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PLASTIC & RECONSTRUCTIVE SURGERY

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

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outline
Outline
  • Terminology
  • Anatomy of Skin and Hand
  • Pathology
  • Medications
  • Anesthesia
  • Supplies, Instrumentation, and Equipment
  • Considerations and Post-op Care
  • Procedures: Skin and Hand
terminology
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
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
purposes of plastic reconstructive surgery
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
anatomy physiology
Anatomy & Physiology
  • Multi-system/structure involvement
  • Non-specific anatomically unlike peripheral vascular or orthopedics
anatomy physiology integumentary system
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
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 system1
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
Accessory Structures of the Integumentary System
  • Hair
  • Nails
  • Glands:
  • Sebaceous Glands
  • Sweat Glands/Sudoferous Glands
  • Merocrine Glands
  • Apocrine Glands
  • Ceruminous Glands
sebaceous 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
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 glands1
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 glands2
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
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
The Hand
  • Wrist
  • Palm
  • Fingers
wrist carpus
Wrist (Carpus)
  • 8 carpal bones
  • Arranged in 2 rows 4 each: distal and proximal
  • Proximally articulate with distal ulna and radius
palm metacarpus
Palm (Metacarpus)
  • Metacarpals
  • 5 per hand
  • Long, cylindrical shaped
fingers digits
Fingers (digits)

Phalanges

14 per hand

3 phalanges per finger or digit

Numbered 1-5 beginning with the thumb

hand joints
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
Nerves in the Hand
  • Branches of brachial plexus supply innervation to the forearm and hand
  • Radial
  • Median
  • Ulnar
radial nerve
Radial Nerve
  • Along radius
  • Sensation to forearm and hand
  • Extensor muscles of the forearm
median nerve
Median Nerve
  • 2 branches
  • Innervate:
  • Skin of lateral 2/3 of hand
  • Flexor muscles of the forearm
  • Intrinsic muscles of the hand
ulnar nerve
Ulnar Nerve
  • Innervates
  • Skin of medial 1/3 of hand
  • Some flexor muscles of hand and wrist
muscles and tendons of the hand
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
Compartments or Tunnels of the Hand
  • One main anterior (palm)
  • Posterior or dorsally there are six
tendon sheaths of the hand
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
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
Pathology

I. Burns

  • Injury resulting from heat, cold, chemicals, radiation, gases, or electricity that causes tissue damage
burn classification
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

First Degree Burn
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

Second Degree Burn
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

Third Degree Burn
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.

Fourth Degree Burn
5 th and 6 th degree burns
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
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.

Lund-Browder Method (perdriatrics) vs. Rule of Nines (everybody)
burn assessment
Burn Assessment
  • Rule of Nines

← 4.5%

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
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
  • http://www.aasfe.org/crocker-stephenson-2.html The Story
skin grafts
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
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)
autografts1
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
autografts2
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

Dermatomes
dermatome
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
Donor Site
  • Covered with a mesh-like medicated dressing
graft care
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
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
graft care post placement
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
ii acne
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
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
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
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
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
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
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
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
vii nose and chin
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)

Palatoschisis = cleft palate

May see alone or in conjunction

May be unilateral or bilateral

Surgical intervention = cheiloplasty and palatoplasty

VIII. Cleft Lip & Palate
ix breasts
Gynecomastia

Liposuction

Cancer

Congenital deformity

Aesthetic reasons

Medical reasons

Mammoplasty

IX. Breasts
x abdomen
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 pathology
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)
hand pathology1
Hand Pathology
  • Trigger Finger
  • Stenosis of digital tendons
  • Surgical intervention needed if digit becomes “locked”
hand pathology2
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
hand pathology3
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%
hand surgery
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
hand surgery1
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

