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Managing Plastic Surgery Patients Part One. Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery San Leandro Surgery Center. The 8 Aspects of Plastic Surgery. Congenital: clefts, nevi, vascular tumors

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Rex moulton barrett md plastic reconstructive surgery san leandro surgery center

Managing Plastic Surgery Patients Part One

Rex Moulton-Barrett, MDPlastic & Reconstructive SurgerySan Leandro Surgery Center

The 8 aspects of plastic surgery
The 8 Aspects of Plastic Surgery

  • Congenital: clefts, nevi, vascular tumors

    ear reconstruction, hand anomalies

  • Hand: nerve compression, tumors/soft tissue, trauma

  • Head and Neck:resection and reconstructivesurgery

  • Skin cancer: excision and reconstruction

  • Burn Reconstruction

  • General Reconstruction: truck, abdomen, lower limb

  • Breast: reduction, reconstruction

  • Cosmetic

2 ways to get in trouble in medicine
2 ways to get in trouble in medicine



Gorney s rule
Gorney’s Rule

  • Extent of problem should = the concern

  • Operate on ‘ Sylvia ’ : secure, young, listens, verbal,intelligent, attractive

  • Don’t operate on ‘Simon’: single, insecure, male, overexpectent, narcissistic

Post operative complications
Post operative complications

  • 5.4% complication rate clean surgery cases : 50% preventable

  • Blue Cross Aneheim refuses to pay for complications: April 2008

  • Specifically: pressure sores, sternal wounds, line/foley sepsis

  • Record insurance profits 2007: aggressive disclaimer policies

  • Post op infection most frequent complication: 1/2 mil/yr USA

  • Average cost per infection is $3,000

  • Post operative infections associated: 2 x procedure mortality

What stops wound healing
What stops wound healing

  • Infection

  • Foreign body

  • Tension/reduced vascularity: venous,arterial,both

  • Inflammation: allergic, autoimmune, mechanical

  • Steroids and cytotoxic agents

  • Tumors

  • Munchausen’s Syndrome

Controlling surgical site infections
Controlling Surgical Site Infections

  • Saline versus water irrigation similar infections rates

  • Transfusion during cardiac surgery increases rate

  • Supplemental hydration does not change rate

  • Hypothermia core temp< 36 C (96.8)

  • Prophylactic antibiotics < one hour before incision

  • One dose IV as good as multiple & less C diff later

  • Cardiac patient glucose control < 200 mg/dl

  • Best no hair removal < shave < razor

  • Maintaining oxygenation

  • Maintaining arterial, venous and capillary circulation

Hypothermia and wound infection
Hypothermia and wound infection

  • 200 pts undergoing colorectal surgery: hypothermia assoc with 19% infection rate, vrs 6% non hypothermia

    Kurz, et al, 1996: NEJM 334(19):1209-1215

  • Hypothermia leads to vasoconstriction

  • Vasoconstriction reduces tissue partial pressure O2

  • Tissue hypoxygenation = decreased neutrophil phagocytosis

  • Every drop of 1.5 C assoc. complications cost $ 2,500-7,000

  • Influenced by warming: preop pt, fluids, bed, irrigations, room temp, length of procedure, body surface area exposed, inhalation gases

Patterns of blood supply
Patterns of blood supply

  • Random (2:1 ratio)

  • Axial

  • Random and Axial

    ( rectus: type 3 )

Tension compression
Tension / Compression

  • Venous: decreased cap refill: < 3 seconds

  • Arterial: increased cap refill: > 5 seconds

    or no refill: > 5 seconds

  • Creep phenomenon: 3 x 1 minute stretches 3 minutes apart

  • Cyanosis: requires O2 sat of <80% and 2.38 g/deoxyhemoglobin

    not present if arterial ischemia/vasoconstriction or severe anemia

Rex moulton barrett md plastic reconstructive surgery san leandro surgery center

  • Pre surgery prophylaxis

  • Prevalence: 24% after elective surgery!!

  • Risks factors

  • Who should get Lovenox: enoxaparin

  • Clinical signs of DVT

  • Clinical Signs of PE

Dvt preventive stockings
DVT Preventive Stockings

  • Reduce post-MI DVT p<0.003 (Kier,1993:Eur Heart J 14,1365-68.)

