LECTURE 1: Plastic & Reconstructive Surgery  Benign Cutaneous lesions

Mirela M. Mijares, md, ipapras, fpcs o Fibroma

o Xanthelasma
“Refine” o Keloid
General Surgery o Benign Adnexal Tumor
o Keloid
Plastic Surgery o Lipoma
-branch of surgery dealing with the repair or restoration of injured,  Congenital Anomalies
deformed, or destroyed parts of the body, especially by transfer of o Cleft Lip & Palate
tissues as skin or bone, from other parts or from another individual o Midfacial Cleft
Webster’s International Collegiate Dictionary o Lateral Facial Cleft
o Bilateral Facial Cleft
-that aspect of the discipline of surgery in which interest and o Frontonasal Meningocoele
concentration are focused on the restoration of form & functions of o Congenital Probosces
areas affected by trauma, aging, congenital defects, cancer or prior  Eye, Nose, Ear Deformities
surgery  Vascular Anomalies
Schwartz Textbook of Surgery  Gut Anomalies
 Thermal Injuries
“plastic” o Scalding
Plastikos (Grk) – to mold, shape, or form o Chemical
1919 – Plastic Surgery – Its Principles and Practice o Flame
- John Staige Davis o Electrical
o Contact
“reconstructive” o Flash
-correction of MAJOR defects due to trauma, congenital defects,  Burn complications
benign/malignant disease o Burn syndactyly
o Marjolins ulcer
“comestic”/ “anesthetic” o Boutonniere Deformity
-correction of MINOR defects due to the aging process or surgery o Marjolin’s Ulcer
done to enhance the appearance of non-deceased body parts o Burn Scar Contracture
 Cutaneous Malignancies
Plastic surgery is NOT cosmetic surgery
o Basal Cell Carcinoma
o Squamous Cell Carcinoma
The origins of the art of plastic surgery in ancient history are related to
o Malignant Melanoma
the relief of FACIAL deformity
 Head & Neck Tumors
HISTORY OF PLASTIC SURGERY  Craniofacial Injuries
Papyrus Ebers – 1580 BC – record the use of lint, honey and animal  Facial Bone Fractures
grease for wound care  Hand Surgery
 Cosmetic Surgery
Sushruta Samhita (500BC) o Rhinoplasty
-hindu physician who performed nasal reconstruction procedures o Augmentation Mammoplasty
o Abdominal Dermolipectomy
Gallen of Pergamum (120 – 201 AD) o Suction-Assisted Lipectomy
Greek physican who treated Roman gladiators
PRINCIPLES OF PLASTIC SURGERY
Celsus (1st century AD) 1. The doctor-patient relationship based on Integrity is
Roman physician who described operations for facial injuries fundamental in plastic surgery as in any other discipline.
2. Elective surgery means that the patient “elects” to undergo
SEMMELWEISS (19th century) surgery. Proper preparation is necessary.
Hungarian obstetrician who was the first to emphasize the importance 3. The surgeon must carefully weigh the risks associated with
of ASEPSIS in operations the procedure as well as the benefits.
4. In the initial consultation, the surgeon must define the
LOUIS PASTEUR (19th century) deformity as well as recognize the “true” versus the
French scientist who first presented the Germ Theory of disease “apparent” defect.
5. TEAM APPROACH – The concept of a group of clinicians
JOSEPH LISTER (19th century) from a variety of disciplines working on a problem yields the
English surgeon who started the use of carbolic acid treated (phenol) optimal care for complex problems.
gauze dressings 6. In the preoperative planning, the surgeon must consider a
“reconstructive ladder” but on occasion, must resort to a
WW II – birth of plastic surgery as specialty “reconstructive elevator”
7. The plastic surgeon must avoid overaggressive surgery. The
WW II – maturation of plastic surgery as a discipline principle of “less is more” particularly applies to planning
cosmetic cases.
1937 - formation of American Board of Plastic Surgery 8. Replace like with like.
-Composite graft
1962 – breast implants (Cronin & Gerow) -Rotation – Advancement Flaps
9. In facial reconstruction, surgery must replace the missing
1978 – creation of the Philippine Board of Plastic Surgery part or parts.
10. In general, the involved aesthetic unit or subunit must be
SCOPE reconstructed.
-not limited to just skin & adnexae, but also to subjacent tissues in 11. Autogenous reconstruction is generally preferable to
locations as diverse as the face & hands, the neck & abdominal wall, alloplastic reconstruction.
the extremities & the GUT, the breast & scalp 12. When resurfacing complex defects, the reconstructive flap
must fill the defect three dimensionally.
13. The timing of the surgical intervention can be problematic and
should always be carefully considered.
 Wound Coverage
  Normal – none
 Superficial –epidermis
 Superficial Partial Thickness – epidermis, upper half of the
dermis
 Deep Partial Thickness – epidermis, whole of the dermis
REQUISITES FOR SUCCESSFUL PLASTIC SURGERY  Full Thickness – epidermis, dermis, subcutaneous
1. Sense of Form
2. Good Aesthetic Judgment Simple defect without tissue loss
3. Ability to visualize results  Complex/Composite
-structures underlying the skin
1.Sense of Form e.g., muscle, fascia, bone, or blood vessels are likewise,
 Acceptable proportions of human form involved
 Existing cultural standards
 LEONARDO DA VINCI’S “DIVINE PROPORTIONS” complex defect with tissue loss

