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Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery San Leandro Surgery Center

Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery San Leandro Surgery Center

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Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery San Leandro Surgery Center

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  1. Managing Plastic Surgery Patients Part One Rex Moulton-Barrett, MDPlastic & Reconstructive SurgerySan Leandro Surgery Center

  2. The 8 Aspects of Plastic Surgery • Congenital: clefts, nevi, vascular tumors ear reconstruction, hand anomalies • Hand: nerve compression, tumors/soft tissue, trauma • Head and Neck:resection and reconstructivesurgery • Skin cancer: excision and reconstruction • Burn Reconstruction • General Reconstruction: truck, abdomen, lower limb • Breast: reduction, reconstruction • Cosmetic

  3. 2 ways to get in trouble in medicine • DON’T GO WHEN YOU ARE CALLED • DON’T CALL WHEN YOU GET THERE

  4. Gorney’s Rule • Extent of problem should = the concern • Operate on ‘ Sylvia ’ : secure, young, listens, verbal,intelligent, attractive • Don’t operate on ‘Simon’: single, insecure, male, overexpectent, narcissistic

  5. Post operative complications • 5.4% complication rate clean surgery cases : 50% preventable • Blue Cross Aneheim refuses to pay for complications: April 2008 • Specifically: pressure sores, sternal wounds, line/foley sepsis • Record insurance profits 2007: aggressive disclaimer policies • Post op infection most frequent complication: 1/2 mil/yr USA • Average cost per infection is $3,000 • Post operative infections associated: 2 x procedure mortality

  6. What stops wound healing • Infection • Foreign body • Tension/reduced vascularity: venous,arterial,both • Inflammation: allergic, autoimmune, mechanical • Steroids and cytotoxic agents • Tumors • Munchausen’s Syndrome

  7. Controlling Surgical Site Infections • Saline versus water irrigation similar infections rates • Transfusion during cardiac surgery increases rate • Supplemental hydration does not change rate • Hypothermia core temp< 36 C (96.8) • Prophylactic antibiotics < one hour before incision • One dose IV as good as multiple & less C diff later • Cardiac patient glucose control < 200 mg/dl • Best no hair removal < shave < razor • Maintaining oxygenation • Maintaining arterial, venous and capillary circulation

  8. Hypothermia and wound infection • 200 pts undergoing colorectal surgery: hypothermia assoc with 19% infection rate, vrs 6% non hypothermia Kurz, et al, 1996: NEJM 334(19):1209-1215 • Hypothermia leads to vasoconstriction • Vasoconstriction reduces tissue partial pressure O2 • Tissue hypoxygenation = decreased neutrophil phagocytosis • Every drop of 1.5 C assoc. complications cost $ 2,500-7,000 • Influenced by warming: preop pt, fluids, bed, irrigations, room temp, length of procedure, body surface area exposed, inhalation gases

  9. Patterns of blood supply • Random (2:1 ratio) • Axial • Random and Axial ( rectus: type 3 )

  10. Tension / Compression • Venous: decreased cap refill: < 3 seconds • Arterial: increased cap refill: > 5 seconds or no refill: > 5 seconds • Creep phenomenon: 3 x 1 minute stretches 3 minutes apart • Cyanosis: requires O2 sat of <80% and 2.38 g/deoxyhemoglobin not present if arterial ischemia/vasoconstriction or severe anemia

  11. DVT • Pre surgery prophylaxis • Prevalence: 24% after elective surgery!! • Risks factors • Who should get Lovenox: enoxaparin • Clinical signs of DVT • Clinical Signs of PE

  12. DVT Preventive Stockings • Reduce post-MI DVT p<0.003 (Kier,1993:Eur Heart J 14,1365-68.) • May be as effective as pneumatic compression or low dose heparin • Standing position ankle vein pressure in 5´7˝ adult is 86mmHg • 20-30 mmHg if standing ineffective at compressing s/d leg veins • 4 classes: 20-30,30-40,40-50 & 50-60 mmHg • 2 categories: ready made and custom • 2 broad types: elastmeric ( day time ), non-elastameric ( straps ) • Compression garments > 22mm Hg can cause thrombosis: knee • elastomerics: woven:excellent, expensive, strong 3 knitted: circular, flat (custom), cut & sew(custom) elasticity from synthetic rubber or latex weave breathability related to thickness and cotton/nylon

