Post on 23-Dec-2015
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 Dermatome-instrument used to incise skin, for thin skin transplants/can
be a tool for debridement Dermis-inner sensitive (nerve rich), vascular (capillaries) layer of skin Donor site-area of body used as source of a graft Epidermis-outer, non-sensitive, non-vascular layer of skin Erythema-small spot or reddened area of skin Graft-tissue transplanted or implanted in a part of the body to repair a
defect Plastic-”(plastikos) to mold or shape with one’s hands” (Caruthers & Price, 2001)
Plastic surgery-surgery performed to repair, restore, or reconstruct a body structure
Recipient site-area of body that receives grafts
Terminology & Procedures -plasty-restorative or reconstructive Abdominoplasty-abdominal wall Blepharoplasty-eyelid Cheiloplasty/Palatoplasty-cleft palate Mammoplasty-breasts Mentoplasty-chin Rhinoplasty-nose Rhytidectomy-face lift W, X, Y or Z-plasty-skin (burns/scars) Excision of Cancerous Neoplasms (basal cell, squamous cell, malignant
melanoma) Lipectomies-liposuction Microlipo-extraction Collagen injection Dermabrasion-removal of scars, tatoos, acne scars Scar Revision
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 Multi-system/structure involvement Non-specific anatomically unlike peripheral
vascular or orthopedics
Anatomy & PhysiologyIntegumentary System Skin (cutaneous membrane)-outer covering of the
body Function of: Protection from external forces (sunrays) Defense against disease Fluid balance preservation Maintenance of body temperature Waste excretion (sweat) Sensory input (temp/pain/touch/pressure) Vitamin D synthesis
Integumentary System Layers 2 main: Epidermis (outer) Composed of 4-5 layers called strata Constantly proliferating (newly forming) and shedding (thousands a day) Five week process Dermis (inner) Connective tissue Composed of nerves, capillaries, hair follicles, nails, and glands Two divisions: Reticular layer-thick layer of collagen for strength, protection, and
pliability Papillary layer-”named for papilla or projections the groundwork for
fingerprints” (Caruthers & Price, 2001)
Integumentary System
•Subcutaneous Layer/Hypodermis
•Not really a layer but serves as an anchor for the skin to the underlying structures
•Composition: adipose (fat) & loose connective tissue•Purpose: insulation & internal organ protection
Accessory Structures of the Integumentary System Hair Nails Glands: Sebaceous Glands Sweat Glands/Sudoferous Glands1. Merocrine Glands 2. Apocrine Glands3. Ceruminous Glands
Sebaceous Glands Oil (sebum) producing glands Travels through ducts emptying in the hair follicle Fluid regulation Softens hair and skin Makes skin and hair pliable Activity stimulated by sex hormones Activity begins in adolescence, continues throughout
adulthood, decreasing with aging
Sweat (Sudoriferous) Glands Merocrine Cover most of the body Openings are pores Secretion 1° water and
some salt Stimulated by heat or
stress
Sweat (Sudoriferous) Glands Apocrine Larger than Merocrine glands Located in external genitalia
and axillae Ducts in hair follicles Secrete water, salt, proteins,
fatty acids Activated at puberty Stimulated by pain, stress,
sexual arousal
Sweat (Sudoriferous) Glands Ceruminous External auditory canal Secrete cerumen
(earwax) No sweat glands
located in following areas:
Some regions of external genitalia, nipples, lips
Palate Roof of the mouth Anterior portion = hard
palate Composed of maxilla,
palatine bones, mucous membrane
Posterior portion = soft palate
Composed of muscle, fat, mucous membrane
Terminates or ends at uvula (opening of oropharynx)
Function of palate to separate nose from mouth
Function swallowing and speech
The Hand Wrist Palm Fingers
Wrist (Carpus) 8 carpal bones Arranged in 2 rows 4
each: distal and proximal
Proximally articulate with distal ulna and radius
