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Presentation on theme: "PLASTIC & RECONSTRUCTIVE SURGERY"— 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
Fibrous Dysplasia -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

5 Purposes of Plastic & Reconstructive Surgery
Dede Koswara Correct congenital anomalies or defects Correct traumatic or pathologic (disease) deformities or disfigurements Improve appearance (cosmetic) Restore appearance and function

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 Merocrine Glands Apocrine Glands 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 Female patient who suffers with severe burns on 70% of her body
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 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 5th 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

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 5th and 6th 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 Clarify I and D (incision and drainage)

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 Dermabrasion also used for removal of tattoos, birthmarks, and fine epidermal wrinkles

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.

A- Asymmetry. If the mole is asymmetrical, it is potentially cancerous. B- Border. If the mole has an irregular border, it could be cancerous.

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 cheiloschisis Palatoschisis = cleft palate - Say 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 Panniculus? The ROLL may have to tape out of the way esp. in groin procedures. May find Lovelies underneath them ex. Food, yeast, etc.

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 Trigger Finger Stenosis of digital tendons
Surgical intervention needed if digit becomes “locked”

70 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

71 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%

72 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

73 Hand Surgery Goal: Restoration of appearance Restoration of function
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 Re-implantation can involve hand transplants with new techniques and improvements

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
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 Give ex of procedures ask positions

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) Hyperbaric unit? Pressurized high oxygen content chamber Room temp 80° F +

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


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