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E}TASlilKC SKJRGEEEY

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Dr. l. Fish and Dr. A. Freiberg
Avinash Islur and CIaire Thurgur, chapter editors
Gilbert Tang, associate editor

BASIC PRTNCIPLES ... ..... .. 2 €ETANIOFACTIILFRACTEIIRES .. ......E8


Stages of Wound Healing Craniofacial Assessment
Abnormal Healing Radiographic Examination
Factors lnfluencing Wound Healing Mandibular Fractures
Wound Closure Maxillary Fractures
Management of Contaminated Wounds Nasal Fractures
Dressings Zygomatic Fractures
Sutures and Suturing Techniques Orbital Blow-out Fractures
Skin Grafts
Other Crafts PEDIATRIC pLASTIC S{IRGERY . .. . ..2X
f taDs Cleft Lip
Cleft Palate
TAE IIAND ,.., 7 Syndactyly
History Polydactyly
General Assessment Hemangioma
General Management
Amputations tsREAST RECONSTRE CT[$N ...., ...22
Tendons lmplant Reconstruction
Fractures and Dislocations Autologous Reconstruction
Dupuytren's Disease N ipple/Areol a Reconstruction
Carpal Tunnel Syndrome (CTS)
Hand lnfections AESTT{ETIC SURGERY ., .. ...23
Rheumatoid Hand Face
Breast
TFTERM,|iLINJIXREES .........I3 Other
Burns
Pathophysiology of Bum Wound $IIRGICALPROCEDEIRES .... ......,24
Diagnostic Notes Release of Trigger Finger
lndications for Transfer To Burn Centre Decompression of Carpal Tunnel
Acute Care of Burn Patients Reduction Mammaplasty
Chemical Bums
Electrical Burns COMMON EMERGENGEES . .. ........24
Frostbite Amputations
Extensive Mangling lniuries
soFT TISSUE TNFECTTONS . .. .... ...i6 Maior Laceration with Serious Hemorrhage
Leltut tt!s Companment Syndromes
Necrotizing Fasciitis High Pressure lnjection lniuries

sKxN LESTONS ... ....E6 ITEFEITENCES .. ....24


Management

ULCERS .......17
Pressure Ulcers {Sores)
Leg Ulcers

MCCQE 2002 Review Notes Plastic Surgery - PLI


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STAGES OF WCIT'ND HEAI.TNG


D growth factors released bv tissues plav an imDortant role
I lnflammatorv phase' 0-2 davs
...f"htii and organismi cleared via inflammatory response, e.g. macrophages, granulocytes
U re-epithelialization phase: 2-5 davs
. from edges oiwound and from dermal appendages i.e. pilo-sebaceous adnexae
. epithelial cells migrate better in a moist''environirent i.e. wet dressing
fl proliferdtivephase:5-42-days - ,..,.,,
. fibroblasts anmcted to wound by macrophages
. collagen synthesis by fibroblastd leads tb inireasing tensile strength
. gnnulation tissue formed with neovascularization
. at 6 weeks the wou.nd strength is at 40% and is strong enough to tolerate moderate forces
I remodeling phase: 6 weeks-l yeai
. collagen crosslinks, scai flattens,i, (. i/!lr, l:r'lf{,j-t(:,}r,lttlj(ilils,r .

.at6months,tissuestrengthpIateausat$!o$.9finormaltissuestrength

A$NORMAL T{EAX,TNG
D hypertrophic scars (these generally improve with time if left to heal)
. hypertrophic tissue does not cross the boundaries ofthe scar
. common sites include back, shoulder. stemum
. red, raised, frequently pruritic
, ,, : I r, treatment is conservative . ,,
I amenable to sureical revision
O keloid scars (these do;ot resolve spontaneouslv)
. tissue extends beyond the s&r boundari6S iunlike hVp'ertrophic scars)
.

