PLASTIC & RECONSTRUCTIVE SURGERY



PLASTIC & RECONSTRUCTIVE SURGERY

Terminology

➢ Dermatome-instrument used to incise skin, for thin skin transplants/ debridement

➢ Dermis-inner sensitive (nerve rich), vascular (capillaries) layer of skin

➢ Donor site-area of body used as source of a graft

➢ Epidermis-outer, non-sensitive, non-vascular layer of skin

➢ Erythema-small spot or reddened area of skin

➢ Graft-tissue transplanted or implanted in a part of the body to repair a defect

➢ Plastic-”(plastikos) to mold or shape with one’s hands” (Caruthers & Price, 2001)

➢ Plastic surgery-surgery performed to repair, restore, or reconstruct a body structure

➢ Recipient site-area of body that receives grafts

➢ -plasty-restorative or reconstructive

➢ Abdominoplasty-abdominal wall

➢ Blepharoplasty-eyelid

➢ Cheiloplasty/Palatoplasty-cleft palate

➢ Mammoplasty-breasts

➢ Mentoplasty-chin

➢ Rhinoplasty-nose

➢ Rhytidectomy-face lift

➢ W, X, Y or Z-plasty-skin (burns/scars)

➢ Excision of Cancerous Neoplasms (basal cell, squamous cell, malignant melanoma)

➢ Lipectomies-liposuction

➢ Microlipo-extraction

➢ Collagen injection

➢ Dermabrasion-removal of scars, tatoos, acne scars

➢ Scar Revision

Purposes of Plastic & Reconstructive Surgery

➢ Correct congenital anomalies or defects

➢ Correct traumatic or pathologic (disease) deformities or disfigurements

➢ Improve appearance (cosmetic)

➢ Restore appearance and function

Anatomy & Physiology

➢ Multi-system/structure involvement

➢ Non-specific anatomically unlike peripheral vascular or orthopedics

Integumentary System

➢ Skin (cutaneous membrane)-outer covering of the body

o Function of:

o Protection from external forces (sunrays)

o Defense/Protection against disease

o Fluid balance preservation

o Maintenance of body temperature

o Waste excretion (sweat)

o Sensory input (temp/pain/touch/pressure)

o Vitamin D synthesis

2 Main Layers

➢ Epidermis (outer)

o Constantly proliferating (newly forming) and shedding (thousands a day)

o Five week process

o Composed of 4-5 layers called strata

▪ Stratum basalis bottom layer; only layer that undergoes mitosis; as divides becomes second layer

▪ Stratum spinosum flattens as pushes up; prickly in appearance

▪ Stratum granulosum granules of keratohylin precursor to keratin; nucleus begins fading, result = cells begin dying off

▪ Stratum lucidum clear looking deadcells; keratohylin turns into eleidin

▪ Stratum corneum eleidin converts to keratin; all cells dead; upper area of epidermis; cells shed as reach body surface; dead layer offers barrier to foreign organisms; it cannot be inhabited

➢ Dermis (inner)

o Connective tissue

o Composed of nerves, capillaries, hair follicles, nails, and glands

o Three divisions:

▪ Papillary layer- top; hills and valleys; prominent soles and palm; gripping; meissner’s corpusules detect light touch

▪ Reticular layer-middle; larger number of blood vessels; glands; thick layer of collagen for strength, protection, and pliability; pacinian corpusules here that detect pressure (as tire hands/fingers go numb)

▪ Subcutaneuous layer (hypodermis)-bottom; anchors skin to underlying structures; adipose tissue and loose connective tissue; insulation and protection for internal organs

➢ Accessory Structures of the Integumentary System

o Hair

o Nails

o Glands-found in dermis (reticular layer):

▪ Sebaceous Glands

• Oil (sebum) producing glands

• Travels through ducts emptying in the hair follicle

• Fluid regulation

• Softens hair and skin

• Makes skin and hair pliable

• Activity stimulated by sex hormones

• Activity begins in adolescence, continues throughout adulthood, decreasing with aging

• Sweat Glands/Sudoriferous Glands (No sweat glands located in some regions of external genitalia, nipples, lips)