Palm (Metacarpus) Metacarpals 5 per hand Long, cylindrical
shaped
Fingers (digits)
Phalanges 14 per hand3 phalanges per finger or digitNumbered 1-5 beginning with the thumb
Hand Joints Metacarpals articulate with the phalanges Diarthroses or freely-moveable joints Synovial hinge joints Metacarpophalangeal joints or MPJ referred
to as the (knuckles)
Nerves in the Hand Branches of brachial
plexus supply innervation to the forearm and hand
Radial Median Ulnar
Radial Nerve Along radius Sensation to forearm
and hand Extensor muscles of
the forearm
Median Nerve 2 branches Innervate: Skin of lateral 2/3 of
hand Flexor muscles of the
forearm Intrinsic muscles of the
hand
Ulnar Nerve Innervates Skin of
medial 1/3 of hand
Some flexor muscles of hand and wrist
Muscles and Tendons of the Hand 40 muscles are
responsible for movement of the hand, wrist, and fingers
Most are on anterior aspect of the hand
Anterior muscles are for flexion
Fewer posterior muscles are for extension
Compartments or Tunnels of the Hand One main anterior
(palm) Posterior or dorsally
there are six
Tendon Sheaths of the Hand Finger and thumb tendons
are contained in a tendon sheath
Serves to protect Lined with synovium
Pulleys are attached to the bones along the tendon sheath
Serve to hold the tendon to the bones they pass over
Hand Circulation 2 primary arteries Brachial splits below the
elbow >radial and ulnar arteries
Radial supplies lateral aspect of arm
Ulnar supplies medial aspect of arm
Join to form palmar and superficial palmar arches
Names of hand veins correlate with their arteries
Pathology I. Burns Injury resulting from heat, cold, chemicals,
radiation, gases, or electricity that causes tissue damage
Burn Classification Depth 1st degree - involvement just epidermis 2nd degree - involvement to dermis 3rd degree - penetrates full thickness of skin Can affect underlying structures 4th degree - char burns 5th degree - most of the hypodermis is lost, charring and
exposing the muscle (and some bone) underneath. 6th degree - the most severe form. Almost all the muscle tissue
in the area is destroyed, leaving almost nothing but charred bone.
Damage to blood vessels, nerves, muscles, tendons, and possibly bone density in 3rd thru 6th degree.
Burns Video - http://video.about.com/firstaid/Burns.htm this video only covers 1st thru 3rd degree)
First Degree Burn Superficial Epidermis involvement Redness or erythema Healing rapid
Second Degree Burn Partial Thickness Burn Epidermis and Dermis If Deepest Epithelial
layer undamaged will heal
Infection can result in damage same as third degree burn
Blistering, pain, moist/red/pink in appearance
Third Degree Burn Full-Thickness Burn Epidermis and Dermis
destroyed Extends to subcutaneous
layer and structures Requires skin grafts to heal Dry, pearly white, charred
surface (eschar) No sensation
Fourth Degree Burn Damage to bones,
tendons, muscles, blood vessels, and nerves
Charring Electrical burns most
common Extensive skin grafting
required Patient might survive
and/or limb might be saved.
5th and 6th Degree Burns Fifth and sixth degree burns are most often
diagnosed during an autopsy. The damage goes all the way to the bone and everything between the skin and the bone is destroyed. It is unlikely that a person (or limb) would survive this type of injury.
Healing Remember that first-degree burns require
three to five days to heal, second-degree burns take two to six weeks to heal, and third- and fourth-degree burns take many weeks to months to heal.
Lund-Browder Method (perdriatrics) vs. Rule of Nines (everybody) Lund-Browder Method -
used in the evaluation of all pediatric patients.
The Lund-Browder system uses fixed percentages for the feet, arms, torso, neck, and genitals, but the values assigned to the legs and head vary with a child's age.
Is more accurate but also more difficult to use.