2. Good Aesthetic Judgment SKIN GRAFT

 Anthropometry  Sheet of skin, including the epidermis & varying thickness
 Proportion of dermis, completely severed from a donor site &
 Standards of Beauty transferred elsewhere to cover a defect.

What is Beauty? Types of Skin Graft

-Face  Split Thickness Skin Graft (STSG)
- Figure a. Thin - .008 - .012 inch
- Style & Fashion b. Medium - .013 -.016 inch
-Cultural Standards c. Thick - .017 - .020inch
 Full-Thickness Skin Graft (FTSG)
Relative Standards of Beauty -more than .020 inch

PRS as a specialty Thin stsg – epidermis + upper ¼ of dermis

-basic general surgery Medium stsg – epidermis + ½ of dermis
- at least 4 years Thick stsg – epidermis + ¾ of dermis
-three years plastic & reconstructive surgery Full-thickness skin graft – all of epidermis and dermis
-specialty boards
STSG vs FTSG
“Success in plastic surgery is a matter of balance between Beauty and stsg ftsg
Blood Supply.” Thickness < .020 inch >.020 inch
Donor Sites Wide areas limited
Hope versus truth Harvest dermatome Surgical blade
Revascularization easy Difficult
LECTURE 2: Reconstruction
Cosmesis inferior Superior
Principles and Clinical Applications
Harvesting STSGS
General Principle:
-employ the simplest possible method of reconstruction
Indications for FTSG
Reconstructive Ladder  Coverage of lower eyelid defects
 Resurfacing defects over face & volar aspect of the hands
Primary Closure
Local Flap Clinical Evaluation of Wound for coverage
Skin Graft  Granulation tissue fine, velvety, with clean surface devoid
Distant flap of necrotic debris
 Wound edges clean & not edematous
Reconstructive Elevator  No foreign bodies
 Wound surface culture NOT accurate
Primary Closure  Amount of secretions on the wound surface
Local Flap  10-15% rate of wound healing/wk
Skin Graft
Distant flap Evaluation of wound infection

Goals of Reconstruction  Quantitative Bacteriology

- To provide viable coverage a. Punch Biopsy
- To restore form, contour, function b. Rapid slide technique
 Clinical Assessment
The method or manner of reconstruction will depend on the nature, a. Quality of granulation tissues
location, extent & specific requirements of any given defect. b. Appearance of wound edges
c. Presence of necrotic debris
Classification of Defects
Patient preparation for wound coverage
 Simple/Cutaneous
a. Partial – Thickness (PT)  Local Wound Care
*Superficial PT o Mechanical cleansing
*Deep PT o Removal of foreign bodies
b. Full Thickness (FT) o Debridement
o Infection control
Levels of Thickness of Injuries  Systemic Preparation
o Laboratory exams – hgb, total protein
Epidermis, Dermis/Corium, Subcutis, Muscles, tendons and fascia o Cardiopulmonary clearance
 o Nutritional support
Care of SG Recipient Site
 SALINE solution (NSS) is the ONLY safe solution for  “TIE-OVER” bolus dressings
washing injured tissues.  New generation dressings
 Proper immobilization using molds and splints
Topical Antibacterials  Closed dressings
 Silver nitrate .5%  No opening for 5-10 days, except with signs of infection
 Silver sulfadiazine 11% (Flammazine)
 Silver sulfadiazine + cerium nitrate (Flammacerium) Debridement of Necrotic Tissues
 Mafenide Acetate (Mafylon)
 Povidone Iodine vs. Cadoxemer Iodine Care of SG Donor Site
(Betadine) (Iodosorb)  Use new generation dressings
 Gentamycin (Garamycin)  Keep dry
 Furacin (Fucidin)  Thin, occlusive dressings