* Merocrine Glands

* Cover most of the body

* Openings are pores

* Secretion 1° water and some salt

* Stimulated by heat or stress

* Apocrine Glands

* Larger than merocrine glands

* Located in external genitalia and axillae

* Ducts in hair follicles

* Secrete water, salt, proteins, fatty acids

* Activated at puberty

* Stimulated by pain, stress, sexual arousal

* Ceruminous Glands

* External auditory canal

* Secrete cerumen (earwax)

Palate

Roof of the mouth

Anterior portion = hard palate

Composed of maxilla, palatine bones, mucous membrane

Posterior portion = soft palate

Composed of muscle, fat, mucous membrane

Terminates or ends at uvula (opening of oropharynx)

Function of palate to separate nose from mouth

Function swallowing and speech

Palate

The Hand

Wrist

Palm

Fingers

Wrist (Carpus)

8 carpal bones

Arranged in 2 rows 4 each: distal and proximal

Proximally articulate with distal ulna and radius

Palm (Metacarpus)

Metacarpals

5 per hand

Long, cylindrical shaped

Fingers (digits)

Phalanges

14 per hand

3 phalanges per finger or digit

Numbered 1-5 beginning with the thumb

Hand Joints

Metacarpals articulate with the phalanges

Diarthroses or freely-moveable joints

Synovial hinge joints

Metacarpophalangeal joints or MPJ referred to as the (knuckles)

Nerves in the Hand

Branches of brachial plexus supply innervation to the forearm and hand

Radial

Median

Ulnar

Radial Nerve

Along radius

Sensation to forearm and hand

Extensor muscles of the forearm

Median Nerve

2 branches

Innervate:

Skin of lateral 2/3 of hand

Flexor muscles of the forearm

Intrinsic muscles of the hand

Ulnar Nerve

Innervates

Skin of medial 1/3 of hand

Some flexor muscles of hand and wrist

Muscles and Tendons

of the Hand

40 muscles are responsible for movement of the hand, wrist, and fingers

Most are on anterior aspect of the hand

Anterior muscles are for flexion

Fewer posterior muscles are for extension

Compartments or Tunnels

of the Hand

One main anterior (palm)

Posterior or dorsally are six

Tendon Sheaths of the Hand

Finger and thumb tendons are contained in a tendon sheath

Serves to protect

Lined with synovium

Pulleys are attached to the bones along the tendon sheath

Serve to hold the tendon to the bones they pass over

Hand Circulation

2 primary arteries

Brachial splits below the elbow >radial and ulnar arteries

Radial supplies lateral aspect of arm

Ulnar supplies medial aspect of arm

Join to form palmar and superficial palmar arches

Names of hand veins correlate with their arteries

Mammary glands

See chapter 14 of Price

Breasts or Mammary Glands

Modified sweat glands

Anterior to pectoralis major muscle

Between 2nd and 6th ribs

Lateral to sternum

Extend to axilla

Accessory organ to female reproductive system (milk production for the infant)

Functionless in male

Thicker under nipple/thinner at periphery

Each gland has 15-20 lobes

Each lobe has a duct that merge into the nipple

Rich in blood supply, lymphatic vessels and nerves which arise from the anterior thorax

Skin Pathology

I. Burns

Injury resulting from heat, chemicals, radiation, gases, or electricity that causes tissue damage

Burn Classification

Depth

1st degree involvement just epidermis

2nd degree involvement to dermis

3rd degree penetrates full thickness of skin

Can affect underlying structures

4th degree char burns

Damage to blood vessels, nerves, muscles, tendons, and possibly bone density

First Degree Burn

Superficial

Epidermis involvement

Redness or erythema

Healing rapid

Second Degree Burn

Partial Thickness Burn

Epidermis and Dermis

If Deepest Epithelial layer undamaged will heal

Infection can result in damage same as third degree burn

Blistering, pain, moist/red/pink in appearance

Third Degree Burn

Full-Thickness Burn

Epidermis and Dermis destroyed

Extends to subcutaneous layer and structures

Requires skin grafts to heal

Dry, pearly white, charred surface (eschar)

No sensation

Fourth Degree Burn

Damage to bones, tendons, muscles, blood vessels, and nerves

Charring

Electrical burns most common

Extensive skin grafting required

Burn Assessment

Lund-Browder Method

Rule of Nines

Rule of Nines

Increments of 9% BSA (body surface area)

