Rhytidectomy Plastics Operative Sequence Rhytidectomy Overall Purpose of Procedure To improve the appearance of the patients face and neck area Rhytidectomy Rhytid s medical term for a wrinkle ID: 911995
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Slide1
Plastics and Reconstructive Procedures
Slide2Rhytidectomy
Plastics
Operative Sequence
Slide3Rhytidectomy
Overall Purpose of Procedure
: To improve the appearance of the patients face and neck area.
Slide4Rhytidectomy
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
BrowiftEyelid liftChin ImplantsMalar implants (mid-face cheek implants)
Slide5Rhytidectomy
- Facelift -
Slide6Rhytidectomy
- 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.
Slide7Rhytidectomy
Wound Classification
: 1
Slide8Operative Sequence
1- Incision
2- Hemostasis3- Dissection
4- Exposure5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation
8- Closure
9- Dressing Application
Slide9Rhytidectomy
Instrumentation
: Plastics TrayPositioning: 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 siteDraping: Head drape.
Slide10Rhytidectomy
Begin your Operative SequencePrior 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.
Slide11Rhytidectomy
cont. Operative SequenceHemostasis: Handheld Bovie and hemostats.
Slide12Rhytidectomy
cont. Operative SequenceDissection 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.
Slide13Rhytidectomy
cont. Operative SequenceExploration 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.
Slide14Rhytidectomy
cont. Operative SequenceSurgical 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
Slide15Rhytidectomy
cont. Operative SequenceHemostasis and Irrigation:All bleeding is controlled with cautery, possibly Bi-polar.
Use of warm Saline to irrigate.
Slide16Rhytidectomy
cont. Operative SequenceClosure: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.
Slide17Rhytidectomy
Major Arteries:
External Carotid ArteryFacial
Slide18Rhytidectomy
Major Veins:
Internal Jugular Vein
Major Nerves:Cranial Nerve VII - Facial Nerve
Slide19Blepharoplasty
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.
Slide20Blepharoplasty
Visit:
http://www.drmeronk.com/videos.html
Slide21Lipectomy
Plastic Procedures
Operative Sequence
Slide22Lipectomy
Overall Purpose of Procedure
:
To remove excess fatty deposits from many different areas of the human body.
Areas include:
Hips and Thighs
AbdomenBreastFaceButtocksAnywhere there is bulk fatty deposits
Slide23Lipectomy
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.
Slide24Lipectomy
a 12-year old girl who at 5-foot-5 weighed 230 pounds.
Slide25Lipectomy
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.
Slide26Lipectomy
Wound Classification
: 1
Slide27Operative Sequence
1- Incision
2- Hemostasis3- Dissection
4- Exposure5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation
8- Closure
9- Dressing Application
Slide28Lipectomy
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.
Slide29Lipectomy
Begin your Operative SequencePrior 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.
Slide30Lipectomy
cont. Operative SequenceHemostasis: Handheld Bovie
Slide31Lipectomy
cont. Operative SequenceDissection and Exposure:All dissection is made with the lipo cannual that the surgeon has previously chosen.
Slide32Lipectomy
cont. Operative SequenceExploration and Isolation:
A tunnel is created by passing the cannula underneath the skin. The suction is off at this point.
Slide33Lipectomy
cont. Operative SequenceSurgical 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
Slide34Lipectomy
cont. Operative SequenceHemostasis and Irrigation:All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Slide35Lipectomy
cont. Operative SequenceClosure: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.
Slide36Lipectomy
Major Arteries:
Depends on area of Lipectomy
Slide37Lipectomy
Major Veins:
Depends on area of LipectomyMajor Nerves:
Depends on area of Lipectomy
Slide38Abdominoplasty
Plastic Procedures
Operative Sequence
Slide39Abdominoplasty
Overall Purpose of Procedure
: A.K.A. Tummy Tuck To remove excess fat and tighten abdominal skin.
Slide40Abdominoplasty
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.
