Short note on plastic surgery

1. Plastic and Reconstructive Surgery

2. 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

3. Categories of Reconstructive Surgery
• Correction of Congenital Anomalies
• Improvement of appearance
• Resection of tumors that leave large soft-
tissue defects
• Repair of traumatic injuries

4. GOAL
The goal of Plastic Surgery is to
restore normal function and
appearance

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

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

7. PRE OPERATIVE CARE
• Informed consent and realistic expectations
• Reinforce the information given by the
surgeon and answer questions and concerns
• Before and after the treatment photographs
can be shown of similar cases.
• Explain the time frame of healing
• Explain that the final results of the cosmetic
procedure are affected by age, health and the
skin type.

8. Perioperative Nursing Considerations
• 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

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

10. Interventions

11. INTERVENTIONS

12. 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)

13. 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

14. Skin Preparation
• Most skin marking is done prior to patient
going to sleep-don’t wash off.
• Colorless solution is preferred to observe true
skin color

15. 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

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

17. Tissue Expanders

18. Breast Implants

19. Facial Implants

20. Dermatome

21. Skin Mesher

22. Skin Mesher

23. Head Light & Light Source

24. Lighted Retractors

25. Jackson Pratt Drain

26. Suction Assisted Lipectomy

27. Instrumentation

28. Gillies needle holder

29. Stevens scissors

30. Castroviejo Forceps

31. Hartman Mosquito

32. Skin Hook

33. Liposuction Cannulas

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

35. Pressure Infuser

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

37. 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

38. 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

39. 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

40. Brow Lift Before & After

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

42. 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

43. 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

44. Post-Op Dressing

45. Rhytidectomy Before & After

46. 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

47. 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

48. Chin implant Before & After

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

50. Cheek Implant Before & After

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

52. Jaw Implant Before & After

53. 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

54. 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

55. 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

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

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

58. Post-Op Splint

59. Rhinoplasty Before & After

60. 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

61. 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

62. Ear Dressing

63. Otoplasty Before & After

64. 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

65. 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

66. Cleft Lip Before & After

67. 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

68. 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

69. Cleft Palate Before & After

70. 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

71. 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

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

73. Post Op Dressing

74. Augmentation Before & After

75. 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

76. 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

77. Mastopexy Before & After

78. Reduction Mammoplasty

79. 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 – 6-8 hr
• Risks: bleeding, infection, scarring, loss of
circulation to flap

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

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

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

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

84. 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.

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

86. • 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.

87. 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.

88. 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

89. Latissimus Dorsi Flap After

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

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

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

93. ABDOMINOPLASTY
• Abdominal skin
flap is elevated
up to ribs.
• Abdominal
muscles are
pulled and
sutured
together.

94. ABDOMINOPLASTY
• The skin flap is
stretched down
and extra skin is
removed
• A new hole for
umbilicus is made
• Umbilicus and
skin are sutured in
place

95. Abdominal Binder

96. Abdominoplasty Before & After

97. 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

98. Botox Injection

99. Collagen Injection

100. 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

101. Laser
• CO2 laser used
• Best for fine lines around eyes & mouth

102. Chemical peel
• Chemical solution
applied to skin to treat
wrinkles, acne scars,
sun damaged skin
• Alphahydroxy-weak
• Trichloroacetic-
medium
• Phenol-strong

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

104. Split Thickness Skin Graft

105. Full Thickness Skin Graft

106. 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

107. Skin Flap

108. 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

109. POST OPERATIVE MANAGEMENT
• Mild analgesics may be needed.
• Observe for signs of infection and take
appropriate measures for prevention and
treatment.
• If surgery involves alteration in circulation care
fully monitor for circulation eg: face lift- warm,
pink skin that blanches on pressure indicates
adequate circulation.
• Supportive, compressive dressing and ice packs
as necessary in the immediate post operative
period.

110. THANK YOU