3Overall Purpose of Procedure: RhytidectomyOverall Purpose of Procedure:To improve the appearance of the patients face and neck area.
4Rhytidectomy Rhytid =‘s medical term for a wrinkle Define the procedure:Rhytidectomy can mean many different types of procedures dealing with the head and neck.FaceliftBrowiftEyelid liftChin ImplantsMalar implants (mid-face cheek implants)
6Rhytidectomy - Anatomy - The Platysma muscle is a flat, thin muscle that lies uderneath the skin of the anterior and lateral neck.Deep to the muscle lies the superficial layer of the deep cervical fascia.
9Rhytidectomy Instrumentation: Plastics Tray Positioning: The patient can be in supine position, arms on arm boards. Can also be in Fowlers.Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit. Must clean and comb hair away from incision siteDraping: Head drape.
10Rhytidectomy Begin your Operative Sequence Prior to incision, must have pre-op photos in room!Incisions are marked bilaterally and injected with localIncision: 15 kb on #3 handle for incision.Made around the ear, under the earlobe and extends into the hairline.One side is done at a time.
11Rhytidectomy cont. Operative Sequence Hemostasis: Handheld Bovie and hemostats.
12Rhytidectomy cont. Operative Sequence Dissection and Exposure:The skin is undermined to the nasolabial fold, area of the mental foramen and to the midline of the neck to the thyroid cartilage.Use of Metz, Double and Single Skin hooks, Adsons, and Stevens scissors.
13Rhytidectomy cont. Operative Sequence Exploration and Isolation:Care is taken not to damage the Facial nerve and artery.If a tighter lift is desired, the Platysmal and SMAS (Superficial Musculoaponeurotic System) is dissected and lifted.
14Rhytidectomy cont. Operative Sequence Surgical Repair:Excess fat is removed and skin flap edges are grasped with Allis’s.The skin is drawn upward and redraped to the proper degree of tension. The excess skin is excised along the angle of the clamps.Excellent Facelift Video
15Rhytidectomy cont. Operative Sequence Hemostasis and Irrigation:All bleeding is controlled with cautery, possibly Bi-polar.Use of warm Saline to irrigate.
16Rhytidectomy cont. Operative Sequence Closure:Incisions are usually closed with a 4-0 Nylon behind the ear and a 5-0 in front of and around the ear.Staples may be used in the hairline.The circulator will prepare the local for the opposite side.Repeat procedure on the opposite side.
18Rhytidectomy Major Veins: Major Nerves: Internal Jugular Vein Cranial Nerve VII - Facial Nerve
19BlepharoplastyFact: According to the American Society for Aesthetic Plastic Surgry, in year 2008 more than 195,000 people in the United States underwent cosmetic eye surgery. Blepharoplasty has become the most sought-after facial plastic surgery procedure, surpassing facelift, rhinoplasty, facial implants, and forehead lift.
22LipectomyOverall Purpose of Procedure:To remove excess fatty deposits from many different areas of the human body.Areas include:Hips and ThighsAbdomenBreastFaceButtocksAnywhere there is bulk fatty deposits
23Lipectomy Define the procedure: Liposuction, also known as lipoplasty ("fat modeling"), liposculpture or suction lipectomy ("suction-assisted fat removal") is a cosmetic surgery operation that removes fat from many different sites on the human body.
24Lipectomy a 12-year old girl who at 5-foot-5 weighed 230 pounds.
25LipectomyLiposuction is not a low-effort alternative to exercise and diet. It is a form of body contouring with significant risks and is not a weight loss method. The amount of fat removed varies by doctor, method, and patient, but is typically less than 10 pounds.There are several factors that limit the amount of fat that can be safely removed in one session.Ultimately, the operating physician and the patient make the decision. There are negative aspects to removing too much fat. Unusual "lumpiness" and/or "dents" in the skin can be seen in those patients "over-suctioned". The more fat removed the higher the surgical risk.
