Plastic Surgery

E}TASlilKC SKJRGEEEY http :l I unive rs lty. anabsboc k. ec

nr,'l/

Dr. l. Fish and Dr. A. Freiberg Avinash Islur and CIaire Thurgur, chapter editors Gilbert Tang, associate editor

BASIC

PRTNCIPLES

... ..... ..

2

Stages of Wound Healing

Abnormal Healing Factors lnfluencing Wound Healing Wound Closure Management of Contaminated Wounds

Nasal Fractures

Zygomatic Fractures Orbital Blow-out Fractures

PEDIATRIC pLASTIC

,..,

7

History General Assessment General Management

S{IRGERY

CT[$N

tsREAST RECONSTRE

Tendons

lmplant Reconstruction

Fractures and Dislocations Dupuytren's Disease Carpal Tunnel Syndrome (CTS) Hand lnfections Rheumatoid Hand

Autologous Reconstruction N ipple/Areol a Reconstruction AESTT{ETIC

.........I3

Pathophysiology of Bum Wound Diagnostic Notes

.,

.. ...23

Breast

Other

$IIRGICALPROCEDEIRES

....

......,24

Release of Trigger Finger Decompression of Carpal Tunnel

lndications for Transfer To Burn Centre Acute Care of Burn Patients Chemical Bums Electrical Burns

Reduction Mammaplasty

COMMON EMERGENGEES . ..

Frostbite

..

.... ...i6

Leltut tt!s Necrotizing Fasciitis

...

...., ...22

SURGERY

Burns

sKxN LESTONS

.. . ..2X

Face

TFTERM,|iLINJIXREES

TNFECTTONS .

.

Cleft Lip Cleft Palate Syndactyly Polydactyly Hemangioma

Amputations

soFT TISSUE

......E8

Maxillary Fractures

Sutures and Suturing Techniques Skin Grafts Other Crafts f taDs

IIAND

..

Mandibular Fractures

Dressings

TAE

€ETANIOFACTIILFRACTEIIRES Craniofacial Assessment Radiographic Examination

........24

Amputations Extensive Mangling lniuries Maior Laceration with Serious Hemorrhage Companment Syndromes High Pressure lnjection lniuries

....E6 ITEFEITENCES

..

....24

Management

ULCERS

.......17

Pressure Ulcers {Sores) Leg Ulcers

MCCQE 2002 Review Notes

Plastic Surgery

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PLI

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STAGES OF WCIT'ND HEAI.TNG D growth factors released bv tissues plav an imDortant role I lnflammatorv phase' 0-2 davs ...f"htii and organismi cleared via inflammatory response, U re-epithelialization phase: 2-5 davs

e.g. macrophages, granulocytes

. from edges oiwound and from dermal appendages i.e. pilo-sebaceous adnexae . epithelial cells migrate better in a moist''environirent i.e. wet dressing ,..,.,, fl proliferdtivephase:5-42-days . fibroblasts anmcted to wound by macrophages . collagen synthesis by fibroblastd leads tb inireasing tensile strength . gnnulation tissue formed with neovascularization . at 6 weeks the wou.nd strength is at 40% and is strong enough to tolerate moderate forces I remodeling phase: 6 weeks-l yeai . collagen crosslinks, scai flattens,i, (. i/!lr, l:r'lf{,j-t(:,}r,lttlj(ilils,r .

.at6months,tissuestrengthpIateausat$!o$.9finormaltissuestrength

A$NORMAL D hypertrophic

T{EAX,TNG

scars (these generally improve with time if left to heal) hypertrophic tissue does not cross the boundaries ofthe scar

. . common sites include back, shoulder. stemum . red, raised, frequently pruritic . ,, , ,, : I r, treatment is conservative I amenable to sureical revision O keloid scars (these do;ot resolve spontaneouslv) . tissue extends beyond the s&r boundari6S iunlike hVp'ertrophic scars) . common sites include sternum, deltoid. earlobe . collagen: whorls rather than bundles . increased frequency in darker skinned people . treatment:_pressure dressings, silicone sheets, topical steroids, intralesional steroid injection, .

radiation theraov,

su

reical resection

recurwith'siirgicil revision , .. may u cnronlc wouncls . fail to heal within 3 months . examples: diabetic ulcers, pressure ulcers, venous stasis ulcers . may heal with meticulous wound care, but many will require surgical intervention

