Presentation on theme: "PLASTIC & RECONSTRUCTIVE SURGERY"— Presentation transcript:
1PLASTIC & RECONSTRUCTIVE SURGERY Neurofibromatosis
2Outline Terminology Anatomy of Skin and Hand Pathology Medications AnesthesiaSupplies, Instrumentation, and EquipmentConsiderations and Post-op CareProcedures: Skin and Hand
3TerminologyDermatome-instrument used to incise skin, for thin skin transplants/can be a tool for debridementDermis-inner sensitive (nerve rich), vascular (capillaries) layer of skinDonor site-area of body used as source of a graftEpidermis-outer, non-sensitive, non-vascular layer of skinErythema-small spot or reddened area of skinGraft-tissue transplanted or implanted in a part of the body to repair a defectPlastic-”(plastikos) to mold or shape with one’s hands” (Caruthers & Price, 2001)Plastic surgery-surgery performed to repair, restore, or reconstruct a body structureRecipient site-area of body that receives grafts
4Terminology & Procedures Fibrous Dysplasia-plasty-restorative or reconstructiveAbdominoplasty-abdominal wallBlepharoplasty-eyelidCheiloplasty/Palatoplasty-cleft palateMammoplasty-breastsMentoplasty-chinRhinoplasty-noseRhytidectomy-face liftW, X, Y or Z-plasty-skin (burns/scars)Excision of Cancerous Neoplasms (basal cell, squamous cell, malignant melanoma)Lipectomies-liposuctionMicrolipo-extractionCollagen injectionDermabrasion-removal of scars, tatoos, acne scarsScar Revision
5Purposes of Plastic & Reconstructive Surgery Dede KoswaraCorrect congenital anomalies or defectsCorrect traumatic or pathologic (disease) deformities or disfigurementsImprove appearance (cosmetic)Restore appearance and function
7Anatomy & Physiology Integumentary System Skin (cutaneous membrane)-outer covering of the bodyFunction of:Protection from external forces (sunrays)Defense against diseaseFluid balance preservationMaintenance of body temperatureWaste excretion (sweat)Sensory input (temp/pain/touch/pressure)Vitamin D synthesis
8Integumentary System Layers 2 main: Epidermis (outer) Composed of 4-5 layers called strataConstantly proliferating (newly forming) and shedding (thousands a day)Five week processDermis (inner)Connective tissueComposed of nerves, capillaries, hair follicles, nails, and glandsTwo divisions:Reticular layer-thick layer of collagen for strength, protection, and pliabilityPapillary layer-”named for papilla or projections the groundwork for fingerprints” (Caruthers & Price, 2001)
9Integumentary System Subcutaneous Layer/Hypodermis Not really a layer but serves as an anchor for the skin to the underlying structuresComposition: adipose (fat) & loose connective tissuePurpose: insulation & internal organ protection
10Accessory Structures of the Integumentary System HairNailsGlands:Sebaceous GlandsSweat Glands/Sudoferous GlandsMerocrine GlandsApocrine GlandsCeruminous Glands
11Sebaceous Glands Oil (sebum) producing glands Travels through ducts emptying in the hair follicleFluid regulationSoftens hair and skinMakes skin and hair pliableActivity stimulated by sex hormonesActivity begins in adolescence, continues throughout adulthood, decreasing with aging
12Sweat (Sudoriferous) Glands MerocrineCover most of the bodyOpenings are poresSecretion 1° water and some saltStimulated by heat or stress
13Sweat (Sudoriferous) Glands ApocrineLarger than Merocrine glandsLocated in external genitalia and axillaeDucts in hair folliclesSecrete water, salt, proteins, fatty acidsActivated at pubertyStimulated by pain, stress, sexual arousal
14Sweat (Sudoriferous) Glands CeruminousExternal auditory canalSecrete cerumen (earwax)No sweat glands located in following areas:Some regions of external genitalia, nipples, lips
