CONGENITAL
HAND
LOWER LIMB
Genital SurgerY
EYES
COSMETICS
KELOID
SCAR REVISION
RHINOPLASTY
FACIAL AUGMENTATION
BREAST
FACE
TMJ ANKYLOSIS
This is a common birth defect seen in @1 in 900 births. Here, there is a discontinuity in the upper lip or the palate, in various combinations.
Though emotionally very traumatic to the parents, with proper and timely intervention by a well trained plastic surgeon, these deformities can be corrected with minimal residual disabilities.
Usually a cleft lip child is operated at 3 months of age, when he has attained weight of at least 6 kg’s, with a hemoglobin of @ 10 gm %.
The palate is repaired at the age of 13 – 14 months before the child starts speaking.
Once the child is older he may require bone grafting for the alveolus at 8 – 10 years of age and a nose correction at 18-20 yrs of age.
Children with cleft palate may have to undergo speech therapy sometimes to help them attain normal speech.
Presently, our hospital is involved in the “SMILE TRAIN PROJECT”, providing free cleft surgeries to the poor and deserving patients below 18 yrs of age. This project is funded by the SMILE TRAIN Organization, based in the USA. For more details and for donations please visit their site www.smiletrain.org.
This is a condition seen to be on the rise in our population too. This presents as tingling sensation in the hand, more so in the index and middle fingers, which may or may not be associated with weakness and hand fatigue.
This is caused by compression of one of the nerves supplying the hand, at the wrist. Commonly seen because of repetitive movements at the wrist, like in people working on computers for a long time
Treatment involves splinting in the early stages or a surgical decompression at the wrist. Early treatment prevents any permanent nerve damage.
Hand is a very important part of the human body and any injury or disability to this causes a lot of morbidity. Hand injuries are on the rise nowadays and are mainly related to industrial accidents or road traffic accidents. In both cases the injuries are usually complex, requiring multiple procedures to repair the skin, tendons, nerves and bones.
Many a times a small glass cut injury of the hand may have underlying nerve injuries or tendon injuries and if not recognized and treated at the time of injury, may lead to permanent disabilities.
Sometimes the hand or limb may be totally severed from the body and needs to be reattached. This is known as ‘Reimplantation’ and involves reattaching the bones, nerves, tendons and vessels, usually done under the microscope. If brought within 4 –5 hrs of injury these parts can be replanted back, provided they are not badly crushed or in multiple pieces.
Similarly, sometimes fingers may be crushed or lost. In such cases if not replantable, at least the thumb has to be reconstructed to provide function to the hand.
The Hand is indispensable and needs to be repaired
and taken care of properly by a plastic surgeon to provide good adequate
function and form to the hand.
With the increase in vehicular traffic, the rate of accidents has also increased resulting in severe trauma to the lower limb. These again are complex injuries and require proper management by an orthopaedician and a plastic surgeon right from the outset, working as a team, to help the injury heal faster and with minimal disability.
If the exposed structures are not covered with good vascular viable tissues soon, then these structures like the bone, tendons and nerves, get infected or die resulting in permanent disabilities.
For this various procedures ranging from skin grafting to local flaps or micro vascular free tissue transfers are used, depending on the given case.
The first aim is to preserve vital structures and provide function, aesthesis is secondary. But once stabilized secondary procedures can be done to improve the aesthesis also.
This is a birth defect affecting males, where in the child passes urine from the undersurface of his penis, instead of the tip.
This is a correctable condition, where a new tube has to be made to replace the defect, to help the patient pass urine from the tip. If done properly with attention to detail, by a well trained plastic surgeon, the results are very good. The procedure is usually done at @ 3 yrs of age, just before the child goes to school.
This is a procedure done for cases with congenital absence of vagina. A new vagina is created and lined with a skin graft. The procedure is done preferably just before sexual initiation or before marriage.
This is a condition where, there is drooping of the upper eyelid, which covers the pupillary area thereby affecting sight, apart from being a cosmetic deformity too. Sometimes if severe, has to be operated soon to prevent permanent loss of vision in the eye. The corrective procedure involves shortening the muscle responsible for lifting the eyelid.
This involves correction of the ‘Baggy Eyelids’, seen with ageing. Corrected by incisions below the eyelids, where excess skin and fat are removed to correct the deformity. In milder cases, injection of filler materials like collagen, can help correct the deformity.
The first visible signs of aging appear in the face. Usually consultation is sought by the patient to improve facial skin quality and to tighten it. Sagging of forehead skin, sagging of cheek fat, prominent nasolabial folds (crease between the cheek and the lip) and jowling (skin folds hanging by the sides of the jaws) are the signs which one sees.