 Except for 0.5% silver nitrate, ALL topical result in Complications of Skin Grafting
DELAYED epithelialization of the wound.  Bleeding
 Infection
 Seroma Formation
Wound Dressings
 Regular wound care to prepare for definitive coverage “Our main business is not to see what lies ahead dimly at a distance,
 Open dressings over face; occlusive elsewhere but to do what lies clearly at hand”
 Debridement may be done at bedside or at the OR under Thomas Carlyle
anesthesia LECTURE 3: SKIN FLAPS

Open vs. Closed dressings Skin Grafting Coverage No Longer Sufficient

 Areas of dense scarring
Side notes:  Exposure of vital structures
 Open dressings are mentioned ONLY to be condemned  Areas of functional stress
 No open dressings for deep injuries  Following peripheral nerve surgery
 Except for injuries over the face  When secondary surgical procedures are still planned in the
 For burns with deep injuries to the face, coverage is done so future
there will be better penetration of the topical antibacterial
into the burned escar Skin Grafts versus Skin Flaps
Wound Dressings
 Traditional gauze (OS) Skin Flaps
o plain Basic Principles & Clinical Applications
o medicated
o limitations -composite of skin, subcutaneous fat, fascia, muscle and bone, taken
 plain – must be dry at all times, without any from an area, to cover a composite defect elsewhere, either severed
soilage or secretions from the wound and there completely from its blood supply, or attached through a vascular
should be about 64 layers of ordinary gauze so pedicle
bacteria does not penetrate
 Gauze Dressings Classification of Flaps
 Main drawback of OS is that it sticks to the I. As to incorporated tissues
surface of the wound, during removal it is painful a. Cutaneous
to the patient, and patient is going to loss RBC b. Muscles
and Hemoglobin is going to go down if done on a c. Myocutaneous
daily basis – must wet with NSS before removing d. Fasciocutaneous
 Biologic Dressings e. osteomyocutanous
o Amnion
o Cadaver skin Cutaneous Flaps
o Porcine skin Soleus Muscle Flap
o Porcine xenograft Gastrocnemius Muscle Myocutaneous Flap
 New Generation Dressings Myocutaneous: Tram Flap
o Duoderm Latissimus Mm. Myocutaneous Flap
o Acticoat Latissimus Dorsi Muscle Myocutaneous Flap
o Kaltostat Pectoralis Major MM. Myocutaneous Flap
o Tubular net dressing Gastrocnemius MM. Myocutaneous Flap
PMMMCF + 5th Rib + STSG
o Polyurethane Dressings
 Opsite, Tegaderm II. According to Pattern of Blood Supply
o Hydrogels a. Random-Pattern
 Intrasite, Comfeel  pattern of vascularity is random
o Hydrocolloids meaning determent on the cutaneous blood
 Duoderm, Hydrocoil supply, no specific anatomically specified blood
o Hydrocellular Dressings supply
 Allevyn, Hydrosorb  need to have a proportion 1-1:5 length
Skin Substitutes and width
 Cultured autologous cells  Rotation
 Epicel  Advancement
 Intergra Dermal Regeneration Template  Transposition
 Dermagrait TC  Interpolated
 Transcyte  Tubed
e.g of random-pattern flap – Rhomboid/Limberg
Harvesting SGs  Rotation-Advancement flaps
Dermatome & SG Mesher o Cleft lip repair with Millard I technique.
 o Scalp flaps  CHON malnutrition among pregnant
women tagged as most probable
etiologic factor
b. Axial – Pattern o Syndromic
 success is better  29% of CL+/- CP show other associated
 Arterial flap (e.g. Deltopectoral flap) congenital anomalies
 Muscle flap (e.g. Soleus M. Flap)  More than 150 syndromes include CL
 Myocutaneous flap (e.g. Pectoralis Major or +/- CP as a feature
gluteus Maximus M.)  30% CL+/- CP with short stature
 Island Flap (e.g. Palatoplasty)  Classification of Cleft Lip:
o Unilateral
III. According to attachment to Donor Site  Complete
a. Pedicled  Incomplete
b. Free, Microvascularized o Bilateral
 Complete
IV. According to Distance Between Donor and Recipient sites  Incomplete
a. Local  Early consideration in management:
 Laterally – based plantar flap o Airway
 Gluteus Maximus Muscle Myocutaneous Flap o Feeding
b. Distant o Co-existing anomalies