Hand Surgery
medications
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
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
instrumentation basic plastics tray
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
Nasal Instruments
  • Rhinoplasty/Nasal tray
    • Vienna Nasal speculums
    • Single skin hooks
    • Cottle or Joseph double prong skin hooks
    • Cottle knife
    • Cottle or Fomon Retractor
    • Cottleosteotomes (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
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
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
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
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
Hand Instruments
  • Minor orthopedic tray
  • Minor plastic tray
  • Small vascular instruments (re-implantations)
  • Metacarpal retractors
  • Pediatric deavers
hand equipment
Hand Equipment
  • Sitting stools
  • ECU
  • Suction
  • Hand table
  • Tourniquet
  • Tower Equipment including insufflator
positioning
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
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
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
Post-Operative Care
  • Maintain asepsis until all dressings are secured prior to removal of drapes
rhytidectomy1
Rhytidectomy
  • Overall Purpose of Procedure:
    • To improve the appearance of the patients face and neck area.
rhytidectomy rhytid s medical term for a wrinkle
RhytidectomyRhytid =‘s medical term for a wrinkle
  • Define the procedure:
    • Rhytidectomy can mean many different types of procedures dealing with the head and neck.
    • Facelift
    • Browift
    • Eyelid lift
    • Chin Implants
    • Malar implants (mid-face cheek implants)
rhytidectomy anatomy
Rhytidectomy- Anatomy -
  • The Platysma muscle is a flat, thin muscle that lies uderneath the skin of the anterior and lateral neck.
  • Deep to the muscle lies the superficial layer of the deep cervical fascia.
rhytidectomy2
Rhytidectomy
  • Wound Classification: 1
operative sequence
Operative Sequence
  • 1- Incision
  • 2- Hemostasis
  • 3- Dissection
  • 4- Exposure
  • 5- Procedure (Specimen Collection possible)
  • 6- Hemostasis
  • 7- Irrigation
  • 8- Closure
  • 9- Dressing Application
rhytidectomy3
Rhytidectomy
  • Instrumentation: Plastics Tray
  • Positioning: The patient can be in supine position, arms on arm boards. Can also be in Fowlers.
  • Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit. Must clean and comb hair away from incision site
  • Draping: Head drape.
rhytidectomy begin your operative sequence
RhytidectomyBegin your Operative Sequence
  • Prior to incision, must have pre-op photos in room!
  • Incisions are marked bilaterally and injected with local
  • Incision: 15 kb on #3 handle for incision.
  • Made around the ear, under the earlobe and extends into the hairline.
  • One side is done at a time.
rhytidectomy cont operative sequence
Rhytidectomycont. Operative Sequence
  • Hemostasis: Handheld Bovie and hemostats.
rhytidectomy cont operative sequence1
Rhytidectomycont. Operative Sequence
  • Dissection and Exposure:
  • The skin is undermined to the nasolabial fold, area of the mental foramen and to the midline of the neck to the thyroid cartilage.
  • Use of Metz, Double and Single Skin hooks, Adsons, and Stevens scissors.
rhytidectomy cont operative sequence2
Rhytidectomycont. Operative Sequence
  • Exploration and Isolation:
  • Care is taken not to damage the Facial nerve and artery.
  • If a tighter lift is desired, the Platysmal and SMAS (Superficial Musculoaponeurotic System) is dissected and lifted.
rhytidectomy cont operative sequence3
Rhytidectomycont. Operative Sequence
  • Surgical Repair:
    • Excess fat is removed and skin flap edges are grasped with Allis’s.
    • The skin is drawn upward and redraped to the proper degree of tension. The excess skin is excised along the angle of the clamps.
    • Excellent Facelift Video
rhytidectomy cont operative sequence4
Rhytidectomycont. Operative Sequence
  • Hemostasis and Irrigation:
    • All bleeding is controlled with cautery, possibly Bi-polar.
    • Use of warm Saline to irrigate.
rhytidectomy cont operative sequence5
Rhytidectomycont. Operative Sequence
  • Closure:
    • Incisions are usually closed with a 4-0 Nylon behind the ear and a 5-0 in front of and around the ear.
    • Staples may be used in the hairline.
    • The circulator will prepare the local for the opposite side.
    • Repeat procedure on the opposite side.
rhytidectomy4
Rhytidectomy
  • Major Arteries:
    • External Carotid Artery
    • Facial
rhytidectomy5
Rhytidectomy
  • Major Veins:
    • Internal Jugular Vein
  • Major Nerves:
    • Cranial Nerve VII - Facial Nerve
blepharoplasty
Blepharoplasty