. common sites include sternum, deltoid. earlobe


. collagen: whorls rather than bundles
. increased frequency in darker skinned people
. treatment:_pressure dressings, silicone sheets, topical steroids, intralesional steroid injection,
radiation theraov, su reical resection
, .. may
u cnronlc
recurwith'siirgicil revision
wouncls
. fail to heal within 3 months
. examples: diabetic ulcers, pressure ulcers, venous stasis ulcers
. may heal with meticulous wound care, but many will require surgical intervention
F'ACTORS INFLUENCING WOIIND HEALING
Local (reversible): General (often irreversible):
fl mechanical (local trauma, tension) tr nutrition (protein, vit C, Oz)
I infection E peripherai vascular disease [PVD]
D hematoma/seroma ! imokins
tr blood supply D diabetei
I retained foreign body Q chronic illness
'(, j Ll cancer I ir ( )E, inirnunocomprornised (steroid6, chemotherapy)
r fl previously inadiated tissues I hypenension (gfN)
D self induced (diagnosis of exclusion) , ,E uremia ,.;
' 'E
,.,, ,remote infection
E'obesitv
disease (cVD)
,,F, :qll,:qin.vascular
WOUND CI,OSURE
I t\:r I .:( j Frirnary Closure (Irirst Intention)
D definition: wound '
closure by direct approximation of edges within hours of wound creation
(i.e. with sutures, flap, skin lraft, etc.l
,;r,,, _
Ll lnolcanon: clean wounds
.

Secondary Closure (Second Intention)


D definitio-n: wound leh open to heal by grinulation, epithelialization and contraction (myofibroblasts)
E indication: when primary
'anentibn,closure is n6t-possible or nbt indicated for any reason, including infection,
delay in medical loss of skin
n inferior cosmetic result, requires dressing changes, psychological impact of open wound

Tertiary. Closure (Delayed Prtun3rq.Closure)


U definition: intentionally interrupt healing process (i.e. with packing),
then wound is usually closed at 4-10 days post-injury
E indication: contaminated wounds wherd initial primirv closure is contraindicated
fl prolongation of inflammatory phase lowers bacierial cbunt and lessens chance of infection after closure

PL2 - Plastic Surgery MCCQE 2002 Review Notes


MANAGEMENT OF €ONTAMTNATED W@ETNDg
', :[,wound is considered contaminated when it contains more than 100,000 bacteria/gram
E acute contaminated wound t< 24 hr)
' ..
debridement: sureical {blade, inieation}
ciosurF: p4tnary clo,syre with pronbfiJament (contraindications to primary closure;
, animal and human bites, crush iniuries)
'rr' 'r i'lrl'cl.'6"clear\de hnd copiouslv irrieate opbn wound with physiologicsolutions
::r(1r('r (;'\'ri Salihe (NS)
orRingels Lactate (RL) (rio ioap, alcohol, orotherinitants)
. 'li.e.-Normal
svstemic antibiotics if wound
"older
than 8 hours
o +/- tetanus (Tetanus toxoid (Td) 0.5 mL lM)
. alwavs check tetanus immunization status: reimmunize if patient has received
less than three tetanus immunizations, if the last Td was rirore than l0 years ago,
i or if last Td unknown
.
if high risk wound (e-g. soil equipment, major trauma) then reimmunize
if lait fd was more th-an 5 yea'rs ago
n follow up in 48 hours
D chronic contaminated wounds (e.9. lacerations > 24 hours, ulcers)
.
debridement: sursical or mtchanical (e.9. wet-to-dry dressings)
.
closure: final closuire via delaved wouhdclosure {tehiarv clos-ure} orskin graft
" successful closure 4gpends cin decreasi,ne bacteria count to I00,000/gram-or less
oriorto closure and heouent dressing changes
.
iopical antibacterial creAms {see Table 9l
sybtemic antibiotics are not useful - no penetration into the bed of gnnulation tissue
'
DRESSINGS
' !U eoals are absotption, protection, compression,
Tst laver {contah laver)
cosmesis
.. clean wounds, heal bv;re-epithelialization.
o protect new epithelium
. use nonadherbnt imp,regnated gauze (e.g. Jelonet, Bactigras or Sofratulle)
.
chronic/contaminated wounds:
. mechanicallv debride nonviable tissue
. use adheredt Saline or Betadine soaked eauze ("wet-to-drv" dressing)-
. dead tissue adheres to gauze and is remSved with dressing change
D 2nd layer.(absorbent layer)
. saline soaked gairze, to encoumge exudate into dressing by "wick" effect
[ 3rd laver (orotective laver)
.'dry'gauze held iir place with roller gauze or tape