15Palate Roof of the mouth Anterior portion = hard palate Composed of maxilla, palatine bones, mucous membranePosterior portion = soft palateComposed of muscle, fat, mucous membraneTerminates or ends at uvula (opening of oropharynx)Function of palate to separate nose from mouthFunction swallowing and speech
17Wrist (Carpus) 8 carpal bones Arranged in 2 rows 4 each: distal and proximalProximally articulate with distal ulna and radius
18An easy way to remember the 8 carpal bones- Scaphoid (Skay-foid)LunateTriquetrumPisiformTrapeziumTrapezoidCapitateHamateSome Lovers Try Positions That They Can’t Handle
19Palm (Metacarpus)Metacarpals5 per handLong, cylindrical shaped
20Fingers (digits) Phalanges 14 per hand 3 phalanges per finger or digit Numbered 1-5 beginning with the thumb
21Hand Joints Metacarpals articulate with the phalanges Diarthroses or freely-moveable jointsSynovial hinge jointsMetacarpophalangeal joints or MPJ referred to as the (knuckles)
22Nerves in the HandBranches of brachial plexus supply innervation to the forearm and handRadialMedianUlnar
23Radial Nerve (purple) Runs with the radius Sensation to forearm and small section handExtensor muscles ofthe forearm
24Median Nerve (Blue) 2 branches Innervates: Skin of lateral 2/3 of hand Flexor muscles of the forearmIntrinsic muscles of the hand
25Ulnar Nerve (Yellow) Innervates Skin of medial 1/3 of hand Some flexor muscles of hand and wrist
26Muscles and Tendons of the Hand 40 muscles are responsible for movement of the hand, wrist, and fingersMost are on anterior aspect of the handAnterior muscles are for flexionFewer posterior muscles are for extension
27Compartments or Tunnels of the Hand One main anterior (palm)Posterior or dorsally there are 56 total compartments
28Tendon Sheaths of the Hand Finger and thumb tendons are contained in a tendon sheathServes to protectLined with synoviumPulleys are attached to the bones along the tendon sheathServe to hold the tendon to the bones they pass over
29Hand Circulation 2 primary arteries Brachial splits below the elbow >radial and ulnar arteriesRadial supplies lateral aspect of armUlnar supplies medial aspect of armJoin to form palmar and superficial palmar archesNames of hand veins correlate with their arteries
30Female patient who suffers with severe burns on 70% of her body PathologyI. BurnsInjury resulting from heat, cold, chemicals, radiation, gases, or electricity that causes tissue damageFemale patient who suffers with severe burns on 70% of her body
31Burn Classification Depth 1st degree - involvement just epidermis 2nd degree - involvement to dermis3rd degree - penetrates full thickness of skinCan affect underlying structures4th degree - char burns5th degree - most of the hypodermis is lost, charring and exposing the muscle (and some bone) underneath.6th degree - the most severe form. Almost all the muscle tissue in the area is destroyed, leaving almost nothing but charred bone.Damage to blood vessels, nerves, muscles, tendons, and possibly bone density in 3rd thru 6th degree.Burns Video - this video only covers 1st thru 3rd degree)Add sx. And interventions for each
32First Degree Burn Superficial Epidermis involvement Redness or erythemaHealing rapid
33Second Degree Burn Partial Thickness Burn Epidermis and Dermis If Deepest Epithelial layer undamaged will healInfection can result in damage same as third degree burnBlistering, pain, moist/red/pink in appearance
34Third Degree Burn Full-Thickness Burn Epidermis and Dermis destroyed Extends to subcutaneous layer and structuresRequires skin grafts to healDry, pearly white, charred surface (eschar)No sensation
35Fourth Degree BurnDamage to bones, tendons, muscles, blood vessels, and nervesCharringElectrical burns most commonExtensive skin grafting requiredPatient might survive and/or limb might be saved.
