Barbie Without Plastic Surgery Plastic and Reconstructive Surgery

Barbie Without Plastic Surgery

Plastic and Reconstructive Surgery

Objectives • • Identify the goal of plastic surgery Describe categories of plastic surgery Describe the risks Describe Perioperative Nursing Considerations

History of Plastic Surgery • Practiced for thousands of years • Artificial ears & noses found on Egyptian mummies • Evidence that ancient Hindus used skin flaps to reconstruct noses

Categories of Reconstructive Surgery • Correction of Congenital Anomalies • Improvement of appearance • Resection of tumors that leave large softtissue defects • Repair of traumatic injuries

The goal of Plastic Surgery is to restore normal function and appearance (Cover the hole)

Treatment Options • Surgery – Cosmetic – Reconstructive/Revision – Lipectomy – Tissue Expansion

Treatment Options • Collagen/Fat/Botox Injection • Skin Resurfacing – Laser – Chemical Peel – Dermabrasion

Perioperative Nursing Considerations

Assessment • Plastic surgery often results in a change of body image and self esteem • Perioperative nurses must possess: – Respect for the patient – A nonjudgmental attitude – Effective communication skills

Nursing Diagnosis • • • Disturbed Body Image Anxiety Deficient Knowledge Risk For Positioning Injury Risk For Ineffective Tissue Perfusion Risk For Infection

Outcome 0. 280 Patient is free from signs and symptoms of infection Nursing Diagnoses Risk for infection (00004) Nursing Interventions Implements aseptic technique (Im. 300) Protects from cross-contamination (Im 300. 1)

Nursing Interventions Minimizes the length of invasive procedure by planning care (Im. 760) Administers care to wound sites (Im. 290) Administer care to invasive device sites (Im. 250) Classifies surgical wound (A. 350. 1) Reclassify if becomes contaminated

Nursing Interventions Evaluates factors associated with increased risk for postop infection at the completion of the procedure (E. 320) Modifies wound class if there are major breaks in aseptic technique during the procedure.

General Considerations

Anesthesia • Local anesthesia is often used in conjunction with sedation, regional and general anesthesia • Epinephrine may be added to prolong anesthetic action & provide hemostasis • Epinephrine generally not used in local on digits (fingers/toes)

Positioning • Position patient so that all operative sites appropriately exposed and airway easily observed & accessed • OR bed may be turned for ease of access • Provide comfort measures, such as pillow under knees, as some procedures are long in duration • Always check patient after position changes

Skin Preparation • Most skin marking is done prior to patient going to sleep-don’t wash off when prepping • Colorless solution is preferred to observe true skin color • Avoid pooling of prep around or in eyes or ears

Draping • Blue towels and medium sheets are used when large amounts of skin must be exposed • Head drape used when working on face, ears & neck • Both sides of body may be exposed for comparison purposes

Supplies/Equipment • Marker/Methylene Blue • Undyed suture often used, clear may be used on face • Bipolar • Silastic and Teflon Implants – Available in several sizes and shapes – Contraindicated for use in an infected area

Tissue Expanders

Breast Implants

Facial Implants

Dermatome

Skin Mesher

Skin Mesher

Head Light & Light Source

Lighted Retractors

Jackson Pratt Drain

Microscope

Suction Assisted Lipectomy

Instrumentation

Gillies needle holder

Stevens scissors

Castroviejo Forceps

Hartman Mosquito

Skin Hook

Liposuction Cannulas

Medications • Local Injections – Lidocaine (Xylocaine) – Bupivicaine (marcaine) • Topical – Cocaine 4% • Tumescent Anesthesia – 1 liter NS with 500 -1000 mg lidocaine & 1 mg epinephrine

Pressure Infuser

Dressings • Apply even pressure over wound to prevent dead spacing, seromas & hematomas • Collect drainage • Provide comfort for the patient • Protect wound

Brow lift • Minimizes forehead creases, drooping eyebrows, hooding over eyes, furrowed forehead and frown lines by removing excess tissue, altering muscles & tightening forehead skin • Length: 1 -3 hours • Risks: facial nerve injury, muscle weakness, asymmetrical look, infection, scarring

Open Brow Lift • Hair is tied with rubber bands on either side of incision • Coronal incision is made running ear to ear • Skin of forehead is lifted, excess skin is removed & muscles altered

Endoscopic Brow Lift • 3 -5 short (1 inch) incisions made • Endoscope inserted to view muscle & tissue • Elevator inserted through different incision to lift skin • Underlying tissue & muscle removed or altered

Brow Lift Before & After

Rhytidectomy (Face Lift) • Improves sagging facial skin, jowls & loose neck skin by removing excess fat, tightening muscles, & redraping skin. • Length: several hours • Risks: Facial nerve injury, infection, bleeding, poor healing, scarring, asymmetry or change in hairline