Burn Assessment Rule of Nines ← 4.5%
Rule of Nines Increments of 9% BSA (body surface area) Head and Neck (front and back)= 9% Anterior Trunk = 18% Posterior Trunk = 18% Upper Extremity (front & back)= 9% Lower Extremity x 1(front & back)= 18% Perineum = 1%
Burn Surgical Intervention Debridement - medical term referring to the removal
of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Skin Grafting http://www.aasfe.org/crocker-stephenson-2.html
The Story
Skin Grafts Autograft - taken from part of the patient’s body Homograft or Allograft– graft taken from same
species as recipient (cadaver) Stored in a tissue bank Heterograft or Xenograft – Taken from one species
and used on another species (pigskin/porcine skin or cowskin/bovine)
Synthetic Skin These means reduce fluid loss and protect the wound
Autografts Classified by the source of their vascular supply and
tissue involved Factors for determining choice of grafting method: Location of defect Amount of area to be covered Depth of defect Underlying tissue involvement at defect Cause of defect (trauma, disease, or heredity)
Autografts (FTSG) Full Thickness Skin Graft Consists of epidermis and all of the dermis May include greater than 1 mm of the subcutaneous layer Because is a deep excision at the donor site, limited to smaller areas of
grafting (face, neck, hands, axillae, elbow, knees, feet) Especially used for covering squamous cell or basal cell carcinomas Donor site must be closed Cannot reuse donor site Excised by a skin graft knife Prevent contraction of a wound better than a split-thickness graft
Autografts (STSG) Split-Thickness Skin Graft Involves removal of epidermis and dermis to a depth
of up to 1mm Can be used over large body surfaces (back, trunk,
legs) Donor site regenerates quickly and can reuse in
about 2 weeks if it has been properly cared for Graft excised with a dermatome Graft can be stretched or enlarged by a skin graft
mesher
Dermatomes Used to remove STSG Brown - oscillating blade Padgett-Hood-rotating
blade housed in drum Powered by nitrogen or
electricity Hall Reese Can be hand held
Dermatome Connect blade to dermatome before passing off the power cord Test in a safe place Blades are disposable Take care with blades Surface of blade protected with a guard (are 4 sizes) Secure blade and guard with screwdriver Guard should not cover the cutting edge of blade Dermatome Graft thickness (depth) determined by small lever on side of dermatome
(in tenth of a millimeter increments) Set at 0 before procedure and after changing blades Adjust per surgeon directions or surgeon may adjust Width of graft determined by gaps in edges of plate that are one to four
inches
Donor Site Covered with a mesh-like medicated dressing
Graft Care Do not allow to dry out Place in a basin with small amount of warm
saline until ready to use
Mesh Graft Device Manually operated/roller like device Used with a split thickness skin graft to expand (meshing)
the size of the skin graft Skin graft is placed on a plastic derma-carrier, which holds
the graft flat prior to placing in the mesh graft device If more than one graft used, each is placed on its own derma-
carrier Derma-carriers come in various sizes (sized in ratios) If ratio on derma-carrier says 3:1, means graft will cover
three times the area it would have if not meshed Meshing creates netted effect When skin graft placed on site being grafted, epithelial tissue
will grow in between the slits
Mesh Graft Device
Graft Care Post Placement Will likely be secured as it needs to stay in
place until healing can ensue May use a pressure type dressing
II. Acne Inflammatory disease of skin Formation of pustules or pimples Face, neck, upper body affected Related to stress, diet, and hormonal activity Bacteria can invade and cause pits and scars Surgical intervention requires removal of pits
and scars via dermabrasion
III. Aging Elastic fiber number decrease Lost adipose tissue Collagen fiber loss, slows healing Wrinkling and sagging result Surgical intervention = Conservative
nonsurgical intervention to invasive surgical intervention
Rhytidectomy = “face-lift”
IV. Sun Exposure Sunlight exposure thickens epidermis and
damages elastin Damaged elastin allows for formation of pre-
malignant and malignant cells Prevention best (sunscreen) Can resurface skin pharmaceutically or
surgically No sunscreen can lead to Melanoma.
Melanoma A form of skin cancer that begins in melanocytes (the cells that
make the pigment melanin). Melanoma usually begins in a mole. The most dangerous type of skin cancer. It begins as a dark skin lesion and may spread rapidly to other areas
on the skin and within the body.
HOW DO I KNOW IF I HAVE MELANOMA?
The ABCD’s A- Asymmetry. If the mole is asymmetrical, it is potentially
cancerous.
B- Border. If the mole has an irregular border, it could be cancerous.
HOW DO I KNOW IF I HAVE MELANOMA? C- Color. If the mole has more than one color
or is blue, pink, or white, it could be cancerous.
D- Diameter. If the mole has a diameter of
larger than 6 mm, it could be cancerous.