Fact: According to the American Society for Aesthetic Plastic Surgry, in year 2008 more than 195,000 people in the United States underwent cosmetic eye surgery. Blepharoplasty has become the most sought-after facial plastic surgery procedure, surpassing facelift, rhinoplasty, facial implants, and forehead lift.

blepharoplasty1
Blepharoplasty

Visit:

http://www.drmeronk.com/videos.html

lipectomy1
Lipectomy
  • Overall Purpose of Procedure:
    • To remove excess fatty deposits from many different areas of the human body.
    • Areas include:
      • Hips and Thighs
      • Abdomen
      • Breast
      • Face
      • Buttocks
      • Anywhere there is bulk fatty deposits
lipectomy2
Lipectomy
  • Define the procedure:
    • Liposuction, also known as lipoplasty ("fat modeling"), liposculpture or suction lipectomy ("suction-assisted fat removal") is a cosmetic surgery operation that removes fat from many different sites on the human body.
lipectomy3
Lipectomy
  • Liposuction is not a low-effort alternative to exercise and diet. It is a form of body contouring with significant risksand is not a weight loss method. The amount of fat removed varies by doctor, method, and patient, but is typically less than 10 pounds.
  • There are several factors that limit the amount of fat that can be safely removed in one session.
  • Ultimately, the operating physician and the patient make the decision. There are negative aspects to removing too much fat. Unusual "lumpiness" and/or "dents" in the skin can be seen in those patients "over-suctioned". The more fat removed the higher the surgical risk.
lipectomy4
Lipectomy
  • Wound Classification: 1
operative sequence1
Operative Sequence
  • 1- Incision
  • 2- Hemostasis
  • 3- Dissection
  • 4- Exposure
  • 5- Procedure (Specimen Collection possible)
  • 6- Hemostasis
  • 7- Irrigation
  • 8- Closure
  • 9- Dressing Application
lipectomy5
Lipectomy
  • Instrumentation: Plastics tray. Assortment of liposuction cannulas. Liposuction machine and tubing.
  • Positioning: Depends on the area of fat removal.
  • Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit.
  • Draping: Also depends on area prepped.
lipectomy begin your operative sequence
LipectomyBegin your Operative Sequence
  • Prior to Incision:
    • Some MDs inject a solution to “melt” the fatty deposits. This is usually Lidocaine and LR or NACL This makes removal easier.
    • Mark the site and have the surgeon pick out the appropriate size cannula.
    • ST will connect the cannula to the suction tubing and throw end to circ.
  • Incision: 15 kb on #3 handle for incision.

Incision is only ½ inch at most.

lipectomy cont operative sequence
Lipectomycont. Operative Sequence
  • Hemostasis: Handheld Bovie
lipectomy cont operative sequence1
Lipectomycont. Operative Sequence
  • Dissection and Exposure:
    • All dissection is made with the lipo cannual that the surgeon has previously chosen.
lipectomy cont operative sequence2
Lipectomycont. Operative Sequence
  • Exploration and Isolation:
    • A tunnel is created by passing the cannula underneath the skin.
    • The suction is off at this point.
lipectomy cont operative sequence3
Lipectomycont. Operative Sequence
  • Surgical Repair
    • Once the tunneling process is done a few times, the suction is turned on. This allows the surgeon to “break up” the fatty deposits before attempting suctioning.
    • The surgeon removes the desired amount of fat, checking the area periodically.
    • The tubing will need cleaning with NACL during the procedure.
    • Lipo video
lipectomy cont operative sequence4
Lipectomycont. Operative Sequence
  • Hemostasis and Irrigation:
    • All bleeding is controlled with cautery.
    • Use of warm Saline to irrigate.
lipectomy cont operative sequence5
Lipectomycont. Operative Sequence
  • Closure:
    • The small incision is closed with a 4-0 or

5-0 Nylon.

