PLASTIC & RECONSTRUCTIVE

SURGERY

Neurofibromatosis

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

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

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

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

Anatomy & Physiology Multi-system/structure involvement Non-specific anatomically unlike peripheral

vascular or orthopedics

Anatomy & PhysiologyIntegumentary 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

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)

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

Accessory Structures of the Integumentary System Hair Nails Glands: Sebaceous Glands Sweat Glands/Sudoferous Glands1. Merocrine Glands 2. Apocrine Glands3. Ceruminous Glands

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

Sweat (Sudoriferous) Glands Merocrine Cover most of the body Openings are pores Secretion 1° water and

some salt Stimulated by heat or

stress

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

Sweat (Sudoriferous) Glands Ceruminous External auditory canal Secrete cerumen

(earwax) No sweat glands

located in following areas:

Some regions of external genitalia, nipples, lips

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

The Hand Wrist Palm Fingers

Wrist (Carpus) 8 carpal bones Arranged in 2 rows 4

each: distal and proximal

Proximally articulate with distal ulna and radius

An easy way to remember the 8 carpal bones-

Scaphoid (Skay-foid) Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate HamateSome Lovers Try Positions

That They Can’t Handle

Palm (Metacarpus) Metacarpals 5 per hand Long, cylindrical

shaped

Fingers (digits)

Phalanges 14 per hand3 phalanges per finger or digitNumbered 1-5 beginning with the thumb

Hand Joints Metacarpals articulate with the phalanges Diarthroses or freely-moveable joints Synovial hinge joints Metacarpophalangeal joints or MPJ referred

to as the (knuckles)

Nerves in the Hand Branches of brachial

plexus supply innervation to the forearm and hand

Radial Median Ulnar

Radial Nerve (purple) Runs with the radius Sensation to forearm and small

section hand Extensor muscles of

the forearm

Median Nerve (Blue) 2 branches Innervates:

Skin of lateral 2/3 of hand

Flexor muscles of the forearm

Intrinsic muscles of the hand

Ulnar Nerve (Yellow) Innervates Skin of

medial 1/3 of hand

Some flexor muscles of hand and wrist

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

Compartments or Tunnels of the Hand One main anterior

(palm) Posterior or dorsally

there are 5 6 total compartments

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

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

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

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 - http://video.about.com/firstaid/Burns.htm this video only covers 1st thru 3rd degree)

First Degree Burn Superficial Epidermis involvement Redness or erythema Healing rapid

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

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

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.

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.

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.

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.

Burn Assessment -Rule of Nines

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%

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

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

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)

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

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

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

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

Donor Site Covered with a mesh-like medicated dressing

Graft Care Do not allow to dry out Place in a basin with small amount of warm

saline until ready to use

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

Mesh Graft Device

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?

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

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”

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.

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.

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.

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.

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

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

Neoplasm Example

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

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

IX. Breasts Gynecomastia Liposuction

Cancer Congenital deformity Aesthetic reasons Medical reasons Mammoplasty

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

Hand Pathology1. DeQuervain’s Disease Stenosis/inflammation

of tendons in first dorsal wrist compartment

Treatment conservative with anti-inflammatories or surgical (rare recurrence after surgery)

Hand Pathology2. Trigger Finger Stenosis of digital

tendons Surgical intervention

needed if digit becomes “locked”

Hand Pathology3. 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

Hand Pathology4. 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%

Hand Surgery5. 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

Hand Surgery6. 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

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

burn patients

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

InstrumentationBasic 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

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

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

Cheiloplasty & Palatoplasty Instruments/Supplies Basic plastic tray #15 blade Oral instruments Mouth Gag (Jennings/Davis/McIvor)

+ assorted blades 2x2 gauze for dressing

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

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

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

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

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

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

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)

Post-Operative Care Maintain asepsis until all dressings are

secured prior to removal of drapes