F'ACTORS INFLUENCING WOIIND HEALING Local (reversible): General (often irreversible):

fl mechanical (local trauma, tension) I infection D hematoma/seroma tr blood supply I retained foreign body Ll cancer fl previously inadiated tissues

'(, j

r

D self induced

tr nutrition (protein, vit C, Oz) E peripherai vascular disease [PVD] ! imokins D diabetei

I

ir

(

Q chronic illness )E, inirnunocomprornised (steroid6, chemotherapy) I hypenension (gfN)

, ,E uremia ,.; ,.,, ,remote infection ' 'E E'obesitv

(diagnosis of exclusion)

,,F,

:qll,:qin.vascular

disease (cVD)

WOUND CI,OSURE I

t\:r I .:( j

Frirnary Closure (Irirst Intention)

D definition: wound

'

closure by direct approximation of edges within hours of wound creation

(i.e. with sutures, flap, skin lraft, etc.l ,;r,,, _ Ll lnolcanon: clean wounds

.

Secondary Closure (Second Intention)

D definitio-n: wound leh open to heal by grinulation, epithelialization and contraction (myofibroblasts) E indication: when primary 'anentibn,closure is n6t-possible or nbt indicated for any reason, including infection,

n

delay in medical loss of skin inferior cosmetic result, requires dressing changes, psychological impact of open wound

Tertiary. Closure (Delayed Prtun3rq.Closure)

U definition: intentionally interrupt

E

fl PL2

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healing process (i.e. with packing), then wound is usually closed at 4-10 days post-injury indication: contaminated wounds wherd initial primirv closure is contraindicated prolongation of inflammatory phase lowers bacierial cbunt and lessens chance of infection after closure

Plastic Surgery

MCCQE 2002 Review Notes

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MANAGEMENT OF €ONTAMTNATED W@ETNDg ,wound is considered contaminated when it contains more than 100,000 E acute contaminated wound t< 24 hr)

:[

bacteria/gram

' ..

debridement: sureical {blade, inieation} ciosurF: p4tnary clo,syre with pronbfiJament (contraindications to primary closure; , animal and human bites, crush iniuries) 'rr' 'r i'lrl'cl.'6"clear\de hnd copiouslv irrieate opbn wound with physiologicsolutions ::r(1r('r

(;'\'ri

(RL) (rio ioap, alcohol, orotherinitants)

(NS)

Salihe orRingels Lactate "older . 'li.e.-Normal than 8 hours svstemic antibiotics if wound

o +/- tetanus (Tetanus toxoid (Td) 0.5 mL lM)

. alwavs check tetanus immunization

status: reimmunize if patient has received than l0 years ago,

less than three tetanus immunizations, if the last Td was rirore

i

or if last Td unknown if high risk wound (e-g. soil equipment, major trauma) then reimmunize if lait fd was more th-an 5 yea'rs ago n follow up in 48 hours chronic contaminated wounds (e.9. lacerations > 24 hours, ulcers) debridement: sursical or mtchanical (e.9. wet-to-dry dressings) closure: final closuire via delaved wouhdclosure {tehiarv clos-ure} orskin graft closure 4gpends cin decreasi,ne bacteria count to I00,000/gram-or less " successful oriorto closure and heouent dressing changes iopical antibacterial creAms {see Table 9l sybtemic antibiotics are not useful - no penetration into the bed of gnnulation tissue

.

D

. .

. '

DRESSINGS

are absotption, protection, compression, ' !U eoals Tst laver {contah laver)

cosmesis

.. clean wounds, heal bv;re-epithelialization. o protect new epithelium

. use nonadherbnt imp,regnated gauze (e.g. Jelonet, Bactigras or Sofratulle) chronic/contaminated wounds: . mechanicallv debride nonviable tissue . use adheredt Saline or Betadine soaked eauze ("wet-to-drv" dressing). dead tissue adheres to gauze and is remSved with dressing change 2nd layer.(absorbent layer) . saline soaked gairze, to encoumge exudate into dressing by "wick" effect 3rd laver (orotective laver) .'dry'gauze held iir place with roller gauze or tape

.

