1. Plastics and Reconstructive Procedures

2. Plastics Operative Sequence
Rhytidectomy

3. Overall Purpose of Procedure:
Rhytidectomy
Overall Purpose of Procedure:
To improve the appearance of the patients face and neck area.

4. Rhytidectomy Rhytid =‘s medical term for a wrinkle
Define the procedure:
Rhytidectomy can mean many different types of procedures dealing with the head and neck.
Facelift
Browift
Eyelid lift
Chin Implants
Malar implants (mid-face cheek implants)

5. Rhytidectomy - Facelift -

6. Rhytidectomy - Anatomy -
The Platysma muscle is a flat, thin muscle that lies uderneath the skin of the anterior and lateral neck.
Deep to the muscle lies the superficial layer of the deep cervical fascia.

7. Wound Classification: 1
Rhytidectomy
Wound Classification: 1

8. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application

9. Rhytidectomy Instrumentation: Plastics Tray
Positioning: The patient can be in supine position, arms on arm boards. Can also be in Fowlers.
Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit. Must clean and comb hair away from incision site
Draping: Head drape.

10. Rhytidectomy Begin your Operative Sequence
Prior to incision, must have pre-op photos in room!
Incisions are marked bilaterally and injected with local
Incision: 15 kb on #3 handle for incision.
Made around the ear, under the earlobe and extends into the hairline.
One side is done at a time.

11. Rhytidectomy cont. Operative Sequence
Hemostasis: Handheld Bovie and hemostats.

12. Rhytidectomy cont. Operative Sequence
Dissection and Exposure:
The skin is undermined to the nasolabial fold, area of the mental foramen and to the midline of the neck to the thyroid cartilage.
Use of Metz, Double and Single Skin hooks, Adsons, and Stevens scissors.

13. Rhytidectomy cont. Operative Sequence
Exploration and Isolation:
Care is taken not to damage the Facial nerve and artery.
If a tighter lift is desired, the Platysmal and SMAS (Superficial Musculoaponeurotic System) is dissected and lifted.

14. Rhytidectomy cont. Operative Sequence
Surgical Repair:
Excess fat is removed and skin flap edges are grasped with Allis’s.
The skin is drawn upward and redraped to the proper degree of tension. The excess skin is excised along the angle of the clamps.
Excellent Facelift Video

15. Rhytidectomy cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery, possibly Bi-polar.
Use of warm Saline to irrigate.

16. Rhytidectomy cont. Operative Sequence
Closure:
Incisions are usually closed with a 4-0 Nylon behind the ear and a 5-0 in front of and around the ear.
Staples may be used in the hairline.
The circulator will prepare the local for the opposite side.
Repeat procedure on the opposite side.

17. Rhytidectomy
Major Arteries:
External Carotid Artery
Facial

18. Rhytidectomy Major Veins: Major Nerves: Internal Jugular Vein
Cranial Nerve VII - Facial Nerve

19. Blepharoplasty
Fact: According to the American Society for Aesthetic Plastic Surgry, in year 2008 more than 195,000 people in the United States underwent cosmetic eye surgery. Blepharoplasty has become the most sought-after facial plastic surgery procedure, surpassing facelift, rhinoplasty, facial implants, and forehead lift.

20. Blepharoplasty
Visit:

21. Plastic Procedures Operative Sequence
Lipectomy

22. Lipectomy
Overall Purpose of Procedure:
To remove excess fatty deposits from many different areas of the human body.
Areas include:
Hips and Thighs
Abdomen
Breast
Face
Buttocks
Anywhere there is bulk fatty deposits

23. Lipectomy Define the procedure:
Liposuction, also known as lipoplasty ("fat modeling"), liposculpture or suction lipectomy ("suction-assisted fat removal") is a cosmetic surgery operation that removes fat from many different sites on the human body.

24. Lipectomy a 12-year old girl who at 5-foot-5 weighed 230 pounds.

25. Lipectomy
Liposuction is not a low-effort alternative to exercise and diet. It is a form of body contouring with significant risks and is not a weight loss method. The amount of fat removed varies by doctor, method, and patient, but is typically less than 10 pounds.
There are several factors that limit the amount of fat that can be safely removed in one session.
Ultimately, the operating physician and the patient make the decision. There are negative aspects to removing too much fat. Unusual "lumpiness" and/or "dents" in the skin can be seen in those patients "over-suctioned". The more fat removed the higher the surgical risk.

26. Wound Classification: 1
Lipectomy
Wound Classification: 1

27. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application

28. Lipectomy
Instrumentation: Plastics tray. Assortment of liposuction cannulas. Liposuction machine and tubing.
Positioning: Depends on the area of fat removal.
Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit.
Draping: Also depends on area prepped.