Head and Neck = 9%

Anterior and Posterior Trunk = 18%

Upper Extremity = 9%

Lower Extremity = 18%

Perineum = 1%

Burn Surgical Intervention

Debridement

Skin Grafting

Skin Grafts

Autograft - taken from part of the patient’s body

Homograft or Allograft– graft taken from same species as recipient (cadaver)

Stored in a tissue bank

Heterograft or Xenograft – Taken from one species and used on another species (pigskin/porcine skin or cowskin/bovine)

Synthetic Skin

These means reduce fluid loss and protect the wound

Autografts

Classified by the source of their vascular supply and tissue involved

Factors for determining choice of grafting method:

Location of defect

Amount of area to be covered

Depth of defect

Underlying tissue involvement at defect

Cause of defect (trauma, disease, or heredity)

Autografts

(FTSG) Full Thickness Skin Graft

Consists of epidermis and all of the dermis

May include greater than 1 mm of the subcutaneous layer

Because is a deep excision at the donor site, limited to smaller areas of grafting (face, neck, hands, axillae, elbow, knees, feet)

Especially used for covering squamous cell or basal cell carcinomas

Donor site must be closed

Cannot reuse donor site

Excised by a skin graft knife

Prevent contraction of a wound better than a split-thickness graft

Autografts

(STSG) Split-Thickness Skin Graft

Involves removal of epidermis and dermis to a depth of up to 1mm

Can be used over large body surfaces (back, trunk, legs)

Donor site regenerates quickly and can reuse in about 2 weeks if it has been properly cared for

Graft excised with a dermatome

Graft can be stretched or enlarged by a skin graft mesher

Dermatomes

Used to remove STSG

Brown - oscillating blade

Padgett-Hood-rotating blade housed in drum

Powered by nitrogen or electricity

Hall

Reese

Can be hand held

Dermatome

Connect blade to dermatome before passing off the power cord

Test in a safe place

Blades are disposable

Take care with blades

Surface of blade protected with a guard (are 4 sizes)

Secure blade and guard with screwdriver

Guard should not cover the cutting edge of blade

Dermatome

Graft thickness (depth) determined by small lever on side of dermatome (in tenth of a millimeter increments)

Set at 0 before procedure and after changing blades

Adjust per surgeon directions or surgeon may adjust

Width of graft determined by gaps in edges of plate that are one to four inches

Donor Site

Covered with a mesh-like medicated dressing

Graft Care

Do not allow to dry out

Place in a basin with small amount of warm saline until ready to use

Mesh Graft Device

Manually operated/roller like device

Used with a split thickness skin graft to expand (meshing) the size of the skin graft

Skin graft is placed on a plastic derma-carrier, which holds the graft flat prior to placing in the dermatome

If more than one graft used, each is placed on its own derma-carrier

Derma-carriers come in various sizes (sized in ratios)

If ratio on derma-carrier says 3:1, means graft will cover three times the area it would have if not meshed

Meshing creates netted effect

When skin graft placed on site being grafted, epithelial tissue will grow in between the slits

Graft Care Post Placement

Will likely be secured as it needs to stay in place until healing can ensue

May use a pressure type dressing

II. Acne

Inflammatory disease of skin

Formation of pustules or pimples

Face, neck, upper body affected

Related to stress, diet, and hormonal activity

Bacteria can invade and cause pits and scars

Surgical intervention requires removal of pits and scars via dermabrasion

III. Aging

Elastic fiber number decrease

Lost adipose tissue

Collagen fiber loss, slows healing

Wrinkling and sagging result

Surgical intervention = Conservative nonsurgical intervention to invasive surgical intervention

Rhytidectomy = “face-lift”

IV. Sun Exposure

Sunlight exposure thickens epidermis and damages elastin

Damaged elastin allows for formation of pre-malignant and malignant cells

Prevention best (sunscreen)