  • May be as effective as pneumatic compression or low dose heparin

  • Standing position ankle vein pressure in 5´7˝ adult is 86mmHg

  • 20-30 mmHg if standing ineffective at compressing s/d leg veins

  • 4 classes: 20-30,30-40,40-50 & 50-60 mmHg

  • 2 categories: ready made and custom

  • 2 broad types: elastmeric ( day time ), non-elastameric ( straps )

  • Compression garments > 22mm Hg can cause thrombosis: knee

  • elastomerics: woven:excellent, expensive, strong 3 knitted: circular, flat (custom), cut & sew(custom)

    elasticity from synthetic rubber or latex weave

    breathability related to thickness and cotton/nylon


  • Jobst: 18-25 or 25-35mmHg

  • Sigvaris: synthetic rubber threads covering nylon

  • JuZo: increase upper stretch for big thighs

  • Medi: spandex thread inlaid into woven row

  • Camp: double wrapped yarns

  • Venosan: nylon, Lycra and cotton graduated

  • Convalec: inelastic cohesive unnaflex

  • 3m Health: elastomeric high stretch adhesive microfoam

  • TED: most well known

  • Ibizi: Segreta ( Lycra )

Venous thromboembolism assessment risk score 0 1 low 2 4 moderate 5 or greater high risk
Venous Thromboembolism Assessment Risk Score:0-1 Low, 2-4 Moderate, 5 or greater high risk

  • Hip fracture surgery (5)

  • Total hip/knee replacement (5)

  • >70 yrs (3)

  • H/o DVT/PE (3)

  • Paralysis (3)

  • abdo/pelvis/leg (2)

  • # hip/pelvis/leg (2)

  • 61-70 yrs (2)

  • (1)

  • Obesity >20% ideal body weight

  • Varicose veins / varicose swelling

  • inflammatory bowel disease

  • Bedrest preop > 48 hrs

  • Myeloproliferative

  • Malignancy

  • < 6 weeks post-partum

  • Acute ischaemic stroke

  • 41-60 yrs

  • Major surgery

  • CHF

  • Severe respiratory disease

  • sepsis

Suggested prophylaxis regimen
Suggested prophylaxis Regimen

  • Low:early ambulation, TED’s, +/- Sequentials, 20 degree knee flex

  • Moderate: Sequentials +/- TED’s, 20 degree knee flex

    Heparin 5,000 SQ q 8-12 hrs or

    Levenox 40mg SQ q 24 hrs or

    Lenenox 30 SQ q 12 hrs

  • Severe: Sequentials +/- TED’s

    Heparin 5,000 SQ q 8 hrs or

    Lovenox 30 mg q 12 hrs

    Place temporary Greenfield Filter prior to surgery

Well s clinical dx scoring criteria
Well’s Clinical Dx Scoring Criteria

Anand SS, et. al. Does this patient have deep vein thrombosis? JAMA, 1998; 279:2094-1099

  • Entire Leg swollen (1)

  • 10cm below tibial tuberosity >3cm calf enlargement (1)

  • Pitting edema (1)

  • Collateral engorged non varicose veins (1)

  • Alternative likely diagnosis (-3)

If the score > 3: high risk and 85% probability

0: low risk and 5% probability

Clinical presentation dvt
Clinical Presentation DVT

  • 1/2 million hospitalized DVT/yr US

  • 10% die

  • Stasis, hypercoagulation, endothelial injury

  • Pain then swelling, Howman’s negative 2/3’s

  • Clinical exam 3/4’s negative, some arise proximal

  • Assoc with popliteal valvular insufficiency

  • 1/3 of calf thrombi will propagate and embolize

  • Di-Dimer: fibrin degrad products: only 2% false neg

  • Colorflow Duplex: falsenegative20% below & 5% above knee

  • Thrombolytic therapy more successful than anticoagulation

Symptoms of pulmonary embolus
Symptoms of Pulmonary Embolus

  • 73% dyspnea

  • 60% pleuritic chest pain

  • 43% cough associated chest pain

Clinical presentation pulmonary embolus well s score
Clinical Presentation Pulmonary EmbolusWell’s Score

Thromb Haemost. 2000 Mar;83(3):416-20

Clinical Signs and Symptoms of DVT?Yes +3

PE Is #1 Diagnosis, or Equally LikelyYes +3

Heart Rate > 100?Yes +1.5

Immobilization at least 3 days, or

Surgery in the Previous 4 weeksYes +1.5

Previous, objectively diagnosed PE or DVT?Yes +1.5

Hemoptysis?Yes +1

Malignancy w/ Rx within 6 mo, or palliative?Yes +1

  • Score of <4: only 8% had PE by D-dimer testing

  • MRI 97% sensitive, 95% specific

  • Anticoagulation prevent DVT propagation, reduces PE

  • Hospitalization with unfractionated heparin

  • Thrombolytic therapy for massive emboli

Fat embolus 5 15 mortality
Fat Embolus: 5-15% mortality

  • Who is at risk: closed fractures, tummy tucks, liposuction

  • <3 days after surgery

  • 25% have petechial rash

  • SOB, tachypnea, hemoptysis, crackles, ARDS

  • Non specific w/u:

    fat in blood, snow storm CXR, serum lipase & phospholipase B

  • Management: if acute, left lat position

    IV ethanol, dextran, steroids

    New: IV Lipostabil (3-sn-phosphatidylcholine ethanol 96% V/V)250mg in 5ml: 40mls slow IV then 80ml/day divided 20ml QID