SETTTIRES AND SUTE RING TECTTNIGIIES


,dnesthesia
I lidocaine +/- epinephrine -.
I never use eoin'eohrine for finsers, toes, penis, nose, ears and tissue edges lsmall skin flaps)
E iniect anesthetic into, not aroilnd, wound before debridement and inigation
D toxic limit of lidocaine:
o without epinephrine 5 me/kSJhour
. with epinbphrine 7 mgiklhdur ( I 'riirr'i,'ii'\'lcc of lo,6 solution contains I 0 mg
lidocalne) ,, ii .'. (j { .'|a i!r ii:, i iri I
E early signs of toxicity are CNS excitation follow6d by CNS, respiratory and cardiovascular depression
Sutures {see Table l)
E use of d oarticular suture material is highlv dependent on sureeon preference
fl bacterial infection: monofilament < mu'ltifilambnt (braided]
E tissue reaction: svnthetic < organic
fl dehiscence of tisLue under stiess: nonabsorbable < absorbable

Table I. SutureTgrpes
Type Description Indications

Surgical gut organic, absorbable monofi lament Subcutaneous closure and ligation
(plain or chromic)

'notygty.Slif i"iai synthetlc. absorbable monofilament le.g- ilionocryl I Transcutaneous and subcuticular closure
and braided (e.g. Vicryl, Dexonl

Nylon Synthetic, nonabsorbable monofi lament (e.g. Ethilon) Soft tissue approximation and microsurgery procedures
and braided {e.g. Nurolonl

Polypropylene Synthetic nonabsorbable monofi lament Genenl soft tissue approximation, used in
(e.g. Prolene) contaminatediinlected wounds

silk Nonabsorbable multifi lament Transcutaneous closure

MCCQE 2002 Review Notes Plastic Surgery - PL3


Elsic.Suturing Techniques
U basrc DnncrDles
' . minimize tissue trauma: follow curve of needle, handle, wound edges gently (use toothed forceps)
o enough tension to approximate edges - do not strangulate
. use tte finest needlb'and suture o5ssible
o to ensure good cosmesrs:
. eveit skin edees when closine
. avoid tension-on skin {close i"n lavers)
c ensure eoual width and depth oltissue on both sides
. remove sutures within 7- l0'days (5 days for the face; l4 days if over a iciint)
:' r ]'r'' rLr
I- basic suture methods
- - ;-simple inienubted - for face and when scarrins is Iess importaht
. subbuticular - ilood cosmetic result; weak, used in combiriation with deep sutures
, . vertical mattress - for areas difficult to evert dorsum of the hand}
. horizontal mattress - everting, time saving {e.g.
. continuous over and over - time savine

simple interrupted ' ''subcuticular horizontal mattress vertical mattress


Figurc l. Basic Suture Methods
lllustalion bg Baseu Khan

SKIN GRAFTS
E definition: a segment of skin detached from its blood supply and dependent on
revascularization from the recipient site
I donor site selection
n must consider size, color, hair pattem, texture and thickness of skin required
.usuallytaken from inconspicuous areas {e.g. buttocks, lateral thighs, etc.)
.for facial grafts, preferable to take graft from above clavicle {e.9. post-auricular area}
E slcin graft "take" occurs in 3 phases
.plasmatic imbibition - nourishment via diffusion (first 48 hours)
.inosculation - vessels in gnft connect with those in recipient bed
.neovascular ingrowth - gmft revascularized by ingrowth of new vessels into bed
E reouirements for survival
" bed: well vascularized (bone and tendon are unsuitable beds]
. contact between graft and recipient bed : fully immobile
. staples, sutures, splinting, and appropriate dressings (pressure).,,,,,,,,,
are used to prevent hematoma, seroma, and movement of graft
. recipient site: clean {to prevent infection)
'rliI lypg5i,,ll ; j ':'.i rii .:i ]:; I

" ' . autograft - from same individual


. allograft - from same species, different individual
- from different species e.g. porcine
_
u *^^i lgloeraft
lltEDlt g|t6tL
t Drevents accumulation of fluids
o iovers a larger area
. has significant contractures
I not cosmetically appealing
n best for contaminated recipient site