365th and 6th Degree BurnsFifth and sixth degree burns are most often diagnosed during an autopsy. The damage goes all the way to the bone and everything between the skin and the bone is destroyed. It is unlikely that a person (or limb) would survive this type of injury.
37HealingRemember that first-degree burns require three to five days to heal, second-degree burns take two to six weeks to heal, and third- and fourth-degree burns take many weeks to months to heal.
38Lund-Browder Method (perdriatrics) vs. Rule of Nines (everybody) Lund-Browder Method - used in the evaluation of all pediatric patients.The Lund-Browder system uses fixed percentages for the feet, arms, torso, neck, and genitals, but the values assigned to the legs and head vary with a child's age.Is more accurate but also more difficult to use.
40Rule of Nines Increments of 9% BSA (body surface area) Head and Neck (front and back)= 9%Anterior Trunk = 18%Posterior Trunk = 18%Upper Extremity (front & back)= 9%Lower Extremity x 1(front & back)= 18%Perineum = 1%
41Burn Surgical Intervention Debridement - medical term referring to the removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.Skin GraftingThe Story - Milwaukee Journal Sentinel - The Phoenix Man - George Bennett – 70% burn -underground tankClarify I and D (incision and drainage)
42Skin 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 bankHeterograft or Xenograft – Taken from one species and used on another species (pigskin/porcine skin or cowskin/bovine)Synthetic SkinThese means reduce fluid loss and protect the wound
43AutograftsClassified by the source of their vascular supply and tissue involvedFactors for determining choice of grafting method:Location of defectAmount of area to be coveredDepth of defectUnderlying tissue involvement at defectCause of defect (trauma, disease, or heredity)
44Autografts (FTSG) Full Thickness Skin Graft Consists of epidermis and all of the dermisMay include greater than 1 mm of the subcutaneous layerBecause 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 carcinomasDonor site must be closedCannot reuse donor siteExcised by a skin graft knifePrevent contraction of a wound better than a split-thickness graft
46Autografts (STSG) Split-Thickness Skin Graft Involves removal of epidermis and dermis to a depth of up to 1mmCan 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 forGraft excised with a dermatomeGraft can be stretched or enlarged by a skin graft mesher
48Dermatomes Used to remove STSG Brown - oscillating blade Padgett-Hood-rotating blade housed in drumPowered by nitrogen or electricityHallReeseCan be hand held
49Dermatome Connect blade to dermatome before passing off the power cord Test in a safe placeBlades are disposableTake care with bladesSurface of blade protected with a guard (are 4 sizes)Secure blade and guard with screwdriverGuard should not cover the cutting edge of bladeDermatomeGraft thickness (depth) determined by small lever on side of dermatome (in tenth of a millimeter increments)Set at 0 before procedure and after changing bladesAdjust per surgeon directions or surgeon may adjustWidth of graft determined by gaps in edges of plate that are one to four inches
50Donor SiteCovered with a mesh-like medicated dressing
51Graft Care Do not allow to dry out Place in a basin with small amount of warm saline until ready to use
52Mesh Graft Device Manually operated/roller like device Used with a split thickness skin graft to expand (meshing) the size of the skin graftSkin graft is placed on a plastic derma-carrier, which holds the graft flat prior to placing in the mesh graft deviceIf more than one graft used, each is placed on its own derma-carrierDerma-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 meshedMeshing creates netted effectWhen skin graft placed on site being grafted, epithelial tissue will grow in between the slits
54Graft Care Post Placement Will likely be secured as it needs to stay in place until healing can ensueMay use a pressure type dressingAnything wrong here?