Rex moulton barrett md plastic reconstructive surgery san leandro surgery center

  • 5% of population have MRSA in the nose

  • This group accounts for 38% of MRSA infections arising within hospital

  • 62% of MRSA infections arise in hospital

  • ie 62% are true nosocomial in origin

  • watch the housekeeping, lab, clerical, catering and ancillary staff carefully for glove changing between rooms / beds

Specific procedures
Specific Procedures

  • Breast Reconstruction

  • Cleft Surgery

  • Hand surgery

  • Burns

  • Cosmetic: Abdominoplasty


    Eyelid Surgery


    Augmentation +/- mastopexy

    Post - bariatric surgery

Breast reconstruction
Breast Reconstruction

  • Reduction of the opposite breast after lumpectomy

  • Tissue expansion and exchange implantation

  • ‘Tram’: Transverse rectus abdominus myocutaneous

  • Double Trams and supercharged Trams

  • Latissimus Dorsi with implant

  • Free Flaps: Tram, Perforator Tram, DIEP, IGF

  • Fat grafting

Free flaps rectus diep siea igap flaps

Free Flaps: Rectus, DIEP SIEA, IGAP Flaps

Cleft surgery
Cleft Surgery

  • Cleft Lip & Palate > Palate > Lip

  • Pierre Robin syndrome: microgenia and airway obstruction

  • Craniofacial Synostoses:

    Apert’s: hydrocephalus and airway obstruction

    Velocardiofacial: palate, cardiac and ectopic carotids

    Sticklers: palate and retinal detachments

    Klippel-Feil: palate and C 1-2 subluxation

    Crouzon’s: 80% optic nerve compression

Rex moulton barrett md plastic reconstructive surgery san leandro surgery center

Pierre Robin




Klippel Feil


Cleft palate airway obstruction
Cleft Palate & Airway Obstruction

  • Repair separates oropharynx from nasopharynx

  • Compensatory tongue hypertrophy

  • Separation can lead to crowding of orophrynx

  • Microgenia/midfacial retrusion increase crowding

  • IV steroids lead to reduced hospitalization

  • Tongue suture always placed for airway control

Hand surgery
Hand Surgery

  • Allen’s Test

  • Cap refill

  • Elevation

  • Surgical positioning:

    ulnar nerve and

    median nerve compression,

    brachial nerve plexopathy

Capillary refill
Capillary Refill

  • Normal Tissue Capillary Refill is 3-5 seconds

  • Nail Capillary Refill test is < 2 seconds

  • Unreliable in presence of hypothermia and severe anemia

Allen s test
Allen’s Test

Dominant Ulnar > Radial Artery 8.1%

May be higher in populations with h/o ABG’s

1. Elevate hand 30 seconds

2. Make fist elevated

3. Apply pressure over Radial and Ulnar Arteries

4. Open hand while elevated, it should be blanched

5. Release one vessel pressure, should refill in 7 seconds

Median neuropathy
Median Neuropathy

  • Motor: thumb opposition and abduction

    radial 2 lumbricals

  • Sensory: radial 3 1/2 fingers

Rex moulton barrett md plastic reconstructive surgery san leandro surgery center

Ulnar Neuropathy

  • Motor: All intrinsics except thumb opposition & abduction

    radial 2 lumbricals

  • Sensory: Ulnar 1 1/2 sensory

Brachial plexopathy
Brachial Plexopathy

  • poor positioning

  • downward brachial traction

  • shoulder hyperextension

  • descent of the thorax

  • prolonged arm abduction

  • responds to IV steroids

  • true neuropraxia: up to 6 week recovery

Cosmetic abdominoplasty
Cosmetic: Abdominoplasty

  • Not panniculectomy, umbilicus preserved

  • Modern technique utilises low incision

  • Corsetting rectus and oblique muscles

  • Closure in jack- knife sitting position

  • Complications mostly related to tension

  • DVT/PE increased risk if:

    obese, concomitant hysterectomy, liposuction

  • Atelectasis risk when combined breast surgery

  • Commonest cause of SOB: too tight dressings

  • Muscle relaxants, firm abdominal binders and jack=knife positioning in a surgical bed reduce pain