The dressing that you apply will need to be a pressure dressing, applied depending on area of Lipectomy.

lipectomy6
Lipectomy
  • Major Arteries:
    • Depends on area of Lipectomy
lipectomy7
Lipectomy
  • Major Veins:
    • Depends on area of Lipectomy
  • Major Nerves:
    • Depends on area of Lipectomy
abdominoplasty
Abdominoplasty

Plastic ProceduresOperative Sequence

abdominoplasty1
Abdominoplasty

Overall Purpose of Procedure:

A.K.A. Tummy Tuck

To remove excess fat and tighten abdominal skin.

abdominoplasty2
Abdominoplasty

Define the procedure:

The tightening of the abdominal skin through an incision jut above the pubic hair line.

Can be combined with Liposuction.

Can also include a Thigh Lift.

abdominoplasty3
Abdominoplasty
  • Indications for Abdominoplasty
    • Loss of muscle tone in the lower abdominal region
    • Lose skin and fat in the abdominal region resulting from weight loss.
abdominoplasty4
Abdominoplasty

Wound Classification: 1

operative sequence2
Operative Sequence

1- Incision

2- Hemostasis

3- Dissection

4- Exposure

5- Procedure (Specimen Collection possible)

6- Hemostasis

7- Irrigation

8- Closure

9- Dressing Application

abdominoplasty5
Abdominoplasty

Instrumentation: Major/Minor tray depending on patient size.

Positioning: Supine with arms on arm boards.

Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit.

Draping: Can be as many as 8 towels.

abdominoplasty begin your operative sequence
AbdominoplastyBegin your Operative Sequence

Prior to Incision: MD will mark incision.

It will be necessary to flex the able to aid in closure.

Incision:

10 KB across pubic line, from Iliac crest to Iliac crest.

Can be made from north to south, from umbilicus to pubis.

abdominoplasty cont operative sequence
Abdominoplastycont. Operative Sequence

Hemostasis: Handheld Bovie

abdominoplasty cont operative sequence1
Abdominoplastycont. Operative Sequence

Dissection and Exposure:

The abdomen is dissected through the subcutaneous tissue and fat down to the rectus muscle using the bovie.

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Abdominoplastycont. Operative Sequence
  • Exploration and Isolation:
    • The abdomen is also dissected up towards the chest.
    • This creates a flap that will be pulled down towards the pubis once the excess skin is excised.
    • Have Volkmans and Deavers available.
abdominoplasty cont operative sequence3
Abdominoplastycont. Operative Sequence

Surgical Repair:

Both of the Rectus muscles are tightened using a 0 Ticron.

The skin flaps are pulled together, excess skin and fat is removed.

The table is flexed and the abdomen is closed.

Video:

Abdominoplasty Surgery Video

abdominoplasty cont operative sequence4
Abdominoplastycont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.

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Abdominoplastycont. Operative Sequence

Closure:

Abdomen is closed with 0 Ticron.

Subcutaneous tissue is close using 3-0 Vicryl.

The skin is closed using 3-0 Prolene.

Steristrips and Mastisol.

Must apply an abdominal binder for support.

abdominoplasty6
Abdominoplasty

Major Arteries:

No major since we are superficial, or above the rectus muscles

abdominoplasty7
Abdominoplasty

Major Veins:

No major since we are superficial, or above the rectus muscles

Major Nerves:

Splanchnic nerve

cheiloplasty key lo plasty and palatoplasty
Cheiloplasty (key-lo-plasty) and Palatoplasty

Plastic ProceduresOperative Sequence

palatoplasty
Palatoplasty
  • Overall Purpose of Procedure:
    • A.K.A. Cleft Palate
    • To reassemble normal pathology of the palate.
palatoplasty1
Palatoplasty

Define the procedure: The palate is made up of a hard portion anteriorly and a soft portion posteriorly.

