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Rules of Thumb in Plastic Surgery

Author's details

Dr.Khashau Eleburuike
MBBS (Ilorin) MSc. Global Health Karolinska Institute.
Resident doctor in family medicine in Northen Sweden.

Reviewer's details

Dr Khadijat Ohunene Aliu
MBBS, FWACS
Consultant Burns, Plastic and Reconstructive Surgeon. General Hospital Ikorodu

Rules of Thumb in Plastic Surgery

Background

Plastic Surgery in Sub-Saharan Africa is a growing field with unique challenges due to limited resources, a high burden of trauma-related injuries, burns, congenital deformities, and the prevalence of conditions such as Noma and keloids. Access to reconstructive and plastic surgery is often limited, making it crucial to prioritize essential services and apply practical, resource-efficient solutions.

In sub-Saharan Africa, like elsewhere, plastic surgery is guided by principles that ensure safety, effectiveness, and cultural sensitivity. Given the region’s unique challenges, certain rules of thumb are essential.

Prioritise Reconstructive Over Aesthetic Procedures

– Reconstructive Focus: In sub-Saharan Africa, plastic surgery often addresses congenital deformities, trauma, burns, and post-surgical defects. Prioritising reconstructive procedures helps address pressing healthcare needs.

– Functionality First: Restoring function and improving the quality of life should be the primary goal, with aesthetic outcomes as a secondary consideration.

Cultural Sensitivity

– Respect Local Norms: Understand and respect the cultural beliefs and practices surrounding body image and surgical intervention. Engage with patients and their families to align surgical goals with cultural expectations.

– Informed Consent: Ensure patients are fully informed about the procedure, risks, and outcomes, considering literacy levels and language barriers.

Resource Optimisation

– Utilise Available Resources: Resource limitations in many areas mean surgeons must be adept at using locally available materials and techniques that are cost-effective and sustainable.

– Innovation and Adaptability: Surgeons should be creative and adaptable, often needing to modify standard procedures to suit the local context.

Training and Skill Development

– Focus on Training: Building local capacity through training programs for surgeons, nurses, and support staff is crucial for the long-term sustainability of plastic surgery services.

– Mentorship and Collaboration: Encourage collaboration with international experts and institutions to foster knowledge exchange and skill development.

Prevention and Education

– Emphasise Prevention: Public health education on burn prevention, trauma care, and congenital anomalies is essential to reduce the need for complex reconstructive surgery.

– Community Engagement: Engage with communities to raise awareness about the availability and benefits of plastic surgery, reducing stigma and misconceptions.

Ethical Practice

– Avoid Exploitative Practices: Ensure that surgeries are performed with the patient’s best interest in mind, avoiding procedures driven by financial incentives or external pressures.

– Equitable Access: Strive to provide equitable access to plastic surgery, ensuring that all segments of the population, including the economically disadvantaged, can benefit.

Postoperative Care and Follow-up

– Ensure Adequate Follow-up: Given the challenges of long-term follow-up in some regions, plan for practical postoperative care that patients can realistically adhere to.

– Patient Education: Educate patients and their caregivers on postoperative care, signs of complications, and the importance of follow-up visits.

Rules of thumb

1. Trauma and Burn Management

Trauma and burns are leading causes of morbidity, particularly from road accidents, domestic injuries, and occupational hazards. The management of burns and trauma is a core component of plastic surgery in this region.

Rules of Thumb

Early Debridement and Grafting:

In severe burn cases, early wound debridement and skin grafting reduce the risk of infection and improve outcomes. For smaller burns, conservative management with proper wound dressing is essential.

Hydration First:

For burns covering large body surface areas, prompt fluid resuscitation is the priority. Monitor fluid balance closely and start fluid replacement as per the Parkland formula or similar protocols.

Address Scarring and Contractures:

Focus on early interventions to minimize scarring and contractures in burn patients. Splinting, physical therapy, and early surgical release of contractures help improve functional outcomes.

Multidisciplinary Approach for Trauma:

For traumatic injuries, especially complex fractures or facial trauma, a multidisciplinary approach involving orthopaedics, general surgery, plastic surgery and later psychiatry are crucial. Reconstructive surgery often comes after life-saving interventions.

Guidelines

WHO Guidelines on Burn Care:

Recommends early wound care, pain management, and rehabilitation, particularly for children and burn victims in low-resource settings. Prevention programs are also emphasized, focusing on education and safer cooking practices.

AFRO Burns Guidelines:

Promote early grafting and rehabilitation, emphasizing the importance of training healthcare workers in burn management to reduce mortality and improve quality of life post-recovery.

2. Congenital Deformities

Conditions like cleft lip and palate are common in sub-Saharan Africa, often requiring plastic surgery to improve function and appearance.

Rules of Thumb

Early Intervention for Cleft Lip and Palate:

Early surgical correction, ideally between 3 to 6 months of age for cleft lip and 9 to 12 months for cleft palate, can help with feeding difficulties and speech development. If early surgery is not feasible, prepare for later interventions while managing feeding challenges.

Postoperative Speech Therapy:

Following surgery for cleft palate, speech therapy and follow-up are crucial for proper speech development, particularly in areas with limited resources.

Multistage Surgery:

Many congenital deformities require multistage surgeries. Prioritize functional outcomes in the first stage, followed by cosmetic and further corrective procedures.

Guidelines

Smile Train and Global Surgery Guidelines:

Promote early surgical interventions for cleft lip and palate. Training local surgeons and expanding access to surgery are key to managing the high burden of congenital deformities.

3. Keloid and Hypertrophic Scarring

Keloids and hypertrophic scars are more common in darker skin types, making them a significant concern in sub-Saharan Africa.