29. Lipectomy Begin your Operative Sequence
Prior to Incision:
Some MDs inject a solution to “melt” the fatty deposits. This is usually Lidocaine and LR or NACL This makes removal easier.
Mark the site and have the surgeon pick out the appropriate size cannula.
ST will connect the cannula to the suction tubing and throw end to circ.
Incision: 15 kb on #3 handle for incision.
Incision is only ½ inch at most.

30. Lipectomy cont. Operative Sequence
Hemostasis: Handheld Bovie

31. Lipectomy cont. Operative Sequence
Dissection and Exposure:
All dissection is made with the lipo cannual that the surgeon has previously chosen.

32. Lipectomy cont. Operative Sequence
Exploration and Isolation:
A tunnel is created by passing the cannula underneath the skin.
The suction is off at this point.

33. Lipectomy cont. Operative Sequence
Surgical Repair
Once the tunneling process is done a few times, the suction is turned on. This allows the surgeon to “break up” the fatty deposits before attempting suctioning.
The surgeon removes the desired amount of fat, checking the area periodically.
The tubing will need cleaning with NACL during the procedure.
Lipo video

34. Lipectomy cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate.

35. Lipectomy cont. Operative Sequence
Closure:
The small incision is closed with a 4-0 or
5-0 Nylon.
The dressing that you apply will need to be a pressure dressing, applied depending on area of Lipectomy.

36. Lipectomy
Major Arteries:
Depends on area of Lipectomy

37. Lipectomy
Major Veins:
Depends on area of Lipectomy
Major Nerves:

38. Plastic Procedures Operative Sequence
Abdominoplasty 38

39. Abdominoplasty A.K.A. Tummy Tuck
Overall Purpose of Procedure:
A.K.A. Tummy Tuck
To remove excess fat and tighten abdominal skin. 39

40. Abdominoplasty Define the procedure:
The tightening of the abdominal skin through an incision jut above the pubic hair line.
Can be combined with Liposuction.
Can also include a Thigh Lift. 40

41. Abdominoplasty Indications for Abdominoplasty
Loss of muscle tone in the lower abdominal region
Lose skin and fat in the abdominal region resulting from weight loss. 41

42. Wound Classification: 1
Abdominoplasty
Wound Classification: 1 42

43. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application 43

44. Abdominoplasty
Instrumentation: Major/Minor tray depending on patient size.
Positioning: Supine with arms on arm boards.
Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit.
Draping: Can be as many as 8 towels. 44

45. Abdominoplasty Begin your Operative Sequence
Prior to Incision: MD will mark incision.
It will be necessary to flex the able to aid in closure.
Incision:
10 KB across pubic line, from Iliac crest to Iliac crest.
Can be made from north to south, from umbilicus to pubis. 45

46. Abdominoplasty cont. Operative Sequence
Hemostasis: Handheld Bovie 46

47. Abdominoplasty cont. Operative Sequence
Dissection and Exposure:
The abdomen is dissected through the subcutaneous tissue and fat down to the rectus muscle using the bovie. 47

48. Abdominoplasty cont. Operative Sequence
Exploration and Isolation:
The abdomen is also dissected up towards the chest.
This creates a flap that will be pulled down towards the pubis once the excess skin is excised.
Have Volkmans and Deavers available. 48

49. Abdominoplasty cont. Operative Sequence
Surgical Repair:
Both of the Rectus muscles are tightened using a 0 Ticron.
The skin flaps are pulled together, excess skin and fat is removed.
The table is flexed and the abdomen is closed.
Video:
Abdominoplasty Surgery Video 49

50. Abdominoplasty cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate. 50

51. Abdominoplasty cont. Operative Sequence
Closure:
Abdomen is closed with 0 Ticron.
Subcutaneous tissue is close using 3-0 Vicryl.
The skin is closed using 3-0 Prolene.
Steristrips and Mastisol.
Must apply an abdominal binder for support. 51

52. Abdominoplasty Major Arteries:
No major since we are superficial, or above the rectus muscles 52

53. Abdominoplasty Major Veins: Major Nerves:
No major since we are superficial, or above the rectus muscles
Major Nerves:
Splanchnic nerve 53

54. Cheiloplasty (key-lo-plasty) and Palatoplasty
Plastic Procedures Operative Sequence
Cheiloplasty (key-lo-plasty) and Palatoplasty 54

55. Overall Purpose of Procedure:
Palatoplasty
Overall Purpose of Procedure:
A.K.A. Cleft Palate
To reassemble normal pathology of the palate. 55

56. Palatoplasty
Define the procedure: The palate is made up of a hard portion anteriorly and a soft portion posteriorly.
A cleft occurs in the midline and may one or both palates.
The repair is usually done around 18 months since a function of the palate is speech development. 56

57. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application 57

58. Palatoplasty
Instrumentation: Plastics/Minor tray depending on patient size.
Positioning: Supine with arms on arm boards.
Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.
Draping: Head drape with ¾ drape or green sheet as a lower body drape. 58