28LipectomyInstrumentation: Plastics tray. Assortment of liposuction cannulas. Liposuction machine and tubing.Positioning: Depends on the area of fat removal.Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit.Draping: Also depends on area prepped.
29Lipectomy Begin your Operative Sequence Prior to Incision:Some MDs inject a solution to “melt” the fatty deposits. This is usually Lidocaine and LR or NACL This makes removal easier.Mark the site and have the surgeon pick out the appropriate size cannula.ST will connect the cannula to the suction tubing and throw end to circ.Incision: 15 kb on #3 handle for incision.Incision is only ½ inch at most.
31Lipectomy cont. Operative Sequence Dissection and Exposure:All dissection is made with the lipo cannual that the surgeon has previously chosen.
32Lipectomy cont. Operative Sequence Exploration and Isolation:A tunnel is created by passing the cannula underneath the skin.The suction is off at this point.
33Lipectomy cont. Operative Sequence Surgical RepairOnce the tunneling process is done a few times, the suction is turned on. This allows the surgeon to “break up” the fatty deposits before attempting suctioning.The surgeon removes the desired amount of fat, checking the area periodically.The tubing will need cleaning with NACL during the procedure.Lipo video
34Lipectomy cont. Operative Sequence Hemostasis and Irrigation:All bleeding is controlled with cautery.Use of warm Saline to irrigate.
35Lipectomy cont. Operative Sequence Closure:The small incision is closed with a 4-0 or5-0 Nylon.The dressing that you apply will need to be a pressure dressing, applied depending on area of Lipectomy.
36LipectomyMajor Arteries:Depends on area of Lipectomy
37LipectomyMajor Veins:Depends on area of LipectomyMajor Nerves:
44AbdominoplastyInstrumentation: Major/Minor tray depending on patient size.Positioning: Supine with arms on arm boards.Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit.Draping: Can be as many as 8 towels.44
45Abdominoplasty Begin your Operative Sequence Prior to Incision: MD will mark incision.It will be necessary to flex the able to aid in closure.Incision:10 KB across pubic line, from Iliac crest to Iliac crest.Can be made from north to south, from umbilicus to pubis.45
47Abdominoplasty cont. Operative Sequence Dissection and Exposure:The abdomen is dissected through the subcutaneous tissue and fat down to the rectus muscle using the bovie.47
48Abdominoplasty cont. Operative Sequence Exploration and Isolation:The abdomen is also dissected up towards the chest.This creates a flap that will be pulled down towards the pubis once the excess skin is excised.Have Volkmans and Deavers available.48
49Abdominoplasty cont. Operative Sequence Surgical Repair:Both of the Rectus muscles are tightened using a 0 Ticron.The skin flaps are pulled together, excess skin and fat is removed.The table is flexed and the abdomen is closed.Video:Abdominoplasty Surgery Video49
50Abdominoplasty cont. Operative Sequence Hemostasis and Irrigation:All bleeding is controlled with cautery.Use of warm Saline to irrigate.50
51Abdominoplasty cont. Operative Sequence Closure:Abdomen is closed with 0 Ticron.Subcutaneous tissue is close using 3-0 Vicryl.The skin is closed using 3-0 Prolene.Steristrips and Mastisol.Must apply an abdominal binder for support.51
52Abdominoplasty Major Arteries: No major since we are superficial, or above the rectus muscles52
53Abdominoplasty Major Veins: Major Nerves: No major since we are superficial, or above the rectus musclesMajor Nerves:Splanchnic nerve53
54Cheiloplasty (key-lo-plasty) and Palatoplasty Plastic Procedures Operative SequenceCheiloplasty (key-lo-plasty) and Palatoplasty54
55Overall Purpose of Procedure: PalatoplastyOverall Purpose of Procedure:A.K.A. Cleft PalateTo reassemble normal pathology of the palate.55
56PalatoplastyDefine the procedure: The palate is made up of a hard portion anteriorly and a soft portion posteriorly.A cleft occurs in the midline and may one or both palates.The repair is usually done around 18 months since a function of the palate is speech development.56
