1. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 1

2. 2 CHAPTER 19 Plastic and Reconstructive Surgery

3. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 3 Objectives After studying this chapter, you will be able to: –Recognize the relevant anatomy and physiology of the skin and its underlying tissues –Summarize the pathology that prompts plastic/reconstructive surgical intervention and the related terminology

4. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 4 Objectives (cont’d.) –Determine any special preoperative plastic/reconstructive diagnostic procedures/tests –Determine any special preoperative preparation procedures related to plastic/reconstructive surgical procedures –Indicate the names and uses of plastic/reconstructive instruments, supplies, and specialty equipment

5. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 5 Objectives (cont’d.) –Determine the intraoperative preparation of the patient undergoing a plastic/reconstructive procedure –Summarize the surgical steps of the plastic/reconstructive procedures –Interpret the purpose and expected outcomes of the plastic/reconstructive procedures

6. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 6 Objectives (cont’d.) –Recognize the immediate postoperative care and possible complications of the plastic/reconstructive procedures –Assess any specific variations related to the preoperative, intraoperative, and postoperative care of the plastic/reconstructive patient

7. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 7 Introduction Plastic, or cosmetic, and reconstructive surgery –Primary goal: restoration of appearance or function to a particular body structure –Encompasses a wide spectrum of many systems and structures

8. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 8 Diagnostic Procedures and Tests Diagnosis of conditions that may require plastic/reconstructive surgery –Often accomplished by visual examination Imaging studies –Often used to determine the type and severity of a condition Standard X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) scanning

9. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 9 Instrumentation, Routine Equipment, and Supplies Instrumentation –Instrument sets will vary from institution to institution –Plastic Instrumentation set: refer to Table 19-1 Generally equipped with delicate skin instruments, larger soft tissue instruments, and some small bone instruments –Nasal set: refer to Tables 19-2 and 19-3 Tailored to suit the plastic surgeon’s needs

10. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 10 Instrumentation, Routine Equipment, and Supplies (cont’d.) Equipment –Dermatome: used to cut thin slices of skin for grafting Several types and brands are available Oscillating-blade–type dermatome –Powered by electricity or nitrogen –Cord must be secured –Sterile disposable blade is used for each patient

11. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 11 Instrumentation, Routine Equipment, and Supplies (cont’d.) Other types of dermatomes –Ferris-Smith, Watson, and Weck –Padgett and Reese Additional supplies –Mesh graft device –Derma-carriers Other routine equipment and OR furniture –Refer to text

12. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 12 Skin Graft Procedures Skin graft sources –Homograft: obtained from the same species –Heterograft or xenograft: obtained from a dissimilar species Skin graft categories –Full-thickness skin grafts (FTSG): composed of the epidermis and all of the dermis –Split-thickness skin grafts (STSG): involves removing the epidermis and half of the dermis

13. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 13 Skin Graft Procedures (cont’d.) Choice of donor site is influenced by many factors, including: –Age, sex, and general health of the patient –Location of the wound to be grafted –Size of surface area to be covered –Condition of potential donor sites

14. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 14 Skin Graft Procedures (cont’d.) Ideal donor sites –Abdomen –Back –Chest –Lateral and ventral aspects of the thighs

15. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 15 Skin Graft Procedures (cont’d.) Cutaneous membrane (i.e., skin) responsibilities –Protection from external forces –Defense against disease and infection –Preservation of fluid balance –Vital in regulating body temperature –Excretion of waste via sweat –Sensory input through receptors –Synthesis of vitamin D

16. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 16 Skin Graft Procedures (cont’d.) Integumentary system layers: refer to Figure 19-3 –Epidermis and dermis Epidermis layers: innermost to outmost –Stratum basale –Stratum spinosum –Stratum granulosum –Stratum lucidum –Stratum corneum

17. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 17 Skin Graft Procedures (cont’d.) Dermis divisions –Reticular layer –Papillary layer Subcutaneous layer –Not actually considered part of the skin –Serves to anchor skin to underlying structures –Consists of adipose (fat) and loose connective tissue

18. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 18 Skin Graft Procedures (cont’d.) Accessory structures of the integumentary system –Hair –Nails –Sebaceous glands –Sudoriferous glands –Apocrine sweat glands –Ceruminous gland

19. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 19 Skin Graft Procedures (cont’d.) Causes of burns –Heat, radiation, chemicals, gases, or electricity Burn classifications: refer to Figure 19-4 –First-degree burns –Second-degree burns –Third-degree burns –Fourth-degree burns

20. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 20 Skin Graft Procedures (cont’d.) Abbreviated Burn Severity Index criteria –Age and sex of the patient –Presence of inhalation injury –Depth of the burn (according to degree) –Percentage of total body surface burned Rule of nines –Refer to Table 19-4 and Figure 19-4 Full- and split-thickness skin grafts –Procedure: refer to text

21. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 21 Scar Revision A type of aesthetic surgical procedure –Patient wishes for an improved appearance and the scar is not as conspicuous as previously Simple scar revision –Procedure: refer to text Z-plasty scar revision –Procedure: refer to text

22. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 22 Head and Face Procedures Most individuals are very self-conscious of how their face looks to the public –Trauma and congenital defects can cause facial features that the affected person would like to be cosmetically improved Congenital defects can also cause problems with speech development and swallowing

23. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 23 Head and Face Procedures (cont’d.) Common procedures –Blepharoplasty –Endoscopic brow lift –Malar implants –Mentoplasty –Otoplasty –Rhinoplasty: external technique –Rhytidectomy

24. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 24 Head and Face Procedures (cont’d.) –Cleft lip repair: rotation advancement technique –Cleft palate repair: V-Y palatoplasty technique

25. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 25 Hand Procedures Hand anatomy –Extensive: refer to Figures 19-16 through 19- 20 Regions –Wrist, palm, and fingers Terms –Volar surface, dorsal surface or dorsum, radial, and ulnar

26. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 26 Hand Procedures (cont’d.) Several factors affect viability of replantation –Type of injury –Location of the amputation on the affected structure –Extent of damage to underlying structures –Care of the severed part –Time elapsed between accident and initiation of replantation

27. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 27 Hand Procedures (cont’d.) Procedures –Subtotal palmar fasciectomy for Dupuytren’s contracture –Toe-to-hand transfer –Centralization of radial dysplasia –Release of syndactyly –Ablation of radial thumb and collateral ligament –Reattachment for polydactyly of hand

28. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 28 Breast Procedures Primary function of the female breast –Produce milk Provides nutrition and vital immunities to the newborn and infant In Western society in particular –Breasts are a symbol of femininity Aesthetic qualities

29. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 29 Breast Procedures (cont’d.) Include: –Augmentation mammoplasty –Transverse rectus abdominis musculocutaneous flap –Nipple reconstruction –Mastopexy: anchor technique

30. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 30 Abdominal Procedures Plastic abdominal procedures –Performed to enhance the patient’s image of his/her body –Not be confused with panniculectomy Removal of apron of abdominal fat in the formerly obese patient who has lost large amount of weight Common procedures –Tumescent liposuction –Abdominoplasty

31. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 31 Summary This chapter reviewed: –Anatomy and physiology of the skin and its underlying tissues –Pathology that prompts plastic/reconstructive surgical intervention –Plastic/reconstructive surgery equipment –Plastic/reconstructive surgery procedures –Plastic/reconstructive surgery preoperative, intraoperative, and postoperative care