PL4 - Plastic Surgery MCCOE 2002 Review Notes


Table 2. Skin Gra-frcs

Split Thickness Skin Graft (SISG) Full Thickness Skin Graft (F"[sG)
Definition Epidermis and part of dermis Epidermis and all of dermis
Donor Site More sites Limited donor sites
llealing Re-epithelialization via dermal appendages Primary closure or split thickness skin gnft
Re,haruesting -10 days (fasteron scalpl
Graft take Good; shoner nutrient diffusion distance Lower rate of survival
Contraction More Less
r;'
Sensation POOr Good
Aesthetic Poor Good
Comments Can be meshed for greater area Use on hce, fingers tips and over ioins
Advantage - Take wellin less hvorable conditions Resist contraction, potential for growth,
textu re/prgment more norrnal
Disadvantage ppnnact signifi q4ntly, abnormal pigmentation, Require well vascularized bed
nrgn suscepuollrry ro uauma

rhin
.l
f Epidermis
spllr I nlcKness ---l Medium
sKrn uran I
t-,
L_ Thick
Dermis
fuil I nrcKness
Skin Graft

Subcutaneous Tissue

Drawing bq Karen Petruculli

OTETER GRAFTS

Table 3. Various Grafts


Graft Type Use Prcfered Donor Site
Bone Repair dgid defects Cnnial, rib, iliac, fibula
Cartilage Restore contour of ear and nose Ear, nasal septum, costal cartilage
Tendon Repair damaged tendon Palmaris Iongus, plantaris
Nerve Conduit for regeneration across newe gap Sural. forearm, cutaneous arm
VesseI Bridge vascular gaps (i.e. {ree flaps} Forearm or foot vesse'ls for small vessels,
saphenous vein for larger vessels
Dermis Contour restoration (+/- fat for bulk) Thick skin of bunock or abdomen

F'[.APS
I definition: tissue transferred from one site to another with vascular supply intact
{not dependent on neovascularization} unlike a graft
fl classifidd according to blood supply to skin: random and axial
fl indications for flaoi
I soft tissue coveraee i,e. oaddine bonv prominences
. reconstruction i.e:after facial, bieast,bi lower leg tissue loss
c' to lmprove Dlooo supply to Deo l.e. oone
provide vascular recipient bed for skin graft

' 1;6prove sensation (rierves to skin flap intact)


MCCQE 2002 Review Notes Plastic Surgery - PL5
I may require. use of tissue expanders pre-operatively to increase available tissue (especially in scalp area]
vta mecnanlcal Stretcnt ng
" consists of subcut"aneous silicon reservoir into which saline is iniected
intermittentlv over several weeks
! main comolication: flap necrosis, caused by
.
extiinsic comprbssion (dressing too iightl
c excess tenslon on wound closure
o vascular thrombosis {poor microsurgical anastomosis}
.
hematoma
I need to monitor flap viabiliw
. skin colour, capillary ri:fiI1, post puncture bleeding, Doppler monitoring
Randorn Pattern Flaos (see Fieure 3)
n skin and subdermal tissue with-random vascularsupplv
Q limited length: width ratio to ensure adequate blood slpply (on face I .5: l, rest of body l: I )
U " .
TVDeS
rotation
. Limbere {rhombicl
. Z-olasfr - used to eain or to chanee
- the line of direction of the central limb of Z
(i.i:. relbase of scar"contractures)
" advancement flaps (single/bipedicle, V-Y Y-Vl
Asial Drt*am Flanc
D flap contains a w6ll defined artery and vein
I allbws sreater leneth: width ratio-(5-6: l)
. feninslrlarll6p - skin and v'essel intact.in pedicle (see Figure 4a]
. island flao -
j vbssel intact lsee Fieure 4b)
_. freq fl4p vascular supply anastciinosed at recjpient site by microsurgical techniques
I can be sub'clAssified accordine'to tissue content
. offl;D:
musculocutaneous/myoEutaneous: vascular sufply !o skin fqom musculocutaneous perforating vessels
" fasciocutaneous - vaslular supply from plexus sJp6rficial to fascia
Free Flaps
I transolantine exoandable donortissue from one part ofthe bodv to another
I tissue must 6e dble to suryive on a single-pedicl6d blood supply with an artery and draining vein
I use microsureical technique
. the tra"nsplanted part is reanastomosed to recipient site vessels to reestablish blood flow
. survival fates > 95%
e e.g. Tralrsverce Rectus Abdomipal Myocutaneous {TRAM), radial forearm, scapular
. cai be fuscicutaneous, muscle flap, cir osseous

Rotation Flap

Limberg Flap

Figure 3. Wound Care Flaps, llandono Pattern


lllustratio n b g Teddtl Came ro n V-Y Advancement Flap

r.FI,AP

4a. Peninsular Axial Pattern


lllustralons bu Karen Petruccelli
PL6 - Plastic Surgery MCCOE 2002 Review Notes
http:/luniversity.arabsbool<.com

