INTRODUCTION OF

PLASTIC SURGERY

PROF.BUCHARI KASIM,SpBP
DR.FRANK BIETRA BUCHARI,SpBP
MISUNDERSTANDING (1976) :

Purpose for beauty only, esp : woman

Demands for urban with better sosio
economic
To do with plastic material
Western technology unsuitable with
religious teaching esp : Islam
PHYSICAL LOCATION
DEFORMITY and DISHARMONY
Located on superfacial part/outer
surface of body from "top to toe"
esp most expose part : FACE &
HANDS
Main complaint : FORM and/or
FUNCTION
Result of Expose Perception :
1. Him/herself
2. Closest SOCIAL
3. The other
 UU Kes.RI ps.17 (1992) : Pelaksanaan
tindakan Bedah Plastik harus dilakukan
oleh tenaga kesehatan yang mempunyai
keahlian dan kewenangan. Penerapan
tidak boleh bertentangan dengan norma
yang berlaku dalam masyarakat yaitu
norma hukum, agama, kesusilaan dan
kesopanan.
 Dari Timur Sushruta abad ke 6 SM
diterjemahkan oleh kebudayaan Islam dan
diteruskan ke dunia Barat melalui Sisilia dan
Andalusia.
 Keluarga Branca dari Sisilia mempraktekkan metode India
(Abad ke 15) .
Tagliocozzi dari Bologna menerapkan metode India (Abad ke
16) metode Italia (buku : De Curtorum Chirurgia)
 Abul Kasim Az Zahrawi (936 1013 AD) mengarang buku
ajar Bedah Al Tasrif sebanyak 27 jilid
Barat mengenalnya : Abulkasis de Chirurgia
(Blepharoplastik)
PENERAPAN

Assesment of patient :

N ature
G oal
E xpectation
L imitation
A lternative
R isks
SELECTION OF PATIENT

Minor Deformity
Max complaint
5

4
Psychosocial
3
Complaint
2

1 Major Deformity
Min complaint
0 1 2 3 4 5
Physical complaint

* MARK GORNEY CHART

 Jenis tindakan :
1. BP Rekonstruktif
2. BP Aestetik (Bedah Kosmetik)

Rekonstruktif Aestetik
 Jenis kasus :
1. Rural Plast. Surg.
2. Urban Plast. Surg.
( BK : 3rd Asean Congress of Plastic Surgery 1986 )
 Ethiology :

1. Traumatic Injuries
2. Congenital Deformities
3. Neoplasm (Benign/Malignant)
4. Infection/Squele
5. Pure Aesthetic Complaints
PENERAPAN BEDAH PLASTIK

Bedah Plastik Kedaruratan

(Emergency Plastic Surgery)

Bedah Plastik Elektif

(Elective Plastic Surgery)

Bedah Plastik Superelektif / Estetik

(Superelective Plastic Surgery)

Bedah Plastik Kontroversi

(Controversial Plastic Surgery)
EMERGENCY
PLASTIC SURGERY
BURN (LUKA BAKAR)
Kerusakan kulit yang disebabkan oleh:

Api dan Air panas

Sengatan LISTRIK
Zat KIMIA
Radiasi
LUKA BAKAR MORBIDITAS
MORTALITAS

PENATALAKSANAAN DARI FASE AWAL

SAMPAI FASE LANJUT
GOALS

Mempertahankan agar pasien HIDUP

(ALIVE)
Mengurangi rasa sakit, kontrol infeksi, dan
melakukan tindakan operasi jika perlu utk
memaksimalkan hasil kosmetik dan fungsi
dari anggota gerak
Yang sering terjadi : pasien-pasien yg
meninggalkan rumah sakit SANGAT
MENAKUTKAN!!!
 KITA HANYA
MENYELAMATKAN
HIDUPNYATIDAK
KEHIDUPANNYA
FUNGSI KULIT:

1. Penutup jaringan dibawahnya

2. Melindungi trauma
3. Mencegah penguapan
4. Mencegah infeksi, bakteri dan jamur
5. Mengatur penguapan cairan
3 fase LUKA BAKAR:
Akut : 0-72 jam (ABC)
Sub-Acut: 21 hari

Lanjut: s/d 8-12 bulan ( scar,

keloid, hypertropik scar,

kontraktur)
PROBLEMS

4 Stages Acute Management

1. Anticipation of shock/fluid resuscitation
and respiratory function disorder.
2. Prevention of secondary infection.
3. Proper management of burned tissue with
early grafting of deep burn skin loss.
4. Prevention of complication including late
complication contracture and keloid.
DIAGNOSE

1. Ethiology Grade

2. GRAde Deep : I, II, & III

3. SUrface area % BSA

4. LOcation Specific areas

{ D : e-burn gr@sulo }
 ETIOLOGI

Anamnesis : Grade/Severity
SCALD I & II
FLAME II & III
ELECTRICAL III
CHEMICAL III
INHALATION respiratory
GRADE

