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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.

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

Fibrous Dysplasia

  • -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
  • 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
an easy way to remember the 8 carpal bones
An easy way to remember the 8 carpal bones-
  • Scaphoid (Skay-foid)
  • Lunate
  • Triquetrum
  • Pisiform
  • Trapezium
  • Trapezoid
  • Capitate
  • Hamate

Some Lovers Try Positions That They Can’t Handle

palm metacarpus
Palm (Metacarpus)
  • Metacarpals
  • 5 per hand
  • Long, cylindrical shaped
fingers digits
Fingers (digits)


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 purple
Radial Nerve (purple)
  • Runs with the radius
  • Sensation to forearm and small section hand
  • Extensor muscles of

the forearm

median nerve blue
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
Ulnar Nerve (Yellow)
  • 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 5
  • 6 total compartments
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

Female patient who suffers with severe burns on 70% of her body

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 - this video only covers 1st thru 3rd degree)
first degree burn

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


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.
  • 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)
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
  • The Story - Milwaukee Journal Sentinel - The Phoenix Man - George Bennett – 70% burn -underground tank
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
  • 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)
  • (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
  • (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
Used to remove STSG

Brown - oscillating blade

Padgett-Hood-rotating blade housed in drum

Powered by nitrogen or electricity



Can be hand held

  • 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
  • Anything wrong here?
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.
  • 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
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) -Say cheiloschisis

Palatoschisis = cleft palate

- Say palatoschisis

May see alone or in conjunction

May be unilateral or bilateral

Surgical intervention = cheiloplasty and palatoplasty

VIII. Cleft Lip & Palate
ix breasts



Congenital deformity

Aesthetic reasons

Medical reasons


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





Crush injury


Reimplantation of digits is a microvascular procedure


Restoration of appearance

Restoration of function


Hand Surgery
  • Local anesthetics
  • Hemostatics
  • Mineral oil (for skin with dermatome use)
  • Antibiotic irrigants and ointments
  • All solutions must be warmed especially on burn patients
  • 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
  • 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
  • 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