D

[

SETTTIRES

AND

SUTE RING TECTTNIGIIES

,dnesthesia

I I

E

D

E

lidocaine +/- epinephrine -. never use eoin'eohrine for finsers, toes, penis, nose, ears and tissue edges lsmall skin flaps) iniect anesthetic into, not aroilnd, wound before debridement and inigation toxic limit of lidocaine: o without epinephrine 5 me/kSJhour . with epinbphrine 7 mgiklhdur ( I 'riirr'i,'ii'\'l cc of lo,6 solution contains I 0 mg lidocalne) ,, ii .'. (j { .'|a i!r ii:, i iri I early signs of toxicity are CNS excitation follow6d by CNS, respiratory and cardiovascular depression

Sutures

E fl E

fl

{see Table l)

use of d oarticular suture material is highlv dependent on sureeon preference bacterial infection: monofilament < mu'ltifilambnt (braided] tissue reaction: svnthetic < organic dehiscence of tisLue under stiess: nonabsorbable < absorbable

Table

I.

SutureTgrpes

Type

Description

Indications

Surgical gut (plain or chromic)

organic, absorbable monofi lament

Subcutaneous closure and ligation

'notygty.Slif

i"iai

synthetlc. absorbable monofilament le.g- ilionocryl and braided (e.g. Vicryl, Dexonl

I

Transcutaneous and subcuticular closure

Nylon

Synthetic, nonabsorbable monofi lament (e.g. Ethilon) and braided {e.g. Nurolonl

Soft tissue approximation and microsurgery procedures

Polypropylene

Synthetic nonabsorbable monofi lament

Genenl soft tissue approximation, used in contaminatediinlected wounds

Nonabsorbable multifi lament

Transcutaneous closure

(e.g. Prolene)

silk

MCCQE 2002 Review Notes

Plastic Surgery

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Techniques Elsic.Suturing U basrc DnncrDles '

. minimize tissue trauma: follow curve of needle, handle, wound edges gently (use toothed forceps) o enough tension to approximate edges - do not strangulate . use tte finest needlb'and suture o5ssible o to ensure good cosmesrs:

. eveit skin edees when closine . avoid tension-on skin {close i"n lavers) c ensure

eoual width and depth oltissue on both sides 7- l0'days (5 days for the face; l4 days if over a iciint) :' r ]'r'' rLr

. remove sutures within

I- basic suture methods - - ;-simple inienubted - for face and when scarrins is Iess importaht . subbuticular - ilood cosmetic result; weak, used in combiriation with deep sutures , . vertical mattress - for areas difficult to evert dorsum of the hand} . horizontal mattress - everting, time saving {e.g. . continuous over and over - time savine

simple interrupted

Figurc

l.

''subcuticular

'

horizontal

mattress

vertical mattress

Basic Suture Methods

lllustalion bg Baseu Khan

SKIN GRAFTS E definition: a segment

I E

E

'rliI

of skin detached from its blood supply and dependent on revascularization from the recipient site donor site selection n must consider size, color, hair pattem, texture and thickness of skin required usuallytaken from inconspicuous areas {e.g. buttocks, lateral thighs, etc.) for facial grafts, preferable to take graft from above clavicle {e.9. post-auricular area} slcin graft "take" occurs in 3 phases plasmatic imbibition - nourishment via diffusion (first 48 hours) inosculation - vessels in gnft connect with those in recipient bed neovascular ingrowth - gmft revascularized by ingrowth of new vessels into bed reouirements for survival well vascularized (bone and tendon are unsuitable beds] " bed: contact between graft and recipient bed : fully immobile staples, sutures, splinting, and appropriate dressings (pressure).,,,,,,,,, are used to prevent hematoma, seroma, and movement of graft recipient site: clean {to prevent infection)

. . . . .

. . . lypg5i,,ll ; j ':'.i rii .:i ] " ' . autograft - from same individual . allograft - from same species, different individual :;

I

- from different species e.g. porcine _ lgloeraft u *^^i lltEDlt g|t6tL t Drevents accumulation of fluids o iovers a larger area . has significant contractures I not cosmetically appealing

n best for contaminated recipient site

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Plastic Surgery

MCCOE 2002 Review Notes

Table 2. Skin

Gra-frcs

Split Thickness Skin Graft (SISG)

Full Thickness Skin Graft (F"[sG)

Definition

Epidermis and part of dermis

Epidermis and all of dermis

Donor Site

More sites

Limited donor sites

llealing

Re-epithelialization via dermal appendages

Primary closure or split thickness skin

Re,haruesting Graft take

Good; shoner nutrient diffusion distance

Lower rate of survival

Contraction

More

Less

Sensation

-10 days (fasteron scalpl

r;'