Rhytidectomy • Incision is made close to or in the hairline • Skin and subcutaneous tissue are mobilized by undermining (separation from their attachments) • Avoid injury to facial & greater auricular nerves

Rhytidectomy • After deep tissues are tighten with sutures, the excess skin is pulled up and back, trimmed and sutured into place • Drains may be placed

Post-Op Dressing

Rhytidectomy Before & After

Facial Implants • Improve & enhance facial contours using shaped implants to build up the chin, cheeks & jaw line • Length: Chin 30 min – 1 hr, Cheek 30 -45 min, lower jaw 1 -2 hr • Risks : shifting or imprecise positioning of implant, infection, scar tissue around implant causing unnatural shape

Chin Implant • Incision is made inside mouth or under the chin • A pocket is created in front of the jawbone • Implant is inserted & wound closed

Chin implant Before & After

Cheek Implant • Incision is made either inside the upper lip or lower eyelid • Implant is placed either directly on or below cheek bone

Cheek Implant Before & After

Lower Jaw Implant • Internal incisions are made on either side of the lower lip • A pocket is created and the implant is inserted

Jaw Implant Before & After

Rhinoplasty • Reshape nose by reducing or increasing size, removing hump, changing shape of tip, narrowing span of nostrils, changing angle between nose and upper lip • Length: 1 -2 hours • Risks: infection, temporary swelling & bruising around eyes & nose, headaches, bleeding, stiffness

Rhinoplasty • Incisions are made inside the nose or at the base of the nose, providing access to the cartilage and bone which can then be sculpted into shape

Rhinoplasty • Hump is removed with a chisel or rasp, then the nasal bones are brought together to form a narrower bridge • Cartilage is trimmed to reshape the tip of the nose

Rhinoplasty • Trimming the septum improves the angle between the nose and upper lip

Rhinoplasty • If the nostrils are too wide, small wedges of skin are removed from the base to bring them closer together

Post-Op Splint

Rhinoplasty Before & After

Otoplasty • Sets prominent ears back closer to the head, or reduce the size of large ears • Length: 2 -3 hours • Risks: infection, scarring, blood clot formation on the ear, recurrence of protrusion

Otoplasty • Incision is made in the back of the ear so cartilage can be sculpted or folded • Stitches are used to close the incision and help maintain the new shape

Ear Dressing

Otoplasty Before & After

Cleft Lip Repair • Correction of a congenital split in the upper lip. Incidence 1 in 800 babies • Length: 30 min-1 hour • Risks: Pain, Restlessness, difficulty with feeding

Cleft Lip Repair • Incision is made along each side of cleft • Outer portion of cleft will be turned down & muscle and skin of lip is pulled together and sutured

Cleft Lip Before & After

Cleft Palate Repair • Correction of a congenital deformity that results in a cleft in the hard palate, soft palate or both • Length: 1 -1. 5 hours • Risk: Pain, decrease in appetite requiring an IV for 1 -2 days

Cleft Palate Repair • Incision is made on both sides of the separation, tissue from each side is moved to the center of the roof of the mouth and sutured

Cleft Palate Before & After

Augmentation Mammoplasty • Use of implants to enhance breast size, correct breast asymmetry, or recreate the breast after mastectomy • Length: 1 -2 hours • Risks: deflation, scar tissue around implant (capsular contracture), infection, change in nipple sensation, difficult mammograms

Augmentation Mammoplasty • Incisions are made to • keep scar as inconspicuous as possible, in the breast crease, around the nipple, or in the armpit. Breast tissue & skin is lifted to make a pocket for the implant

Augmentation Mammoplasty • Implants may be placed in front or behind the muscle

Post Op Dressing

Augmentation Before & After

Mastopexy (Breast Lift) • Raise and reshape sagging breasts by removing excess skin & repositioning remaining tissue and nipples • Length: 1 -3 hours • Risks: infection, skin loss, scarring, unevenly positioned nipples, loss of sensation in nipples or breast

Mastopexy • The skin outlined by the incision is removed • The nipple & areola are moved up and the skin surrounding the areola is brought down and together to reshape the breast

Mastopexy Before & After

Reduction Mammoplasty

Reduction Before & After

Breast Reconstruction • Performed either immediately after mastectomy or can be delayed • Accomplished via tissue flap or with tissue expander & implant • Length: expanders – 1 hr; latissimus flap – 3 -4 hr; TRAM flap – 5 -7 hr; DIEP flap – 68 hr • Risks: bleeding, infection, scarring, loss of circulation to flap

Tissue Expanders • Tissue expander is placed below the pectoralis muscle, wound is closed & expander inflated until skin blanches