Fhysiology of the Shin


u sKn eDroermls ano oermts
I blood'vessels and nerves are found in the dermis
D acts as a banier to infection, prevents loss of fluids, maintains body temperature

tsTIRNS
D etiolosv: Children - most commonlv scald bums
Adults - most commonly flame bums

PAFFIOPFI.IOTOGY OF EEIRN WOUNE) {see Fieure 17}


B zone of coasulation - cells irreversiblv damaeed = cellular deJth
I zone of stasis - poorly perfused, celli iniured and will die in 24-48 hours without proper treatmenti
sludeine of capillaried theed to Drevent swelline and infection I
I flaors favoring cell survival: moist, aseptic environment, rich blood supply
'
E zone of hyperemia - Eells will recover in 7 days, equivalent to superficial buni

Anterior

4t /2"rc

Zone of hyperemia
i:3
W Zoneofstasis

f] zone ofcoagulation

Figure 17. Zones of Therrnal Iniury Figure 18.


Itule of 9's for Total Body $urface Area
lllusbation bg M. Gail Rudahcwkh

DUTGNOSTIC NOTES
D estimate body surface area =TBSA) - rule of 9's includes second and third degree burns only
nate bum size (total bod
dren underase
ildren
{children under age l0 use a Lund-Browder chart)
-patient's
O patch
for patchy_b
'atchv bums, ntb pEpalm represents approximatelv l% of the TBSA
. u n1s-.
-Fatie
TBSA > 50% have ba'sal metabolic rate'(BMR) 1.5-21. predicted
tr age --.more
more complications
cgmplications if.< or > 60 years old
if < 3 o
tr pepth classificaiion (see Table 7)
tr tocauon
.
face. hands. feet, perineum are critical areas reouirins soecial care of a bum unit
.
circLimfereritial bdms arg manqged with eschardtomf(ah incision down to and including fat)
to Drevent toumiouet effect of Sschar
! watch forlnhalation iniury, associated iniuries (fractures), co-morbid factors
(concunent d isability, aliohol ism, renal ili sease )
Red Flag
r-l Susp6ct inhalation iniurv if bnrn sustained in closed space, singed nasal hairs,/eyebrows,
sooi around nares,/oril calitv, hoarseness, and coniunitisitis. REquires immediate
intubation due to impendinjairway edema.

Table 7. Burn Depth (see Colour Atlas [rL)


Nomenclature T[aditional Depth Clinical Featlrres
Nomenclature
Partial thickness First degree Epidermis Erythema, rvhite plaque
{superficial)
Partial thickness Second degree Into Superifical dermis Clear fluid, superficial blisters, painful
(Deepl

Deep partial thickness Second degree lnto deep dermis Difficult to distinguish from full thickness
Full thickness Third deeree Throueh dermis Hard, leather-like texture of skin
Fourth dEgree involves, underlying tissue, eschar formation, purple fluid, insensate
muscle. Done

MCCOE 2002 Review Notes Plastic Surgery - PLl3


ENDTC"Hil@NS F@R TRANSFER TO BURN CENTEAE
Alnerican Burrr Association Criteria
!! total 2oand 3o bums > l006 TBSA in patients < I 0 or >, ,50 years of age
total 2oand 3o bums > 20% TBSA in batients anv ase
E 3'bums > 5% TBSA in oatients anv aee
D 2o or 3o bums with threat of seriorjs finctional or cosmetic impairment
(i.e. face, hands, feet, genitalia, perineum, maior ioints), contrbctures
E inhalation_ iniury (maylead to reispiratory
inhalation injury respiratory distiess)
distiessl
D electrical bums {inteinal iniurv urideresiimated bv tSSRtr ,. '; 1

