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Barbie Without Plastic Surgery Plastic and Reconstructive Surgery Objectives • • • • Identify the goal of plastic surgery Describe categories of plastic surgery Describe the risks Describe Perioperative Nursing Considerations 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 Categories of Reconstructive Surgery • Correction of Congenital Anomalies • Improvement of appearance • Resection of tumors that leave large softtissue defects • Repair of traumatic injuries The goal of Plastic Surgery is to restore normal function and appearance (Cover the hole) Treatment Options • Surgery – – – – Cosmetic Reconstructive/Revision Lipectomy Tissue Expansion Treatment Options • Collagen/Fat/Botox Injection • Skin Resurfacing – Laser – Chemical Peel – Dermabrasion Perioperative Nursing Considerations 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 Nursing Diagnosis • • • • • • Disturbed Body Image Anxiety Deficient Knowledge Risk For Positioning Injury Risk For Ineffective Tissue Perfusion Risk For Infection 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) Nursing Interventions Nursing Interventions General Considerations 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) 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 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 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 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 Tissue Expanders Breast Implants Facial Implants Dermatome Skin Mesher Skin Mesher Head Light & Light Source Lighted Retractors Jackson Pratt Drain Microscope Suction Assisted Lipectomy Instrumentation Gillies needle holder Stevens scissors Castroviejo Forceps Hartman Mosquito Skin Hook Liposuction Cannulas Medications • Local Injections – Lidocaine (Xylocaine) – Bupivicaine (marcaine) • Topical – Cocaine 4% • Tumescent Anesthesia – 1 liter NS with 500-1000mg lidocaine & 1mg epinephrine Pressure Infuser Dressings • Apply even pressure over wound to prevent dead spacing, seromas & hematomas • Collect drainage • Provide comfort for the patient • Protect wound 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 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 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 Brow Lift Before & After 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 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 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 Post-Op Dressing Rhytidectomy Before & After Facial Implants • Improve & enhance facial contours using shaped implants to build up the chin, cheeks & jaw line • Length: Chin 30 min – 1 hr, Cheek 30-45 min, lower jaw 1-2 hr • Risks : shifting or imprecise positioning of implant, infection, scar tissue around implant causing unnatural shape 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 Chin implant Before & After Cheek Implant • Incision is made either inside the upper lip or lower eyelid • Implant is placed either directly on or below cheek bone Cheek Implant Before & After Lower Jaw Implant • Internal incisions are made on either side of the lower lip • A pocket is created and the implant is inserted Jaw Implant Before & After 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 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 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 Rhinoplasty • Trimming the septum improves the angle between the nose and upper lip Rhinoplasty • If the nostrils are too wide, small wedges of skin are removed from the base to bring them closer together Post-Op Splint Rhinoplasty Before & After 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 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 Ear Dressing Otoplasty Before & After 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 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 Cleft Lip Before & After 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 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 Cleft Palate Before & After 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 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 Augmentation Mammoplasty • Implants may be placed in front or behind the muscle Post Op Dressing Augmentation Before & After 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 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 Mastopexy Before & After Reduction Mammoplasty Reduction Before & After 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 – 68 hr • Risks: bleeding, infection, scarring, loss of circulation to flap Tissue Expanders • Tissue expander is placed below the pectoralis muscle, wound is closed & expander inflated until skin blanches Tissue Expanders • Additional inflation occurs 2-3 weeks postop and every 7 days thereafter • When maximum expansion is achieved the expander is exchanged for permanent implant Tissue Expanders After TRAM Flap • Transverse Rectus Abdominis Myocutaneous • Skin, fat & muscle are dissected and tunneled to the midline of the abdomen • Blood vessels remain intact TRAM Flap • Flap is brought to the chest wall with the thinnest part of the flap superior & medial, thickest part inferior & lateral TRAM Flap Before & After 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. Diep Flap • Decrease in abdominal wall morbitiy • Longer surgery time • Risk – flap failure due to microvascular thrombosis 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. 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. 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 Latissimus Dorsi Flap After Nipple Reconstruction • A star shaped incision is made to form the new nipple • The areola is shaded by tattooing • Tissue expander Abdominalplasty • Flattens abdomen by removing excess fat & skin and tightening abdominal muscles • Length : 2-5 hours • Risks: blood clots, infection bleeding under skin flap Abdominoplasty • Incision is made from hip bone to hip bone just above pubic area • Umbilicus is freed from surrounding tissue Abdominoplasty • Abdominal skin flap is elevated up to the ribs • Abdominal muscles are tightened by pulling them together and suturing 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 Abdominal Binder Abdominoplasty Before & After 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 Botox Injection Collagen Injection 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 Laser • CO2 laser used • Best for fine lines around eyes & mouth Chemical peel • Chemical solution applied to skin to treat wrinkles, acne scars, sun damaged skin • Alphahydroxy-weak • Trichloroaceticmedium • Phenol-strong Dermabrasion • Refinish skin’s top layer through scraping • Best for coarse wrinkles and scars Skin Grafts • Split thickness (STSG) contains epidermis & part of dermis from donor site • Full thickness (FTSG) contains both epidermis & dermis from donor site 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 Split Thickness Skin Graft • Graft may be meshed to increase area of coverage • Graft secured with suture or staples Split Thickness Skin graft 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 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 Full Thickness Skin Graft 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 Skin Flap 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 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 Operating Mend • http://operationmen d.ucla.edu/