  13. Manufacturers • Jobst: 18-25 or 25-35mmHg • Sigvaris: synthetic rubber threads covering nylon • JuZo: increase upper stretch for big thighs • Medi: spandex thread inlaid into woven row • Camp: double wrapped yarns • Venosan: nylon, Lycra and cotton graduated • Convalec: inelastic cohesive unnaflex • 3m Health: elastomeric high stretch adhesive microfoam • TED: most well known • Ibizi: Segreta ( Lycra )

  14. Venous Thromboembolism Assessment Risk Score:0-1 Low, 2-4 Moderate, 5 or greater high risk • Hip fracture surgery (5) • Total hip/knee replacement (5) • >70 yrs (3) • H/o DVT/PE (3) • Paralysis (3) • abdo/pelvis/leg (2) • # hip/pelvis/leg (2) • 61-70 yrs (2) • (1) • Obesity >20% ideal body weight • Varicose veins / varicose swelling • inflammatory bowel disease • Bedrest preop > 48 hrs • Myeloproliferative • Malignancy • < 6 weeks post-partum • Acute ischaemic stroke • 41-60 yrs • Major surgery • CHF • Severe respiratory disease • sepsis

  15. Suggested prophylaxis Regimen • Low:early ambulation, TED’s, +/- Sequentials, 20 degree knee flex • Moderate: Sequentials +/- TED’s, 20 degree knee flex Heparin 5,000 SQ q 8-12 hrs or Levenox 40mg SQ q 24 hrs or Lenenox 30 SQ q 12 hrs • Severe: Sequentials +/- TED’s Heparin 5,000 SQ q 8 hrs or Lovenox 30 mg q 12 hrs Place temporary Greenfield Filter prior to surgery

  16. Well’s Clinical Dx Scoring Criteria Anand SS, et. al. Does this patient have deep vein thrombosis? JAMA, 1998; 279:2094-1099 • Entire Leg swollen (1) • 10cm below tibial tuberosity >3cm calf enlargement (1) • Pitting edema (1) • Collateral engorged non varicose veins (1) • Alternative likely diagnosis (-3) If the score > 3: high risk and 85% probability 0: low risk and 5% probability

  17. Clinical Presentation DVT • 1/2 million hospitalized DVT/yr US • 10% die • Stasis, hypercoagulation, endothelial injury • Pain then swelling, Howman’s negative 2/3’s • Clinical exam 3/4’s negative, some arise proximal • Assoc with popliteal valvular insufficiency • 1/3 of calf thrombi will propagate and embolize • Di-Dimer: fibrin degrad products: only 2% false neg • Colorflow Duplex: falsenegative20% below & 5% above knee • Thrombolytic therapy more successful than anticoagulation

  18. Symptoms of Pulmonary Embolus • 73% dyspnea • 60% pleuritic chest pain • 43% cough associated chest pain

  19. Clinical Presentation Pulmonary EmbolusWell’s Score Thromb Haemost. 2000 Mar;83(3):416-20 Clinical Signs and Symptoms of DVT?Yes +3 PE Is #1 Diagnosis, or Equally LikelyYes +3 Heart Rate > 100?Yes +1.5 Immobilization at least 3 days, or Surgery in the Previous 4 weeksYes +1.5 Previous, objectively diagnosed PE or DVT?Yes +1.5 Hemoptysis?Yes +1 Malignancy w/ Rx within 6 mo, or palliative?Yes +1 • Score of <4: only 8% had PE by D-dimer testing • MRI 97% sensitive, 95% specific • Anticoagulation prevent DVT propagation, reduces PE • Hospitalization with unfractionated heparin • Thrombolytic therapy for massive emboli