59. Palatoplasty Begin your Operative Sequence
Prior to Incision: MD will mark incision.
Incision: Mouth gag is inserted ( i.e. McIvor)
15 or 10 KB is used to incise the palate to make flaps. 59

60. Palatoplasty cont. Operative Sequence
Hemostasis: Bayonet Bovie or needle tip. 60

61. Palatoplasty cont. Operative Sequence
Dissection and Exposure:
The flaps are elevated with skin hooks. 61

62. Palatoplasty cont. Operative Sequence
Exploration and Isolation:
None needed 62

63. Palatoplasty cont. Operative Sequence
Surgical Repair:
Once the flap are elevated, they are closed in three layers.
Nasal Mucosa
Muscle
Palatal mucoa 63

64. Palatoplsty cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate. 64

65. Palatoplsty cont. Operative Sequence
Closure:
Chromic suture is used to closed palate.
A traction suture is placed in the body of the tongue.
This is usually a 0 Silk.
Is an upper airway obstruction is suspected, they will use the traction suture to pull the tongue forward. 65

66. Palatoplsty
Major Arteries:
ascending palatal artery 66

67. Palatoplsty Major Veins: Major Nerves: Palatal vein
greater and lesser palatine nerves 67

68. Plastic Procedures Operative Sequence
Cheiloplasty 68

69. Overall Purpose of Procedure:
Cheiloplasty
Overall Purpose of Procedure:
A.K.A. Cleft Lip
To reassemble normal pathology of the lip. 69

70. Cheiloplasty Define the procedure:
A unilateral cleft lip results from failure of the union of the maxillary and median nasal processes, thus creating a split or cleft in the lip on either the left or right side.
It may be just a notching of the lip or extend completely through the lip into the nose and palate.
Can be Bi-lateral. 70

71. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application 71

72. Cheiloplasty
Instrumentation: Plastics/Minor tray depending on patient size.
Positioning: Supine with arms on arm boards.
Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.
Draping: Head drape with ¾ drape or green sheet as a lower body drape. 72

73. Cheiloplasty Begin your Operative Sequence
Incision:
15 and 11 KBs
Hemostasis: Handheld Bovie
Dissection and Exposure/Surgical Repair: abnormal tissue is dissected and flaps are ID’d for clourse 73

74. Cheiloplasty cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate. 74

75. Cheiloplasty cont. Operative Sequence
Closure:
Closure is begun with 4-0 or 5-0 Chromic. The muscle layer is followed by the mucosal layer and then skin.
No dressing is usually needed.
Might need to apply restraints to child to reduce chance of child destroying all completed work. 75

76. Plastic Procedures Operative Sequence
Rhinoplasty 76

77. The goal of the procedure is to improve the appearance of the nose.
Rhinoplasty
Overall Purpose of Procedure:
The goal of the procedure is to improve the appearance of the nose. 77

78. Rhinoplasty Define the procedure:
A Rhinoplasty is performed through internal incisions (if possible) so that there is no scar.
This is done by reshaping the underlying framework of the nose by rasping the dorsal hump, partial excision of the lateral and alar cartilage, shortening the septum an osteotomy of the nasal bones. 78

79. Wound Classification: 1
Rhinoplasty
Wound Classification: 1 79

80. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application 80

81. Rhinoplasty
Instrumentation: ENT/Plastics tray depending on patient size. Assorted Minor Bone instruments.
Positioning: Supine with arms on arm boards.
Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit.
Draping: Head Drape. ¾ drape for lower body coverage. 81

82. Rhinoplasty Begin your Operative Sequence
Incision:
Intranasal incisions are made with 15 KB, Joseph Knife, Joseph elevator or Button Knife. 82

83. Rhinoplasty cont. Operative Sequence
Hemostasis: Handheld Bipolar Bovie 83

84. Rhinoplasty cont. Operative Sequence
Dissection and Exposure:
The skin and the soft tissue are elevated from the underlying nasal bones and cartilage. 84

85. Rhinoplasty cont. Operative Sequence
Exploration and Isolation:
Full exposure of the nasal bones and cartilage with nasal speculum. 85

86. Rhinoplasty cont. Operative Sequence
Surgical Repair:
The tip of the nose is reshaped by excising portions of the alar and lateral cartilage of each side.
This can accomplished with a small rasp, Ronguer, or scissors. 86

87. Rhinoplasty cont. Operative Sequence
Surgical Repair:
Osteotomies of the nasal bones are done medially and laterally to narrow the nasal bridge.
This can be done with osteotomes and a mallet.

