1. Barbie Without Plastic Surgery

2. Plastic and Reconstructive Surgery

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)

7. Treatment Options Surgery Cosmetic Reconstructive/Revision Lipectomy
Tissue Expansion

8. Treatment Options Collagen/Fat/Botox Injection Skin Resurfacing Laser
Chemical Peel
Dermabrasion

9. Perioperative Nursing Considerations

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)
Minimizes cross-contamination by understanding and implementing infection control practices when preparing instruments and supplies for use.
    Environment positive air pressure, temp, humidity, doors closed
    Equipment and supplies
    Personnel
     Traffic control
    Prescribed ABx
 Skin prep

13. 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

14. 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.

15. General Considerations

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

21. Tissue Expanders

22. Breast Implants

23. Facial Implants

24. Dermatome

25. Skin Mesher

26. Skin Mesher

27. Head Light & Light Source

28. Lighted Retractors

29. Jackson Pratt Drain

30. Microscope

31. Suction Assisted Lipectomy

32. Instrumentation

33. Gillies needle holder

34. Stevens scissors
                                             

35. Castroviejo Forceps
                                             

36. Hartman Mosquito
                                             

37. Skin Hook
                                             

38. Liposuction Cannulas

39. Medications Local Injections Topical Tumescent Anesthesia
Lidocaine (Xylocaine)
Bupivicaine (marcaine)
Topical
Cocaine 4%
Tumescent Anesthesia
1 liter NS with mg lidocaine & 1mg epinephrine

40. Pressure Infuser

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

42. 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

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

45. Brow Lift Before & After

46. 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

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

49. Post-Op Dressing

50. Rhytidectomy Before & After
                                                                                                                                       

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

52. 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

53. Chin implant Before & After

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

55. Cheek Implant Before & After

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

57. Jaw Implant Before & After

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

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

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

63. Post-Op Splint

64. Rhinoplasty Before & After

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

67. Ear Dressing

68. Otoplasty Before & After

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

71. Cleft Lip Before & After
                                                

72. Cleft Palate Repair
Correction of a congenital deformity that results in a cleft in the hard palate, soft palate or both
Length: 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

74. Cleft Palate Before & After
                   
                   

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
                                                                                           

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

78. Post Op Dressing

79. Augmentation Before & After
                      
                      

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

82. Mastopexy Before & After

83. Reduction Mammoplasty

84. Reduction Before & After

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

88. Tissue Expanders After
                                                                                          

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

91. TRAM Flap Before & After

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

97. Latissimus Dorsi Flap After

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
                                                                             
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
                                                                             
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

103. Abdominal Binder

104. Abdominoplasty Before & After

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

106. Botox Injection

107. Collagen Injection

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

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

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

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

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

115. Split Thickness Skin graft

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

118. Full Thickness Skin Graft

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

120. Skin Flap

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

126. Operation Mend http://operationmend.ucla.edu/
Wounded U.S. soldiers receive reconstructive surgeries thanks to "Operation Mend" partnership between UCLA and Brooke Army Medical Center

127. Operating Mend