58PalatoplastyInstrumentation: Plastics/Minor tray depending on patient size.Positioning: Supine with arms on arm boards.Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.Draping: Head drape with ¾ drape or green sheet as a lower body drape.58
59Palatoplasty Begin your Operative Sequence Prior to Incision: MD will mark incision.Incision: Mouth gag is inserted ( i.e. McIvor)15 or 10 KB is used to incise the palate to make flaps.59
60Palatoplasty cont. Operative Sequence Hemostasis: Bayonet Bovie or needle tip.60
61Palatoplasty cont. Operative Sequence Dissection and Exposure:The flaps are elevated with skin hooks.61
62Palatoplasty cont. Operative Sequence Exploration and Isolation:None needed62
63Palatoplasty cont. Operative Sequence Surgical Repair:Once the flap are elevated, they are closed in three layers.Nasal MucosaMusclePalatal mucoa63
64Palatoplsty cont. Operative Sequence Hemostasis and Irrigation:All bleeding is controlled with cautery.Use of warm Saline to irrigate.64
65Palatoplsty cont. Operative Sequence Closure:Chromic suture is used to closed palate.A traction suture is placed in the body of the tongue.This is usually a 0 Silk.Is an upper airway obstruction is suspected, they will use the traction suture to pull the tongue forward.65
69Overall Purpose of Procedure: CheiloplastyOverall Purpose of Procedure:A.K.A. Cleft LipTo reassemble normal pathology of the lip.69
70Cheiloplasty Define the procedure: A unilateral cleft lip results from failure of the union of the maxillary and median nasal processes, thus creating a split or cleft in the lip on either the left or right side.It may be just a notching of the lip or extend completely through the lip into the nose and palate.Can be Bi-lateral.70
72CheiloplastyInstrumentation: Plastics/Minor tray depending on patient size.Positioning: Supine with arms on arm boards.Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.Draping: Head drape with ¾ drape or green sheet as a lower body drape.72
73Cheiloplasty Begin your Operative Sequence Incision:15 and 11 KBsHemostasis: Handheld BovieDissection and Exposure/Surgical Repair: abnormal tissue is dissected and flaps are ID’d for clourse73
74Cheiloplasty cont. Operative Sequence Hemostasis and Irrigation:All bleeding is controlled with cautery.Use of warm Saline to irrigate.74
75Cheiloplasty cont. Operative Sequence Closure:Closure is begun with 4-0 or 5-0 Chromic. The muscle layer is followed by the mucosal layer and then skin.No dressing is usually needed.Might need to apply restraints to child to reduce chance of child destroying all completed work.75
77The goal of the procedure is to improve the appearance of the nose. RhinoplastyOverall Purpose of Procedure:The goal of the procedure is to improve the appearance of the nose.77
78Rhinoplasty Define the procedure: A Rhinoplasty is performed through internal incisions (if possible) so that there is no scar.This is done by reshaping the underlying framework of the nose by rasping the dorsal hump, partial excision of the lateral and alar cartilage, shortening the septum an osteotomy of the nasal bones.78
81RhinoplastyInstrumentation: ENT/Plastics tray depending on patient size. Assorted Minor Bone instruments.Positioning: Supine with arms on arm boards.Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.Draping: Head Drape. ¾ drape for lower body coverage.81
82Rhinoplasty Begin your Operative Sequence Incision:Intranasal incisions are made with 15 KB, Joseph Knife, Joseph elevator or Button Knife.82
84Rhinoplasty cont. Operative Sequence Dissection and Exposure:The skin and the soft tissue are elevated from the underlying nasal bones and cartilage.84
85Rhinoplasty cont. Operative Sequence Exploration and Isolation:Full exposure of the nasal bones and cartilage with nasal speculum.85
86Rhinoplasty cont. Operative Sequence Surgical Repair:The tip of the nose is reshaped by excising portions of the alar and lateral cartilage of each side.This can accomplished with a small rasp, Ronguer, or scissors.86
87Rhinoplasty cont. Operative Sequence Surgical Repair:Osteotomies of the nasal bones are done medially and laterally to narrow the nasal bridge.This can be done with osteotomes and a mallet.