V. Eyelids Blepharochalasis = loss of muscle tone or relaxation
of the eyelids Causes wrinkling and thinning Poor results surgically Dermachalasis = relaxation and hypertrophy of
eyelid skin Bags under the eyes Easily corrected surgically Ptosis = eyelid drooping Muscle shortening repairs this
VI. Neoplasms Any new or abnormal growth May be benign, pre-malignant, or malignant Caused by exposure direct or indirect to
chemicals or the sun Removal surgically can be chemical, laser, or
minor surgical
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
IX. Breasts Gynecomastia Liposuction
Cancer Congenital deformity Aesthetic reasons Medical reasons Mammoplasty
X. Abdomen Abdominoplasty or tummy tuck Thinning of abdominal fat and tightening of
abdominal muscles Removing fat and excess skin from mid to lower
abdomen Can do in addition to liposuction
Panniculectomy = removal of fat apron in obese patients
Hand Pathology1. DeQuervain’s Disease Stenosis/inflammation
of tendons in first dorsal wrist compartment
Treatment conservative with anti-inflammatories or surgical (rare recurrence after surgery)
Hand Pathology2. Trigger Finger Stenosis of digital
tendons Surgical intervention
needed if digit becomes “locked”
Hand Pathology3. DuPuytren’s
Disease Related to traumatic
injury Contracture of palmar
fascia May be seen as a
nodule in the palm, dimpling or pit in the palm, or fibrous cord from palm to fingers
Surgical intervention warranted if movement and function are impaired
Hand Pathology4. Ganglion Cyst Benign lesion in
hand or wrist Filled with
synovial fluid coming from a tendon sheath or joint
Results from trauma or tissue degeneration
May aspirate Surgical removal Recurrence 50%
Hand Surgery5. Rheumatoid Arthritis
(RA) Disease that attacks the
synovial tissues Most common connective
tissue disease Loss of joint function Anti-inflammatory meds
treat Surgical intervention
required to stabilize a weakened joint or replace a damaged structure
Hand Surgery6. Hand Trauma Cuts Sprains Fractures Burns Crush injury Amputation Reimplantation of digits is a microvascular procedure
Goal: Restoration of appearance Restoration of function
KEY GOAL = FUNCTION
Medications Local anesthetics Hemostatics Mineral oil (for skin with dermatome use) Antibiotic irrigants and ointments All solutions must be warmed especially on
burn patients
Supplies Basin pack Beaver blades Knife blades of surgeons choice Medicine cups Mineral oil Sterile tongue blade used in conjunction with dermatome to stretch skin
as graft being removed Derma-carrier Drains of surgeon’s choice Needle tip cautery electrode Marking pen Ruler or calipers Luer lock control syringes 25 and 27ga needles
InstrumentationBasic Plastics Tray Basic Plastics Tray:
Towel clips Micro mosquitoes Hemostats Allises Littler, Iris, tenotomy scissors Small metz fine and blunt tipped Small mayo straight and curved Bandage scissors NH fine and crile-wood Adsons smooth and with teeth Adson-brown, bishop-harmon, debakey Skin hooks single and double pronged Senn retractors, Army-Navy, Spring Retractors #3, #7,knife handles, beaver handle Freer, small key elevators Frazier suction tip 8F angled with “finger cut-off” valve
Nasal Instruments Rhinoplasty/Nasal tray
Vienna Nasal speculums Single skin hooks Cottle or Joseph double prong skin hooks Cottle knife Cottle or Fomon Retractor Cottle osteotomes (4, 7, 9, 12mm) Ballenger chisel Ballenger swivel knife Joseph nasal bayonets, right and left Freer septal chisels curved and straight Joseph rasp or Double ended Maltz rasp Cushing Bayonet forceps with teeth Jansen Bayonet dressing forceps Takahashi Forceps Cottle cartilage crusher
Abdominoplasty Instruments/Supplies Basic Plastic Set Fiberoptic Retractor Set Abdominal retractor tray (deavers,
richardsons, etc.) Lap sponges Umbilical template Abdominal drapes (universal) or Laparotomy Extension blade for the cautery
Cheiloplasty & Palatoplasty Instruments/Supplies Basic plastic tray #15 blade Oral instruments Mouth Gag (Jennings/Davis/McIvor)
+ assorted blades 2x2 gauze for dressing
Mammoplasty Instruments & Supplies Basic Plastic Tray Minor Tray #15 blades Local with Epinephrine Control syringes and local needles Fiberoptic retractor set Extension tip available for cautery Laparotomy sponges Chest drapes (universal or laparotomy) Suture of surgeon preference Dressing
Hand Supplies Basin pack Basic pack Extremity sheet or hand/arm drape Split sheet Half sheet for lower part of body #15 blades Stockinettes Esmark Tourniquet and padding for (cast type) Suture of preference Anesthetics of choice (local) Control syringes and 25/27ga. hypo needles Dressing of surgeon choice Elastic bandage
Hand Instruments Minor orthopedic tray Minor plastic tray Small vascular instruments (re-implantations) Metacarpal retractors Pediatric deavers
Hand Equipment Sitting stools ECU Suction Hand table Tourniquet Tower Equipment including insufflator
Positioning Depends on area being operated on Care to padding depending on which position
used Extreme care with a burned patient with
moving Guard all IV lines, trach tubes, ET tubes Do not delay transport to the OR
Prepping Colorless solution preferred if using skin graft
so skin color can be seen Donor and graft sites prepped separately Solutions used should be warmed Prep gentle and about 3 minutes (less time
than normal skin) Keep patient covered with warm blankets
until ready to prep, keep blankets on as much area as possible
Special Considerations Strict aseptic technique Death related to septicemia and pneumonia in severely
burned patients Environmental temperature should be geared to prevent
hypothermia, prevent microbial invasion, and aid in the healing process
Body temp will be monitored throughout on burn patients with a rectal, esophageal, or tympanic probe
Patient will be in isolation post-op May go to hyperbaric unit to promote healing I & O carefully monitored (urine and blood loss)
Post-Operative Care Maintain asepsis until all dressings are
secured prior to removal of drapes
Plastics and Reconstructive
Procedures
Rhytidectomy
PlasticsOperative Sequence
Rhytidectomy
•Overall Purpose of Procedure:– To improve the appearance of the patients face and neck area.
