plastic & reconstructive surgery. outline terminology anatomy of skin and hand pathology ...

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)

http://video.about.com/firstaid/Burns.htm

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

http://www.aasfe.org/crocker-stephenson-2.html

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

Neoplasm Example

http://upload.wikimedia.org/wikipedia/en/c/cc/Colon_cancer_2.jpg

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.


• 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.


• 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.


– 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

http://www.eesedu.com/dtcf/pages/PS_Procedure.htm


• Hemostasis and Irrigation:– All bleeding is controlled with cautery,

possibly Bi-polar. – Use of warm Saline to irrigate.


• 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

http://upload.wikimedia.org/wikipedia/commons/f/f6/Facial_artery.PNG

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.

Blepharoplasty

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

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

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


Dissection and Exposure:All dissection is

made with the lipo cannual that the surgeon has previously chosen.


Exploration and Isolation:A tunnel is created by passing the

cannula underneath the skin. The suction is off at this point.


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

http://www.youtube.com/watch?v=nfRsBijqS4E

http://www.youtube.com/watch?v=nfRsBijqS4E


Hemostasis and Irrigation:All bleeding is controlled with cautery. Use of warm Saline to irrigate.


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


Abdominoplasty


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


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



Dissection and Exposure: The abdomen is

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


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.


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

http://www.youtube.com/watch?v=fYl_5Mb69nE

http://www.youtube.com/watch?v=fYl_5Mb69nE


Hemostasis and Irrigation: All bleeding is controlled with

cautery. Use of warm Saline to irrigate.


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


Palatoplasty


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.

Palatoplasty

Instrumentation: Plastics/Minor tray depending on patient size.


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.


Dissection and Exposure: The flaps are

elevated with skin hooks.


Exploration and Isolation: None needed


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


Cheiloplasty


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.

Cheiloplasty

Instrumentation: Plastics/Minor tray depending on patient size.


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


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

Cheiloplasty cont. Operative Sequence


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

• 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


• Dissection and Exposure:– The skin and the

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


• Exploration and Isolation: – Full exposure

of the nasal bones and cartilage with nasal speculum.


• 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.


• 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.


• O.R. Live video:• Rhinoplasty

- Nasal Valve Reconstruction

• Procedure:Smooth procedure

http://video.google.com/videoplay?docid=2637271328496878019&ei=tGsVSpfYLYG2rgLg_djlBQ&q=rhinoplasty&hl=en




http://video.google.com/videoplay?docid=-8504897707527523617&q=Rhinoplasty+&ei=GYItSOH8L6WarQLgl-WACg&hl=en

http://video.google.com/videoplay?docid=-8504897707527523617&q=Rhinoplasty+&ei=GYItSOH8L6WarQLgl-WACg&hl=en


• Hemostasis and Irrigation:– All bleeding is controlled with cautery. – Use of warm Saline to irrigate.


• 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


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.



We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts.


We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts.


Wound Classification: 1Wound Classification: 1

Operative SequenceOperative Sequence





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


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


Exploration and Isolation: None at this point.

Exploration and Isolation: None at this point.


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




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.


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.


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


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


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

plastic & reconstructive surgery. outline terminology anatomy of skin and hand pathology ...

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