  20. Fat Embolus: 5-15% mortality • Who is at risk: closed fractures, tummy tucks, liposuction • <3 days after surgery • 25% have petechial rash • SOB, tachypnea, hemoptysis, crackles, ARDS • Non specific w/u: fat in blood, snow storm CXR, serum lipase & phospholipase B • Management: if acute, left lat position IV ethanol, dextran, steroids New: IV Lipostabil (3-sn-phosphatidylcholine ethanol 96% V/V)250mg in 5ml: 40mls slow IV then 80ml/day divided 20ml QID

  21. MRSA • 5% of population have MRSA in the nose • This group accounts for 38% of MRSA infections arising within hospital • 62% of MRSA infections arise in hospital • ie 62% are true nosocomial in origin • watch the housekeeping, lab, clerical, catering and ancillary staff carefully for glove changing between rooms / beds

  22. Specific Procedures • Breast Reconstruction • Cleft Surgery • Hand surgery • Burns • Cosmetic: Abdominoplasty Facelift Eyelid Surgery Liposuction Augmentation +/- mastopexy Post - bariatric surgery

  23. Breast Reconstruction • Reduction of the opposite breast after lumpectomy • Tissue expansion and exchange implantation • ‘Tram’: Transverse rectus abdominus myocutaneous • Double Trams and supercharged Trams • Latissimus Dorsi with implant • Free Flaps: Tram, Perforator Tram, DIEP, IGF • Fat grafting

  24. Delayed, Double Pedicle, Supercharged TRAMs

  25. Free Flaps: Rectus, DIEP SIEA, IGAP Flaps

  26. Cleft Surgery • Cleft Lip & Palate > Palate > Lip • Pierre Robin syndrome: microgenia and airway obstruction • Craniofacial Synostoses: Apert’s: hydrocephalus and airway obstruction Velocardiofacial: palate, cardiac and ectopic carotids Sticklers: palate and retinal detachments Klippel-Feil: palate and C 1-2 subluxation Crouzon’s: 80% optic nerve compression

  27. Pierre Robin Crouzon’s Apert’s Stickler Klippel Feil Velocardiofacial

  28. Cleft Palate & Airway Obstruction • Repair separates oropharynx from nasopharynx • Compensatory tongue hypertrophy • Separation can lead to crowding of orophrynx • Microgenia/midfacial retrusion increase crowding • IV steroids lead to reduced hospitalization • Tongue suture always placed for airway control

  29. Hand Surgery • Allen’s Test • Cap refill • Elevation • Surgical positioning: ulnar nerve and median nerve compression, brachial nerve plexopathy

  30. Capillary Refill • Normal Tissue Capillary Refill is 3-5 seconds • Nail Capillary Refill test is < 2 seconds • Unreliable in presence of hypothermia and severe anemia

  31. Allen’s Test Dominant Ulnar > Radial Artery 8.1% May be higher in populations with h/o ABG’s 1. Elevate hand 30 seconds 2. Make fist elevated 3. Apply pressure over Radial and Ulnar Arteries 4. Open hand while elevated, it should be blanched 5. Release one vessel pressure, should refill in 7 seconds

  32. Median Neuropathy • Motor: thumb opposition and abduction radial 2 lumbricals • Sensory: radial 3 1/2 fingers

  33. Ulnar Neuropathy • Motor: All intrinsics except thumb opposition & abduction radial 2 lumbricals • Sensory: Ulnar 1 1/2 sensory

  34. Brachial Plexopathy • poor positioning • downward brachial traction • shoulder hyperextension • descent of the thorax • prolonged arm abduction • responds to IV steroids • true neuropraxia: up to 6 week recovery

  35. Cosmetic: Abdominoplasty • Not panniculectomy, umbilicus preserved • Modern technique utilises low incision • Corsetting rectus and oblique muscles • Closure in jack- knife sitting position • Complications mostly related to tension • DVT/PE increased risk if: obese, concomitant hysterectomy, liposuction • Atelectasis risk when combined breast surgery • Commonest cause of SOB: too tight dressings • Muscle relaxants, firm abdominal binders and jack=knife positioning in a surgical bed reduce pain