55II. Acne Inflammatory disease of skin Formation of pustules or pimples Face, neck, upper body affectedRelated to stress, diet, and hormonal activityBacteria can invade and cause pits and scarsSurgical intervention requires removal of pits and scars via dermabrasionDermabrasion also used for removal of tattoos, birthmarks, and fine epidermal wrinkles
56III. Aging Elastic fiber number decrease Lost adipose tissue Collagen fiber loss, slows healingWrinkling and sagging resultSurgical intervention = Conservative nonsurgical intervention to invasive surgical interventionRhytidectomy = “face-lift”
57IV. Sun ExposureSunlight exposure thickens epidermis and damages elastinDamaged elastin allows for formation of pre-malignant and malignant cellsPrevention best (sunscreen)Can resurface skin pharmaceutically or surgicallyNo sunscreen can lead to Melanoma.
58MelanomaA form of skin cancer that begins in melanocytes (the cells that make the pigment melanin). Melanoma usually begins in a mole.The most dangerous type of skin cancer.It begins as a dark skin lesion and may spread rapidly to other areas on the skin and within the body.
59HOW DO I KNOW IF I HAVE MELANOMA? The ABCD’s A- Asymmetry. If the mole is asymmetrical, it is potentially cancerous.B- Border. If the mole has an irregular border, it could be cancerous.
60HOW DO I KNOW IF I HAVE MELANOMA? C- Color. If the mole has more than one color or is blue, pink, or white, it could be cancerous.D- Diameter. If the mole has a diameter of larger than 6 mm, it could be cancerous.
61V. EyelidsBlepharochalasis = loss of muscle tone or relaxation of the eyelidsCauses wrinkling and thinningPoor results surgicallyDermachalasis = relaxation and hypertrophy of eyelid skinBags under the eyesEasily corrected surgicallyPtosis = eyelid droopingMuscle shortening repairs this
62VI. Neoplasms Any new or abnormal growth May be benign, pre-malignant, or malignantCaused by exposure direct or indirect to chemicals or the sunRemoval surgically can be chemical, laser, or minor surgical
64VII. Nose and Chin Rhinoplasty - reshaping the nose Can be done with other nasal procedures to restore upper respiratory function post-traumaMentoplasty – reshaping the chin
65VIII. Cleft Lip & PalateCleft = split or gap between two structures that normally are joinedCheiloschisis = cleft lip (hair lip) -Say cheiloschisisPalatoschisis = cleft palate- Say palatoschisisMay see alone or in conjunctionMay be unilateral or bilateralSurgical intervention = cheiloplasty and palatoplasty
66IX. Breasts Gynecomastia Liposuction Cancer Congenital deformity Aesthetic reasonsMedical reasonsMammoplasty
67X. Abdomen Abdominoplasty or tummy tuck Thinning of abdominal fat and tightening of abdominal musclesRemoving fat and excess skin from mid to lower abdomenCan do in addition to liposuctionPanniculectomy = removal of fat apron in obese patientsPanniculus? The ROLL may have to tape out of the way esp. in groin procedures. May find Lovelies underneath them ex. Food, yeast, etc.
68Hand Pathology 1. DeQuervain’s Disease Stenosis/inflammation of tendons in first dorsal wrist compartmentTreatment conservative with anti-inflammatories or surgical (rare recurrence after surgery)
69Hand Pathology Trigger Finger Stenosis of digital tendons Surgical intervention needed if digit becomes “locked”
70Hand Pathology DuPuytren’s Disease Related to traumatic injury Contracture of palmar fasciaMay be seen as a nodule in the palm, dimpling or pit in the palm, or fibrous cord from palm to fingersSurgical intervention warranted if movement and function are impaired
71Hand Pathology Ganglion Cyst Benign lesion in hand or wrist Filled with synovial fluid coming from a tendon sheath or jointResults from trauma or tissue degenerationMay aspirateSurgical removalRecurrence 50%
72Hand Surgery Rheumatoid Arthritis (RA) Disease that attacks the synovial tissuesMost common connective tissue diseaseLoss of joint functionAnti-inflammatory meds treatSurgical intervention required to stabilize a weakened joint or replace a damaged structure
