Plastic Surgery Flashcards
Types of Plastic Surgery
- cosmetic
- reconstructive
- bariatric
types of reconstructive plastic surgery
- cancer
- burns
- trauma
- infection
- congenital (present from birth)
Functions of the skin
- protection from UV radiation, mechanical and chemical stress
- reduce evaporation of bodily fluids
- thermoregulation
- immunological Function
- sensory function
how does the skin contribute to thermoregulation?
the skin is able to control sweating and blood flow
structure of the skin
- epidermis
- Dermis
- Subcutis (technically not part of the skin and is an underlying tissue)
Epidermis
- is 95% keratinocytes
- has melanocytes
- has langerhans cells
- NO blood vessels (gets nourishment through dermal capillaries)
keratinocytes
- cells that form a barrier against heat, UV, water loss, bacteria, fungi, virus, parasites
- they have fast turn over
- they migrate from the basal layer (this allows for cell differentiation)
- they secrete keratin and lipids which form the ECM
keratin
a protein that causes cells to be tough and pack together
melanocytes
- cells that produce melanin (a pigment in the skin that leads to color)
- these are found deep in the epidermis
- they can pass melanin to other cells
Langerhans cells
- antigen presenting cells
- they belong to the skin immune system
Dermis
A thick layer of living cells below the epidermis
- connective tissue
- tensile strength and elasticity
- hair follicles
- sweat glands
- sebaceous glands
- blood vessels
Subcutis
- not part of the skin but is an underlying tissue (rich in adipose)
- allows for the attachment of skin to muscle or bone
- has blood vessels
how do wounds heal?
- hemostasis
- inflammatory phase
- proliferation phase
- remodeling phase
Hemostasis:
this is used to prevent and stop bleeding
-vessel constriction and blood clot formation
what happens during the inflammatory phase of healing of wounds?
- vasodilation with immune cell migration
- clearing of wound debris, bacteria, and dead cells
- causes pain, swelling, redness and heat
what happens during the proliferation phase of healing of wounds?
- granulation tissue (new connective tissue with microscopic blood vessels that are used to fill wounds)
- fibroblasts (produce the structural framework of animal tissues)
- myofibroblasts (differentiated fibroblasts that contain actin)
what happens during the remodeling phase of healing of wounds?
- this begins roughly 3 weeks after and can last up to two years
- reshaping collagen fibers into more orderly pattens
- reducing the number of capillaries
What do you need to do for patients with minor wounds?
- PMS
- Tetanus Vaccination status
- Pain management
- suturing
- antibiotics
PMS
- pulsation
- is there a pulse - motor function
- can they wiggle toes or fingers or is the wound affecting ability - sensation
- do they feel anything near or around the wound (pinch the area and ask where they feel it)
Suturing
- used to hold body tissues together after a wound or surgery
- surgeons try to do this in the natural lines of the skin to leave minimal scarring
primary closure
this is when the wound is cleaned and closed within 8 hours
primary delayed closure
- you wait 3-4 days before closure, treat with a bandage
- almost equal results with primary closure
- used for things contaminated for more than 8 hours or bite wounds
secondary closure
- the wound is left open
- this is for people with thin skin or bad skin conditions
- this can cause massive scarring
- risk of infection
tensions free closure
incisions in the relaxed skin tension lines
ellipsoid Excision
- cuts all the way around the wound to avoid skin tags (“dog ears”)
- helps make the wound look nicer
Atraumatic technique
this is when the skin is in bad condition or something is wrong
- you are gentle and only make holes where the needles need to go in
what are the optimal conditions for patients?