88. Rhinoplasty cont. Operative Sequence
O.R. Live video:
Rhinoplasty - Nasal Valve Reconstruction
Procedure:Smooth procedure

89. Rhinoplasty cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate. 89

90. Rhinoplasty cont. Operative Sequence
Closure:
Suturing is very minimal for Rhinoplasties.
MD will choose a small Chromic or 5-0. 90

91. Rhinoplasty Major Arteries:
The external nose is supplied by the facial artery
Internal - anterior and posterior ethmoid arteries 91

92. Rhinoplasty Major Veins: Major Nerves:
Veins in the nose essentially follow the arterial pattern
Major Nerves:
The sensation of the nose is derived from the first 2 branches of the trigeminal nerve 92

93. Plastic Procedures Operative Sequence
Mammoplasty 93

94. Mammoplasty Overall Purpose of Procedure:
Often refers to enlargement of the breasts, but can be reduction.
Can also be the rebuilding of breast tissue after weight loss or cancer or any reason to change the appearance or symmetry. 94

95. Mammoplasty Define the procedure:
We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts. 95

96. Wound Classification: 1
Mammoplasty
Wound Classification: 1 96

97. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application 97

98. Mammoplasty
Instrumentation: Major/Minor tray depending on patient anatomy/size.
Positioning: Sitting position or able to be placed in the sitting position intra-op.
Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep entire anterior portion chest, from just below the clavicle to two inches below the inframammary crease and laterally to the axilla.
Draping: 4 to 6 blue towel placed under and around both breasts and a modified lap drape. 98

99. Mammoplasty Begin your Operative Sequence
Prior to Incision:
Photos must be taken and available in the O.R.
MD will mark the patients breasts while sitting up.
Incision:
Incision is made along the markings with a 10 Kb. The incision for a reduction Mammoplasty is a called a keyhole incision. It starts around the nipple, going from 7 o’clock to 5 o’clock, in a clockwise manner.
Two additional diagonal incisions lines are made from the bottom of the nipple to the natural mammary fold. The angle will depend on the amount of tissue to be removed. 99

100. Mammoplasty cont. Operative Sequence
Hemostasis: Handheld Bovie
100

101. Mammoplasty cont. Operative Sequence
Dissection and Exposure:
The skin flaps are de-epithelized with numerous 10 KB’s, cautery etc.
Exposure is gained with Volkmans or hand retraction
101

102. Mammoplasty cont. Operative Sequence
Exploration and Isolation:
None at this point.
102

103. Mammoplasty cont. Operative Sequence
Surgical Repair:
The breast tissue is cut down to the medial and lateral margins.
The nipple and areola are not excised from the pedicle.
ALL EXCISED TISSUE IS WEIGHED.
The circ will keep the surgical team apprised of the total weight removed from each side if both sides are reduced.
Video: Breast Reduction
103

104. Mammoplasty cont. Operative Sequence
Once the desired amount is taken off, the skin is temporarily closed with desired suture or staples.
The patient may be sat up to obtain a better view of the reduced breasts, to determine if the reduction is adequate.

105. Mammoplasty cont. Operative Sequence
The patient is returned to the supine position and attention is directed to the other breast, where the same procedure is followed.
Once the second side is temporarily closed, the patient is once again sat up to compare both breasts and t determine if further work is needed.
If the MD is satisfied, the patient is returned to the supine position and permanent closure begins.

106. Mammoplasty cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
106

107. Mammoplasty cont. Operative Sequence
Closure:
Hemovac drains can be used for drainage of wound(s).
Closure of the breasts is completed with Vicryl (3-0) and a running Prolene (4-0) stitch.
The nipple will be sewn into place with a 5-0 Nylon.
107

108. A Simpler Approach

109. Mammoplasty Major Arteries: Internal mammary artery
Lateral thoracic artery
Thoracodorsal artery
Intercostal artery
Thoracoacromial artery
109

110. Mammoplasty Major Veins: Major Nerves: Axillary vein
Thoracic intercostal nerves T3-T5
Researchers believe sensation to the nipple derives from the lateral cutaneous branch of T4.
110

111. Hand Surgery Reasons performed: Congenital deformities Disease Trauma
Can be performed by plastic surgeons, orthopedic or orthopedic “hand-surgeons”, and neurosurgeons

112. Hand Surgery Traumatic Injury: Laceration closure
Ganglion cyst excision
Carpal Tunnel Release
DeQuervain’s Repair
DuPuytren’s Contracture Release
Trigger Finger Release
Toe to Hand Transfer
Release of Syndactyly (webbed fingers)
Reduction of polydactyly (extra digit)
Radial dysplasia (club hand) correction
Traumatic Injury:
Laceration closure
Digital Reimplantation
Tennorhaphy
Neurorrhaphy
Restoration of vascularity
Bone approximation
Italicized info seen in children must consider special needs of children when performing surgery on children

113. Summary Terminology Anatomy of Skin and Hand Pathology Medications
Anesthesia
Supplies, Instrumentation, and Equipment
Considerations and Post-op Care
Procedures: Skin and Hand