A cleft occurs in the midline and may one or both palates.

The repair is usually done around 18 months since a function of the palate is speech development.

operative sequence3
Operative Sequence

1- Incision

2- Hemostasis

3- Dissection

4- Exposure

5- Procedure (Specimen Collection possible)

6- Hemostasis

7- Irrigation

8- Closure

9- Dressing Application

palatoplasty2
Palatoplasty

Instrumentation: Plastics/Minor tray depending on patient size.

Positioning: Supine with arms on arm boards.

Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.

Draping: Head drape with ¾ drape or green sheet as a lower body drape.

palatoplasty begin your operative sequence
PalatoplastyBegin your Operative Sequence

Prior to Incision: MD will mark incision.

Incision: Mouth gag is inserted ( i.e. McIvor)

15 or 10 KB is used to incise the palate to make flaps.

palatoplasty cont operative sequence
Palatoplastycont. Operative Sequence

Hemostasis: Bayonet Bovie or needle tip.

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Palatoplastycont. Operative Sequence

Dissection and Exposure:

The flaps are elevated with skin hooks.

palatoplasty cont operative sequence2
Palatoplastycont. Operative Sequence
  • Exploration and Isolation:
    • None needed
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Palatoplastycont. Operative Sequence

Surgical Repair:

Once the flap are elevated, they are closed in three layers.

Nasal Mucosa

Muscle

Palatal mucoa

palatoplsty cont operative sequence
Palatoplstycont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.

palatoplsty cont operative sequence1
Palatoplstycont. Operative Sequence

Closure:

Chromic suture is used to closed palate.

A traction suture is placed in the body of the tongue.

This is usually a 0 Silk.

Is an upper airway obstruction is suspected, they will use the traction suture to pull the tongue forward.

palatoplsty
Palatoplsty

Major Arteries:

ascending palatal artery

palatoplsty1
Palatoplsty

Major Veins:

Palatal vein

Major Nerves:

greater and lesser palatine nerves

cheiloplasty
Cheiloplasty

Plastic ProceduresOperative Sequence

cheiloplasty1
Cheiloplasty

Overall Purpose of Procedure:

A.K.A. Cleft Lip

To reassemble normal pathology of the lip.

cheiloplasty2
Cheiloplasty

Define the procedure:

A unilateral cleft lip results from failure of the union of the maxillary and median nasal processes, thus creating a split or cleft in the lip on either the left or right side.

It may be just a notching of the lip or extend completely through the lip into the nose and palate.

Can be Bi-lateral.

operative sequence4
Operative Sequence

1- Incision

2- Hemostasis

3- Dissection

4- Exposure

5- Procedure (Specimen Collection possible)

6- Hemostasis

7- Irrigation

8- Closure

9- Dressing Application

cheiloplasty3
Cheiloplasty

Instrumentation: Plastics/Minor tray depending on patient size.

Positioning: Supine with arms on arm boards.

Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.

Draping: Head drape with ¾ drape or green sheet as a lower body drape.

cheiloplasty begin your operative sequence
Cheiloplasty Begin your Operative Sequence

Incision:

15 and 11 KBs

Hemostasis: Handheld Bovie

Dissection and Exposure/Surgical Repair: abnormal tissue is dissected and flaps are ID’d for clourse

cheiloplasty cont operative sequence
Cheiloplasty cont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.

cheiloplasty cont operative sequence1
Cheiloplasty cont. Operative Sequence

Closure:

Closure is begun with 4-0 or 5-0 Chromic. The muscle layer is followed by the mucosal layer and then skin.

No dressing is usually needed.