73Hand Surgery Goal: Restoration of appearance Restoration of function Hand TraumaCutsSprainsFracturesBurnsCrush injuryAmputationReimplantation of digits is a microvascular procedureGoal:Restoration of appearanceRestoration of functionKEY GOAL = FUNCTIONRe-implantation can involve hand transplants with new techniques and improvements
74Medications Local anesthetics Hemostatics Mineral oil (for skin with dermatome use)Antibiotic irrigants and ointmentsAll solutions must be warmed especially on burn patients
75Supplies Basin pack Beaver blades Knife blades of surgeons choice Medicine cupsMineral oilSterile tongue blade used in conjunction with dermatome to stretch skin as graft being removedDerma-carrierDrains of surgeon’s choiceNeedle tip cautery electrodeMarking penRuler or calipersLuer lock control syringes25 and 27ga needles
76Instrumentation Basic Plastics Tray Towel clipsMicro mosquitoesHemostatsAllisesLittler, Iris, tenotomy scissorsSmall metz fine and blunt tippedSmall mayo straight and curvedBandage scissorsNH fine and crile-woodAdsons smooth and with teethAdson-brown, bishop-harmon, debakeySkin hooks single and double prongedSenn retractors, Army-Navy, Spring Retractors#3, #7,knife handles, beaver handleFreer, small key elevatorsFrazier suction tip 8F angled with “finger cut-off” valve
77Nasal Instruments Rhinoplasty/Nasal tray Vienna Nasal speculums Single skin hooksCottle or Joseph double prong skin hooksCottle knifeCottle or Fomon RetractorCottle osteotomes (4, 7, 9, 12mm)Ballenger chiselBallenger swivel knifeJoseph nasal bayonets, right and leftFreer septal chisels curved and straightJoseph rasp or Double ended Maltz raspCushing Bayonet forceps with teethJansen Bayonet dressing forcepsTakahashi ForcepsCottle cartilage crusher
78Abdominoplasty Instruments/Supplies Basic Plastic SetFiberoptic Retractor SetAbdominal retractor tray (deavers, richardsons, etc.)Lap spongesUmbilical templateAbdominal drapes (universal) or LaparotomyExtension blade for the cautery
80Mammoplasty Instruments & Supplies Basic Plastic TrayMinor Tray#15 bladesLocal with EpinephrineControl syringes and local needlesFiberoptic retractor setExtension tip available for cauteryLaparotomy spongesChest drapes (universal or laparotomy)Suture of surgeon preferenceDressing
81Hand Supplies Basin pack Basic pack Extremity sheet or hand/arm drape Split sheetHalf sheet for lower part of body#15 bladesStockinettesEsmarkTourniquet and padding for (cast type)Suture of preferenceAnesthetics of choice (local)Control syringes and 25/27ga. hypo needlesDressing of surgeon choiceElastic bandage
82Hand Instruments Minor orthopedic tray Minor plastic tray Small vascular instruments (re-implantations)Metacarpal retractorsPediatric deavers
83Hand Equipment Sitting stools ECU Suction Hand table Tourniquet Tower Equipment including insufflator
84Positioning Depends on area being operated on Care to padding depending on which position usedExtreme care with a burned patient with movingGuard all IV lines, trach tubes, ET tubesDo not delay transport to the ORGive ex of procedures ask positions
85PreppingColorless solution preferred if using skin graft so skin color can be seenDonor and graft sites prepped separatelySolutions used should be warmedPrep 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
86Special Considerations Strict aseptic techniqueDeath related to septicemia and pneumonia in severely burned patientsEnvironmental temperature should be geared to prevent hypothermia, prevent microbial invasion, and aid in the healing processBody temp will be monitored throughout on burn patients with a rectal, esophageal, or tympanic probePatient will be in isolation post-opMay go to hyperbaric unit to promote healingI & O carefully monitored (urine and blood loss)Hyperbaric unit? Pressurized high oxygen content chamber Room temp 80° F +
87Post-Operative CareMaintain asepsis until all dressings are secured prior to removal of drapes