  • 3 component surgery: muscle, fat, skin

  • Swelling and bleeding very individual

  • Skin survives on random pattern blood supply: tension and smoking can kill (15% smoker slough )

  • Unilateral swelling and pain = hematoma

  • Bilateral tightness in the neck associated with platysma corsetting

  • Relative emergency for skin survival and potential airway compression

Eyelid surgery
Eyelid Surgery

From Rees, 1996

  • Contents within orbital septum closed space

  • Ophthalmic vein, nerve and artery contained within the orbital septum

  • Bleeding after surgery is an absolute emergency, loss of vision can occur within 20 minutes ( 1:20,000 )

  • Release sutures and or lateral canthotomy


  • Traditional, wet, superwet and tumescent

  • Calculation of blood loss

  • Calculation of fluid resusitation

  • Admission to hospital > 6 hours, > 6 litres

Liposuction and fluid rescusitation
Liposuction and fluid rescusitation

  • Traditional 150ml aspirate=drop 1% Hct

  • ie > 2 L needs transfusion

  • IV replacement cc for cc in OR, + cc/cc RR

  • Tumescent: 1 L RL+ 1 cc 1:1,000 epi+ 50cc 1% lido 2 ml in then > 10 minutes 1 cc asp. out,

    Up to 6 L no X match required

    can use up to 35mg/kg: lido in fat

    replace cc/cc in OR, or less

  • Cranberry drainage from the ports for 3 days

Breast augmentation mastopexy
Breast Augmentation +/- Mastopexy

  • Dressings designed to push implants down

  • Commonest cause of SOB: dressings too tight

  • Implants over the muscle hurt much less

  • Muscle relaxants reduce pain, mostly pectoral pain

  • Unilateral chest pain & no swelling:pneumothorax ?

  • Unilateral pain and swelling: hematoma ?

  • Bilateral pain: tight dressings &/or muscle spasm ?

Post bariatic surgery
Post - Bariatic Surgery

  • Risk of bariatric surgery assoc BMI

  • Calculation BSA=(height cms x weight kg/3600)/2 M2

    BMI=weight kg/M2 height

  • Procedures after: abdominoplasty

    circumferential lipectomy

    extended thighplasty



    facelift and eyelid surgery

Clinical test case 1
Clinical Test case 1

  • 44 yr old Vietnamese male undergoes elective cleft palate repair. S/p surgery he is noted to be cyanotic, O2 sat 85%, inspiratory stridor, intercostal recession, labored breathing and normal neck and oral exam

Clinical test case 2
Clinical Test case 2

  • 30 yr old 250 female with h/o bariatric surgery, s/p 150 pound weight loss c/o SOB, tachycardia 110, 1 day post op. S/p abdominoplasty, O2 sat 90%, shallow breath sounds at bases of lungs, calfs non tender and feels well

Clinical test case 3
Clinical Test case 3

  • 74 yr lady 1 day s/p quad blepharoplasty c/o left thigh pain 1 day post op and SOB with mild chest pain on coughing. Her HR is 110, O2 sat 88%, decreased BS at left base and some crackles left base of lung

Clinical test case 4
Clinical Test case 4

  • 4 hours after heparinization, the patient complains of reduced vision in the left eye, there is some bulging of the eye and some early bruising. The pupil is reactive to light and accommodation

Clinical test case 5
Clinical Test case 5

  • 1 hour after abdominoplasty with liposuction a patient complains of extreme shortness of breath, right sided chest pain and the urge to defecate. The chest exam reveals crackles and decreased breath sounds at the right apex, EKG severe RBBB, blood drawn for cardiac enzymes normal and serum lipase elevated and there are petechiae on the anterior chest

Clinical test case 6
Clinical Test case 6

  • 3 hours after abdominoplasty a 66 yr old previously hypertensive, post bariatric patient with a history of severe lumbosacral back DJD needs high doses of PCA meds to control her abdominal dyscomfort. 5 hours after surgery her BP drops to 70/50 and she becomes drousy with shallow respirations and pin point pupils

Clinical test 7
Clinical Test 7

  • A demanding 63 yr old lady undergoes an uneventful facelift and 6 hours after surgery requests IV MS just 1 hour after her last pain medication because of increased right sided facial pain. Her dressing are intact and there is no sign of bleeding into her dressings. She says she feels the right side of her neck is tight

What s new in plastic surgery

What’s New In Plastic Surgery ?

Rex Moulton-Barrett, MD

Plastic & Reconstructive Surgery

San Leandro Surgery Center