Erythema

Blister

Pinprick ( - )
 Grade 1-2
Thermal injury reaches epidermal
and dermal layers
The injured area is moist, with blister
formation

Grade 2-3
Progressive stasis zone necrosis and coagulation
necrosis of epidermis occur, dermis and deep layer
tissues of dermis are completely destroyed by
thermal injury. No blood flow can be found in the
necrotic area, the wound is pale
Electrical Burn
Cemical Burn
ESTIMATION OF BODY SURFACE AREA

Hands Palm = 1%
Lund & Browder Chart
 Penilaian pada Anak:
Kepala : 14%
Tungkai kaki : 16%
Bagian lain sama dengan dewasa

Pada Bayi :
Kepala, lehar : 18%
Tungkai kaki : 14%
Bagian lain sama dengan dewasa
PATOFISIOLOGI

Fluid Electrolit Protein

Fluid Electrolit Protein

Increase
permeability

Interstitial tissue
Interstitial tissue

Haemoconsentration HYPOVOLUMIC SHOCK

SEVERITY OF BURN

Severe Moderate Mild

Indikasi Rawat inap

10 - 50 thn :
Grade 2 >15%
Grade 3 >3%
<10 & >40 thn :
Grade 2 10%
Grade 3
Wajah, tangan, kaki dan perineum
Melingkar pada daerah ekstremitas
Listrik
Trauma Inhalasi
 Second and third degree burns >10% body surface area
(BSA) in patients <10 or >50 years old.
Second and third degree burns >20% BSA in other
groups.
Second and third degree burns with serious threat of
functional or cosmetic impairment that involve
face,hands, feet, genitalia, perineum, and major joints.
Third degree burns >5% BSA in any age group.
Electrical burns, including lightening injury.
Chemical burns with serious threat of functional
orcosmetic impairment.
 Inhalation injury with burn injury.
Circumferential burns with burn injury.
Burn injury in patients with pre-existing medical
disordersthat could complicate management, prolong
recovery, or affect mortality.
Any burn patient with concomitant trauma (for example
fractures) in which the burn injury poses the greatest risk
of morbidity or mortality. However, if the trauma poses
the greater immediate risk, the patient may be treated in
a trauma center initially until stable, before being
transferred to a burn center.
MANAGEMENT

General/Medical Treatment :
Fluid Resusitation
Prevention infection
Local : Topical Antibiotic
Surgery :
a. Debridement
b. Excharatomy
c. Excicion + Grafting
d. Granulating Tissue + Grafting
PERTOLONGAN PERTAMA

Jauhkan dari sumber trauma

Bebaskan jalan nafas
Perbaiki pernafasan
Perbaiki sirkulasi
Bilas dengan air mengalir
Penutup luka/tubuh diganti dengan yang
bersih
Analgetik dan ATS
 ESTIMATION OF
FLUID RESUSCITATION
Parkland Hospital Formula :
24 hours
4 ml Lact. Ringers x % BSA x Kg BW = X ml
x ml in first 24 hours
x ml in first 8 hours
x ml in next 16 hours
24 48 hours Koloid

SHOCK : Loading 2000 cc in one hour 7 hours (1/2 x ml-2000cc)

 CONTOH:
Luka bakar Api, BB:50 kg, luas luka bakar 40%
Tanpa Shock:
4 ml Lact. Ringers x % BSA x Kg BW = X ml
4 x 40 x50 = 8000 ml RL/24jam
8 jam pertama: x 8000ml= 4000 ml
16 jam kedua : 4000 ml
 Dengan Shock:
Loading : 2000 ml dalam waktu 1 jam
8 jam pertama 7 jam - 2000 ml RL
16 jam kedua : 4000 ml RL
HARI PERTAMA :

ANAK :
2 CC X BB X % LUAS LB + KEBUTUHAN FAALI
KEBUTUHAN FAALI :
< 1 TAHUN : BB X 100 CC
1-3 TAHUN : BB X 75 CC
3-5 TAHUN : BB X 50 CC
 The use of formal fluid resuscitation is
reserved for patients with burns involving
more than 15% to 20% TBSA.
The fluid administered should be lactated
Ringer (LR) solution is relatively hypotonic
and contains sodium, potassium,calcium
chloride, and lactate
 It is important to remember that the
formula provides merely an estimate
of fluid requirements. Fluid should be
titrated to achieve a urine output of 30
cc/hr in adults and 1 cc/kg/per hour
in children
PERAWATAN LUKA

Bilas dengan alir yang mengalir

Kulit yang terkelupas dibuang
Bullae dgn cairan >5 cc jangan dikelupas,
<5cc dihisap menggunakan spuit
Luka dikeringkan dan diolesi cream
antibiotik
Perawatan terbuka atau tertutup dengan
balutan
Dirawat diruangan Steril
 Foley catheter : urine out put / hours 1 -2ml /
kg BW/ hours
CVP
Renal function
Serum electrolite level
Albumin / Globulin
ATTENTION