I
lJ chemical bums posinq
posing thre'at of functional or'cosmetic impa
threat bf inipairment
E bums associateil with majortrauma . , ..i,,...,i,iir:1,^i;;,,;ili;
AcurE cARE oF' EURFr pAqreryFg.tni;;oi;11;l:a'
: ':rr';r)tt
RespiratoryDistress
tr if inhalation iniury suspected (bum sustained in closed space, sinsed nose hairVevebrows, soot around
nares and oral'caviry, hoarseness, conjunctivitis, history of explosiSns or flash bum6), intubate immediately
beiore edema occurs
E acute causes
" carbon monoxide (CO) poisoning {treat with 100% Oz, decreases half-life of carboxryhemoglobin
from 210 minutes to minutes)
. eschar encircling chest59 (perform escharotomy)
u late onset
. due to smoke inhalation and pulmonary injury
. risk of pulmonary insufficiency (up to 48 hours) and pulmonary edema [48-72 hours)
. causes'chemical'injury to alveioiai basement membiane and fulmonary edema
. if humidified Oz not duccessful, mav need to intubate and ventilate
n watch for secondary lung infections'(after I week) Ieading to progressive pulmonary insufficiency
. watch for bronchopneumonia (up to 25 days)
Burn Shock
D definition: hvpovolemia due to movement of HzO and Na+ in zone of stasis and eeneralized increased
capillarv permeabiliw in all oreans {occurs if > 30% TBSA}
D reiuscitaiion with Paikland forinula' to restore plasma volume and cardiac output (see Table 8l
. 4 cc Rinser's/ke/% TBSA over first 24 hou'n
. TBSA noiinclude lst deeree areas
. 12 of ddes
this in I st 8 hours post 6um. rest in next I 6 hours

E
" in followins 6 hours eive'0.35-0.5 cc plasma/kePATBSA, then D5W at rate to maintain normal serum Na*
extra fluid administration. rEquired in bum's greaterihan 80% TBSA, associated traumatic injury, electrical bum,
_ inhalation iniury, delayed st€irt of resuscitati6n, pediatric bums, and 4o burns
U mOnlIOf feSUSClIatlOn :,....,r, r,, t,,.,.,,..
. urine output is the best measure
o maintain urine output > 0.5 cdkghr ladults) and I.0 cdkg/hour (children
r also maintain a cle'ar sensorium,-HR < 12O/minute, mean *BP > 70 mmHe < l2
years)

Thble 8. Eurn Shock Resuscitation


I

Efour0-8 | ZccRingerb/kgP'TBSAoverShi;'ursii1"t:it':" itri:lir,ititiri;r

Hour 8 -24t l,':':r2..Ringer's/kg/%TBSAoVer't6hours


Hour 24 - 3O I 0.35-0,5 cc plasma/kgf,tTBSA

> Hour 3o I D5W at nte to ....


maintain normal serum sodium : 1

.l::.::j . .;i-. ..- : ii;1.'-!.':iI


,l - ,...:.i..1
* don't forget to add maintenance fluid to resuscitation
|
Burn Wound
n eoals 3rd degree bum wound care
- rofprevent infection {one of the. most significant causes of death in bum paiientsl
. most common organisms include S.ailreus, P. aeruginosa and C. albicans
Day l-3: Gnm positive
Day 3-5: Gram negafive
.
remove dead tissue
.
cover wound with skin as soon as possible
E surgicallv debride necrotictissue, excise to viable (bleedins) tissue
tr topical, antimicrobials to prevent bacterial infection {from pltient's gut flora or caregivers} and
seconoarv sepsrs
! importani to bbtain earlv wound closure
I de'epsecondorthirddeiereeburn>sizeof aquarter:indicationforskinsraft
Q prevention of wound con-tractures: pfessure drbssings, ioint splints, early-physiotherapy

PLl4 - Plastic Surgery MCCOE 2002 Review Notes


, I ir' jl(i'i,
Table 9. Topical Antibiotic Therapy
Antibiotic Fain with Application Fenetration Adverse E$fects

None Minimal Methemoglobinemia, stains

Minimal Medium Slowed healing, leukopenia

Modente Well S)owed healing, acid-base abnormalities

:i iif i-lil
Other Considerationo in Burn Management
D nutrition: calories. viiamin C, vitamin AICuz*, 7p2+, fs2+
lJ tmmunosuDDressron ano Sepsls
n eastrointedtinal {Gl} bleed mav occur with bums > 40% TBSA
. treatment': tube feedind or NPO, antacids, Hz blockers
fl renal failure sgcondary to hypbvo.lgmia . rq,re
. beware oI neDirotoxlc antlDlotlcs ln Durn care
I tetanus toxoid shou'ld be administered to all patients sustaining bums deeper than superficial
partial thickness

