Plastics and
Reconstructive
Procedures
Plastics
Operative Sequence
Rhytidectomy
Rhytidectomy
• Overall Purpose of
Procedure:
– To improve the appearance of
the patients face and neck area.
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)
Rhytidectomy
- Facelift -
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.
Rhytidectomy
• Wound Classification: 1
Operative Sequence
•
•
•
•
•
•
•
•
•
123456789-
Incision
Hemostasis
Dissection
Exposure
Procedure (Specimen Collection possible)
Hemostasis
Irrigation
Closure
Dressing Application
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.
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.
Rhytidectomy
cont. Operative Sequence
• Hemostasis: Handheld Bovie and hemostats.
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.
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.
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
Rhytidectomy
cont. Operative Sequence
• Hemostasis and Irrigation:
– All bleeding is controlled with cautery,
possibly Bi-polar.
– Use of warm Saline to irrigate.
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.
Rhytidectomy
•Major
Arteries:
– External Carotid
Artery
– Facial
Rhytidectomy
• Major Veins:
– Internal Jugular Vein
• Major Nerves:
– Cranial Nerve VII Facial Nerve
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.
Blepharoplasty
 Visit:
 http://www.drmeronk.com/videos.html
Plastic Procedures
Operative Sequence
Lipectomy
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
Lipectomy

Define the
procedure:
 Liposuction, also known as
lipoplasty ("fat modeling"),
liposculpture or suction
lipectomy ("suctionassisted fat removal") is a
cosmetic surgery operation
that removes fat from many
different sites on the human
body.
Lipectomy
a 12-year old girl who at 5-foot-5 weighed 230 pounds.
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 "oversuctioned". The more fat removed the higher the surgical
risk.
Lipectomy
Wound
Classification: 1
Operative Sequence









1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection
possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
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.
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.
Lipectomy
cont. Operative Sequence

Hemostasis: Handheld Bovie
Lipectomy
cont. Operative Sequence

Dissection and
Exposure:
 All dissection is
made with the lipo
cannual that the
surgeon has
previously chosen.
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.
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
Lipectomy
cont. Operative Sequence

Hemostasis and Irrigation:
 All bleeding is controlled with cautery.
 Use of warm Saline to irrigate.
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.
Lipectomy
 Major Arteries:
 Depends on
area of
Lipectomy
Lipectomy

Major Veins:
 Depends on area of
Lipectomy

Major Nerves:

Depends on area of
Lipectomy
Plastic Procedures
Operative Sequence
Abdominoplasty
Abdominoplasty

Overall Purpose of Procedure:
 A.K.A. Tummy Tuck
 To
remove excess fat and tighten
abdominal skin.
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.
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.
Abdominoplasty
 Wound
Classification: 1
Operative Sequence









1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection
possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
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.
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.
Abdominoplasty
cont. Operative Sequence

Hemostasis: Handheld Bovie
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.
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.
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
Abdominoplasty
cont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.
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.

Abdominoplasty
 Major
Arteries:
 No
major
since we are
superficial,
or above the
rectus
muscles
Abdominoplasty

Major Veins:

No major since we
are superficial, or
above the rectus
muscles
Major Nerves:

Splanchnic nerve
Plastic Procedures
Operative Sequence
Cheiloplasty (key-lo-plasty) and
Palatoplasty
Palatoplasty

Overall Purpose
of Procedure:
A.K.A. Cleft
Palate
 To reassemble
normal pathology
of the palate.

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.
Operative Sequence









1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
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.
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.
Palatoplasty
cont. Operative Sequence

Hemostasis: Bayonet Bovie or needle tip.
Palatoplasty
cont. Operative Sequence

Dissection and
Exposure:

The flaps are elevated
with skin hooks.
Palatoplasty
cont. Operative Sequence

Exploration and
Isolation:

None needed
Palatoplasty
cont. Operative Sequence

Surgical Repair:

Once the flap are
elevated, they
are closed in
three layers.
 Nasal
Mucosa
 Muscle
 Palatal mucoa
Palatoplsty
cont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.
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.

Palatoplsty
 Major

Arteries:
ascending palatal
artery
Palatoplsty

Major Veins:
Palatal vein

Major Nerves:

greater and lesser palatine
nerves
Plastic Procedures
Operative Sequence
Cheiloplasty
Cheiloplasty
 Overall
Purpose of Procedure:
A.K.A. Cleft Lip
 To reassemble normal pathology of
the lip.

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.
Operative Sequence









1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
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.
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
Cheiloplasty
cont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.
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.

Plastic Procedures
Operative Sequence
Rhinoplasty
Rhinoplasty
• Overall Purpose of Procedure:
– The goal of the procedure is to improve
the appearance of the nose.
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.
Rhinoplasty
• Wound Classification: 1
Operative Sequence
•
•
•
•
•
•
•
•
•
1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
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.
Rhinoplasty
Begin your Operative Sequence
– Incision:
• Intranasal
incisions are made
with 15 KB,
Joseph Knife,
Joseph elevator or
Button Knife.
Rhinoplasty
cont. Operative Sequence
• Hemostasis: Handheld Bipolar Bovie
Rhinoplasty
cont. Operative Sequence
• Dissection and
Exposure:
– The skin and the soft
tissue are elevated from
the underlying nasal
bones and cartilage.
Rhinoplasty
cont. Operative Sequence
• Exploration and
Isolation:
– Full exposure of the
nasal bones and
cartilage with nasal
speculum.
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.
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.
Rhinoplasty
cont. Operative Sequence
• O.R. Live video:
• Rhinoplasty - Nasal Valve Reconstruction
• Procedure:Smooth procedure
Rhinoplasty
cont. Operative Sequence
• Hemostasis and Irrigation:
– All bleeding is controlled with cautery.
– Use of warm Saline to irrigate.
Rhinoplasty
cont. Operative Sequence
• Closure:
• Suturing is very minimal for Rhinoplasties.
• MD will choose a small Chromic. 4-0 or 5-0.
Rhinoplasty
• Major Arteries:
– The external nose is
supplied by the facial
artery
– Internal - anterior and
posterior ethmoid
arteries
Rhinoplasty
• 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
Plastic Procedures
Operative Sequence
Mammoplasty
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.

Mammoplasty

Define the
procedure:

We will cover
reduction or the
removal of excess
breast tissue to
provide symmetry of
both breasts.
Mammoplasty
 Wound
Classification: 1
Operative Sequence









1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection
possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
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.
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.
Mammoplasty
cont. Operative Sequence

Hemostasis: Handheld Bovie
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
Mammoplasty
cont. Operative Sequence

Exploration and
Isolation:

None at this point.
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
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.
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.
Mammoplasty
cont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.
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.

A Simpler Approach
Mammoplasty
 Major
Arteries:





Internal mammary
artery
Lateral thoracic
artery
Thoracodorsal
artery
Intercostal artery
Thoracoacromial
artery
Mammoplasty

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.
Hand Surgery





Reasons performed:
Congenital deformities
Disease
Trauma
Can be performed by plastic surgeons,
orthopedic or orthopedic “hand-surgeons”,
and neurosurgeons
Hand Surgery









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
Summary








Terminology
Anatomy of Skin and Hand
Pathology
Medications
Anesthesia
Supplies, Instrumentation, and Equipment
Considerations and Post-op Care
Procedures: Skin and Hand