Rhytidectomy
Rhytid =‘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- Facelift -
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.
Rhytidectomy
•Wound Classification: 1
Operative Sequence
• 1- Incision• 2- Hemostasis• 3- Dissection • 4- Exposure• 5- Procedure (Specimen Collection
possible)• 6- Hemostasis • 7- Irrigation• 8- Closure• 9- Dressing Application
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
• 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
• Hemostasis: Handheld Bovie and hemostats.
Rhytidectomy cont. 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 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 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 Sequence
• Hemostasis and Irrigation:– All bleeding is controlled with cautery,
possibly Bi-polar. – Use of warm Saline to irrigate.
Rhytidectomy cont. 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.
Rhytidectomy
•Major Arteries:– External Carotid
Artery– Facial
Rhytidectomy
• Major Veins:– Internal Jugular Vein
• Major Nerves:– Cranial Nerve VII -
Facial Nerve
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.
Lipectomy
Plastic ProceduresOperative Sequence
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
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.
Lipectomya 12-year old girl who at 5-foot-5 weighed 230 pounds.
Lipectomy
Liposuction is not a low-effort alternative to exercise and diet. It is a form of body contouring with significant risks and 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.
Lipectomy
Wound Classification: 1
Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection
possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application
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
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
Hemostasis: Handheld Bovie
Lipectomy cont. Operative Sequence
Dissection and Exposure:All dissection is
made with the lipo cannual that the surgeon has previously chosen.
Lipectomy cont. 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 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 Sequence
Hemostasis and Irrigation:All bleeding is controlled with cautery. Use of warm Saline to irrigate.
Lipectomy cont. 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.
Lipectomy
Major Arteries:Depends on
area of Lipectomy
Lipectomy
Major Veins:Depends on area of
Lipectomy
Major Nerves: Depends on area
of Lipectomy
Abdominoplasty
Plastic ProceduresOperative Sequence
Abdominoplasty
Overall Purpose of Procedure:
A.K.A. Tummy Tuck To remove excess fat and tighten abdominal skin.
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.
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.
Abdominoplasty
Wound Classification: 1
Operative Sequence
1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection
possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application
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
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
Hemostasis: Handheld Bovie
Abdominoplasty cont. Operative Sequence
Dissection and Exposure: The abdomen is
dissected through the subcutaneous tissue and fat down to the rectus muscle using the bovie.
Abdominoplasty cont. 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 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 Sequence
Hemostasis and Irrigation: All bleeding is controlled with
cautery. Use of warm Saline to irrigate.
Abdominoplasty cont. 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.
Abdominoplasty
Major Arteries:No major since we are superficial, or above the rectus muscles
Abdominoplasty
Major Veins: No major since
we are superficial, or above the rectus muscles
Major Nerves: Splanchnic
nerve
Cheiloplasty (key-lo-plasty) and Palatoplasty
Plastic ProceduresOperative Sequence
Palatoplasty
Overall Purpose of Procedure:
A.K.A. Cleft Palate
To reassemble normal pathology of the palate.
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 Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection
possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application
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
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
Hemostasis: Bayonet Bovie or needle tip.
Palatoplasty cont. Operative Sequence
Dissection and Exposure: The flaps are
elevated with skin hooks.
Palatoplasty cont. Operative Sequence
Exploration and Isolation: None needed
Palatoplasty cont. Operative Sequence
Surgical Repair: Once the
flap are elevated, they are closed in three layers.