Might need to apply restraints to child to reduce chance of child destroying all completed work.

rhinoplasty
Rhinoplasty

Plastic ProceduresOperative Sequence

rhinoplasty1
Rhinoplasty

Overall Purpose of Procedure:

The goal of the procedure is to improve the appearance of the nose.

rhinoplasty2
Rhinoplasty

Define the procedure:

A Rhinoplasty is performed through internal incisions (if possible) so that there is no scar.

This is done by reshaping the underlying framework of the nose by rasping the dorsal hump, partial excision of the lateral and alar cartilage, shortening the septum an osteotomy of the nasal bones.

rhinoplasty3
Rhinoplasty

Wound Classification: 1

operative sequence5
Operative Sequence

1- Incision

2- Hemostasis

3- Dissection

4- Exposure

5- Procedure (Specimen Collection possible)

6- Hemostasis

7- Irrigation

8- Closure

9- Dressing Application

rhinoplasty4
Rhinoplasty

Instrumentation: ENT/Plastics tray depending on patient size. Assorted Minor Bone instruments.

Positioning: Supine with arms on arm boards.

Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.

Draping: Head Drape. ¾ drape for lower body coverage.

rhinoplasty begin your operative sequence
RhinoplastyBegin your Operative Sequence

Incision:

Intranasal incisions are made with 15 KB, Joseph Knife, Joseph elevator or Button Knife.

rhinoplasty cont operative sequence
Rhinoplastycont. Operative Sequence

Hemostasis: Handheld Bipolar Bovie

rhinoplasty cont operative sequence1
Rhinoplastycont. Operative Sequence

Dissection and Exposure:

The skin and the soft tissue are elevated from the underlying nasal bones and cartilage.

rhinoplasty cont operative sequence2
Rhinoplastycont. Operative Sequence
  • Exploration and Isolation:
    • Full exposure of the nasal bones and cartilage with nasal speculum.
rhinoplasty cont operative sequence3
Rhinoplastycont. Operative Sequence

Surgical Repair:

The tip of the nose is reshaped by excising portions of the alar and lateral cartilage of each side.

This can accomplished with a small rasp, Ronguer, or scissors.

rhinoplasty cont operative sequence4
Rhinoplastycont. Operative Sequence
  • Surgical Repair:
    • Osteotomies of the nasal bones are done medially and laterally to narrow the nasal bridge.
    • This can be done with osteotomes and a mallet.
rhinoplasty cont operative sequence5
Rhinoplastycont. Operative Sequence
    • O.R. Live video:
    • Rhinoplasty- Nasal Valve Reconstruction
  • Procedure:Smooth procedure
rhinoplasty cont operative sequence6
Rhinoplastycont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.

rhinoplasty cont operative sequence7
Rhinoplastycont. Operative Sequence

Closure:

Suturing is very minimal for Rhinoplasties.

MD will choose a small Chromic. 4-0 or 5-0.

rhinoplasty5
Rhinoplasty

Major Arteries:

The external nose is supplied by the facial artery

Internal - anterior and posterior ethmoid arteries

rhinoplasty6
Rhinoplasty

Major Veins:

Veins in the nose essentially follow the arterial pattern

Major Nerves:

The sensation of the nose is derived from the first 2 branches of the trigeminal nerve

mammoplasty
Mammoplasty

Plastic ProceduresOperative Sequence

mammoplasty1
Mammoplasty

Overall Purpose of Procedure:

Often refers to enlargement of the breasts, but can be reduction.

Can also be the rebuilding of breast tissue after weight loss or cancer or any reason to change the appearance or symmetry.

mammoplasty2
Mammoplasty
  • Define the procedure:
  • We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts.
mammoplasty3
Mammoplasty

Wound Classification: 1

operative sequence6
Operative Sequence

1- Incision

2- Hemostasis

3- Dissection

4- Exposure

5- Procedure (Specimen Collection possible)

6- Hemostasis

7- Irrigation

8- Closure

9- Dressing Application

mammoplasty4
Mammoplasty

Instrumentation: Major/Minor tray depending on patient anatomy/size.