 TRAMF (tranversus rectus abdominis muscle flap) o Midle ear infection
 LDMMCF (Latissimus dorsi M. Myocutaneous o Deafness
Flap)  Surgical management:
 Abdominal Jump Flap I and II with “sandwich flap”  Timing of Surgery – Cleft Lip
 Gastrocnemius Muscle Myocutaneous Flap  At least 10 wks of age
 For Bilateral, one side at a time at 6 months
Flap surgery is TIME CONSUMING interval
 Timing of surgery – Cleft Palate
Knowledge of Basic anatomy and Principles of Reconstruction  18-20 months of age
Necessary  MIDFACE retrussion as complication of early
repair.
LECTURE 4: CONGENITAL DEFORMITIES Rule of Tens
10
PEDIATRIC AGE GROUP -weeks of age
-body weight (lbs)
 Craniofacial Anomalies -hemoglobin
 Cleft lip -WBC count
 Cleft Palate
 Facial Clefts  Preparation for Surgery
 Meningocoeles (e.g. frontonasal menigocoeles)
 Ear Defromities  Pediatric clearance for surgery
 No upper respiratory tract infection
Ear Deformities  No medical contraindications to surgical repair
o Cockle Shell Ear Deformity under general anesthesia
Cleft Lip
 Incidence:  Surgical Techniques
o Highest among Asians; Lowest among blacks  Old Techniques
o Caucasians – 1:1000 live births  Lip adhesion
o Blacks – 1:3000 live births  Straight –Line repair (Rose-Thompson)
o Asians – 1:500 live births  Rectangular Flap
o CL +/- occurs TWICE more commonly among 
males than in females.  Triangular Flap
o CP without CL occurs more commonly than in 
males.  Millard I & II (1962)
o More lateral than bilateral  Most popular surgical repair
o More commonly occurs in the left than in the right  Rotation advancement flaps
 Embryology  “cut-as-you-go” procedure
o Lip structures develop between 4-7 weeks of  Flexible; favoured by young surgeons
gestation  Good access for nasal repair
o Palatal structure form between 6-8 weeks of  Scars easier camouflaged
gestation  Secondary revisions possible
 Etiologic Factors
o Maternal malnutrition Bilateral Cleft Palate
o Radiation  “Rule of Tens” also applied
o Drugs, alcohol. Tobacco
 Repair usually done in 2-3 stages, in six-month intervals
o Maternal infection
 Orthodontic appliances employed in the presence of
o Pollutants
protruding prolabium
 Categories of Cleft Lip
Cleft Palate
o Genetic
 Surgical repair: 18-20 months of age
 25% of cases present a positive family
history  Surgical Technique
 Positive family hx is twice as common in  Von Langenbeck
CL +/- as it is in CP alone  Old technique with high
o Environmental incidence of dehiscence
 CP appears to be more environmental  Veau-Wardill-Kilner
than genetic  Two flap palatoplasty
 Four-Flap Palatoplasty
  Cleft Palate Surgery
o Island Flaps Gut Anomalies
 Preservation of descending palatine  Hypospadias
vessels  Bladder Exstrophy
 Island Flap –called so because all of the soft  Epispadias
tissue are dissected free from the underlying bone
and only the descending palatine vessels would  Hypospadias
be connected to the surrounding tissues. o Anatomical Components:
 1. Abnormal location of urethral
o Two-Flap Palatoplasty opening on the dorsal penile
aspect
 Post-Operative Care  2. Presence of chordee
o Diet: LIQUID DIET for 1 week; NO SOLID FOOD  Piece of tissue that pulls
ALLOWED the penis downward so
o No breastfeeding that it comes out like a
o No feeding nipples very respectable position
 Wound dehiscence (?)
o By dropper/Syringe
o Arm Splints o Surgical Management
o NGT  Timing: Pre-school age
 Multistage versus Single Stage
Facial Clefts procedure
 Rare incidence  Two stage procedure
 Surgical repair done early only if necessary to preserve because 75% of patients
function come out with chordee
 Multiple Z-plasties done to repair soft tissues only; bony repair  First stage is removal of
not done chordee
 Second stage is creation
Apert’s Syndrome of new urethral opening
 acrocephalosyndactyly – with cleft lip, cleft palate,  Multistage is preferred
deformities of hands, toes, and fingers and club foot ( talipes over single stage
equinovarus) because of the high
complication rate
 Exstrophy of Bladder
 Epispadias with exstrophy