Face-lift is a procedure done to tighten the facial and neck skin producing a youthful appearance by effacing the deep folds. The incision or cut is hidden behind the ear and within the hairline.
This is a type of limited face lift where only the forehead skin is tightened. This can be done via a incision within the hair bearing area or by endoscopy. Sometimes only a muscle division can help by reducing the frown lines in the forehead. This is permanent as compared to BOTOX injections where the result is temporary and the injection has to be repeated.
FACIAL AUGMENTATION
Sometimes there may be isolated facial deformities which need correction by fillers like bone , soft tissue in the form of fat or dermafat grafts or artificial material like MEDPOR or SILICON.
The most common augmentations done are for the hollowness of the cheeks, to make the chin more prominent and for nose augmentation.
This involves sand papering the skin and is almost similar to sand papering wood to make it smooth. Here the superficial layers of skin are sanded off and the skin is allowed to heal by itself. It is usually done for superficial imperfections of the skin like superficial acne scars or tattoo’s.
Patients with darker skin and with deeper lesions are not good candidates for dermabrasion. After dermabrasion, patients have to avoid exposure to direct sunlight for the next few months.
In some individuals the lips are very thin or aging can thin them out. The flattening of the lips produces an effect of lengthening of the distance from the base of the nose to the lip border. Lip enhancement in such cases increases the lip volume to give better definition to the lip contour and also to enhance their overall appeal and sensuousness.
Usually filler materials can be used or fat injections, taken from the persons own body can be used. The only problem with fat injections is the fact that when the individual puts on weight, the fat in the lip also increases in size.
Liposuction means removal of fat by loosening & sucking out fat with the help of a suction apparatus.
Body contouring involves either one or both the above mentioned procedures.
Fat collections around the hips, thighs, buttocks, abdomen, arms, under the chin, upper chest, etc. can be reduced by this procedure.
Liposuction is neither a substitute nor a cure for obesity and is more useful for contouring by removal of fat from a particular area. But there is an overall reduction in body weight.
Persons with mild to moderate obesity with healthy elastic skin or patients with localized collections of fat in certain areas get the best results after liposuction as the healthy elastic skin shrinks after the removal of fat from those areas.
People having loose skin like after losing excess weight, in old age, after multiple pregnancies, need excision of the excess skin to get a satisfactory contour are good candidates for lipectomy.
The fat cells removed, are removed permanently & do not come back again. The number of fat cells present in a person’s body remains constant. When he gains weight the size of the fat cells increases & when he looses weight the size decreases.
The procedure is performed under general or spinal anesthesia. A small cut of 0.5 – 1 cm is made a few inches away from the area to be suctioned usually within skin creases so that they are not noticeable. Then suction cannulae are inserted & fat is sucked out. Anywhere between 500 to 3000 gms. of material can be removed at one sitting. The removed material usually consists of 65 – 85% fat & the remainder being blood, plasma, etc.
After the Surgery:
Snug or tight compressive dressings are applied for 6 – 8 days to help in shrinkage of the skin & to decrease swelling. In most instances, the patient will be required to wear a support or girdle for several weeks to months during the healing period. One might feel localized areas of hardness or firmness in the suctioned areas for 2-4 months following surgery.
Pain is usually present for a day or two after surgery. During the healing period, numbness or discomfort may be present for variable periods of time. Swelling takes 2-3 weeks to come down & it takes 2 – 4 months for the swelling to completely disappear. Sometimes discoloration may be present which may last up to several weeks following surgery.
Results:
Results depend on the expectations of the patients and the amount of fat that is suctioned out. Usually patients with good elastic skin & those who come for limited recontouring are very happy. Older patients & grossly obese patients may not be very happy with the results. Perfection & symmetry are aimed for but are not possible in every patient. Also in some patients all unwanted fat cannot be removed in one sitting, in these patients, the procedure may have to be repeated, but only after all swelling resolves anywhere between 3 – 6 months}.
Rarely rippled or uneven skin or areas of loose skin could result which might require further surgeries to correct them.
The main cause of baldness is heredity and it is a continuous process. There are different methods to treat this condition depending on the individual patient.
Hair transplant is one such procedure where a strip of skin is removed from the back of the head. Under magnification this strip of skin is sliced into small pieces, each containing 1 or 2 hair follicles. These are then transplanted into the bald area. The defect at the back of the head is closed. The implanted hair is covered with a dressing for 3 –4 days. It takes 7 – 12 days for complete healing. Usually the transplanted hair falls off and new hair grows subsequently. This hair is permanent. Usually requires 2 – 3 sittings depending on the area to be covered, to provide a good concentration of hair.
