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A presentation
a. The anatomy of the skin
b. The types of skin grafts
c. Indications of a skin graft
d. Mechanism of a graft take
e. Causes of graft failure
f. How to perform skin grafting
MASTECTOMY:
EPIDEMOLOGY
INCIDENCE
INDICATIONS
ANATOMY OF BREAST
TYPES OF MASTECTOMY
TYPES OF INCISIONS IN MASTECTOMY
MANAGEMENT
POST SURGICAL MANAGEMENT
EARLY COMPLICATIONS
LATE COMPLICATIONS
BREAST RECONSTRUCTIVE SURGERY
A presentation
a. The anatomy of the skin
b. The types of skin grafts
c. Indications of a skin graft
d. Mechanism of a graft take
e. Causes of graft failure
f. How to perform skin grafting
MASTECTOMY:
EPIDEMOLOGY
INCIDENCE
INDICATIONS
ANATOMY OF BREAST
TYPES OF MASTECTOMY
TYPES OF INCISIONS IN MASTECTOMY
MANAGEMENT
POST SURGICAL MANAGEMENT
EARLY COMPLICATIONS
LATE COMPLICATIONS
BREAST RECONSTRUCTIVE SURGERY
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3. Objectives
• Identify the goal of plastic surgery
• Describe categories of plastic surgery
• Describe the risks
• Describe Perioperative Nursing
Considerations
4. 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
5. Categories of Reconstructive
Surgery
• Correction of Congenital Anomalies
• Improvement of appearance
• Resection of tumors that leave large soft-
tissue defects
• Repair of traumatic injuries
6. The goal of Plastic Surgery is to
restore normal function and
appearance
(Cover the hole)
10. 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
11. Nursing Diagnosis
• Disturbed Body Image
• Anxiety
• Deficient Knowledge
• Risk For Positioning Injury
• Risk For Ineffective Tissue Perfusion
• Risk For Infection
12. 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
(Im300.1)
16. 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)
17. 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
18. 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
19. 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
20. 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
41. Dressings
• Apply even pressure over wound to prevent
dead spacing, seromas & hematomas
• Collect drainage
• Provide comfort for the patient
• Protect wound
43. 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
44. 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
47. 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
48. 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
58. 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
59. 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
60. 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
65. 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
66. 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
69. 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
70. 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
72. 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
73. 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
75. 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
76. 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
•
80. 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
81. 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
85. 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
86. Tissue Expanders
• Tissue expander is
placed below the
pectoralis muscle,
wound is closed &
expander inflated until
skin blanches
87. 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
89. TRAM Flap
• Transverse Rectus
Abdominis
Myocutaneous
• Skin, fat & muscle are
dissected and
tunneled to the midline
of the abdomen
• Blood vessels remain
intact
90. TRAM Flap
• Flap is brought to the
chest wall with the
thinnest part of the
flap superior &
medial, thickest part
inferior & lateral
92. 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.
93. Diep Flap
• Decrease in abdominal wall morbitiy
• Longer surgery time
• Risk – flap failure due to microvascular
thrombosis
94. Diep Flap
• A patient with a history of left breast
cancer and mastectomy. She also had
slight ptosis (sagging) of the the right
breast. Preoperative markings had been
made. Left breast reconstruction with
DIEP free flap and right breast lift.
95. 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.
96. 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
98. Nipple Reconstruction
• A star shaped incision
is made to form the
new nipple
• The areola is shaded
by tattooing
• Tissue expander
99. Abdominalplasty
• Flattens abdomen by removing excess fat &
skin and tightening abdominal muscles
• Length : 2-5 hours
• Risks: blood clots, infection bleeding under
skin flap
100. Abdominoplasty
• Incision is made from
hip bone to hip bone
just above pubic area
• Umbilicus is freed
from surrounding
tissue
101. Abdominoplasty
• Abdominal skin flap is
elevated up to the ribs
• Abdominal muscles
are tightened by
pulling them together
and suturing
102. 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
105. 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
108. 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
110. Chemical peel
• Chemical solution
applied to skin to treat
wrinkles, acne scars,
sun damaged skin
• Alphahydroxy-weak
• Trichloroacetic-
medium
• Phenol-strong
112. Skin Grafts
• Split thickness (STSG)
contains epidermis &
part of dermis from
donor site
• Full thickness (FTSG)
contains both
epidermis & dermis
from donor site
113. 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
114. Split Thickness Skin Graft
• Graft may be meshed
to increase area of
coverage
• Graft secured with
suture or staples
116. 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
117. 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
119. 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
121. 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
122.
123.
124.
125.
126. 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/HMoX-y6wXNE
