Plastic Surgery
Skin Pathology
1. Disease
2. Trauma
3. Cosmetic Alteration
Damage or loss of skin/tissue through
Disease
pathological process (disease)
Trauma – Damage or loss through
1. Burns
traumatic event
2. Frostbite – necrosis may require
amputation
3. MVA – motor vehicle accident
4. Falls and blunt injuries
5. Piercing injuries
Cosmetic alteration – addition or
1. Congenital defects
replacement of tissue or removal of excess
2. Scars
or unwanted tissue
3. Lesions
1. Microtia – external ears absent or
Congenital Defects
unusually small
2. Lop ears – ears protrude
abnormally
3. Micrognathia – small chin
4. Prognathia – protruding jaw
5. Syndactylism – fused digits
6. Polydactylism – excess digits
Rearranging/reshaping to improve
Scars
appearance or make less noticeable
1. Benign – non cancerous growth
Lesions
2. Malignant – cancerous growth
1. Nevus – moles
Benign
2. Hemangioma – vessel tumor
3. Lipoma – fatty tumor
4. Verruca – warts
5. Keratosis – dry, scaly skin – may
develop cancer (actinic/seborrheic)
1. Basal cell (BCCA) – most
Malignant
common, spreads locally, rarely
metastasizes
A = asymmetry
2. Squamous cell (SCCA) – may
B = borders are irregular
metastasize to distant organs. Death
C = color, colors unevenly distributed
to 1% of SC patients.
D = diameter > .5cm (1/4”)
3. Melanoma – highly malignant,
often presents as mole that has
changed color, size, appearance
Burns and Plastic Surgery
Burn Assessment Techniques
1. Identify the burn agent
2. Classify the burn
3. Assess the burn
CONTACT WITH:
Identify the burn agent
1. Thermal – fire, hot object/fluid
2. Chemical – corrosive/irritating
3. Electrical – overexposure – deep
damage than apparent
4. Radiation – sunlight, x-rays,
nuclear explosions, radium
1. First degree – superficial – outer
Classify the burn
epidermal layer – quick healing
2. Second degree – epidermis and
part of dermis, moist pink surface
with blisters – slow to heal. Loss of
body fluids and increased infection
risk
3. Third degree – full thickness to
epidermis, dermis and subq – dry,
pearly-white or charred appearance
– eschar forms over dry, destroyed
skin. No sensation. Needs skin graft
4. Fourth degree – “char burns”
extends into bones, tendons and
muscles. Extensive debridement
and skin graft required.
Assess the burn
1. Adult’s Rules of Nines
2. Pediatric Lund-Browder chart
Adult Rules of Nines – divides body into
1. Head and neck = 9%
sections = to multiples of 9%
2. Torso,anterior,posterior = 18% each
3. Upper extremities = 9% each
4. Lower extremities = 18% each
5. Perineum = 1%
Pediatric Lund Browder Chart – based 1. A =1/2 head 9-1/2% (0) – 3-1/2% adult
on burn location and age
2. B = ½ thigh 2-3/4% (0) – 4-3/4% adult
3. C = ½ leg 2-1/2% (0) – 3-1/2% adult
4. D = torso 13% child
5. E = arms = 2% upper, 1-1/2% forearm,
1-1/2% hand.
Plastic Surgery Treatments
Treatment or removal of tissue, lesions
1. General treatment
or scars
2. Burn Treatment
3. Lesion Treatment
4. Liposuction
1.Chemical peel – chemical burn to skin to
General treatment
activate new growth
2. Cryosurgery – freezes tissue/cancer
cells
3. Curettage/cautery – leaves larger scar
4. Debridement – removes dead/damaged
tissue and debris from wound/burn prior to
skin graft/dressing
5. Dermabrasion – smoothing skin by
“sanding” with dermabrader
6. W, Z, Y-V plasty – scar revision
technique involve excision and closure of
scars
1.Amputation – needed to stop infection
Burn Treatment
2.Contracture release – renew elasticity to
scar tissue
3. Escharectomy – excise eschar down to
fascia, covered with biologic dressing 3-5
days, STSG follows
4. Escharotomy – bilateral incision to
remove eschar crusted, necrotic, burned or
diseased tissue. Incision to fascia relieves
pressure, improves circulation and prevents
further necrosis
5. Fasciotomy – Incision extended through
the fascia if escharotomy fails
6. Replacement – skin grafts or tissue flaps
7. Tangential excision – burn tissue excised
until normal debris is reached.