CIIEMICAL BURNS
D coaeulate tissue oroteins causinq necrosis
D sevEriw depends on: wpe of ch6mical {alkali worse than acid},
concenirati6n, ouantiw-,'and contact time, deqree of tissue penetration
E bums are deeB6r than initially appear and m-ay progress with time
LJ rnsoec eves
I corirmon bgents: cement, hydrofluoric acid, phenol, tar
U treatment
. dilution with wdterisinitial treatment " ' l
. wash eyes out with saline and refer to ophthalmoiogy
e repeatecl aDDllcatlon oI Polvsponn tor removal oI taf
. loial care ak'er l2 hours, debridement, topical antibiotics
. wound closure same forthermal bum
E beware: underestimated fluid resuscitation, renal, liver, and pulmonary damage
ELECTRICAL BURNS
tr depth ofbum depends on voltage and resistance ofthe tissue
n in decreasine ord'erof conductioi, nerve, blood, muscle, skin, tendon, fut and bone debridement
n oftenimitl p'unctate burns on skin with massive deep tissue damage which requires
! iniurv more severe in tissue with hieh resistance (i.e.'bone)
U elbarical bums require ongoing mo-nitoring as latent iniuries become manifest
I watch. for
opul monary nl uries €.g..ventricular fi brill ation
. cardi
i

mvoglobrnuna/nemogtoDlnufl&., -;
. frdctlres and dislocations, especially. shoulder and spine
. tissue necrosis secondary to vessel thrombosls
n decrease in RBC (beward of hemonhages)
increased creatinine/potassium and addity indicating tissue destruction
". seizures
. intraperitoneal damaee ;

E treatment
. toDical aeent with sood penetratine abiliw (silver sulfadiazine)
. ion-viablEtissde early and repeat prn {every 48 hrs} to prevent sepsis
. ddbride
maior amputations ffequently requlred
FROSTBITE
D intracellular ice crvstals leadine to cell lvsis
D microvascular occfusions and deriphenl vasoconstriction leading to ischemia
D suoerficial frostbite: onlv skin and subcutaneous tissues frozen
D de'ep frostbite: underlyihg tissues frozen as well
fl man'aeement
o rewarm raoidlv in waterbath (40-42"C)
. after rewaiming, tissue becomes purple, edematous, painful blisters may appear,
resolving after several weeks
'.leave i4iured region oPen to air
leave blisters intact
.debride skin eentlv with dailv whirlpool immersion
{ scrubbi ng, m'assa{e and topi cal oi ntmenls lrot
req u i re.d }
.sursery mlv be ne-eded to ielease constrictive, circumferential eschar
. waii until complete demarcation before proceeding with amputations

MCCQE 2002 Review Notes Plastic Surgery - PLlS


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CET,[,E LTTIS
I non-suppurative infection ofskin and subcutaneous tissues
I signs airii symptoms '
. pain, tendemess, edema, erythema with poorly defined margins
"o iever, chills, malaise (systemjc symptoms'diffeientiate it fronisimple initation)
can lead to lymphangitis (visible red streaking in areas proximal to infection)
, I skin:flora most common org-anisms: S. auTeus, p-hemolytic Strepiocotcus .,
I treatment is antibiotics: firit line Pen G 2 miliion uniti q6-8h'lV + cloxacillin I g gg"8h lV
I outline area of erythema to monitor success of treatmeni i .

. ....,. NECROTTZENG FASCTITIS


: D infection,leading to'gangrene of subcutaneous tissue, and subsequent necrosis of more superficial layers
i i{ )rr ;i{ (see Colour ndas-nf)
:

' _D fjrp" I: B-hemolytic slreptoroccus,Type ll: polymicrobial


u natural hlstorv
o severe pain, fever, edema, tendemess
.infectioh spreads very rapidly
c patients are often very sick and toxic in appearance
.skin tums dusky blue and black (secondaryto thrombosis and necrosis)
.induration, formation of bullae
.cutaneousgangrene, subcutaneous emphysema (Type ll)
D diagnosis
. o severely elevated CK
" hemostlt easily passed along fasbiil plane
D treatment
" fascial biopsy
. surgicai debridemenl r€fitoval of necrotic tissue, copious inigation,
often requires repeated trips to the O.R,
. IV antibiotics: clindamycin 900 mg q8h lV + Pen C 6 million units q4h IV

Red Flag
I Soft frssue Infections: Sus;rect necrotizing fasciitis with rapidly spreading erythema and
ederna. Must dernarcate ergthernatous area on adrnission,in,order,to determine amount
of spread.