94Mammoplasty Overall Purpose of Procedure: Often refers to enlargement of the breasts, but can be reduction.Can also be the rebuilding of breast tissue after weight loss or cancer or any reason to change the appearance or symmetry.94
95Mammoplasty Define the procedure: We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts.95
98MammoplastyInstrumentation: Major/Minor tray depending on patient anatomy/size.Positioning: Sitting position or able to be placed in the sitting position intra-op.Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep entire anterior portion chest, from just below the clavicle to two inches below the inframammary crease and laterally to the axilla.Draping: 4 to 6 blue towel placed under and around both breasts and a modified lap drape.98
99Mammoplasty Begin your Operative Sequence Prior to Incision:Photos must be taken and available in the O.R.MD will mark the patients breasts while sitting up.Incision:Incision is made along the markings with a 10 Kb. The incision for a reduction Mammoplasty is a called a keyhole incision. It starts around the nipple, going from 7 o’clock to 5 o’clock, in a clockwise manner.Two additional diagonal incisions lines are made from the bottom of the nipple to the natural mammary fold. The angle will depend on the amount of tissue to be removed.99
101Mammoplasty cont. Operative Sequence Dissection and Exposure:The skin flaps are de-epithelized with numerous 10 KB’s, cautery etc.Exposure is gained with Volkmans or hand retraction101
102Mammoplasty cont. Operative Sequence Exploration and Isolation:None at this point.102
103Mammoplasty cont. Operative Sequence Surgical Repair:The breast tissue is cut down to the medial and lateral margins.The nipple and areola are not excised from the pedicle.ALL EXCISED TISSUE IS WEIGHED.The circ will keep the surgical team apprised of the total weight removed from each side if both sides are reduced.Video: Breast Reduction103
104Mammoplasty cont. Operative Sequence Once the desired amount is taken off, the skin is temporarily closed with desired suture or staples.The patient may be sat up to obtain a better view of the reduced breasts, to determine if the reduction is adequate.
105Mammoplasty cont. Operative Sequence The patient is returned to the supine position and attention is directed to the other breast, where the same procedure is followed.Once the second side is temporarily closed, the patient is once again sat up to compare both breasts and t determine if further work is needed.If the MD is satisfied, the patient is returned to the supine position and permanent closure begins.
106Mammoplasty cont. Operative Sequence Hemostasis and Irrigation:All bleeding is controlled with cautery.Use of warm Saline to irrigate.106
107Mammoplasty cont. Operative Sequence Closure:Hemovac drains can be used for drainage of wound(s).Closure of the breasts is completed with Vicryl (3-0) and a running Prolene (4-0) stitch.The nipple will be sewn into place with a 5-0 Nylon.107
110Mammoplasty Major Veins: Major Nerves: Axillary vein Thoracic intercostal nerves T3-T5Researchers believe sensation to the nipple derives from the lateral cutaneous branch of T4.110
111Hand Surgery Reasons performed: Congenital deformities Disease Trauma Can be performed by plastic surgeons, orthopedic or orthopedic “hand-surgeons”, and neurosurgeons
112Hand Surgery Traumatic Injury: Laceration closure Ganglion cyst excisionCarpal Tunnel ReleaseDeQuervain’s RepairDuPuytren’s Contracture ReleaseTrigger Finger ReleaseToe to Hand TransferRelease of Syndactyly (webbed fingers)Reduction of polydactyly (extra digit)Radial dysplasia (club hand) correctionTraumatic Injury:Laceration closureDigital ReimplantationTennorhaphyNeurorrhaphyRestoration of vascularityBone approximationItalicized info seen in children must consider special needs of children when performing surgery on children
113Summary Terminology Anatomy of Skin and Hand Pathology Medications AnesthesiaSupplies, Instrumentation, and EquipmentConsiderations and Post-op CareProcedures: Skin and Hand