POOr

Good

Aesthetic

Poor

Good

Comments

Can be meshed for greater area

Advantage

Take

-

Disadvantage

fuil

I

wellin less hvorable conditions

ppnnact signifi q4ntly, abnormal pigmentation, nrgn suscepuollrry ro uauma

rhin

f

.l sKrn uran

spllr

gnft

nlcKness

---l

Use on hce, fingers tips and over

ioins

Resist contraction, potential for growth, textu re/prgment more norrnal Require well vascularized bed

Epidermis

Medium

I

t-,

L_

Thick

Dermis

I nrcKness

Skin Graft Subcutaneous Tissue

Drawing bq Karen Petruculli

OTETER GRAFTS Table 3. Various Grafts Graft Type

Use

Prcfered Donor Site

Bone

Cnnial, rib, iliac, fibula

VesseI

Repair dgid defects Restore contour of ear and nose Repair damaged tendon Conduit for regeneration across newe gap Bridge vascular gaps (i.e. {ree flaps}

Dermis

Contour restoration (+/- fat for bulk)

Cartilage Tendon Nerve

Ear, nasal septum, costal cartilage

Palmaris Iongus, plantaris Sural. forearm, cutaneous arm Forearm or foot vesse'ls for small vessels, saphenous vein for larger vessels Thick skin of bunock or abdomen

F'[.APS

I fl fl

definition: tissue transferred from one site to another with vascular supply intact {not dependent on neovascularization} unlike a graft classifidd according to blood supply to skin: random and axial indications for flaoi I soft tissue coveraee i,e. oaddine bonv prominences . reconstruction i.e:after facial, bieast,bi lower leg tissue loss provide vascular recipient bed for skin graft c' to lmprove Dlooo supply to Deo l.e. oone ' 1;6prove sensation (rierves to skin flap intact)

MCCQE 2002 Review Notes

Plastic Surgery

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may require. use of tissue expanders pre-operatively to increase available tissue (especially in scalp area] vta mecnanlcal Stretcnt ng of subcut"aneous silicon reservoir into which saline is iniected " consists intermittentlv over several weeks main comolication: flap necrosis, caused by extiinsic comprbssion (dressing too iightl c excess tenslon on wound closure o vascular thrombosis {poor microsurgical anastomosis} hematoma

!

. .

I

need to monitor flap viabiliw . skin colour, capillary ri:fiI1, post puncture bleeding, Doppler monitoring

Randorn Pattern Flaos (see Fieure

n

3)

skin and subdermal tissue with-random vascularsupplv Q limited length: width ratio to ensure adequate blood slpply (on face

U

" . . .

I .5:

l, rest of body l: I )

TVDeS

rotation

Limbere {rhombicl Z-olasfr - used to eain or to chanee - the line of direction of the central limb of Z (i.i:. relbase of scar"contractures)

flaps (single/bipedicle, V-Y Y-Vl

" advancement Asial

Drt*am

Flanc

D flap contains a w6ll defined

I

I

artery and vein allbws sreater leneth: width ratio-(5-6: l) feninslrlarll6p - skin and v'essel intact.in pedicle (see Figure 4a] island flao j vbssel intact lsee Fieure 4b) _. freq fl4p vascular supply anastciinosed at recjpient site by microsurgical techniques

. .

can be sub'clAssified accordine'to tissue content

.

"

offl;D:

musculocutaneous/myoEutaneous: vascular sufply !o skin fqom musculocutaneous perforating vessels fasciocutaneous - vaslular supply from plexus sJp6rficial to fascia

Free Flaps

I I I

transolantine exoandable donortissue from one part ofthe bodv to another tissue must 6e dble to suryive on a single-pedicl6d blood supply with an artery and draining vein use microsureical technique . the tra"nsplanted part is reanastomosed to recipient site vessels to reestablish blood flow

. survival fates > 95% e e.g. Tralrsverce Rectus Abdomipal Myocutaneous . cai be fuscicutaneous, muscle flap, cir osseous