Can resurface skin pharmaceutically or surgically

V. Eyelids

Blepharochalasis = loss of muscle tone or relaxation of the eyelids

Causes wrinkling and thinning

Poor results surgically

Dermachalasis = relaxation and hypertrophy of eyelid skin

Bags under the eyes

Easily corrected surgically

Ptosis = eyelid drooping

Muscle shortening repairs this

VI. Neoplasms

Any new or abnormal growth

May be benign, pre-malignant, or malignant

Caused by exposure direct or indirect to chemicals or the sun

Removal surgically can be chemical, laser, or minor surgical

VII. Nose and Chin

Rhinoplasty - reshaping the nose

Can be done with other nasal procedures to restore upper respiratory function post-trauma

Mentoplasty – reshaping the chin

VIII. Cleft Lip & Palate

Cleft = split or gap between two structures that normally are joined

Cheiloschisis = cleft lip (hair lip)

Palatoschisis = cleft palate

May see alone or in conjunction

May be unilateral or bilateral

Surgical intervention = cheiloplasty and palatoplasty

IX. Breasts

Liposuction

Chronic back pain

Aesthetics

Gynecomastia

Mammoplasty

Cancer

Congenital deformity

Aesthetic reasons

Medical reasons

X. Abdomen

Abdominoplasty or tummy tuck

Thinning of abdominal fat and tightening of abdominal muscles

Removing fat and excess skin from mid to lower abdomen

Can do in addition to liposuction

Panniculectomy = removal of fat apron in obese patients

TRAM Flap

Transverse Rectus Abdominus Musculocutaneous Flap

Where breast is reconstructed using the transverse rectus abdominus muscle

Muscle is brought through a tunnel under the skin and positioned as the new breast

Hand Pathology

1. DeQuervain’s Disease

Stenosis/inflammation of tendons in first dorsal wrist compartment

Treatment conservative with anti-inflammatories or surgical (rare recurrence after surgery)

Hand Pathology

Trigger Finger

Stenosis of digital tendons

Surgical intervention needed if digit becomes “locked”

Hand Pathology

DuPuytren’s Disease

Related to traumatic injury

Contracture of palmar fascia

May be seen as a nodule in the palm, dimpling or pit in the palm, or fibrous cord from palm to fingers

Surgical intervention warranted if movement and function are impaired

Hand Pathology

Ganglion Cyst

Benign lesion in hand or wrist

Filled with synovial fluid coming from a tendon sheath or joint

Results from trauma or tissue degeneration

May aspirate

Surgical removal

Recurrence 50%

Hand Surgery

Rheumatoid Arthritis (RA)

Disease that attacks the synovial tissues

Most common connective tissue disease

Loss of joint function

Anti-inflammatory meds treat

Surgical intervention required to stabilize a weakened joint or replace a damaged structure

Hand Surgery

Hand Trauma

Cuts

Sprains

Fractures

Burns

Crush injury

Amputation

Reimplantation of digits is a microvascular procedure

Goal:

Restoration of appearance

Restoration of function

KEY GOAL = FUNCTION

Diagnostics

Visual exam

X-ray

CT Scan

Medications

Local anesthetics

Hemostatics

Mineral oil (for skin with dermatome use)

Antibiotic irrigants and ointments

All solutions must be warmed especially on burn patients

Anesthesia

General

Local with monitored anesthesia

Supplies

Basin pack

Beaver blades

Knife blades of surgeons choice

Medicine cups

Mineral oil

Sterile tongue blade used in conjunction with dermatome to stretch skin as graft being removed

Derma-carrier

Drains of surgeon’s choice

Needle tip cautery electrode

Marking pen

Ruler or calipers

Luer lock control syringes

25 and 27ga needles

Instrumentation

Basic Plastics Tray

Basic Plastics Tray:

Towel clips

Micro mosquitoes

Hemostats

Allises

Littler, Iris, tenotomy scissors

Small metz fine and blunt tipped

Small mayo straight and curved

Bandage scissors

NH fine and crile-wood

Adsons smooth and with teeth

Adson-brown, bishop-harmon, debakey

Skin hooks single and double pronged

Senn retractors, Army-Navy, Spring Retractors

#3, #7,knife handles, beaver handle

Freer, small key elevators

Frazier suction tip 8F angled with “finger cut-off” valve

Nasal Instruments

Rhinoplasty/Nasal tray

Vienna Nasal speculums

Single skin hooks

Cottle or Joseph double prong skin hooks

Cottle knife

Cottle or Fomon Retractor

Cottle osteotomes (4, 7, 9, 12mm)

Ballenger chisel

Ballenger swivel knife

Joseph nasal bayonets, right and left

Freer septal chisels curved and straight

Joseph rasp or Double ended Maltz rasp

Cushing Bayonet forceps with teeth

Jansen Bayonet dressing forceps

Takahashi Forceps

Cottle cartilage crusher

Abdominoplasty Instruments/Supplies

Basic Plastic Set

Fiberoptic Retractor Set

Abdominal retractor tray (deavers, richardsons, etc.)