But, as the hair loss is a continuous process, the original hair of the patient continues to fall leaving areas of baldness in between, which have to be grafted.
In cases of extensive frontal baldness, a skin flap from the side or back of the head is moved to the front with the base still attached to provide blood supply to this hair bearing skin. The hair in this method is denser and grows right from the start. But, some patients may develop a noticeable scar at the entire front hairline.
Scalp reduction or Alopecia reduction is a procedure where the bald area is removed in longitudinal strips at intervals, thereby slowly moving the hair bearing area into the center. Another method is by the insertion of tissue expanders. These are balloon like implants, which are inserted under the hair bearing skin and inflated with water for the next few weeks. Once the hair bearing area is sufficiently expanded, the Alopecia is excised and the expanded skin advanced to cover the defect.
Scars are always present following a cut by surgery or due to any injury. Scars never vanish but they do fade over a period of time. The amount of scar varies from individual to individual due to various factors like person’s age, heredity, race, skin characteristics and the type, direction, location and depth of the wound.
Scar revision is done to make an old and conspicuous scar look better or less noticeable. This is done by removing the old scar, making a new thinner scar and one that is in line with the natural skin creases and hence not readily visible.
KELOID
Keloid is not a normal scar. It is a scar that keeps on growing. Usually there is a tendency in some individuals to from keloids. Some areas like the ear lobes, anterior chest wall and shoulders are common regions for keloid formation. These are usually treated with Cortisone injections given inside the scar and by compression therapy. In spite of this treatment some of the keloids may recur.
RHINOPLASTY - Recontouring of the nose
Rhinoplasty is one of the most common operations performed by cosmetic surgeons today. This procedure is designed to improve the appearance of the nose & involves any or all of the following procedures:
- Reduction of forward projection of the nose
- Removal of humps
- Correction of deviation of the nose
- Narrowing of the bridge of the nose
- Narrowing the tip
- Reduction of nostril size
- Correction of depressed nose
Many patients feel that the change in shape will be so much that it might be the subject of discussion amongst family & friends. But, in reality neither the patient nor the patient’s relatives or friends really remember the original shape of the nose a few weeks after surgery.
The operation is performed in the hospital usually as an inpatient procedure. It takes anywhere from 1 ½ to 3 hours for the procedure, depending on what has to be done. The stay in hospital may be 1-3 days.
The operation is done under anesthesia. The incisions for rhinoplasty are usually made inside the nose. The nasal skin is lifted away from the cartilage & bones. Then the necessary modifications to the skeleton (bones and cartilages) are made. The excess skin redrapes itself onto the new framework.
For depressed noses, augmentation is done by inserting either cartilage from the nose / ear or bone from the rib / hip or silicone implants.
Sometimes if the chin is smaller or disproportionate as compared to the nose or the face as a whole chin enlargement might be needed which can be performed simultaneously
Pain after surgery is moderate & usually decreases in 24 – 48 hrs. Immediately after surgery a splint is applied to the nose, which will remain in position for approximately 5-7 days. The nose will be packed from within for 2-3 days & the patient has to breathe through his mouth. Even after removal of the pack the patient may feel his nose to be congested for several weeks following surgery because of the internal swelling, which will gradually abate.
Some results of the procedure are readily apparent when the splint / dressing is removed. But, it takes 8 – 10 weeks for the proper result to be seen. Even after that minor changes occur over a period of 6 – 8 months.
Abdominoplasty is a procedure designed to remove the excess sagging skin of the abdomen & at the same time the abdominal wall muscles are also tightened to restore the tone lost during pregnancy.
So, this operation is helpful for women with relaxed loose abdominal skin after having children or losing excessive amounts of weight. Sometimes this procedure may have to be combined with liposuction.
In these cases, usually the umbilicus is replanted in the upper abdomen after excising the excess skin, unless a mini abdominoplasty is done.
NON-SURGICAL FACIAL REJUVENATION:
This procedure is useful to correct early signs of aging in the face. These may be in the form of deep frown lines, crows’ feet at the corner of the eyes, hollowness below the eyes and below the cheekbones.
The procedure involves injection of materials known as ‘Fillers’ like COLLAGEN, DERMADEEP, RESTYLANE or PERLENE, to augment the area and give a youthful appearance. This is done as an out patient procedure. The effects last anywhere between 6 – 9 months after which the procedure has to be repeated. But, the upside is that there is no hospitalization and it is not an open surgical procedure. Patients can go back to work even the next day.