{TRAM), radial forearm, scapular

Rotation Flap

Limberg Flap

Figure 3. Wound Care Flaps, llandono Pattern lllustratio n b g Teddtl Came

ro

n

V-Y Advancement Flap

r.FI,AP

4a. Peninsular Axial Pattern lllustralons bu Karen Petruccelli

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Plastic Surgery

MCCOE 2002 Review Notes

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Fhysiology of the Shin

u

I

D

sKn eDroermls ano oermts blood'vessels and nerves are found in the dermis acts as a banier to infection, prevents loss of fluids, maintains body temperature

tsTIRNS

D etiolosv: Children Adults -

most commonlv scald bums most commonly flame bums

PAFFIOPFI.IOTOGY OF EEIRN WOUNE) {see Fieure 17} B zone of coasulation - cells irreversiblv damaeed = cellular deJth I zone of stasis - poorly perfused, celli iniured and will die in 24-48 hours without E

proper treatmenti sludeine of capillaried theed to Drevent swelline and infection I I flaors favoring cell survival: moist, aseptic environment, rich blood supply ' zone of hyperemia - Eells will recover in 7 days, equivalent to superficial buni Anterior

4t /2"rc

i:3

Zone of hyperemia

W

Zoneofstasis

f]

zone ofcoagulation

Figure 17. Zones of Therrnal Iniury

Figure 18. Itule of 9's for Total Body $urface Area

lllusbation bg M. Gail Rudahcwkh

DUTGNOSTIC NOTES body surface area =TBSA) - rule of 9's includes second and third degree burns only D estimate nate bum size (total bod O

dren underase under age l0 use a Lund-Browder chart) ildren {children -patient's patch palm represents approximatelv l% of the TBSA ntb pE for patchy_b u n1s-. 'atchv bums, -Fatie TBSA > 50% have ba'sal metabolic rate'(BMR) 1.5-21. predicted age --.more cgmplications if.< if < 3 o or > 60 years old more complications

.

tr tr pepth classificaiion (see tr tocauon

Table

7)

. .

!

face. hands. feet, perineum are critical areas reouirins soecial care of a bum unit circLimfereritial bdms arg manqged with eschardtomf(ah incision down to and including fat) to Drevent toumiouet effect of Sschar watch forlnhalation iniury, associated iniuries (fractures), co-morbid factors (concunent d isability, aliohol ism, renal ili sease )

Red Flag r-l Susp6ct inhalation iniurv

if bnrn sustained in closed space, singed nasal hairs,/eyebrows, sooi around nares,/oril calitv, hoarseness, and coniunitisitis. REquires immediate intubation due to impendinjairway edema.

Table 7. Burn Depth (see Colour Atlas [rL) Nomenclature

T[aditional

Depth

Clinical Featlrres

Partial thickness {superficial)

First degree

Epidermis

Erythema, rvhite plaque

Partial thickness

Second degree

Into Superifical dermis

Clear fluid, superficial blisters, painful

Deep partial thickness

Second degree

lnto deep dermis

Difficult to distinguish from full thickness

Full thickness

Third deeree

Throueh dermis involves, underlying tissue, muscle. Done

Hard, leather-like texture of skin eschar formation, purple fluid, insensate

(Deepl

Nomenclature

Fourth dEgree

MCCOE 2002 Review Notes

Plastic Surgery

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ENDTC"Hil@NS F@R TRANSFER TO BURN CENTEAE Alnerican Burrr Association Criteria

!!

E D

E

D lJ I E

and 3o bums > l006 TBSA in patients < I 0 or >, ,50 years of age and 3o bums > 20% TBSA in batients anv ase 3'bums > 5% TBSA in oatients anv aee 2o or 3o bums with threat of seriorjs finctional or cosmetic impairment (i.e. face, hands, feet, genitalia, perineum, maior ioints), contrbctures inhalation injury inhalation_ iniury (maylead to reispiratory respiratory distiess) distiessl electrical bums {inteinal iniurv urideresiimated bv tSSRtr ,. '; posing thre'at chemical bums posinq threat bf of functional or'cosmetic impa inipairment bums associateil with majortrauma . , ..i,,...,i,iir:1,^i;;,,;ili;

total total

2o 2o

1

AcurE cARE oF' EURFr pAqreryFg.tni;;oi;11;l:a' : ':rr';r)tt RespiratoryDistress tr

E

if inhalation iniury suspected (bum sustained in closed space, sinsed nose hairVevebrows, soot around nares and oral'caviry, hoarseness, conjunctivitis, history of explosiSns or flash bum6), intubate immediately beiore edema occurs

acute causes " carbon monoxide (CO) poisoning {treat with 100% Oz, decreases half-life of carboxryhemoglobin

from 210 minutes to

minutes)