Nasal Mucosa
Muscle Palatal
mucoa
Palatoplsty cont. Operative Sequence
Hemostasis and Irrigation: All bleeding is controlled with cautery. Use of warm Saline to irrigate.
Palatoplsty cont. 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
Major Arteries: ascending
palatal artery
Palatoplsty Major Veins:
Palatal vein
Major Nerves: greater and lesser
palatine nerves
Cheiloplasty
Plastic ProceduresOperative Sequence
Cheiloplasty
Overall Purpose of Procedure:
A.K.A. Cleft LipTo reassemble normal pathology of the lip.
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 Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection
possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application
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
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
Hemostasis and Irrigation: All bleeding is controlled with cautery. Use of warm Saline to irrigate.
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
Plastic ProceduresOperative Sequence
Rhinoplasty
• Overall Purpose of Procedure:
– The goal of the procedure is to improve the appearance of the nose.
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.
Rhinoplasty
• Wound Classification: 1
Operative Sequence
• 1- Incision• 2- Hemostasis• 3- Dissection • 4- Exposure• 5- Procedure (Specimen Collection
possible)• 6- Hemostasis • 7- Irrigation• 8- Closure• 9- Dressing Application
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
–Incision:• Intranasal incisions are made with 15 KB, Joseph Knife, Joseph elevator or Button Knife.
Rhinoplasty cont. Operative Sequence
• Hemostasis: Handheld Bipolar Bovie
Rhinoplasty cont. Operative Sequence
• Dissection and Exposure:– The skin and the
soft tissue are elevated from the underlying nasal bones and cartilage.
Rhinoplasty cont. Operative Sequence
• Exploration and Isolation: – Full exposure
of the nasal bones and cartilage with nasal speculum.
Rhinoplasty cont. 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 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 Sequence
• O.R. Live video:• Rhinoplasty
- Nasal Valve Reconstruction
• Procedure:Smooth procedure
Rhinoplasty cont. Operative Sequence
• Hemostasis and Irrigation:– All bleeding is controlled with cautery. – Use of warm Saline to irrigate.
Rhinoplasty cont. Operative Sequence
• Closure:• Suturing is very minimal for Rhinoplasties. • MD will choose a small Chromic. 4-0 or 5-0.
Rhinoplasty
• Major Arteries:– The external
nose is supplied by the facial artery
– Internal - anterior and posterior ethmoid arteries
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
Mammoplasty 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.
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.
Mammoplasty Mammoplasty
Define the procedure:
We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts.
Define the procedure:
We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts.
Mammoplasty Mammoplasty
Wound Classification: 1Wound Classification: 1
Operative SequenceOperative Sequence
1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection
possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application
1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection
possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application
MammoplastyMammoplasty
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.
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
Mammoplasty Begin 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.
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 SequenceMammoplasty cont. Operative Sequence
Hemostasis: Handheld Bovie Hemostasis: Handheld Bovie
Mammoplasty cont. Operative SequenceMammoplasty cont. 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
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 SequenceMammoplasty cont. Operative Sequence
Exploration and Isolation: None at this point.
Exploration and Isolation: None at this point.
Mammoplasty cont. Operative SequenceMammoplasty cont. 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
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 SequenceMammoplasty cont. 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.
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 SequenceMammoplasty cont. 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.
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 SequenceMammoplasty cont. Operative Sequence
Hemostasis and Irrigation: All bleeding is controlled with cautery. Use of warm Saline to irrigate.
Hemostasis and Irrigation: All bleeding is controlled with cautery. Use of warm Saline to irrigate.
Mammoplasty cont. Operative SequenceMammoplasty cont. 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.
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.
A Simpler ApproachA Simpler Approach
MammoplastyMammoplasty
Major Arteries: Internal mammary
artery Lateral thoracic
artery Thoracodorsal
artery Intercostal artery Thoracoacromial
artery
Major Arteries: Internal mammary
artery Lateral thoracic
artery Thoracodorsal
artery Intercostal artery Thoracoacromial
artery
MammoplastyMammoplasty
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.
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 Surgery Reasons performed: Congenital deformities Disease Trauma
Can be performed by plastic surgeons, orthopedic or orthopedic “hand-surgeons”, and neurosurgeons
Hand Surgery 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
Summary Terminology Anatomy of Skin and Hand Pathology Medications Anesthesia Supplies, Instrumentation, and Equipment Considerations and Post-op Care Procedures: Skin and Hand