- don’t want smokers (more difficult healing)
- it is important to know if someone has diabetes because they are not good healers
- bad blood vessels is important to be aware of because you may need help building vascularization in the area
1st Degree Burns
- epidermis is affected
- focus on:
- pain management
- moisturizing cream/ after sun
- no further treatment
- increases risk of skin cancer in the region
2nd Degree burns
- dermis is affected
- blisters form (caused by damage to vessels and tissues)
- very painful
- can be superficial or deep
Superficial 2nd degree Burn
-heals without scaring within 14 days
-no surgical treatment required
(sun burn causing blisters is almost always going to be superficial)
Deep 2nd degree burn
- healing time is greater than 3 weeks with scarring
- surgical treatment is required
- stem cells affected in the basal layer of the dermis, around the glads and hair sacs
3rd degree burns
- the subcutis is affected
- skin is blackened with bloody blisters
- painless within the area
- no healing potential
- required surgical intervention
- can be down to the bone
Primary intervention for burns
- put lukewarm water on it
- this helps stop the reaction from occurring
- helps to reduce pain
- rinse for 20-30 minutes
- reduces damage to the area
Rule of Nine
- an evaluation tool to see how much of the body (in a percentage) is affected and helps guide what treatment will occur
- this is not used for 1st degree burns
- the surface of the hands is considered 1% of the body
- each leg is 18%
- each area is 9%
- chest is 9%
- abdomin is 9%
- head is 9%
- upper back is 9%
- lower back is 9%
When do adults need to be hospitalized vs children?
- adults need to be hospitalized if more than 20% of their body is burned
- children need to be hospitalized if more than 10% of their body is burned
circumferential wound
- if the wound goes all the way around the arm, they need o be hospitalized
- the wound can tighten up and we don’t want that
when do you need to transfer to a hospital with a special unit?
- Hands or Face
- Deep or large Burns
- Large Joints or circumferential
- abuse (both children and prostitutes)
- comorbidity (having co-occuring conditions) or pregnancy
What happens once a burn victim is admitted to the hospital?
- they are put into a sterile, heated room
- pain relief (morphine)
- fluids,PVC and KAD
- parkland formula - blood sample
- prophylactic intubation
- necrotomy and covering wound
PVC
peripheral venous catheter
KAD
bladder catheter
Parkland formula
- 4mL x TBSA x Bodyweight in Kg
- half in the first 8 hours and half in the next 16 hours
- there is risk of hypovolemic shock
- will use a bone if you cannot find a good vein
why is it important to take a blood sample?
- check for creatine kinase (important because risk rhabdomyolysis and shock kidney) kidney shock = not good
- CO intoxication (will treat with 100%O2 in a hyperbaric chamber)
why is it important to heck prophylactic intubation?
If the patient inhaled any of the burn, it could mean that the throat is going to swell and this will block respiration
- if the throat swells, this will also prevent an intubation tube from being placed
- can check the nose hairs or soot in the mouth
split-skin grafts
This is containing the epidermis and then part of the dermis
- can be thin, medium and thick
- removed with a dermatome
- the skin will be peeled up and then will curl up slightly, but is able to be stretched
- a machine is used to punch small holes into it and this allows for stretching to occur
advantages of split-skin grafts
- heals easier than full skin
- can cover large areas (meshing allows for an increase up to six times the original size
disadvantages of split-skin grafts
- thin and medium dries up easily (there are no sebaceous glands so cream is needed)
- less optimal cosmetic and functional results
- significant shrinking during healing
Full- skin graft
this contains the epidermis and then the entire dermis
- the donor spot must be directly closable with suture (need to think about where it is coming from and where it is going)
- shrinks about 40% after the excision but can be stretched so that 20% is regained
- there is minimal shrinking during healing
- the flap has its own blood supply
types of flaps
They are classified based on type of blood supply, tissue, or how they are transferred
- random flap
- axial flap
random flap
no clearly defined blood supply
axial flap
- well defined blood supply with a stem and both arterial and venous vessels.
- when this is completely removed from the donor cite it is known as a free flap
types of skin grafts
- Z or Y/V Plastic (used to cover joints or fingers)
- transposition plastic(moving a flap around an axis to some place in close proximity)
