Role of physiotherapy in plastic surgery

1. ROLE OF
PHYSIOTHERAPY IN
PLASTIC SURGERY
Presented By: Priyal Mungra

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CONTENT
• Introduction
• General principles of reconstructive surgery
• Reconstructive surgery of hand
• The skin
• Burns
• Maxillofacial Trauma
• References

3. • PLASTIC SURGERY:
 The word ‘plastic’ comes from the Greek word ‘plastikos’ meaning to mould or to
sculpt: therefore, plastic surgery refers to procedures which involve moulding or
sculpting tissues to achieve reconstruction or cosmetic effect.
 It consist of two aspects: reconstructive and cosmetic surgery.
INTRODUCTION:

4. • Reconstructive Surgery:
 Performed on abnormal structures of the body to improve function or
approximate normal appearance. Abnormalities may stem from
1. Congenital defects/ Developmental abnormalities
2. Trauma/ Disease/ Infection/ Tumors
• Cosmetic Surgery:
 Performed on normal structures of the body to improve appearance.

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 General principles of reconstructive surgery:
• 1.) Pre-op Requirements:
 Range of motion
 Muscle strength
 Mobility status
 Respiratory assessment
 Pre-op exercise programme
 Sensory component
• 2.) What structures are being repaired?:
 Contractile v. Non-contractile tissues
 Healing times for various tissues
 The level of damage to be repaired should be noted pre-op as this will potentially alter
the surgical and rehabilitation protocols.

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3.) Does the repair need to be immobilized?
 Duration of daily immobilization
 Mode of immobilization: cast or removable splint
 Elevation to minimise swelling
 Positioning to encourage full ROM
4.)What stage of rehabilitation is this patient at?
 The stages of rehabilitation are largely dependent on the healing process and the
structure being repaired.
• What the clinician needs to be aware of:
 The healing process of the repaired structure
 The goals of the rehabilitation process
 Safety precautions

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5.) What does the patient need to be educated about?
 Safety precautions to consider
 Pain relief
 Wound care and hygiene
 Advice regarding return to normal activities, such as work and driving
 Return to sport
 Possible complications following repair, and what, if anything, needs to be
monitored

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 Reconstructive surgery of the hand:
 Hand surgery consist of those conducted on the hand, wrist or nerves of the upper
limb. Examples includes
• Congenital abnormalities
• Flexor/ extensor tendon rupture
• Peripheral nerve damage
• Carpal tunnel syndrome
• Trigger finger, boutonnieres deformity
• De Quervains Tenosynovities
• Amputations
• Arthritis

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 FLEXOR TENDON REPAIR:
 Flexor tendon injuries are one of the most common and complex injuries which
occur in the hand.
 Flexor tendon repairs pose more of a challenge than extensor tendon repairs
because of higher risk of adhesions and complications and the higher demands
placed on the flexor tendons by ADLs.
 EXTENSOR TENDON REPAIR:
 Extensor tendon injury may occur to the extensor digitorum, the extensor digiti
minimi, or extensor pollicis longus.
 The zones of injury vary slightly, and the tendon sheath is less complex than that
of the flexor tendons.

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 REHABILITATION POST FLEXOR TENDON REPAIR:
 Flexor tendon injuries of hand divided into three groups on the basis of the
exercise instituted during the first 3 to 4 weeks after tendon repair
1) Immobilization
2) Early passive mobilization
3) Early active mobilization
• Cifaldi Collins and Associates
Immobilization
• 1. Duran and Houser
• 2. Kleinert and colleagues
Early passive
mobilization
• Belfast and Sheffield
Early active
mobilization

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 Treating the immobilized tendon repair:
0
to
3-4
weeks
• Cast or dorsal
protective splint
in wrist and MCP
joint flexion and
IP joint full
extension
3-4
weeks
• Dorsal protective
splint replaces
cast
• Splint modified
to bring wrist to
neutral
• Hourly: 10 rep.
of passive digital
flexion & ext.
with wrist at 10
extension
4-6
weeks
• Dorsal blocking
splint
discontinued
• Gentle blocking
exercise initiated
10 rep., 4-6 times
daily added to
passive flexion
and tendon
gliding
6-8
weeks
• Gentle
resistive
exercise
begins
and
progress
gradually

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 Early Passive Mobilization
• Duran program:
0-3
days
• Dorsal
protective
splint
applied with
wrist in 20
flexion MCP
50, IP full
extension
0-4.5
weeks
• Hourly
exercise
within the
splints
• 10 rep.
passive DIP
extension
with PIP and
MCP flexion
4.5-5.5
weeks
• Splint
replaced
by wrist
cuff
• Continue
active/pass
ive flexion
5.5
weeks
Wrist cuff
discontinued.
Blocking and
fisting
exercise
initiated
7.5
weeks
Light resistive
exercise

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• Kleinert Protocol:
0-3
Days
• Dorsal
protective
splint applied
• Velcro strap
0-4
weeks
• Hourly active
extension to
limits of
splint
• Wound and
scar
management
4-6
weeks
• Splint
discontinued
• Active wrist
and fisting
initiated
• Progressi
ve
resisted
exercise
begin
6-8
weeks

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 Early Active Mobilization:
 Blocking exercises
 Tendon gliding exercises
 Sustained grip activities
 Therapeutic Ultrasound
 Myofascial release

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THE SKIN:
 The skin is the most common tissue a plastic surgeon endeavors to replace as most
of the conditions requiring plastic surgery involve skin, which envelopes the
entire surface of the body and it is an indispensible organ: its total destruction is
incompatible with survival.
 It consist of
• An outer layer- the epidermis
• An inner layer – the dermis