Other Congenital Anomalies

Frontonasal Meningocoele  Omphalocoele
 Meninges, at times, even a portion of the brain, exit into the
Frontonasal area through a cranial defect Other Anomalies: TORSO
 Surgical Repair  Congenital band
o Multi-Stage Repair  Teratoma
 1ST STAGE: Closure of intracranial bony
defect Upper Extremity Anomalies
 2Nd STAGE: Excision of frontonasal mass  Syndactyly

Vascular Anomalies Lower Extremity Anomalies

 Hemangiomas  Congenital Band
o Capillary - superficial  Hammer toe
 Strawberry Type – with tags
 Nevus Flammaeus
o Cavernous - deeper
o Mixed
 Hemangiomas: Management
o Conservative Management in the first year of life.
95% of cases resolve without treatment.
o Lesions involving mucosa, with lower chance at
spontaneous resolution.
o Laser – Argon, YAG (yttrium aluminium garnet)
o Surgery
o Steroids – topical, systemic
o Escharotics
 obsolete – creates scars
o Radiation
 complication: malignancy
 Lymphangioma
o Congenital anomaly involving lymph channels
o With tendency to huge sizes
o Treatment: Surgical
 Cystic Hygroma

Other Vascular Anomalies

 Port-wine stain
 Nevus sebaceous
 Nevus verrucous
 Neurofibroma
 LECTURE 5: BURNS complex wounds
4. Rehabilitation, a. maintain range & Day 1 through
BURNS: Current Concepts in Management reconstruction & reduce edema discharge
reintegration b. strengthen &
Incidence facilitate return to
USA: 1.1 million cases annually society
45,000 hospital admissions
4,500 deaths/year Initial Evaluation
Metro manila: 20,000/year I. Primary Survey
Metro Cebu: 3,000/year A. Airway
B. Bleeding
Etiology C. Circulation
Flame – 40% D. Deformity
Scalding – 30% E. Exposure
Chemical – 10%
Contact – 2% Airway Evaluation & Protection

