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The Increasing Role of Primary and Secondary Plastic Surgery in Trauma Management

Medico Legal

Ms Lena C Andersson, M.D., Dr. Med Consultant Reconstructive and Aesthetic Plastic Surgeon with extensive experience within paediatric and adult trauma

 Over the past ten years we have seen an increasing number of patients requiring plastic surgery due to having suffered trauma. The development of several trauma units throughout the country has triggered this development and around 20% of trauma cases are now receiving plastic surgical involvement in one way or another.

Many cases are defined as combined cases where other disciplines such as orthopaedic surgery, general surgery, neurosurgery, ent-surgery and maxillofacial surgery are co-caring. A large portion patient’s are also admitted into an intensive care trauma unit in order to survive.

The type of injuries involved consists of sharp and blunt mechanical injuries, burns/frostbites and de-gloving injuries where skin, fat and muscle tissues have partly or wholly been injured or removed from certain areas of the body. Other types of injuries, which are commonly seen, are injuries, which relate to the lower limbs where fractures are simultaneously involved. The skin and soft tissues were damaged as the bones were fractured through the external trauma.

Many patients therefore suffer from scarring in multiple areas and also suffer from scarring due to the harvest of either skin grafts or the harvest of other soft tissues, e.g. muscle tissue or fascia/skin tissue that is used for the reconstruction of the limbs, torso or head and neck areas. The initial scarring will have resulted from the trauma but the secondary scarring which is inflicted due to the harvest of tissue in order to salvage/reconstruct the damaged area result in additional scarring which the patient will suffer as a consequence of the initial injuries.

The development of the intensive care and trauma centres have been driving forces in the development of more advanced plastic surgery for trauma. From the 1970s onwards microsurgery has made it possible to start to move tissue around and to connect it micro-surgically in order to provide the blood supply. Before this we had only been able to move tissue locally in order to reconstruct defects that were deeper than just at skin level. Due to this positive development in plastic surgery with improved outcome, it has now become possible to shorten hospitalisation times and patients are discharged much quicker and mobilised much earlier due to the additional reconstruction we are able to offer our patients from a plastic surgical point of view.

It is also possible to avoid chronic fractures, which never heal and sometimes lead to amputation, due to the fact that we are able to bring in healthy vascular tissue into an area, which has been heavily traumatised.

After having suffered scarring due to multiple trauma it is very important for patients to be assessed from a plastic surgical point of view as to whether this scarring can be improved or not. In general terms one should not attempt to improve scarring unless it can be improved to more than 50%. One has to take into consideration that the patient would have to undergo additional procedures and if there are only going to be a small improvement, the patient may find that the additional reconstructive surgery would be little benefit to them.

It should also important to consider that if you offer corrective surgery you should not expose the patient who has already suffered severe injuries to further possibly unnecessary risks. It can therefore sometimes be necessary to reconstruct and to improve scarring in stages rather than during one operation. This is clearly, from a medical point of view, in the patient’s best interest and it can sometimes be safest way forward. Any secondary reconstructive plastic surgery should optimise maximum improvement from a scarring point of view. The patients should also be able to continue with their normal life and have minimal disruption due to further reconstructive surgery.

Many trauma patients also suffer from post-traumatic stress disorder and the timing of the scar corrective surgery must be tuned into the recovery, which the patient is making from a psychological point of view. An assessment by a psychiatrist is nearly always necessary as patients have suffered multiple injuries but it may not be necessary if a patient has just suffered a single scar to an area of the body. This would solely depend on the location of the injury and what impact the injury has had for this individual.

Scarring is after all extremely individual and it reminds the patient of the initial trauma they suffered and every patient has to be carefully assessed on an individual basis before secondary plastic surgical interventions are decided upon. The timing of secondary plastic surgical interventions are also influenced by other disciplines; e.g. orthopaedic surgery has to be conducted before final scarring is improved. The actual external scarring, which the patient has suffered can, as has been mentioned, be improved with corrective plastic surgery, but the ‘internal scarring’, which they have suffered at a psychological level will not necessarily be improved by corrective plastic surgery. The decision making here is delicate and it is of great importance to integrate the patient in this decision process in order to avoid disappointments and unhappy outcomes. The patients also have to be extremely tolerant with regards to the recovery. The healing time for a scar to settle is approximately one year and it may not therefore be possible to start the actual reconstructive process earlier than a year after the original injuries. Any ‘stage’ corrective surgery may further delay the total recovery time even though one may not need to wait the full year between the different stages of the corrections.

A scar can be absolutely devastating initially but six to twelve months later it may have improved around 75% so assessments may initially be necessary in order to reassure the patient but the real planning of further reconstructive surgery or the summary of the extent of the scarring is usually best assessed a year from the initial trauma.

We are now educating more and more plastic surgeons within the trauma field and the trauma sector is continuing to grow. Many patients that were not able to receive the multi-disciplinary care previously do today. With intensive care leading the way in the trauma units, many patients who suffer multidisciplinary injuries now survive, which was simply not possible in the past.