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 BURNS:
 A burn is damage to the tissue that is caused by heat, sunlight, electricity,
chemicals or nuclear radiation.
 Hot liquid or steam, inflammable liquids and gases, and building fires are the
most frequent causes of burns.
 Burns can be thought of the tissue damage that occurs due to heat or other acute
exposure involving the aforementioned factors.
MECHANISM OF INJURY:
 May be thermal or non thermal
 Flame burns-50%
 Scalds from hot liquids, e.g. boiling water, cooling oil-40%
 Contact burn e.g. stoves, heaters, irons
 Electrical burn e.g. electrocution
 Radiation burn

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Skin Grafts:
 3 types-
 Split grafts( epidermis and superficial layers of dermis)
 Full thickness grafts( full dermis thickness)
 Free flaps( skin along with blood vessels)
 The following are the methods available for grafting onto a debrided wound to
obtain closure:
1. Autograft (‘split skin graft’) (own skin)
2. Allograft (donor skin)
3. Xenografts (animal skin)
4. Skin substitutes

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 ROLE OF PHYSIOTHERAPY IN BURN INJURY:
• Prevent deformities
• Maintenance of ROM
• Promote healing
• Protection
Acute Stage
• Maintenance of ROM
• Regain ROM
Sub acute stage

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• Immobilisation post skin reconstruction surgery :
Surgical Procedure Immobilisation Time
Biological Dressings <24hours
Autograft (superficial to
intermediate)
24-48hours
STSG 3-5 days
FTSG 5-7 days

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 When a body part must be immobilised, it should be splinted or positioned in an anti-
deformity position for the minimum length of time possible.
 Categories of Splints:-
• Static or Dynamic
• Rigid or soft
• Dorsal or Volar
• Digit, hand or forearm based
 SPLINTING:

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MANAGEMENT OF OEDEMA:
1. Elevation
 Elevation of the extremities above heart level is the most simple and effective
ways to prevent and decrease oedema.
 A Bradford sling can be used to facilitate elevation.
 This type of sling facilitates both elevation and protection of wound area while
still allowing movement.
 Its foam design also reduces the risk of the development of pressure points or
friction.

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Role of the Physiotherapist in the Rehabilitation of the Sub Acute Burn
Patient:
• MOBILIZATION:
 Active ROM- for affected as well as for non affected parts.
 Passive ROM- for affected parts.
• FREQUENCY, DURATION, RECOMMENDATION:
 Physiotherapy intervention should be twice daily with patients prescribed frequent
active exercises in between sessions.
 For the sedated patient gentle passive range of motion exercises should be done 3
times a day once indicated.
 Dependent on the severity of the burn active and very gentle passive range of motion
exercises for the hand and fingers are begun from day one of injury.

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 CONTRAINDICATION:
 Active or Passive range of motion exercises should not be carried out if there is
suspected damage to extensor tendons (common occurrence with deep dermal
and full thickness burns).
 Flexion of the PIP joints should be avoided at all costs to prevent extensor
tendon rupture.
 The hand should be splinted in the position of safe immobilization or
alternatively a volar PIP extension splint until surgical intervention is discussed.
 Range of motion exercises are also contraindicated post skin grafting as a period
of 3- 5 days immobilization is required to enable graft healing.

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• FIVE PRINCIPLES OF SCAR MASSAGE:

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• SCAR MASSAGE TECHNIQUES:
 Retrograde massage to aid venous return, increase lymphatic drainage,
mobilise fluid
 Effleurage to increase circulation
 Static pressure to reduce swelling
 Finger and thumb kneading to mobilise the scar and surrounding tissue
 Skin rolling to restore mobility to tissue interfaces
 Wringing the scar to stretch and promote collagenous remodelling .
 Frictions to loosen adhesions

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 PT FOLLOWING SKIN GRAFT:
 Aim is to soften and mobilize grafted tissue to enable freedom of movements and
improve nutrition and to restore function.
 Donor area of split skin graft may be treated with UVR to promote healing 3-4 days
after operation.
 E1 dose is given for 3-4 days/week.
 Joints and muscles near grafts should be exercised through full ROM as possible and
all other joints and muscles should be put through general full ROM movement
program.
 Muscles near the grafts over immobilized joints should be moved isometrically, e.g. 5
contractions per muscle every hour.
 This eases some of discomfort and maintain fluid flow through tissues.
 These exercises usually start 5-7 days after grafting.
 Active ROM- for affected as well as for non affected parts.
 Passive ROM- for affected parts.

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MAXILLOFACIAL TRAUMA:
 Fractures of the facial bone can be encountered in isolation with other injuries.
 Facial fractures include mandible, maxilla, nasal bone and zygoma.
 PHYSIOTHERAPY FOR PATIENTS WITH FACIAL BONE FRACTURES:
 Chest Physiotherapy
 Mouth opening exercise
 Low voltage short wave diathermy
 Early Amputation

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 REFERENCES:
 Baskies, M.A., Tuckman, D.V. and Paksima, N. (2008) ‘Management of flexor
tendon injuries following surgical repair’, Bulletin of the NYU hospital for joint
diseases, 66(1), available: SPORTDiscus (accessed 26th Jan 2013).
 Aoife Hale Rhona O’Donovan Sarah Diskin Sarah McEvoy Claire Keohane
Geraldine Gormley PY4017/4019 Module Leader: Norelee Kennedy.
 Thien, T.B. Becker, J.H. and Theis, J.C. (2009) ‘Rehabilitation for flexor tendon
injuries in the hand (review)’ Cochrane Database of Systematic Reviews, Issue 1.

 Megha Sandeep Sheth, Priya Singh Rangey, Neeta Jayprakash Vyas, Srishti Sanat
Sharma “ Physiotherapy in General Medical and Surgical Conditions.”

30. THANK
YOU