As reconstructive microsurgeons, we specialise in facial fractures as well as defects (tissue loss) of all sizes and complexity spanning the whole face and body.
Fractures of the facial bones, such as nasal bones, cheekbones and jaw bones can result in significant impact on facial appearance and function. Common causes include falls, blunt trauma and road traffic accidents. A CT scan is required to evaluate facial fractures accurately.
The blood supply to the face is excellent, as a result, facial bone fractures heal within 3-4 weeks. Our priority is to put back the fracture fragments in as anatomic a position as possible. The bony position is then stabilised with a few mini-titanium plates. All this is accomplished with hidden incisions such as within the mouth.
When critical structures such as facial nerves or vessels are interrupted, they can also be repaired under an operating microscope.
As reconstructive microsurgeons, we specialise in defects (tissue loss) of all sizes and complexity spanning the whole face and body. These defects occur after cancer removal or accidents. Beyond filling a “hole” with tissue, advances in the last few decades enable us to tailor a like-for-like reconstruction. Depending on what needs to be restored, soft tissue flaps comprising different vascularised components such as nerves, fascia, muscles can be harvested while minimizing impact on the donor site. The flap is transplanted to where it is required. The blood vessels are then connected to those in the recipient site using the operating microscope, with sutures finer than a human hair (microvascular anastomosis).
Once integrated with the body by 1-2 weeks, this internal tissue transplant is stable and functions like any other body part. Using the concept of the reconstructive elevator, microsurgical tissue transfer to cover defects is very common nowadays. This is because it offers an abundance of healthy tissue for a durable and aesthetic reconstruction.
Despite such sophisticated methods, there are still many instances where simpler loco-regional flaps, skin grafting and dermal matrices are the preferred method. A case-by-case evaluation and discussion with the patient are thus required.
The lymphatic system consists of multiple lymphatic channels that drain into lymph nodes. Lymph nodes are bean-shaped glands that monitor and cleanse the lymph as it filters through them. Lymph nodes may need to be removed as part of cancer surgery —for example, axillary (armpit) lymph nodes for breast cancer treatment.
When this happens, the lymphatic flow is blocked and the protein-rich fluid accumulates in the arms or legs. This is termed lymphedema. In some patients, the swelling is well-controlled by compression garments and they have a stable course without worsening.
In others, the main lymphatic channels become progressively scarred, resulting in backflow of fluid into the skin. The skin then becomes thickened and loses pliability. Repeated skin infections (cellulitis) can result due to impairment of immune defences in the abnormal skin.
The lymphatic fluid is also rich in lipids (e.g. cholesterol and fatty lipids). Besides fluid and fibrotic tissue, fat also accumulates over time. This contributes to the increase in weight and a feeling of heaviness. Severe cases can affect the ability to move the affected limb.
It is essential to follow-up with a physiotherapist specialising in lymphedema. The aim of conservative therapy is simply to manually push the lymphatic fluid upwards, back towards the heart. Treatment consists of lifelong compression bandages and stockings, massage and skin care.
Compression gloves and stockings are custom made after taking accurate measurements of the patient’s limb. They have to be worn every day, except when bathing or sleeping. They also have to be replaced or tightened every 6-12 months when they become loose, as a certain critical pressure is needed.
The affected arm or leg also needs to be elevated on a pillow at night.
New advances in the last 20 years have focused on “physiologic methods”. These aim to re-establish new drainage pathways for lymphatic fluid to flow.
For example, lymphatic channels can be joined to superficial veins (Lymphatic-venous bypass). This is a minimally-invasive procedure as the lymphatics and veins are just under the skin and can be accessed by targeted incisions. This is suitable for earlier stage patients in whom lymphatic channels are still present.
In later stages, a more viable option would be to transplant lymph nodes or lymphatic channels from elsewhere. In successful cases, patients can be less reliant on compression stockings and also experience resolution of repeated infections.
Some of the swollen tissue can be removed with liposuction or open excision. This reduces the weight of the limb and can improve mobility. However, as these are not physiologic procedures, it is essential to continue complex decongestive therapy as usual.
