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Presentation on theme: "PLASTIC & RECONSTRUCTIVE SURGERY Neurofibromatosis."— Presentation transcript:


2 Outline  Terminology  Anatomy of Skin and Hand  Pathology  Medications  Anesthesia  Supplies, Instrumentation, and Equipment  Considerations and Post-op Care  Procedures: Skin and Hand

3 Terminology  Dermatome-instrument used to incise skin, for thin skin transplants/can be a tool for 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

4 Terminology & Procedures  - 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 Fibrous Dysplasia

5 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 Dede Koswara

6 Anatomy & Physiology  Multi-system/structure involvement  Non-specific anatomically unlike peripheral vascular or orthopedics

7 Anatomy & Physiology Integumentary System  Skin (cutaneous membrane)-outer covering of the body  Function of:  Protection from external forces (sunrays)  Defense against disease  Fluid balance preservation  Maintenance of body temperature  Waste excretion (sweat)  Sensory input (temp/pain/touch/pressure)  Vitamin D synthesis

8 Integumentary System  Layers  2 main:  Epidermis (outer)  Composed of 4-5 layers called strata  Constantly proliferating (newly forming) and shedding (thousands a day)  Five week process  Dermis (inner)  Connective tissue  Composed of nerves, capillaries, hair follicles, nails, and glands  Two divisions:  Reticular layer-thick layer of collagen for strength, protection, and pliability  Papillary layer-”named for papilla or projections the groundwork for fingerprints” (Caruthers & Price, 2001)

9 Integumentary System Subcutaneous Layer/Hypodermis Not really a layer but serves as an anchor for the skin to the underlying structures Composition: adipose (fat) & loose connective tissue Purpose: insulation & internal organ protection

10 Accessory Structures of the Integumentary System  Hair  Nails  Glands:  Sebaceous Glands  Sweat Glands/Sudoferous Glands 1. Merocrine Glands 2. Apocrine Glands 3. Ceruminous Glands

11 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

12 Sweat (Sudoriferous) Glands  Merocrine  Cover most of the body  Openings are pores  Secretion 1° water and some salt  Stimulated by heat or stress

13 Sweat (Sudoriferous) Glands  Apocrine  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

14 Sweat (Sudoriferous) Glands  Ceruminous  External auditory canal  Secrete cerumen (earwax)  No sweat glands located in following areas:  Some regions of external genitalia, nipples, lips

15 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

16 The Hand  Wrist  Palm  Fingers

17 Wrist (Carpus)  8 carpal bones  Arranged in 2 rows 4 each: distal and proximal  Proximally articulate with distal ulna and radius

18 An easy way to remember the 8 carpal bones-  Scaphoid (Skay-foid)  Lunate  Triquetrum  Pisiform  Trapezium  Trapezoid  Capitate  Hamate Some Lovers Try Positions That They Can’t Handle

19 Palm (Metacarpus)  Metacarpals  5 per hand  Long, cylindrical shaped

20 Fingers (digits) Phalanges  14 per hand  3 phalanges per finger or digit  Numbered 1-5 beginning with the thumb

21 Hand Joints  Metacarpals articulate with the phalanges  Diarthroses or freely-moveable joints  Synovial hinge joints  Metacarpophalangeal joints or MPJ referred to as the (knuckles)

22 Nerves in the Hand  Branches of brachial plexus supply innervation to the forearm and hand  Radial  Median  Ulnar

23 Radial Nerve (purple)  Runs with the radius  Sensation to forearm and small section hand  Extensor muscles of the forearm

24 Median Nerve (Blue)  2 branches  Innervates: Skin of lateral 2/3 of hand Flexor muscles of the forearm Intrinsic muscles of the hand

25 Ulnar Nerve (Yellow)  Innervates  Skin of medial 1/3 of hand  Some flexor muscles of hand and wrist

26 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

27 Compartments or Tunnels of the Hand  One main anterior (palm)  Posterior or dorsally there are 5  6 total compartments

28 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

29 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

30 Pathology I. Burns  Injury resulting from heat, cold, chemicals, radiation, gases, or electricity that causes tissue damage Female patient who suffers with severe burns on 70% of her body

31 Burn Classification  Depth  1 st degree - involvement just epidermis  2 nd degree - involvement to dermis  3 rd degree - penetrates full thickness of skin  Can affect underlying structures  4 th degree - char burns  5 th degree - most of the hypodermis is lost, charring and exposing the muscle (and some bone) underneath.  6 th 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 3 rd thru 6 th degree.  Burns Video - this video only covers 1 st thru 3 rd degree)

32 First Degree Burn  Superficial  Epidermis involvement  Redness or erythema  Healing rapid

33 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

34 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

35 Fourth Degree Burn  Damage to bones, tendons, muscles, blood vessels, and nerves  Charring  Electrical burns most common  Extensive skin grafting required  Patient might survive and/or limb might be saved.

36 5 th and 6 th Degree Burns  Fifth 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.

37 Healing  Remember 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.

38 Lund-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.

39 Burn Assessment -Rule of Nines

40 Rule 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%

41 Burn 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 Grafting  The Story - Milwaukee Journal Sentinel - The Phoenix Man - George Bennett – 70% burn - underground tank

42 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

43 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)

44 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


46 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


48 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

49 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

50 Donor Site  Covered with a mesh-like medicated dressing

51 Graft Care  Do not allow to dry out  Place in a basin with small amount of warm saline until ready to use

52 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 mesh graft device  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

53 Mesh Graft Device

54 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  Anything wrong here?

55 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

56 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”

57 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  No sunscreen can lead to Melanoma.

58 Melanoma  A 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.

59 HOW 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.

60 HOW 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.

61 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

62 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

63 Neoplasm Example

64 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

65 VIII. Cleft Lip & Palate  Cleft = split or gap between two structures that normally are joined  Cheiloschisis = cleft lip (hair lip) -Say cheiloschisisSay cheiloschisis  Palatoschisis = cleft palate - Say palatoschisisSay palatoschisis  May see alone or in conjunction  May be unilateral or bilateral  Surgical intervention = cheiloplasty and palatoplasty

66 IX. Breasts  Gynecomastia  Liposuction  Cancer  Congenital deformity  Aesthetic reasons  Medical reasons  Mammoplasty

67 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

68 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)

69 Hand Pathology 2. Trigger Finger  Stenosis of digital tendons  Surgical intervention needed if digit becomes “locked”

70 Hand Pathology 3. 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

71 Hand Pathology 4. 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%

72 Hand Surgery 5. 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

73 Hand Surgery 6. 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

74 Medications  Local anesthetics  Hemostatics  Mineral oil (for skin with dermatome use)  Antibiotic irrigants and ointments  All solutions must be warmed especially on burn patients

75 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

76 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

77 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

78 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

79 Cheiloplasty & Palatoplasty Instruments/Supplies  Basic plastic tray  #15 blade  Oral instruments  Mouth Gag (Jennings/Davis/McIvor) + assorted blades  2x2 gauze for dressing

80 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

81 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

82 Hand Instruments  Minor orthopedic tray  Minor plastic tray  Small vascular instruments (re-implantations)  Metacarpal retractors  Pediatric deavers

83 Hand Equipment  Sitting stools  ECU  Suction  Hand table  Tourniquet  Tower Equipment including insufflator

84 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

85 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

86 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)

87 Post-Operative Care  Maintain asepsis until all dressings are secured prior to removal of drapes

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