Body piercing has been in vogue in our culture from times immemorial. But now it has moved to a different level with people becoming more adventurous and wanting to make a statement. The common areas being the ears, nose, navel, etc.
Though this is a simple procedure, it has to be done with proper knowledge of the anatomy and under proper aseptic conditions to prevent any complications. The most common complication is a keloids formation and the second being infection.
Infection in the ear cartilage is a devastating complication as the whole ear cartilage could die leaving behind a shriveled, deformed ear.
This is a procedure some to improve the contour and projection of the breast. Usually done for cases where there is absence of breast since birth or when the breast size is small or after childbirth when the breast loses its volume.
Here, a prosthesis or implant made of silicone is inserted into the breast under the chest muscle. This can be done via a circumareolar incision (around the dark skin surrounding the nipple) or via an incision in the axilla. Larger implants require an axillary incision. The procedure is done under general anesthesia and requires hospitalization for 2-3 days.
There are limitations with regard to the size the breast can be enlarged. It depends on the amount of available skin in the area. As the implant is placed behind the muscle, it does not interfere with the normal functions as breast feeding and does not interfere with the normal examination of the breast. There is no recorded increased evidence of breast cancer after insertion of silicone implants.
If there is excessive sagging of the breasts, breast tightening or reshaping – “ Mastopexy”, is combined simultaneously with the breast enlargement.
Of breast is done in cases where the breast is too big for the stature of the patient or when the size is causing problems like difficulty in walking or back pain, etc.
Usually patients are young females having large breasts because of overgrowth and this is a cause of emotional distress to them.
Done under general anesthesia, the whole breast size is reduced and the nipple areola complex is moved up, to point forwards and up, rather than down. This procedure in normal course does not interfere with lactation or pregnancy related changes.
Breast reconstructions are a very important part of the rehabilitation of a patient of breast cancer. It is a major psychological trauma, which the patient undergoes when she loses her breast and reconstruction can help alleviate this problem. As the incidence of breast cancer related surgeries is on the rise, so also the reconstructions.
The reconstruction is done using muscle flaps from the back or from the abdomen to form the new breast. If good skin cover is present, silicone implants can be used for reconstructions. The nipple and areola are usually reconstructed at a later date.
Reduction Gynaecomastia ( Male breast reduction):
In some boys during puberty and adolescence, breasts develop to notable sizes. This can be a cause of psychological problems and causes the boys to be embarrassed to remove their clothing in front of others.
But, in most cases the breasts reduce to their normal sizes in 2 – 3 yrs. In some, it persists requiring surgical correction. Sometimes, even in adults this may be present because of hormonal imbalances.
`Gynaecomastia may be of the glandular or fatty type. The glandular type is usually present beneath the nipple and areola, the fatty type being more diffusely spread. Usually both types are present in varying combinations.
The glandular type is removed by an incision or cut around the areola. The fatty element can be removed by liposuction through the same incision. After surgery a pressure dressing is needed to help the skin shrink back. Varying degrees of swelling could persist for 3 – 4 months.
This is a relatively common condition in young females, which can cause problems in feeding the child and in hygiene also. This can be corrected by manipulation in some cases, where as some require surgical correction.
The incidence of facial fractures is also on the increase with increase in the number of vehicular accidents. The most common bones to be fractured in the face are the nasal bones, the cheekbones and the lower jaw. If not treated properly and at the right time, they produce permanent deformities and disabilities like altered vision, cosmetic deformities, difficulty in breathing, difficulty in chewing, etc.
X-rays and CT scan with 3D reconstructions are needed to assess the fracture. The fractures are reduced, brought in alignment and are usually fixed with metal plates and screws. These plates need not be removed unless, the patient wants them to be removed or they are causing problems.
These are needed in cases of extreme trauma to the face with tissue loss or after excisions for cancers of the head and neck region. These usually require multiple complex surgical procedures to provide an aesthetically acceptable appearance.
TMJ ANKYLOSIS
This is a condition where the patient is unable to open his or her mouth and unable to take feeds. This commonly occurs due to some trauma to the jaws which went unnoticed. Here the joint is fused and hence the patient is unable to open the mouth.
Surgical correction is necessary to help the patient eat and also for dental hygiene.
Vitiligo (White patches)
This condition is a very stressful condition because of social stigma
associated with it. Here there is deficiency of the pigment producing
cells of that area of skin. Usually treated medically but sometimes can
be treated surgically by skin grafting or tattooing. But usually done
only when the spot is not growing in size and has been stationary for
a year and no new spots are appearing.