Inhalation burn
face neck

Respiratory distress
first 24 hours & 1-5 days

Intubation
 TRAUMA INHALASI:
RIWAYAT TERBAKAR DIRUANG TERTUTUP
WAJAH DAN BIBIR OEDEMA
RAMBUT, ALIS MATA TERBAKAR
BULU HIDUNG TERBAKAR
ADA JELAGA KEHITAMAN DI LUBANG
HIDUNG
CURIGAI!!!!
I

Lakukan INTUBASI
 Sistemic Antibiotic
Tetanus Prophylactic

Analgesic & Sedatives

Nutritional support :
Formula Curreri (24 hours caloric requirment)
Adult : 25 kilocal/kg BW + 40 kilocal % BSA
Child : 60-90 kilocal/kg BW + 35 kilocal % BSA
SURGERY
Debridement
Escharatomy

Prevention :
Position arm & leg

Thin

Grafting : STSG
Moderate

Large : Electro Dermatome

MESH Graft
Escharotomies are indicated for
fullthickness circumferential burns of
the extremity or for fullthicknes burns
of the chest wall when the eschar
compromises thoracic cage excursion and,
thus, ventilation of the patient.

Escharotomy can be performed at the

bedside using a scalpel or electrocautery.
 TOPICAL ANTIBIOTIC

Silver Sulfadiazine
Cream in consentration of 1 %
Applied twice daily : open or close
Effective Gram + & Gram
Silver Nitrat (0,5 % solution)
Sulfanylon
COMPLICATION

Pulmonary Oedema
Gastrointestinal
33% Curling Ulcer
Infection : - Septichemi
- UTI
- Auricular chondritis
Late Complication
6 months 2 years
1. Contracture
2. Keloid
 Burn injury destroys the bodys layer of
protection from the environment, and dressings
are needed to protect the body from infection
and minimize evaporative heat loss from the
body. The ideal dressing would be inexpensive,
easy to use, require infrequent changes, and
be comfortable.
Late complication Keloid
Finger contracture
Scald Burn (Grade 1-2)
3 minggu
GRADE 2
1,5 BULAN
Grade 3
3 bulan
GRADE 2
1,5 bulan
 1 minggu 3 minggu 5 minggu

10 minggu 24 minggu 30minggu

FLAME BURN Revisi Scar

FTSG
 JANGAN HANYA DAPAT
MENYELAMATKAN
HIDUPNYA.. TAPI JUGA
HARUS DAPAT
MENYELAMATKAN
KEHIDUPANNYA!
Facial Injuries
Fraktur Tulang Wajah

Mandibula
Maxilla
Zigoma
Nasal
1. MANDIBLE FRACTURE

Physical inspection : X PHOTO:panorex

- painfull
- cannot open mouth
MALLOCCLUSION
- hypersalivation
- oedema & echimosis
- deformities
- crepitatio
 Location

Types : - green stick Fx. line : - horrizontal

- simple
- compound - vertical
- complex
- comminuted
- impacted
 Treatment
Teeth
condition
Reduction

Class 1 Class 2 Class 3

Open Close

Internal Fixation Maxilo Mandible

(MINIPLATE) Fixation (MMF)

Orbital & Naso Orbital Ethmoid

Fronto Basilar fx.
Panfacial fx.
TM. Joint Dislocation
 2. MAXILOFACIAL FRACTURE

Force mechanism
* Insp : - asimetri oedem !
* Palp : - bone continuity
- upper & lower jaw (MALLOCCLUSION + )
* Ro- : - Waters position (mento occip. view)
- Pan-oral view (PANOREX)
- CT Scan
* Th :
- Reduction & MM ficsation (wiring)
- Temporary fixation :
BARTONS BANDAGE
- Liquid/soft meal
- Oral hygiene
 3. MAXILA FRACTURE

Displacement : Post & Downword

Le Fort

I. Maxila +
II. Maxila + III. Orbita +
Periform
Opertura Nasal Bone Nasal Bone

CRANIOFACIAL
UPPER LEVEL PIRAMIDAL NOE FX
DISJUNCTION

Th : - Reduction ; * MM Fixation (wiring)

* Miniplate
4. ZYGOMA FRACTURE

Clinical : - cheek flat X Ray : * waters

- okymosis orbita & subconjunctive * CT Scan
- diplopia * Tomogram orbit
- enophthalmos Th. : - conservative oral
- anesthesi n. linfro orbital hygenie fixation

- trouble open/close mouth

5.NASAL FX.

- Pain, bleeding, nasal breathing

- Ro : fx & deviation
- Th :
* Evacuate haematome & seroma
* Reduction 48 hours or after
oedema withdraw
- Compl. : Haematoma
Breath obstruction AESTHETIC

Nasal deformity
Avulsion Injuries
Hand Injuries