Slide41Abdominoplasty
Indications for Abdominoplasty
Loss of muscle tone in the lower abdominal region
Lose skin and fat in the abdominal region resulting from weight loss.
Slide42Abdominoplasty
Wound Classification
: 1
Slide43Operative Sequence
1- Incision
2- Hemostasis3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation 8- Closure9- Dressing Application
Slide44Abdominoplasty
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.
Slide45Abdominoplasty
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.
Slide46Abdominoplasty
cont. Operative SequenceHemostasis: Handheld Bovie
Slide47Abdominoplasty
cont. Operative SequenceDissection and Exposure
:The abdomen is dissected through the subcutaneous tissue and fat down to the rectus muscle using the bovie.
Slide48Abdominoplasty
cont. Operative SequenceExploration 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
.
Slide49Abdominoplasty
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
Slide50Abdominoplasty
cont. Operative SequenceHemostasis and Irrigation:All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Slide51Abdominoplasty
cont. Operative SequenceClosure: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
.
Slide52Abdominoplasty
Major Arteries:
No major since we are superficial, or above the rectus muscles
Slide53Abdominoplasty
Major Veins:
No major since we are superficial, or above the rectus musclesMajor Nerves:
Splanchnic nerve
Slide54Cheiloplasty
(key-lo-
plasty
) and
Palatoplasty
Plastic Procedures
Operative Sequence
Slide55Palatoplasty
Overall Purpose of Procedure
:
A.K.A. Cleft PalateTo reassemble normal pathology of the palate.
Slide56Palatoplasty
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
.
Slide57Operative Sequence
1- Incision
2- Hemostasis3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation 8- Closure9- Dressing Application
Slide58Palatoplasty
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.
Slide59Palatoplasty
Begin your Operative SequencePrior 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.
Slide60Palatoplasty
cont. Operative SequenceHemostasis:
Bayonet Bovie or needle tip.
Slide61Palatoplasty
cont. Operative SequenceDissection and Exposure
:The flaps are elevated with skin hooks.
Slide62Palatoplasty
cont. Operative SequenceExploration and Isolation:
None needed
Slide63Palatoplasty
cont. Operative SequenceSurgical Repair:
Once the flap are elevated, they are closed in three layers.Nasal MucosaMusclePalatal mucoa
Slide64Palatoplsty
cont. Operative SequenceHemostasis and Irrigation:All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Slide65Palatoplsty
cont. Operative SequenceClosure: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.
Slide66Palatoplsty
Major Arteries:
ascending palatal artery
Slide67Palatoplsty
Major Veins:
Palatal veinMajor Nerves:
greater and lesser palatine nerves
Slide68Cheiloplasty
Plastic Procedures
Operative Sequence
Slide69Cheiloplasty
Overall Purpose of Procedure
: A.K.A. Cleft LipTo reassemble normal pathology of the lip.
Slide70Cheiloplasty
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.
Slide71Operative Sequence
1- Incision
2- Hemostasis3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation 8- Closure9- Dressing Application
Slide72Cheiloplasty
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.
Slide73Cheiloplasty
Begin your Operative Sequence
Incision
:15 and 11 KBsHemostasis: Handheld BovieDissection and Exposure/Surgical Repair: abnormal tissue is dissected and flaps are ID’d for clourse
Slide74Cheiloplasty
cont. Operative Sequence
Hemostasis and Irrigation:All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Slide75Cheiloplasty
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.
Slide76Rhinoplasty
Plastic Procedures
Operative Sequence
Slide77Rhinoplasty
Overall Purpose of Procedure
: The goal of the procedure is to improve the appearance of the nose.
Slide78Rhinoplasty
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.
Slide79Rhinoplasty
Wound Classification
: 1
Slide80Operative Sequence
1- Incision
2- Hemostasis3- Dissection
4- Exposure5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation 8- Closure
9- Dressing Application
Slide81Rhinoplasty
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.