. eschar encircling chest59 (perform escharotomy) u late onset . due to smoke inhalation and pulmonary injury . risk of pulmonary insufficiency (up to 48 hours) and pulmonary edema [48-72 hours) . causes'chemical'injury to alveioiai basement membiane and fulmonary edema . if humidified Oz not duccessful, mav need to intubate and ventilate n watch for secondary lung infections'(after I week) Ieading to progressive pulmonary insufficiency . watch for bronchopneumonia (up to 25 days) Burn Shock

D definition: hvpovolemia due to movement of HzO and Na+ in zone

D

E

of stasis and eeneralized increased capillarv permeabiliw in all oreans {occurs if > 30% TBSA} reiuscitaiion with Paikland forinula' to restore plasma volume and cardiac output (see Table 8l . 4 cc Rinser's/ke/% TBSA over first 24 hou'n . TBSA noiinclude lst deeree areas . 12 of ddes this in I st 8 hours post 6um. rest in next I 6 hours " in followins 6 hours eive'0.35-0.5 cc plasma/kePATBSA, then D5W at rate to maintain normal serum Na* extra fluid administration. rEquired in bum's greaterihan 80% TBSA, associated traumatic injury, electrical bum, inhalation iniury, delayed st€irt of resuscitati6n, pediatric bums, and 4o burns

_ U mOnlIOf feSUSClIatlOn

:,....,r, r,, t,,.,.,,..

.

urine output is the best measure o maintain urine output > 0.5 cdkghr ladults) and I.0 cdkg/hour (children years) r also maintain a cle'ar sensorium,-HR < 12O/minute, mean *BP > 70 mmHe < l2

Thble 8. Eurn Shock Resuscitation I

Efour0-8 Hour 8 -24t Hour 24 - 3O > Hour 3o

|

ZccRingerb/kgP'TBSAoverShi;'ursii1"t:it':" itri:lir,ititiri;r

l,':':r2..Ringer's/kg/%TBSAoVer't6hours

I I |

.l::.::j ,l -

0.35-0,5 cc plasma/kgf,tTBSA D5W at .

nte to .... maintain normal serum .;i-. ..-

sodium :

:

1

ii;1.'-!.':iI

,...:.i..1

* don't forget to add maintenance fluid to resuscitation

Burn Wound

n eoals 3rd degree bum wound care - rofprevent infection {one of the. most significant

.

most common organisms include S.ailreus,

Day l-3: Gnm positive

E tr

! I

and C. albicans

Day 3-5: Gram negafive remove dead tissue cover wound with skin as soon as possible surgicallv debride necrotictissue, excise to viable (bleedins) tissue topical, antimicrobials to prevent bacterial infection {from pltient's gut flora or caregivers} and seconoarv sepsrs importani to bbtain earlv wound closure

. .

de'epsecondorthirddeiereeburn>sizeof aquarter:indicationforskinsraft

Q prevention PLl4

causes of death in bum paiientsl

P. aeruginosa

-

of wound con-tractures: pfessure drbssings, ioint splints, early-physiotherapy

Plastic Surgery

MCCOE 2002 Review Notes

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Table

9. Topical Antibiotic Therapy

Antibiotic

:i

Fain with Application

Fenetration

Adverse E$fects

None

Minimal

Methemoglobinemia, stains

Minimal

Medium

Slowed healing, leukopenia

Modente

Well

S)owed healing, acid-base abnormalities

iif i-lil

Other Considerationo in Burn Management

D nutrition: calories. viiamin C, vitamin AICuz*, lJ tmmunosuDDressron ano Sepsls

n

fl I

7p2+, fs2+

eastrointedtinal {Gl} bleed mav occur with bums > 40% TBSA . treatment': tube feedind or NPO, antacids, Hz blockers renal failure sgcondary to hypbvo.lgmia . rq,re . beware oI neDirotoxlc antlDlotlcs ln Durn care tetanus toxoid shou'ld be administered to all patients sustaining bums deeper than superficial partial thickness

