PLASTIC & RECONSTRUCTIVE SURGERY

1. PLASTIC & RECONSTRUCTIVE SURGERY Neurofibromatosis

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

3. 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

4. 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

5. Purposes of Plastic & Reconstructive Surgery DedeKoswara • Correct congenital anomalies or defects • Correct traumatic or pathologic (disease) deformities or disfigurements • Improve appearance (cosmetic) • Restore appearance and function

6. Anatomy & Physiology • Multi-system/structure involvement • Non-specific anatomically unlike peripheral vascular or orthopedics

7. 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

8. 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)

9. 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

10. Accessory Structures of the Integumentary System • Hair • Nails • Glands: • Sebaceous Glands • Sweat Glands/Sudoferous Glands • Merocrine Glands • Apocrine Glands • Ceruminous Glands

11. 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

12. Sweat (Sudoriferous) Glands • Merocrine • Cover most of the body • Openings are pores • Secretion 1° water and some salt • Stimulated by heat or stress

13. 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

14. Sweat (Sudoriferous) Glands • Ceruminous • External auditory canal • Secrete cerumen (earwax) • No sweat glands located in following areas: • Some regions of external genitalia, nipples, lips

15. 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

16. The Hand • Wrist • Palm • Fingers

17. Wrist (Carpus) • 8 carpal bones • Arranged in 2 rows 4 each: distal and proximal • Proximally articulate with distal ulna and radius

18. 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

19. Palm (Metacarpus) • Metacarpals • 5 per hand • Long, cylindrical shaped

20. Fingers (digits) Phalanges 14 per hand 3 phalanges per finger or digit Numbered 1-5 beginning with the thumb

21. Hand Joints • Metacarpals articulate with the phalanges • Diarthroses or freely-moveable joints • Synovial hinge joints • Metacarpophalangeal joints or MPJ referred to as the (knuckles)

22. Nerves in the Hand • Branches of brachial plexus supply innervation to the forearm and hand • Radial • Median • Ulnar

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

24. Median Nerve (Blue) • 2 branches • Innervates: • Skin of lateral 2/3 of hand • Flexor muscles of the forearm • Intrinsic muscles of the hand

25. Ulnar Nerve (Yellow) • Innervates • Skin of medial 1/3 of hand • Some flexor muscles of hand and wrist

26. 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

27. Compartments or Tunnels of the Hand • One main anterior (palm) • Posterior or dorsally there are 5 • 6 total compartments

28. 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

29. 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

30. Pathology 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

31. 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)

32. Superficial Epidermis involvement Redness or erythema Healing rapid First Degree Burn

33. 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

34. 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

35. 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. Fourth Degree Burn

36. 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.

37. 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.

38. 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)

39. Burn Assessment -Rule of Nines

40. 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%

41. 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

42. 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

43. 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)

44. 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

46. 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

48. 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 Dermatomes

49. 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

50. Donor Site • Covered with a mesh-like medicated dressing