Mortality Airway & Breathing

Primary cause of death:  Tracheotomy is contraindicated in patients with burns over
Systemic Inflammatory Response Syndrome (SIRS) the neck because it carries a very high risk for mediastinitis,
which has a very high mortality rate.
“Burning the largest immune organ”  Intubation is usually done rather than tracheostomy
Allgower, Spikes & Schonenberger, BURNS, Vol. 21, Suppl. 1, pp 5- CIRCULATION
549, 1995
Vascular access & initial fluid support
Burning the skin...
 The skin is the largest immune organ Prevention of subsequent DEFORMITIES
 Heat produdes coagulation of proteins on the surface of the
burned skin, forming the LIPID-PROTEIN COMPLEXES Multiple trauma issues
(LPCs)
Incidence of EXPOSURE
SKIN-immune system
 EPIDERMIS Prevention of hypothermia
o Keratinocytes  Vasoconstriction & hypovolemic shock
o Langhan’s cells
 DERMIS II. Burn Specific Secondary Survey
o Dendrocytes A. Burn History
 Nature/etiology of burn
SYSTEM INFLAMMATORY RESPONSE SYNDROME  Time of injury
 Place: closed space/open area
HEAT  Initial care
↓  Medical history
BURNS  Immunization
↓  Other healing deterrents
AICD
↓ B. Physical Examination
Multiple organ failure  Airway patency
↓
 Level of consciousness
Death
 Signs of inhalation injury
SIRS SEPSIS
Inhalation injury: clinical
Clinical Similar to sepsis Similar to sepsis manifestations
Manifestations
 Facial injuries
Time of onset 7th – 12th day First 72 hours post
 Singed nasal hairs
post burn burn
 Perioral burns
Focus of infection No identifiable focus With definite focus
 Tachypnea
Recommended Early debridement Antibiotics
 Hoarseness
management Anti-LPC agent Preventive measures
 Stridor
Goals of treatment
 Active bleeding
 Survival
 Concomitant injuries
 Function
 Cosmesis
C. Initial wound evaluation
 Depth of wounds
Overall management strategy
Phases of Burn Care  Extent of Injuries
Phase Objectives Time  Presence of circumferential components
1.Initial Evaluation & Thorough evaluation 0-72 hours
Depth of burn wounds
Resuscitation & accurate
resuscitation  Superficial
2.Initial wound Exactly identify and Days 1-7  Partial-thickness (PT)
excision & biologic remove all FT o Superficial
closure wounds & achieve o Deep PT
biologic closure  Full thickness
3.Definitive wound Replace temporary Day 7 - weeks
closure with definitive covers
& close small
Levels of Burn Injuries IV. Prevention of SIRS
Control of LPCs
Epidermis, Dermis/Corium, Subcutis, Muscles, tendons and fascia 1. Early surgical debridement
 Normal – none 2. Application of anti-LPC agents
 Superficial –epidermis
 Superficial Partial Thickness – epidermis, upper half of the Silver Sulfadiazine + Cerium Nitrate (Flammacerium)
dermis  Anti-SIRS agent
 Deep Partial Thickness – epidermis, whole of the dermis  Mechanism of Action: Cerium nitrate binds with the LPCs on
 Full Thickness – epidermis, dermis, subcutaneous the burn wound surface, thus preventing them from going
into general circulation, and causing SIRS
Superficial burns
e.g. Sunburn V. Infection Control
 No hospitalization indicated 1. Systemic Antibiotics
 No potential for infection 2. Topical Antibacterials
 Linaments/salve e.g. aloe vera 3. Enteral Feeding
4. Surgical debridement of necrotic tissues
Partial-thickness burns 5. Anti-tetanus coverage
Full-thickness burns
VI. Burn Wound Care
Extent of burn injuries  Intact blisters vs. Ruptured bullae
 Early vs. Delayed debridement
Wallace’s rule of nines  Washing with NSS
Palm + Digits = 1% TBSA  Topical antibacterials
Lund-Browder charts  Dressing materials

D. Laboratory & Radiographs TOPICAL ANTIBACTERIALS

Criteria for Hospitalization  Silver Sulfadiazine (SSD)
 Extremes of ages  Silver Sulfadiazine + Cerium Nitrate
 >15% TBSA PT injuries  Mafenide Acetate (Mafylon)
 >5% TBSA FT injuries  Silver Nitrate
 Involvement of primary areas  Povidone Iodine
o Face  Gentamycin
o Genitalia  Others
o Joints
o Neck Surgical Debridement
 Special burns  Avulsion Technique
o Lightening  Tangential Excision
o Chemicals  Escharectomy
o Electrical  Burn Wound Excision
 Inhalation injury  Extremity Amputation
 Life-threatening associated injuries eg. Head injury
 Presence of wound healing deterrent factores eg. Diabetes Sequential debridement
 Psychiatric conditions Tangential excision
 Close monitoring  Done in partial-thickness burns
 Excision of burn wound using a Humby knife or
III. Fluid Resuscitation dermatome, on tangent until a viable plane is reached
 Burn formulas are used initially as basis for computation of  Drawback: Bleeding
fluid requirement, but HOURLY URINE OUTPUT must be Escharectomy
considered subsequently.  Removal/excision of the burn eschar
 Done in full-thickness injuries
BAXTER-PARKLAND Formula  Vs. Escharotomy – releasing incisions on the eschar to
prevent vascular compromise
First 24 hours: Burn Wound Excision
 Done for injuries deeper than full-thickness; entails
TFR = 4cc x kgBW x %TBSA excision of underlying subcutaneous fat, muscle or
fascia, even bone.
½ of total volume to be given in the first 8 hours ff burn injury;
 May constitute amputation of extremities in case of
remaining ½ to be given in the next 16 hours
severe injuries
Burn Wound Excision: amputation
Second 24 hours:
Limb amputation
0.5 cc/kgBW/%TBSA
VII. Nutritional Support
+
 Ngt
D5W maintenance
 Parenteral nutrition
FLUID RESUSCITATION  HIGH protein/carbohydrate
 Plain LRS given initially in the first 24 hours following burn  Vitamins A,B,C
injury; colloids may be given in the next 24 hours  Minerals – zinc
 In infants, D5 solutions are preferred since they lack Surgical nutrition
glycogen reserves.  High-protein, high carbohydrate diet
 Blood is not given in the first 48 hours, unless there is  Vitamin supplements
significant loss due to concomitant injuries  Commercially-prepared supplements
 Colloids usually ordered also after 48 hours
 VIII. Rehabilitation
 Physical
 Psychosocial Secondary Survey
 Occupational  Inspect for asymmetry and deformity
TOTAL REHABILITATION  Palpation of entire craniofacial skeleton – orbital rims, nose,
Goals: zygomatic arch, midface stability, mandible to detect any
 To restore the patient’s sense of general well-being irregularities or crepitation
 To restore patient’s pre-burn occupational capacity  Investigation of facial nerve function
 Evaluation of facial sensation: supratrochlear, supraorbital,
BURN SEQUELAE infraorbital & infra-alveolar nerve distribution
 Hypertrophic scars  Intranasal inspection for septal hematoma
 Unstable scars  Ophthalmologic examination
 Deformities secondary to scarring  Malocclusion