1. Cryosurgery – defect frozen with super
Lesion Treatment
TX = treatment
cooled elements.
2. Excision – primary closure or graft of op
site
3. Laser – area of skin CA laser beam tx
4. Mohs – exc. Advanced, recurrent skin
CA with minimal removal normal tissue
5. Radiation – skin CA tx with x-rays
6. Topical chemotherapy – anticancer drugs
applied directly to skin lesions 2-3 wks
(Efudex – common tx)
Exc. Fat deposits via metal cannula/suction
Skin grafts and Plastic Surgery
Skin graft donor options
1. Homograft – tissue donor same species,
Homo/hetero used as “biologic” dressings. primarily cadaver skin
Stimulate epithelium formation, promote
2. Hetero-xenograft – tissue donor
growth of granulation tissue, enhance
different species, commonly pigskin
wound healing.
3. Autograft – tissue from patient’s body
Auto graft May be harvested and preserved. Wrap in
Free skin graft – Detached from donor
wet 4x4, tie attached, placing just above
site and moved to recipient site. Blood
normal saline in sterile cup. Place suture in
supply comes to graft from capillary in
lid to maintain position.
growth at recipient site.
4. Replantation – use of completely or
Tissue flap – Tissue in which subq
incompletely severed structures/tissue
vascular system is intact or re-established,
5. Implants – augotenous as well as metal,
then transferred to recipient site. Used for
alloplastic, biodegradable materials that
full thickness/extensive tissue loss.
cannot be reabsorbed into body. Must be
hypoallergenic, nontoxic and
Implants –
Tissue expansion – promotes growth of
noncarcinogenic. Dacron, Teflon, Marlex
new skin to replace damaged skin. Placed
and Silastic used for alloplastic. Ceramic,
under skin to stretch, when appropriate size stainless, titanium also used.
reached, moved onto damaged area.
Prosthetics – synthetic or natural
materials to supplement or replaced
damaged tissue or structures.
1. Full thickness skin graft (FTSG) Wolfe
Skin graft harvesting techniques
2. Split-partial thickness skin graft (STSG)
Thiersch
3. Composite graft
Contains epidermis/dermis, possible subq
FTSG
Results in minimal wound contracture
Results aesthetically pleasing
Adds padding
Covers smaller defects – face, neck, hands,
areas of flexion
Taken free hand with knife
Usually, donor site primarily closed
STSG – donor site regenerates quickly.
Contains epidermis/only portion of dermis
Can be reused in 2 weeks.
Varies in thickness
Dressings –
Results in some wound contracture
Recipient site – gauze mesh, cotton
Looks less like normal skin
sheets, Ace or Webril to maintain contact.
Covers large, denuded areas
Keep moist with NS or 1-3% acetic acid
“harvested” donor site – dermatome
saline. Change daily.
May be enlarged by skin graft mesher
Donor site – Xeroform/medicated gauze Dressings – site dependent
Compound, specialized, epidermis/dermis
Composite graft
Very small, < 2cm in circumference
Liposuction
Common tissue flap techniques
Advancement flaps – advanced to near site
Distant flaps – advanced to distant site
Pattern flap – based on blood supply
pattern
Covers very specific areas – hair transplant
1. Advancement flaps
2. Distant flaps
3. Pattern flaps
1. Tissue expansion flap – used to increase
amount of tissue available for grafting by
stretching. Tissues expands 1-1/2 times.
2. Rotation flap – rotated on axis from
donor to recipient. Muscle/transposition
3. Pedicle flap – tissue remains attached at
one or both ends of donor site. Blood
supply to graft maintained in pedicle.
1. Free flap – donor tissue skin, muscle and
even bone with its vascular bundle.
