (action).
During tendon transfer surgery, the origin of the muscle is left in place; the nerve supply and blood supply to the muscle is left in place. The tendon insertion onto bone is detached and re-sewn into a different place.
It can be sewn into a different bone, or it can be sewn into a different tendon. After its insertion has been moved, when the muscle fires, it will produce a different action, depending on where it has been inserted.
What are the risks to Tendon Transfer Surgery?
All surgery has some risk, although those risks may be small. All surgeries produce a surgical scar. Surgical incisions may develop infection.
All surgeries require the use of anesthesia, and will require a complete history and physical examination by your primary care physician to determine if you have medical risks associated with anesthesia. Evaluation by the anesthesiologist will help outline your risks and options.
When a tendon is transferred and sewn into another position, the tendon transfer will need a period of time to heal, usually about one to two months. A splint or cast may be used, followed by therapy to teach you the new tendon function. Finally, exercises will be needed to strengthen the muscle after your hand surgeon feels the tendon transfer has sufficiently healed.
You will need to follow post-operative instructions. Movement too early can lead to rupture of the tendon transfer. Movement too late can lead to excessive scarring of the tendon with resultant stiffness. Discussion of your individual case with your hand surgeon will help you further understand the risks and benefits associated with tendon transfer surgery.
Recovery and Rehabilitation
Since the hand is a very sensitive part of the body, you may have mild to severe pain following surgery. Your surgeon can prescribe injections or oral medication to make you more comfortable. How long your hand must remain immobilized and how quickly you resume your normal activities depends on the type and extent of surgery and on how fast you heal.
To enhance your recovery and give you the fullest possible use of your hand, your surgeon may recommend a course of rehabilitation (physical and occupational therapy) under the direction of a trained hand therapist. Your therapy may include hand exercises, heat and massage therapy, electrical nerve stimulation, splinting, traction, and special wrappings to control swelling. Keep in mind that surgery is just the foundation for recovery. It's crucial that you follow the therapist's instructions and complete the entire course of therapy if you want to regain the maximum use of your hand.
Radiofrequency (RF) surgery involves passage of radio waves at the frequency of 1.5 to 4.5 MHz. In case of skin lesions, the most commonly used frequency is 3.8 MHz. A radio-surgical unit consists of an electrode, a ground plate and a transformer. The radio waves generated, travel from the electrode tip to the lesion and return to the unit through the ground plate. Radio energy produces steam and vaporizes the tissue fluid resulting in cutting and coagulation of the tissues.
It generates very little heat as compared to conventional electro-cautery. This results in negligible collateral damage, resulting in faster healing and minimal scarring.
Uses of RF in dermatosurgery:
Removal of skin tags, warts, seborrhoic keratoses, syringoma, trichoepithelioma.
Removal of melanocytic naevi, telangectasias, early skin tumors.
Skin biopsies
Skin resurfacing (Radioabrasion) for acne scars, Rhinophyma etc
Dermabrasion
Dermabrasion is a surgery performed most commonly to improve scars due to acne, chicken pox, small pox etc.
As the word implies it involves abrading the skin using motorized diamond dermabrader to eliminate superficial scars. It is performed using local anesthetic block.
Immediately after the surgery the skin becomes red and swollen. There may be some pain, burning or tingling sensation that is controlled with analgesics. The swelling subsides in 3 - 5 days, a crust forms over the abraded area and the healing begins. The crust falls off and exposes the growing epithelium. It is mandatory to take strict sun protection precautions until the normal pigmentation returns completely, which may take 3-4 months.
Scar revision
Scars -whether they're caused by accidents or by surgery- are unpredictable. Many variables can affect the severity of scarring, including the size and depth of the wound, the blood supply to the area, the thickness and color of your skin, and the direction of the scar.
While no scar can be removed completely, plastic surgeons can often improve the appearance of a scar, making it less obvious through the injection or application of certain steroid medications or through surgical procedures known as scar revisions.
Keloid Scars
Keloids are dark, thick, puckered, itchy clusters of scar tissue that grow beyond the edges of the wound or incision. Keloids occur when the body continues to produce the tough, fibrous protein known as collagen after a wound has healed.
Keloids can appear anywhere on the body, more commonly over the breastbone, on the earlobes, and on the shoulders. They occur more often in dark-skinned people than in those who are fair.
Keloids are often treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching, burning and to shrink the scar.
If steroid treatment is inadequate, the scar tissue can be cut out and the wound closed with one or more layers of stitches. A skin graft (see the section on skin grafting) is occasionally used, although the site from which the graft was taken may then develop a keloid.