Slide82Rhinoplasty
Begin your Operative SequenceIncision
:Intranasal incisions are made with 15 KB, Joseph Knife, Joseph elevator or Button Knife.
Slide83Rhinoplasty
cont. Operative SequenceHemostasis:
Handheld Bipolar Bovie
Slide84Rhinoplasty
cont. Operative SequenceDissection and Exposure
:The skin and the soft tissue are elevated from the underlying nasal bones and cartilage.
Slide85Rhinoplasty
cont. Operative SequenceExploration and Isolation:
Full exposure of the nasal bones and cartilage with nasal speculum.
Slide86Rhinoplasty
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
.
Slide87Rhinoplasty
cont. Operative SequenceSurgical 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.
Slide88Rhinoplasty
cont. Operative Sequence
O.R. Live video:Rhinoplasty - Nasal Valve ReconstructionProcedure:Smooth
procedure
Slide89Rhinoplasty
cont. Operative SequenceHemostasis and Irrigation:
All bleeding is controlled with cautery. Use of warm Saline to irrigate.
Slide90Rhinoplasty
cont. Operative SequenceClosure:
Suturing is very minimal for Rhinoplasties. MD will choose a small Chromic. 4-0 or 5-0.
Slide91Rhinoplasty
Major Arteries:
The external nose is supplied by the facial artery Internal - anterior and posterior ethmoid arteries
Slide92Rhinoplasty
Major Veins:
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
Slide93Mammoplasty
Plastic Procedures
Operative Sequence
Slide94Mammoplasty
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.
Slide95Mammoplasty
Define the procedure
:We will cover reduction or the removal of excess breast tissue to provide symmetry of both breasts.
Slide96Mammoplasty
Wound Classification
: 1
Slide97Operative Sequence
1- Incision
2- Hemostasis3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation 8- Closure9- Dressing Application
Slide98Mammoplasty
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.
Slide99Mammoplasty
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.
Slide100Mammoplasty
cont. Operative SequenceHemostasis: Handheld Bovie
Slide101Mammoplasty
cont. Operative SequenceDissection and Exposure
:The skin flaps are de-epithelized with numerous 10 KB’s, cautery etc.Exposure is gained with Volkmans or hand retraction
Slide102Mammoplasty
cont. Operative SequenceExploration and Isolation:
None at this point.
Slide103Mammoplasty
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
Slide104Mammoplasty
cont. Operative SequenceOnce 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.
Slide105Mammoplasty
cont. Operative SequenceThe 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.
Slide106Mammoplasty
cont. Operative SequenceHemostasis and Irrigation:All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Slide107Mammoplasty
cont. Operative SequenceClosure: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.
Slide108A Simpler Approach
Slide109Mammoplasty
Major Arteries:
Internal mammary artery Lateral thoracic artery Thoracodorsal artery Intercostal artery
Thoracoacromial artery
Slide110Mammoplasty
Major Veins:
Axillary vein
Major Nerves:Thoracic intercostal nerves T3-T5 Researchers believe sensation to the nipple derives from the lateral cutaneous branch of T4.
Slide111Hand Surgery
Reasons performed:
Congenital deformitiesDiseaseTraumaCan be performed by plastic surgeons, orthopedic or orthopedic “hand-surgeons”, and neurosurgeons
Slide112Hand Surgery
Ganglion cyst excision
Carpal Tunnel Release DeQuervain’s Repair
DuPuytren’s Contracture ReleaseTrigger Finger ReleaseToe to Hand TransferRelease of Syndactyly (webbed fingers)
Reduction of polydactyly (extra digit)
Radial dysplasia (club hand) correction
Traumatic Injury:
Laceration closure
Digital Reimplantation TennorhaphyNeurorrhaphyRestoration of vascularity Bone approximation
Slide113Summary
Terminology
Anatomy of Skin and HandPathologyMedications
AnesthesiaSupplies, Instrumentation, and EquipmentConsiderations and Post-op CareProcedures: Skin and Hand