1 chapter 29 plastic and reconstructive surgery. 2 elsevier items and derived items © 2010, 2007 by...

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Chapter 29Chapter 29

Plastic and Plastic and Reconstructive SurgeryReconstructive Surgery

2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Plastics and Reconstruction

Review terms and definitions listed at beginning of chapter

Use your medical dictionary if necessary

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Plastics and Reconstruction

Plastic and reconstructive surgical procedures Correction of congenital defects or deformities Alteration of patient’s appearance for cosmetic

purposes

Special psychological needs must be met

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Plastics and Reconstruction

Integumentary system

The epidermis and the dermis.

(From Thibodeau GA, Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby.)

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Plastics and Reconstruction

Dermis Lies directly beneath the epidermis Contains nervous and blood supply of skin Contains hair follicles and sebaceous and

sweat glands

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Plastics and Reconstruction

Skin appendages Hair Sweat glands Sebaceous glands

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Plastics and Reconstruction

Perioperative considerations Prepping and draping

• Prep solutions of choice Betadine

– Used for liposuction or burns

pHisoHex and Hibiclens– Used on face

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Plastics and Reconstruction

Draping

Application of the head drape. The corners of the towel must be handled carefully to avoid contamination.

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Plastics and Reconstruction

Draping (cont.)

Application of the head drape. The corners of the towel must be handled carefully to avoid contamination.

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Plastics and Reconstruction

Draping (cont.)

Application of the head drape. The corners of the towel must be handled carefully to avoid contamination.

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Plastics and Reconstruction

Equipment and instruments Dermabrader Liposuction instruments CO2 laser

Facial implants Dermatome Mesher Endobrow instruments

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Plastics and Reconstruction

Brown dermatome and graft knife.

(A from Fortunato N, McCullough SM: Plastic and reconstructive surgery, St Louis, 1998, Mosby; B from Rothrock J: Alexander’s care of the patient in surgery, ed 17, Philadelphia, Mosby, 2007.)

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Plastics and Reconstruction

Mesher

Manual skin mesher.

(From Fortunato N, McCullough SM: Plastic and reconstructive surgery: Perioperative nursing series, St Louis, 1998, Mosby.)

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Plastics and Reconstruction

Pneumatic power drill To model bone tissue To create anchor holes for wire or screw To cut through bone with an oscillating saw blade

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Plastics and Reconstruction

Endobrow instruments Include variety of periosteal elevators and

instruments for blunt and sharp dissection • Usually are included in a set

• Many are adapted to cautery to aid in hemostasis

• Set also includes a cannula for endoscope to be passed through

The endoscope may or may not be included in the set of instruments; 4- or 5-mm endoscopes in 0- and 30-degree angles are the endoscopes of choice

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Plastics and Reconstruction

Debridement Chemical debridement Surgical debridement Pressurized saline

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Plastics and Reconstruction

Excision of superficial lesions Removed for diagnostic purposes Removed to prevent or treat malignancy

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Plastics and Reconstruction

Scar revision Performed on scars that have not healed properly

• Includes keloid or hyperpigmented scars

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Plastics and Reconstruction

Rotational Flap

The lesion is removed and a flap raised from the perinalar area. The flap is rotated to fit over the defect and the graft site skin closed after healing. (From Garden O, Bradbury A, Forsythe J, Parks R: Principles and Practice of Surgery, ed 5, Edinburgh, 2007, Churchill Livingston Elsevier.)

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Plastics and Reconstruction

Debridement of burns Superficial partial thickness (1st degree) Partial thickness (2nd degree) Full thickness (2nd degree) Full thickness (3rd degree)

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Plastics and Reconstruction

Debridement for burns Performed to excise burned and damaged tissue Burns caused by transfer of heat from external

source to the body Burns are classified as to depth of tissue affected

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Plastics and Reconstruction

Skin grafting Biological graft

• Allograft

• Autograft

• Composite graft

• Split-thickness skin graft

• Full-thickness skin graft

• Xenograft

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Plastics and Reconstruction

Skin graft Synthetic

• Silicone

• Polyethylene

• GORE-TEX

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Plastics and Reconstruction

Debridement for burns Superficial partial thickness, first degree

• Only the outer layer of the epidermis is injured. The skin is red or pink, dry, and painful to touch

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Plastics and Reconstruction

Debridement for burns (cont.) Partial thickness, second degree

• The epidermis and various degrees of the dermis are injured. The skin is blistered, red, and moist

Full thickness, second degree• The epidermis and full dermis are injured. These burns

are characterized by a white, smooth, shiny surface with dry blisters and edema

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Plastics and Reconstruction

Debridement for burns (cont.) Full thickness, third degree The skin, the subcutaneous tissue, the muscle,

and the bone are burned. The third-degree burn is centered in an area of second-degree injury. The skin may be white, brown, or black and appears waxy. There is no pain because the nerves have been destroyed.