Table lO. Soft'fissue Infections (Classified by Depth)


Erysipelas I Subcutaneous(epidermis)infection
Cellulitis I full thickness skin infection
Fasciitis I Fascia
Myositis I Muscle

(See Dermatqlcie& Chapter) i:'rr';" "i ' 'r;ri'|)j'Lrr,r

MANAGEMENT
Non.Malignant Lesions
! incl udes- hvperkeratoti c, fi brous, cvstic. vascu lar and oism ented lesions
D treat with dbrmatological method.d or surgical excisioh iT necessary - to halt further growth,
IOr COSmeSTS Or lI Cltntcallv susptclous
Malienant Lesions
I balal cell carcinoma (BBCI (see Colour Atlas D2I)
. primarilv taneentiai drowth
. Lurettag-e and electr6dessication: for smaller lesions; include a 2'3 mm marein of normal skin
. surgicafexcision: deep infiltrative lesions; 3-5 mm margins beyond visible a-nd palpable tumour border;
mav reoulre sKtn grafi or ilao
. I-ray therapV: less*traumatii and useful in difficult areas to reconstruct, requires a skilled physician
because of manv complications
. cure rate is the dame iapproximately 9)%|,forthe above procedures in competent hands
ii squamous cell carcinoma (SCp)-(see Colour Atlas Dl7)
. pnmantv ventcat growln
. same ontions for ireatment as for basal cell carcinoma
. more aggressive tieatment because more malignant than BCC
PLl6 - Plastic Surgery MCCQE 2002 Review Notes
I melanoma (see Colour Atlas A23)
. excision is prirnarv management
o forlesions < 0.75 inm thiikness: a I cm margin is recommended
. for lesions > 0.75 mm thickness: a 5 cm mariin is recommended
n node dissection for lesions > 0.75 mm
. beware of lesions that regress - tumour is usually deeper than one anticipates
c assess sentinel nodes

Concepts in Exeising Any Skin tr,eqion


U incise along normal skin lines to minimize appearance of scar
E use,spindle ?i.'rp.$ incision to prevent "{og bars" (heaped up skin at end of incision)
u unoermtne sKrn eoges to oecrease wound tenston
! use layered closure-including dermal sutuies when necessary {decreases wound tension)

T,RESSTIRE III,CERS (SORES)


E common sites; heel, sacrum, greater frochanter, ischial tuberosity, elbows, occiput
D staees
. hyperemia - disappears I hour after pressure removed
. ischemia - foliows 2-6 hours Dressure
. necrosis - fo]lows > 6 hours fressure
. ulcer - necrotic area breaks down
tr prevent with good nursing care: clean skin, frequent log rolling, special beds (Kinair), egg crate mattress
treatment
. debridement of necrotic tissue (with dressings + surgical debridement)
o continue with preventative methods
. topical antibiotics of ouestionable value
' osteotomy and closur6 with myocutaneous flap in selected cases
LEG IILCERS
Thble I l. Venous vs. Arterial Ulcers vs. Diabetic Ulcers
Venous (7O% ofv-ascular ulcers) Arterial Diabetie
lnegular wound margins Even wound margins lnegular wound margins
Superficial i
Deep Superficial
Moderately painful Extremely painful Painless
Yellow exudate + granulation tissue Dry,/ necrotic basg ,g1io1r; Necrotic base
Gaiter distribution Distal locations ':-1. :'-'.ir! l Pressure point distribution
Venous stasis discoloration Thin shiny dry skin Thin dry skin
Normal distal pulses Decreased distal pulses Decreased pulses
No rest pain Claudication / rest pain No claudication / rest pain

Venous Stasis Ulcers (see Colour Atlas PL4)


I due to venous hypertension, valvular incompet6nce
E painless, dependent edema, discoloration, commonly over medial malleolus
U treatment
. elevate, pressure stockings, may need skin graft

Aterial lschemic lllcers (see Colour Atlas FL5)


I secondarv to small and,/orlaree vessel disease
! usuallylocatedonthelateralispectsofthesreatandfifthtoesanddorsumoffoot
D painfui, distal, punched out ulcers with hype'rsensitive/ischemic sunounding skin
U treatment
. rest, no elevation, modify risk fuctors (stop smoking, exercise, diet, etc.)
. treat underlying condition (diabetes, proximal afterial occlusion, etc.)
. ultimately, rha/use skin graft, flap, or'amputation

MCCOE 2002 Review Notes Plastic Surgery - PL|T