CIIEMICAL BURNS

D coaeulate tissue oroteins causinq necrosis D sevEriw depends on: wpe of ch6mical {alkali

worse than acid}, concenirati6n, ouantiw-,'and contact time, deqree of tissue penetration E bums are deeB6r than initially appear and m-ay progress with time LJ rnsoec eves I corirmon bgents: cement, hydrofluoric acid, phenol, tar U treatment . dilution with wdterisinitial treatment " ' l . wash eyes out with saline and refer to ophthalmoiogy e repeatecl aDDllcatlon oI Polvsponn tor removal oI taf . loial care ak'er l2 hours, debridement, topical antibiotics . wound closure same forthermal bum E beware: underestimated fluid resuscitation, renal, liver, and pulmonary damage

ELECTRICAL BURNS

tr

depth ofbum depends on voltage and resistance ofthe tissue

n in decreasine ord'erof conductioi, nerve, blood, muscle, skin, tendon, fut and bone debridement tissue damage which requires n oftenimitl p'unctate burns on skin with massive deep ! iniurv more severe in tissue with hieh resistance (i.e.'bone) U elbarical bums require ongoing mo-nitoring as latent iniuries become manifest I watch. for opul monary nl uries €.g..ventricular fi brill ation . cardi mvoglobrnuna/nemogtoDlnufl&., -; . frdctlres and dislocations, especially. shoulder and spine . tissue necrosis secondary to vessel thrombosls i

n decrease in

RBC (beward of hemonhages) increased creatinine/potassium and addity indicating tissue destruction

". seizures . intraperitoneal damaee E treatment . toDical aeent with sood penetratine abiliw (silver sulfadiazine) . ion-viablEtissde early and repeat prn {every 48 hrs} to prevent sepsis . ddbride maior amputations ffequently requlred ;

FROSTBITE D intracellular ice crvstals leadine to cell lvsis D microvascular occfusions and deriphenl vasoconstriction leading D suoerficial frostbite: onlv skin and subcutaneous tissues frozen D de'ep frostbite: underlyihg tissues frozen as well

fl

to ischemia

man'aeement o rewarm raoidlv in waterbath (40-42"C) after rewaiming, tissue becomes purple, edematous, painful blisters may appear, resolving after several weeks leave i4iured region oPen to air leave blisters intact debride skin eentlv with dailv whirlpool immersion req u i re.d } { scrubbi ng, m'assa{e and topi cal oi ntmenls lrot sursery mlv be ne-eded to ielease constrictive, circumferential eschar

.

'. . . . waii until complete demarcation before proceeding with amputations

MCCQE 2002 Review Notes

Plastic Surgery

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PLlS

hfin://universrtv. arabsbooi<.com

CET,[,E LTTIS

I I ,

I I I

. ....,.

non-suppurative infection ofskin and subcutaneous tissues ' signs airii pain, tendemess, edema, erythema with poorly defined margins symptoms'diffeientiate it fronisimple initation) "o iever, chills, malaise (systemjc can lead to lymphangitis (visible red streaking in areas proximal to infection) skin:flora most common org-anisms: S. auTeus, p-hemolytic Strepiocotcus ., treatment is antibiotics: firit line Pen G 2 miliion uniti q6-8h'lV + cloxacillin I g gg"8h lV i outline area of erythema to monitor success of

symptoms

.

treatmeni

.

NECROTTZENG FASCTITIS

D infection,leading to'gangrene of subcutaneous tissue, and subsequent i{ (see Colour ndas-nf) ' _D fjrp" I: B-hemolytic slreptoroccus,Type ll: polymicrobial

:

i i{ )rr ;

necrosis of more superficial layers

:

u

natural hlstorv o severe pain, fever, edema, tendemess infectioh spreads very rapidly c patients are often very sick and toxic in appearance skin tums dusky blue and black (secondaryto thrombosis and necrosis) induration, formation of bullae cutaneousgangrene, subcutaneous emphysema (Type ll) diagnosis

. . . .

D

.

o severely elevated CK " hemostlt easily passed along fasbiil plane

" fascial biopsy

D treatment

. .

surgicai debridemenl r€fitoval of necrotic tissue, copious inigation,

often requires repeated trips to the O.R, IV antibiotics: clindamycin 900 mg q8h lV + Pen C 6 million units q4h IV

Red Flag

I

Soft frssue Infections: Sus;rect necrotizing fasciitis with rapidly spreading erythema and ederna. Must dernarcate ergthernatous area on adrnission,in,order,to determine amount

of spread.

