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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