No matter what approach is taken, keloids have a stubborn tendency to recur, sometimes even larger than before. To discourage this, the surgeon may combine the scar removal with steroid injections, direct application of steroids during surgery, or radiation therapy. Or you may be asked to wear a pressure garment over the area for as long as a year. Even so, the keloid may return, requiring repeated procedures every few years.
Hypertrophic Scars
Hypertrophic scars are often confused with keloids, since both tend to be thick, red, and raised. Hypertrophic scars, however, remain within the boundaries of the original incision or wound. They often improve on their own-though it may take a year or more-or with the help of steroid applications or injections.
If a conservative approach doesn't appear to be effective, hypertrophic scars can often be improved surgically. You may receive steroid injections during surgery and at intervals for up to two years afterward to prevent the thick scar from reforming.
Contractures
Burns or other injuries resulting in the loss of a large area of skin may form a scar that pulls the edges of the skin together, a process called contraction. The resulting contracture may affect the adjacent muscles and tendons, restricting normal movement.
Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a flap. In some cases a procedure known as Z-plasty may be used. And new techniques, such as tissue expansion, are playing an increasingly important role. If the contracture has existed for some time, you may need physical therapy after surgery to restore full function.
Facial Scars
Because of its location, a facial scar is frequently considered a cosmetic problem, whether or not it is hypertrophic. There are several ways to make a facial scar less noticeable. Often it is simply cut out and closed with tiny stitches, leaving a thinner, less noticeable scar.
If the scar lies across the natural skin creases (or "lines of relaxation") the surgeon may be able to reposition it to run parallel to these lines, where it will be less conspicuous. (See Z-plasty)
Some facial scars can be softened using a technique called dermabrasion, a controlled scraping of the top layers of the skin using a hand-held, high-speed rotary wheel. Dermabrasion leaves a smoother surface to the skin, but it won't completely erase the scar.
Z-Plasty
Z-plasty is a surgical technique used to reposition a scar so that it more closely conforms to the natural lines and creases of the skin, where it will be less noticeable. It can also relieve the tension caused by contracture.
In this procedure, the old scar is removed and new incisions are made on each side, creating small triangular flaps of skin. These flaps are then rearranged to cover the wound at a different angle, giving the scar a "Z"pattern. The wound is closed with fine stitches, which are removed a few days later.
Skin Grafting and Flap Surgery
Skin grafts and flaps are more serious than other forms of scar surgery. They're more likely to be performed in a hospital as inpatient procedures, using general anesthesia. The treated area may take several weeks or months to heal, and a support garment or bandage may be necessary for up to a year.
Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area. The graft is said to "take"when new blood vessels and scar tissue form in the injured area. While most grafts from a person's own skin are successful, sometimes the graft doesn't take. In addition, all grafts leave some scarring at the donor and recipient sites.
Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the injured site.
Skin grafting and flap surgery can greatly improve the function of a scarred area. The cosmetic results may be less satisfactory, since the transferred skin may not precisely match the color and texture of the surrounding skin. In general, flap surgery produces better cosmetic results than skin grafts.
Though all surgeons close wounds, there are times when the special skill of a plastic surgeon is needed. Their expertise can improve healing and reduce scaring when a wound is large, jagged or cannot be covered with the skin currently at the site.
Each surgery is unique, and your doctor will talk with you about what type of wound closure option is best in your particular case.
Methods
Small wounds
While basic suturing techniques continue to be essential, surgeons today have a wide range of materials available, including:
Absorbable sutures
Adhesives
Synthetic sutures
Tape
Skin grafts
Using a graft of healthy skin from another part of the body, doctors are able to cover and close wounds where there is a lack of adjacent skin to use.
Tissue expansion
This technique allows plastic surgeons to stretch the skin and underlying tissue. First, a balloon is inserted under the skin. Then, over time, the balloon is filled with water. The process stretches the skin and soon there is enough excess to close the wound. The method is most often used in breast reconstructions, but can be useful in most parts of the body.
Flaps
During this intricate procedure, surgeons move skin, muscle and/or bone from one part of the body to another area. The flap may be kept alive with its own blood vessels or blood vessels from this flap are reattached to vessels in the new location using microsurgery. Flaps are frequently used to treat cancer and trauma patients.
VAC therapy
Vacuum Assisted Closure is a device used to help promote wound healing, through means including removal of infectious materials, fluids and wound contraction for patients with different kind of wounds, burn & ulcers.
It requires indoor stay in the hospital for 2-3 weeks until the wound condition improves and may require a surgery to ultimately close the wound.
Basal cell carcinoma – This is the least dangerous form of skin cancer. It grows slowly and