Table lO. Soft'fissue Infections (Classified by Depth)

Erysipelas Cellulitis Fasciitis Myositis

I I I I

(See Dermatqlcie&

Chapter) i:'rr';" "i '

Subcutaneous(epidermis)infection

full

thickness skin infection

Fascia

Muscle

'r;ri'|)j'Lrr,r

MANAGEMENT Non.Malignant Lesions

!

incl udes- hvperkeratoti c,

D treat with dbrmatological IOr COSmeSTS Or

fi

brous, cvstic. vascu lar and oism ented lesions method.d or surgical excisioh iT necessary - to halt further growth,

lI Cltntcallv susptclous

Malienant Lesions

I

balal cell carcinoma (BBCI (see Colour Atlas D2I)

. primarilv taneentiai drowth . Lurettag-e and electr6dessication: for smaller lesions; include a 2'3 mm marein of normal skin . surgicafexcision: deep infiltrative lesions; 3-5 mm margins beyond visible a-nd palpable tumour border; mav reoulre sKtn grafi or ilao . I-ray therapV: less*traumatii and useful in difficult areas to reconstruct, requires a skilled physician because of manv complications . cure rate is the dame iapproximately 9)%|,forthe above procedures in competent hands ii squamous cell carcinoma (SCp)-(see Colour Atlas Dl7) . pnmantv ventcat growln . same ontions for ireatment as for basal cell carcinoma . more aggressive tieatment because more malignant than BCC

PLl6

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Plastic Surgery

MCCQE 2002 Review Notes

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melanoma (see Colour Atlas A23) . excision is prirnarv management o forlesions < 0.75 inm thiikness: a I cm margin is recommended . for lesions > 0.75 mm thickness: a 5 cm mariin is recommended n node dissection for lesions > 0.75 mm . beware of lesions that regress - tumour is usually deeper than one anticipates c assess sentinel nodes

Concepts in Exeising Any Skin tr,eqion

U incise along normal skin lines to minimize appearance of scar E use,spindle ?i.'rp.$ incision to prevent "{og bars" (heaped up skin u unoermtne sKrn eoges to oecrease

!

at end of incision) wound tenston use layered closure-including dermal sutuies when necessary {decreases wound tension)

T,RESSTIRE III,CERS (SORES)

E common D staees

tr

. . . .

sites; heel, sacrum, greater frochanter, ischial tuberosity, elbows, occiput

hyperemia - disappears I hour after pressure removed

ischemia - foliows 2-6 hours Dressure necrosis - fo]lows > 6 hours fressure ulcer - necrotic area breaks down prevent with good nursing care: clean skin, frequent log rolling, special beds (Kinair), egg crate mattress

treatment . debridement of necrotic tissue (with dressings + surgical debridement) o continue with preventative methods . topical antibiotics of ouestionable value ' osteotomy and closur6 with myocutaneous flap in selected cases

LEG IILCERS Thble I l. Venous vs. Arterial Ulcers vs. Diabetic Ulcers Venous (7O% ofv-ascular ulcers)

Arterial

Diabetie

lnegular wound margins

Even wound margins

lnegular wound margins

Deep Extremely painful

Superficial

Superficial

i

Moderately painful Yellow exudate + granulation tissue Gaiter distribution Venous stasis discoloration Normal distal pulses No rest pain

Painless

Dry,/ necrotic basg Distal

locations

':-1.

,g1io1r; :'-'.ir! l

Thin shiny dry skin Decreased distal pulses Claudication / rest pain

Necrotic base Pressure point distribution

Thin dry skin Decreased pulses No claudication

/ rest pain

Venous Stasis Ulcers (see Colour Atlas PL4)

I

due to venous hypertension, valvular incompet6nce edema, discoloration, commonly over medial malleolus

E painless, dependent U treatment

.

elevate, pressure stockings, may need skin graft

Aterial lschemic lllcers (see Colour Atlas FL5)

I !

secondarv to small and,/orlaree vessel disease

usuallylocatedonthelateralispectsofthesreatandfifthtoesanddorsumoffoot

D painfui, distal, punched out ulcers with U treatment

hype'rsensitive/ischemic sunounding skin

. rest, no elevation, modify risk fuctors (stop smoking, exercise, diet, etc.) . treat underlying condition (diabetes, proximal afterial occlusion, etc.) . ultimately, rha/use skin graft, flap, or'amputation

MCCOE 2002 Review Notes

Plastic Surgery

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