Completely detached/transferred to
recipient site
2. Myocutaneous/musculocutaneous flap –
includes muscle, fascia, subq, skin. Allows
distant transfer to cover large defect
3. Neurosensory flap – sensory nerves to
flap remain intact to provide sensation such
as face, hands, feet
4. Omental flap – omentum mobilized to
cover defects. Most often cover sternum
after infection or radiation necrosis
1.Axial pattern – vessels have axial
orientation
2. Island axial – isolated flap often
tunneled beneath skin to recipient site
3. Random – no axial vessel orientation
Common Facial Procedures
Used to improve acne scars or reduce
elevated scars, dirt, tattoos
Rhytidectomy
Removes excess skin in face and neck with
tightening of underlying supports
Blepharoplasty
Removes excess kin and protruding
periorbital fat of upper/lower lids.
Otoplasty
Corrects congenital deformities of lop ears
or microtia or correct traumatic injury
Rhinoplasty
Reconstruction for deformity
Mouth
Cleft palate – repair deformity to improve
speech pattern, prevent passage of
food/liquid into nasal passage
Cleft lip – repair deformity splitting of lip
that may/may not extend into nose/palate
Dermabrasion
Chin
Neck
Fenulotomy – release of tongue tie
Chin lift/pull – suture endoscopically
placed/tied to remedy redundant chin skin
Orthognathic- correction of foreshortened
jaw or partial absence of chin/cheek
Mentoplasty – cosmetic reshaping of chin.
Often uses silastic implant to build up or
partial mandible removal to shave back
Dissection – cervical nodes, affected
muscle/vascular structures
Cysts – brachial/thyroglossal
Hemangioma,lymphagioma removal
Submental lipectomy – excision excess
chin/neck fat
Common Breast procedures
Mammoplasty/Mammaplasty –
Augmentation – insertion of prosthesis to
reconstruction of breasts
treat hypomastia
Reduction – excision excess breast tissue to
treat macromastia
Reconstructive – post mastectomy
Mastopexy – breast lift to treat breast ptosis
Mastectomy – Excision breast CA
Gynecomastia Excision
Excision of breast tissue - male
Common thoracic and abdominal Plastic Surgery Procedures
Abdominoplasty
Tummy tuck – excision excess fat, abd
wall skin and tightening abd muscles
Suction lipectomy or sculpting
Excision of excess body fat
External genitalia
Correction of genital defects
Common Plastic surgery Procedures for extremities
Corrective surgery for congenital
Club foot or hand
anomalies of hand/foot
Syndactyly/Polydactyly
Soft tissue tumors and pressure ulcers
Often for bed ridden/diabetic pts
Replantation of amputated extremities
Often for traumatic amputations
Microvascular and microneural procedures
Often for trauma/burn victims
Special Instruments – Minor/Basic Plastic Trays
Cutting: Blades, curettes, dermabrader, dermatome (mineral oil applied to skin to aid
gliding), knife dermatomes – Ferris-Smith (used for free hand cutting, interchangeable
blades), Watson (adjustable smooth rod slides over skin as surgeon advances rotationally,
Weck(straight razors with interchangeable guards), Skin graft mesher – used to expand
skin, drill for bones, liposuction curettes and liposuction vacuum machine, osteotome –
used to cut/shape bone, Rasp (Cottle, Fomon, Joseph, Lewis) – used to reshape
bone/cartilage, Scissors – used for dissecting and cutting (plastic surgery, Iris, Tenotomy
or Stevens, Blepharoplassty, Facelift, Fomon or lower lateral, wire cutting scissors.
Grasping/holding: Forceps – Adson, Brown, Hudson, Bishop-Harmon. Used to grasp
delicate tissue. Piercing towel clips.
Retracting/exposing: Skin hooks (Cottle, Gillies, Joseph) used to retract dermis and
provide exposure to underlying structures; may have single/double prongs.
Nerve retractor – Cushing, Love, Sachs – can retract vessels
Suturing/Stapling: Needle holders – Castroviejo – used to hold fine needles
Ryder – used to hold find needles
Staples and staplers
Ligating clip appliers and clips
Measuring: Caliper – Castroviejo, Jameson – used for making precise measurements for
face, eye and ear procedures
Ruler, Metal – Used to make precise measurements for small/large grafts