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Plastics and Reconstruction

Skin Grafts

A dermatome taking a skin graft.

(From Barret JP, Herndon DN: Color atlas of burn care, Philadelphia, 2001, Saunders.)

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Plastics and Reconstruction

Pedicle graft Provides coverage

of a soft tissue defect Classification

• Near graft

• Distant graft

(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and Practice of Surgery, ed 5, Edinburgh, 2007, Churchill Livingston Elsevier.)

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Plastics and Reconstruction

Otoplasty Surgical recreation of the external ear Performed to correct a congenital malformation Primary deformity is absence of the antihelix

and/or the conchal bowl

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Plastics and Reconstruction

Blepharoplasty Resection of the eyelid to improve vision

Upper lid blepharoplasty.A, Retraction of the skin incision using dull rakes. Small bleeders have been coagulated with bipolar electrosurgical unit (ESU). The fat pad is exposed and may be removed with Westcott scissors. B, Closure using 6-0 Vicryl sutures.(From Chen W, Khan J, McCord C: Color atlas of cosmetic oculofacial surgery, 2004, Butterworth Heinemann.)

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Plastics and Reconstruction

Lower-Lid Blepharoplasty

A, Infraciliary incision. B, Upside-down view of the lower lid margin.(From Chen W, Khan J, McCord C: Color atlas of cosmetic oculofacial surgery, 2004, Butterworth Heinemann.)

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Plastics and Reconstruction

Lower-Lid Blepharoplasty (cont.)

C, Canthotomy and resection. D, Lid following resection.(From Chen W, Khan J, McCord C: Color atlas of cosmetic oculofacial surgery, 2004, Butterworth Heinemann.)

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Plastics and Reconstruction

Brow lift Procedure done to lift the supportive structures of

the brow and alleviate drooping of the skin, muscle, and fascia

Can be done as an open or endoscopic procedure

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Plastics and Reconstruction

Open Brow Lift

A, Incisions for brow lift.(From LaTrenta G: Atlas of aesthetic face and neck surgery, Philadelphia, 2004, Saunders.)

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Plastics and Reconstruction

Open Brow Lift (cont.)

B, Closure and removal of redundant scalp tissue.(From LaTrenta G: Atlas of aesthetic face and neck surgery, Philadelphia, 2004, Saunders)

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Plastics and Reconstruction

Endoscopic Brow Lift

A, Incisions for endoscopic lift. B, Subperiosteal dissection.(From LaTrenta G: Atlas of aesthetic face and neck surgery, Philadelphia, 2004, Saunders.)

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Plastics and Reconstruction

Rhytidectomy Redundant and

sagging supportive tissue of the face is reduced and modified to provide a more aesthetic appearance

A, Undermining in the temporal area.(From LaTrenta G: Atlas of aesthetic face and neck surgery, Philadelphia, 2004, Saunders.)

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Plastics and Reconstruction

Rhytidectomy (cont.)

B, Closure of skin flaps and areas of resection.(From LaTrenta G: Atlas of aesthetic face and neck surgery, Philadelphia, 2004, Saunders.)

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Plastics and Reconstruction

Laser skin resurfacing Performed to reduce effects of aging or photo

damage Skin is resurfaced using laser

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Plastics and Reconstruction

Facial augmentation Mentoplasty (chin augmentation) Cheek augmentation Cheiloplasty (lip augmentation)

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Plastics and Reconstruction

Mastopexy Performed to lift the breast and remove

excess skin Performed to correct breast ptosis Can have significant role in improving body

image of patient

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Plastics and Reconstruction

Augmentation mammoplasty Performed to increase the size and improve the

shape of the breast

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Plastics and Reconstruction

Reduction mammoplasty Performed to remove breast tissue with

reconstruction to provide a more aesthetic appearance

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Plastics and Reconstruction

Transverse rectus abdominis myocutaneous (TRAM) flap Breast reconstruction without the use of implants Nipple reconstruction

• Grafting sites Medial thigh crease Postauricular region Labia

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Plastics and Reconstruction

Transverse rectus abdominis myocutaneous (TRAM) flap (cont.)

(From Fortunato N, McCullough SM: Plastic and reconstructive surgery, St Louis, 1998, Mosby.)

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Plastics and Reconstruction

Liposuction Performed to remove excess deep fat

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Plastics and Reconstruction

Panniculectomy (abdominoplasty) Performed to remove excess abdominal wall skin

and adipose tissue and tighten abdominal wall muscles