Lap sponges

Umbilical template

Abdominal drapes (universal) or Laparotomy

Extension blade for the cautery

Cheiloplasty & Palatoplasty Instruments/Supplies

Basic plastic tray

#15 blade

Oral instruments

Mouth Gag (Jennings/Davis/McIvor) + assorted blades

2x2 gauze for dressing

Mammoplasty Instruments & Supplies

Basic Plastic Tray

Minor Tray

#15 blades

Local with Epinephrine

Control syringes and local needles

Fiberoptic retractor set

Extension tip available for cautery

Laparotomy sponges

Chest drapes (universal or laparotomy)

Suture of surgeon preference

Dressing

Hand Supplies

Basin pack

Basic pack

Extremity sheet or hand/arm drape

Split sheet

Half sheet for lower part of body

#15 blades

Stockinettes

Esmark

Tourniquet and padding for (cast type)

Suture of preference

Anesthetics of choice (local)

Control syringes and 25/27ga. hypo needles

Dressing of surgeon choice

Elastic bandage

Hand Instruments

Minor orthopedic tray

Minor plastic tray

Small vascular instruments (re-implantations)

Metacarpal retractors

Pediatric deavers

Hand Equipment

Sitting stools

ECU

Suction

Hand table

Tourniquet

Tower Equipment including insufflator

Equipment

ECU

Suction

Dermatome

Microscope (microscopic procedures)

Positioning

Depends on area being operated on

Care to padding depending on which position used

Extreme care with a burned patient with moving

Guard all IV lines, trach tubes, ET tubes

Do not delay transport to the OR

Prepping

Colorless solution preferred if using skin graft so skin color can be seen

Donor and graft sites prepped separately

Solutions used should be warmed

Prep gentle and about 3 minutes (less time than normal skin)

Keep patient covered with warm blankets until ready to prep, keep blankets on as much area as possible

Draping

Drapes of choice depending on area being prepped

Will have two separate drapes for donor and graft sites

Special Considerations

Strict aseptic technique

Death related to septicemia and pneumonia in severely burned patients

Environmental temperature should be geared to prevent hypothermia, prevent microbial invasion, and aid in the healing process

Body temp will be monitored throughout on burn patients with a rectal, esophageal, or tympanic probe

Patient will be in isolation post-op

May go to hyperbaric unit to promote healing

I & O carefully monitored (urine and blood loss)

Post-Operative Care

Maintain asepsis until all dressings are secured prior to removal of drapes

Plastic and Reconstructive Procedures

Rhytidectomy

Blepharoplsty

Suction Lipectomy

Abdominoplasty

Skin Grafts

Cheiloplasty & Palatoplasty

Rhinoplasty

Mammoplasty

Augmentation Mammoplasty

Reduction Mammoplasty

Breast Reconstruction

Hand Surgery

Reasons performed:

Congenital deformities

Disease

Trauma

Can be performed by plastic surgeons, orthopedic or orthopedic “hand-surgeons”, and neurosurgeons

Hand Surgery

Ganglion cyst excision

DeQuervain’s Repair

DuPuytren’s Contracture Release

Trigger Finger Release

Toe to Hand Transfer

Release of Syndactyly (webbed fingers)

Reduction of polydactyly (extra digit)

Radial dysplasia (club hand) correction

Traumatic Injury:

Laceration closure

Digital Reimplantation

Tennorhaphy

Neurorrhaphy

Restoration of vascularity

Bone approximation

Summary

Terminology

Anatomy of Skin and Hand

Pathology

Medications

Anesthesia

Supplies, Instrumentation, and Equipment

Considerations and Post-op Care

Procedures: Skin and Hand

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