  36. Facelift • 3 component surgery: muscle, fat, skin • Swelling and bleeding very individual • Skin survives on random pattern blood supply: tension and smoking can kill (15% smoker slough ) • Unilateral swelling and pain = hematoma • Bilateral tightness in the neck associated with platysma corsetting • Relative emergency for skin survival and potential airway compression

  37. Eyelid Surgery From Rees, 1996 • Contents within orbital septum closed space • Ophthalmic vein, nerve and artery contained within the orbital septum • Bleeding after surgery is an absolute emergency, loss of vision can occur within 20 minutes ( 1:20,000 ) • Release sutures and or lateral canthotomy

  38. Liposuction • Traditional, wet, superwet and tumescent • Calculation of blood loss • Calculation of fluid resusitation • Admission to hospital > 6 hours, > 6 litres

  39. Liposuction and fluid rescusitation • Traditional 150ml aspirate=drop 1% Hct • ie > 2 L needs transfusion • IV replacement cc for cc in OR, + cc/cc RR • Tumescent: 1 L RL+ 1 cc 1:1,000 epi+ 50cc 1% lido 2 ml in then > 10 minutes 1 cc asp. out, Up to 6 L no X match required can use up to 35mg/kg: lido in fat replace cc/cc in OR, or less • Cranberry drainage from the ports for 3 days

  40. Breast Augmentation +/- Mastopexy • Dressings designed to push implants down • Commonest cause of SOB: dressings too tight • Implants over the muscle hurt much less • Muscle relaxants reduce pain, mostly pectoral pain • Unilateral chest pain & no swelling:pneumothorax ? • Unilateral pain and swelling: hematoma ? • Bilateral pain: tight dressings &/or muscle spasm ?

  41. Post - Bariatic Surgery • Risk of bariatric surgery assoc BMI • Calculation BSA=(height cms x weight kg/3600)/2 M2 BMI=weight kg/M2 height • Procedures after: abdominoplasty circumferential lipectomy extended thighplasty brachyplasty mastopexy/augmentation facelift and eyelid surgery

  42. Clinical Test case 1 • 44 yr old Vietnamese male undergoes elective cleft palate repair. S/p surgery he is noted to be cyanotic, O2 sat 85%, inspiratory stridor, intercostal recession, labored breathing and normal neck and oral exam

  43. Clinical Test case 2 • 30 yr old 250 female with h/o bariatric surgery, s/p 150 pound weight loss c/o SOB, tachycardia 110, 1 day post op. S/p abdominoplasty, O2 sat 90%, shallow breath sounds at bases of lungs, calfs non tender and feels well

  44. Clinical Test case 3 • 74 yr lady 1 day s/p quad blepharoplasty c/o left thigh pain 1 day post op and SOB with mild chest pain on coughing. Her HR is 110, O2 sat 88%, decreased BS at left base and some crackles left base of lung

  45. Clinical Test case 4 • 4 hours after heparinization, the patient complains of reduced vision in the left eye, there is some bulging of the eye and some early bruising. The pupil is reactive to light and accommodation

  46. Clinical Test case 5 • 1 hour after abdominoplasty with liposuction a patient complains of extreme shortness of breath, right sided chest pain and the urge to defecate. The chest exam reveals crackles and decreased breath sounds at the right apex, EKG severe RBBB, blood drawn for cardiac enzymes normal and serum lipase elevated and there are petechiae on the anterior chest

  47. Clinical Test case 6 • 3 hours after abdominoplasty a 66 yr old previously hypertensive, post bariatric patient with a history of severe lumbosacral back DJD needs high doses of PCA meds to control her abdominal dyscomfort. 5 hours after surgery her BP drops to 70/50 and she becomes drousy with shallow respirations and pin point pupils

  48. Clinical Test 7 • A demanding 63 yr old lady undergoes an uneventful facelift and 6 hours after surgery requests IV MS just 1 hour after her last pain medication because of increased right sided facial pain. Her dressing are intact and there is no sign of bleeding into her dressings. She says she feels the right side of her neck is tight

  49. What’s New In Plastic Surgery ? Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery San Leandro Surgery Center