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CHAPTER 19

CHAPTER 19. Plastic and Reconstructive Surgery. Objectives. After studying this chapter, you will be able to: Recognize the relevant anatomy and physiology of the skin and its underlying tissues

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CHAPTER 19

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  1. CHAPTER 19 Plastic and Reconstructive Surgery

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. Skin Graft Procedures (cont’d.) • Ideal donor sites • Abdomen • Back • Chest • Lateral and ventral aspects of the thighs

  14. 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

  15. 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

  16. 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

  17. Skin Graft Procedures (cont’d.) • Accessory structures of the integumentary system • Hair • Nails • Sebaceous glands • Sudoriferous glands • Apocrine sweat glands • Ceruminous gland

  18. 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

  19. 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

  20. 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

  21. 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

  22. Head and Face Procedures (cont’d.) • Common procedures • Blepharoplasty • Endoscopic brow lift • Malar implants • Mentoplasty • Otoplasty • Rhinoplasty: external technique • Rhytidectomy

  23. Head and Face Procedures (cont’d.) • Cleft lip repair: rotation advancement technique • Cleft palate repair: V-Y palatoplasty technique

  24. 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

  25. 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

  26. 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

  27. 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

  28. Breast Procedures (cont’d.) • Include: • Augmentation mammoplasty • Transverse rectus abdominis musculocutaneous flap • Nipple reconstruction • Mastopexy: anchor technique

  29. 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

  30. 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

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