Positioning: Sitting position or able to be placed in the sitting position intra-op.

Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep entire anterior portion chest, from just below the clavicle to two inches below the inframammary crease and laterally to the axilla.

Draping: 4 to 6 blue towel placed under and around both breasts and a modified lap drape.

mammoplasty begin your operative sequence
MammoplastyBegin your Operative Sequence

Prior to Incision:

Photos must be taken and available in the O.R.

MD will mark the patients breasts while sitting up.

Incision:

Incision is made along the markings with a 10 Kb. The incision for a reduction Mammoplasty is a called a keyhole incision. It starts around the nipple, going from 7 o’clock to 5 o’clock, in a clockwise manner.

Two additional diagonal incisions lines are made from the bottom of the nipple to the natural mammary fold. The angle will depend on the amount of tissue to be removed.

mammoplasty cont operative sequence
Mammoplastycont. Operative Sequence

Hemostasis: Handheld Bovie

mammoplasty cont operative sequence1
Mammoplastycont. Operative Sequence

Dissection and Exposure:

The skin flaps are de-epithelized with numerous 10 KB’s, cautery etc.

Exposure is gained with Volkmans or hand retraction

mammoplasty cont operative sequence2
Mammoplastycont. Operative Sequence
  • Exploration and Isolation:
    • None at this point.
mammoplasty cont operative sequence3
Mammoplastycont. Operative Sequence

Surgical Repair:

The breast tissue is cut down to the medial and lateral margins.

The nipple and areola are not excised from the pedicle.

ALL EXCISED TISSUE IS WEIGHED.

The circ will keep the surgical team apprised of the total weight removed from each side if both sides are reduced.

Video: Breast Reduction

mammoplasty cont operative sequence4
Mammoplastycont. Operative Sequence
  • Once the desired amount is taken off, the skin is temporarily closed with desired suture or staples.
  • The patient may be sat up to obtain a better view of the reduced breasts, to determine if the reduction is adequate.
mammoplasty cont operative sequence5
Mammoplastycont. Operative Sequence
  • The patient is returned to the supine position and attention is directed to the other breast, where the same procedure is followed.
  • Once the second side is temporarily closed, the patient is once again sat up to compare both breasts and t determine if further work is needed.
  • If the MD is satisfied, the patient is returned to the supine position and permanent closure begins.
mammoplasty cont operative sequence6
Mammoplastycont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.

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Mammoplastycont. Operative Sequence

Closure:

Hemovac drains can be used for drainage of wound(s).

Closure of the breasts is completed with Vicryl (3-0) and a running Prolene (4-0) stitch.

The nipple will be sewn into place with a 5-0 Nylon.

mammoplasty5
Mammoplasty

Major Arteries:

Internal mammary artery

Lateral thoracic artery

Thoracodorsal artery

Intercostal artery

Thoracoacromial artery

mammoplasty6
Mammoplasty

Major Veins:

Axillary vein

Major Nerves:

Thoracic intercostal nerves T3-T5

Researchers believe sensation to the nipple derives from the lateral cutaneous branch of T4.

hand surgery2
Hand Surgery
  • Reasons performed:
  • Congenital deformities
  • Disease
  • Trauma
  • Can be performed by plastic surgeons, orthopedic or orthopedic “hand-surgeons”, and neurosurgeons
hand surgery3
Ganglion cyst excision

Carpal Tunnel Release

DeQuervain’s Repair

DuPuytren’s Contracture Release

Trigger Finger Release

Toe to Hand Transfer

Release of Syndactyly (webbed fingers)

Reduction of polydactyly (extra digit)

Radial dysplasia (club hand) correction

Traumatic Injury:

Laceration closure

Digital Reimplantation

Tennorhaphy

Neurorrhaphy

Restoration of vascularity

Bone approximation

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