Tissue Expanders • Additional inflation occurs 2 -3 weeks postop and every 7 days thereafter • When maximum expansion is achieved the expander is exchanged for permanent implant

Tissue Expanders After

TRAM Flap • Transverse Rectus Abdominis Myocutaneous • Skin, fat & muscle are dissected and tunneled to the midline of the abdomen • Blood vessels remain intact

TRAM Flap • Flap is brought to the chest wall with the thinnest part of the flap superior & medial, thickest part inferior & lateral

TRAM Flap Before & After

Diep Flap • Deep inferior epigastric perforator flap • Muscle sparing, free Tram flap • Deep inferior epigastric artery and vein are anastomosed to recipient vessels in the chest, usually the internal mammary or the thoracodorsal vessels.

Diep Flap • Decrease in abdominal wall morbitiy • Longer surgery time • Risk – flap failure due to microvascular thrombosis

Diep Flap • A patient with a history of left breast cancer and mastectomy. She also had slight ptosis (sagging) of the right breast. Preoperative markings had been made. Left breast reconstruction with DIEP free flap and right breast lift.

Latissimus Dorsi Flap • An incision is made over old mastectomy site • An oval section of skin, fat and muscle is incised from the back and tunneled through the axilla to the chest wall.

Latissimus Dorsi Flap • Muscle insertion on the humerus & blood vessels are left intact • The flap fills the space left by the missing pectoralis muscle • The island of skin is oriented to the recipient site & sutured in place

Latissimus Dorsi Flap After

Nipple Reconstruction • A star shaped incision is made to form the new nipple • The areola is shaded by tattooing • Tissue expander

Abdominalplasty • Flattens abdomen by removing excess fat & skin and tightening abdominal muscles • Length : 2 -5 hours • Risks: blood clots, infection bleeding under skin flap

Abdominoplasty • Incision is made from hip bone to hip bone just above pubic area • Umbilicus is freed from surrounding tissue

Abdominoplasty • Abdominal skin flap is elevated up to the ribs • Abdominal muscles are tightened by pulling them together and suturing

Abdominoplasty • The skin flap is stretched down and extra skin removed • A new hole for the umbilicus is made • Umbilicus & skin are sutured into place

Abdominal Binder

Abdominoplasty Before & After

Botox Injection • Used to temporarily reduce wrinkles • Botox is a purified form of botulism type A • Works by blocking release of acetylcholine so the muscle does not receive the message to contract • Usually lasts 3 months • Risks: headache, drooping eyelid, paralysis of neighboring muscles

Botox Injection

Collagen Injection

Skin Resurfacing • Used to minimized wrinkles and treat scars & areas of uneven pigmentation • Length: 1 hour • Risks: burning sensation, crust formation for several days, redness for several weeks • 3 methods: laser, chemical peel, dermabrasion

Laser • CO 2 laser used • Best for fine lines around eyes & mouth

Chemical peel • Chemical solution applied to skin to treat wrinkles, acne scars, sun damaged skin • Alphahydroxy-weak • Trichloroaceticmedium • Phenol-strong

Dermabrasion • Refinish skin’s top layer through scraping • Best for coarse wrinkles and scars

Skin Grafts • Split thickness (STSG) contains epidermis & part of dermis from donor site • Full thickness (FTSG) contains both epidermis & dermis from donor site

Split Thickness Skin Graft • Graft is taken from large flat body surfaces (thigh, abdomen, back) using a dermatome • Donor site may be left open to air or covered with a non-adherent dressing

Split Thickness Skin Graft • Graft may be meshed to increase area of coverage • Graft secured with suture or staples

Split Thickness Skin graft

Full Thickness Skin Graft • Graft is taken from area where scar will least visible and provide best skin match • Areas include behind ears, volar elbow crease, groin area

Full Thickness Skin Graft • Graft is excised with a scalpel and underlying subcutaneous tissue is removed • Graft is sutured in placed • Donor site is closed with sutures

Full Thickness Skin Graft

Skin Flaps • Flaps are detached from one area of the body and transferred to the recipient area with original blood supply intact or reestablished • Useful for covering exposed bone & tendon • Used in reconstruction and wound closure

Skin Flap

Mohs Surgery • Performed to treat basal cell & squamous cell carcinoma of the skin, performed in clinic or office • Specimen is examined microscopically; small amounts of tissue continues to be removed until free from cancer • Differs from frozen section in that the entire specimen is examined rather than random sections • Skin defect closed later in the OR

Operation Mend • Wounded U. S. soldiers receive reconstructive surgeries thanks to "Operation Mend" partnership between UCLA and Brooke Army Medical Center • http: //operationmend. ucla. edu/ • http: //youtu. be/HMo. X-y 6 w. XNE

Operating Mend • http: //operationmen d. ucla. edu/