COMPLICATIONS Assessment of Injuries

 Burn Scar contractures  Soft Tissue Injuries
 Marjolin’s Ulcer  Facial Bone Fractures
 Burn syndactyly  Concomitant Injuries
 Facial Abrasions
TEAM APPROACH  Lacerations
 Animal/Human bites
“In medicine, rules are absolute, but results are variable.”
-Celsus Facial Soft Tissue Injuries
 Diagnostic studies
 Photographs
 Precise inspection of injuries
Disclaimer: Due to unfortunate technical problems the following notes  Cleaning & Washing of wounds
are incomplete, reading the book or other references is highly advised.  Removal of foreign bodies
 Ant-tetanus coverage
LECTURE 6: TRAUMA
Cleaning & Washing
Common Causes of Traumatic Injuries  Irrigation with saline solution
 Motorvehicular accidents  Scrubbing & prying out of foreign materials to prevent
 Aggravated Assaults formation of “traumatic tattoos”
 Accidents like animal bites, falls etc  Surgical Debridement
 Sports Injuries
 Motorcycle Accidents Principles of Repair
1. Accurate primary treatment can prevent the need for
Craniofacial Injuries complex secondary reconstruction
2. Meticulous layered repair of the injury with identification of
Initial Evaluation severed glands, ducts, nerves
Primary Survey
 Airway maintenance with cervical spine protection
 Breathing & Ventilation
 Circulation with hemorrhage control
 Disability: neurologic status
 Exposure/environmental control

A: Airway Control & Cervical Spine Protection

 Check airway patency
 Visual inspection of oral cavity, pharynx & larynx

B: Breathing & Ventilation

 Auscultation
 Chest radiograph
 ABG measurement
 Pulse oximetry

C: Circulation
 Check for hypotension
 Fluid replacement
 Hemorrhage control

D: Disability
 Neurologic exam
 Skull radiographs
 CT scan
 Control of ICP
 Medications

E: Environmental Control
 Maintenance of warm ambient temperature following PE
 Use of warm blankets
o Avoidance of hypothermia
 LECTURE 7: Cosmetic Surgery

Oriental vs. Caucasian

Blepharoplasty
 Blepharochalasia
 Dermochalasia
 “Baggy eyes”

The aging face

Old
- presence of furrows
- Extra skin over eyelids – dermochalasia
- Crow’s feet
- Perioral wrinkles
- Nasolabial folds
- Jaw??
- Turkey cobbler deformity

Rhytidectomy/Rhytidoplasty (Face Lift)

Augmentation, Mammoplasty

Cosmetic Procedures for the Aging Face

 Rhytidectomy/Rhytidoplasty (Facelift)
 Blepharoplasty (Removal of Eyebags)
 Botox/Collagen injections

Other Cosmetic Procedures

 Chin Augmentation
 Neck Lift
 Mastopexy (Breast Lift)
 Breast Reduction
 Abdominal Dermolipectomy

Reduction Mammoplasty

Abdominal Dermolipectomy
“Tummy tuck”

Suction-Assisted Lipectomy (Liposuction)

Body Sculpture (Body Contouring)