Rules of Thumb

Early Intervention to Prevent Keloids:

When managing any injury or surgery in individuals prone to keloid formation, early scar management with pressure garments, silicone sheets, and corticosteroid injections can prevent excessive scarring.

Intralesional Steroids for Keloid Treatment:

For existing keloids, intralesional corticosteroids remain the first line of treatment. Surgical excision of keloids is often followed by adjunct therapies, like radiotherapy or steroid injections, to minimize recurrence.

Avoid Trauma in Susceptible Individuals:

If a patient is prone to keloids, minimize unnecessary surgeries, piercings, or trauma that may lead to keloid formation.

Intralesional Steroids for Keloid Treatment:

Guidelines

Keloid Management Guidelines:

Recommend non-invasive treatments (silicone sheets, corticosteroids) as first-line interventions. For surgical removal, a combination of therapies, including postoperative steroids or radiotherapy, is advised to prevent recurrence.

4. Reconstructive Surgery for Noma

Noma is a devastating infection that leads to facial gangrene and disfigurement, predominantly affecting children in areas of extreme poverty and malnutrition.

Rules of Thumb

Early Diagnosis and Antibiotic Therapy:

Noma requires early intervention with antibiotics (usually penicillin and metronidazole) to halt progression. Surgical debridement follows once the infection is controlled.

Reconstructive Surgery Post-Infection:

After the infection subsides, staged reconstructive surgeries to rebuild the face, lips, and jaw may be required. These surgeries should aim for both functional and aesthetic restoration.

Nutritional and Psychological Support:

Patients with Noma need nutritional rehabilitation and psychosocial support to improve their long-term outcomes and reintegration into society.

Guidelines

WHO Guidelines on Noma:

Stress early identification, antibiotic therapy, and community education to prevent Noma. The guidelines also emphasize the need for accessible reconstructive surgery for survivors to restore functionality and appearance.

5. Hand Surgery

Hand trauma, infections, and congenital anomalies are common in sub-Saharan Africa, where plastic surgeons often perform reconstructive hand surgeries.

Rules of Thumb

Early Management of Hand Infections:

Infections like tenosynovitis and deep hand infections require prompt drainage, debridement, and appropriate antibiotics. Delays can lead to permanent dysfunction.

Repair of Tendon Injuries:

Early tendon repair following trauma, especially flexor tendon injuries, is crucial to restoring function. In cases where primary repair is not possible, delayed tendon grafting may be considered.

Postoperative Rehabilitation:

Rehabilitation following hand surgery is essential for good outcomes. Even in resource-limited settings, basic physical therapy can help restore function.

Guidelines

Hand Surgery Guidelines:

Emphasize early surgical intervention for traumatic hand injuries and infections, with a focus on restoring function. Rehabilitation and physiotherapy are critical components of recovery.

6. Microsurgery in Limited Settings

While microsurgery is more challenging to perform in low-resource settings, certain centers in sub-Saharan Africa are developing expertise in this field, particularly for complex trauma and reconstructive surgeries.

Rules of Thumb

Prioritize Essential Microsurgery:

Microsurgical techniques, such as free flaps or replantation, should be reserved for cases where they significantly improve function or survival, given the resource limitations.

Triage for Complex Reconstructive Surgeries:

In cases of complex trauma, such as amputations or severe tissue loss, triage patients based on the likelihood of successful reconstruction and recovery. Focus on patients who can benefit most from microsurgical interventions.

Training and Capacity Building:

Local surgeons should receive training in microsurgical techniques through partnerships and global health initiatives, gradually increasing the availability of these procedures.

Guidelines

Microsurgical Guidelines:

For low-resource settings, these guidelines stress the importance of choosing cases carefully, focusing on trauma and essential reconstructive procedures. Capacity building through training and infrastructure development is critical.

7. Tissue Expansion and Flaps

Tissue expansion and the use of flaps are critical components of reconstructive surgery, especially for managing large defects caused by trauma, burns, or tumor excision.

Rules of Thumb

Use Local Flaps Whenever Possible:

In resource-limited settings, local and regional flaps are often the best options for reconstructing defects, as they do not require microsurgical expertise and have fewer complications.

Tissue Expansion for Large Defects:

For patients with large soft tissue defects, tissue expanders can be used to gradually increase skin for later coverage of the defect. This method is particularly useful in reconstructive surgery for burns or post-tumour excision.

Postoperative Care for Flaps:

Ensure proper monitoring of blood supply and drainage in flap surgeries to prevent complications like necrosis. Early intervention in cases of flap failure is key to avoiding more severe outcomes.

Tissue Expansion for Large Defects:

Guidelines

Flap Surgery Guidelines: Emphasize the use of local flaps in low-resource settings, with tissue expansion techniques reserved for select cases. Proper postoperative monitoring is crucial for flap viability and success.

Conclusion

Plastic surgery in sub-Saharan Africa faces numerous challenges due to resource limitations, a high burden of trauma, burns, congenital deformities, and conditions like keloids and Noma. Rules of thumb like prioritizing early interventions, emphasizing infection control, and using available resources efficiently are critical for improving outcomes. Following WHO guidelines and local protocols helps optimize care delivery, focusing on prevention, early treatment, and rehabilitation.

Capacity building, including training local healthcare providers and expanding access to reconstructive surgeries, is essential to overcoming the significant burden of plastic surgical conditions in the region. By improving access to essential plastic surgery services, particularly for trauma, burns, and congenital conditions, sub-Saharan Africa can enhance the quality of life for countless individuals in need of reconstructive care.