75
Wound closure and the reconstructive ladder Dr. Emilia Ploplys, Surg Tech Conference 2010

a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

  • Upload
    others

  • View
    1

  • Download
    0

Embed Size (px)

Citation preview

Page 1: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Wound closure and the reconstructive ladder

Dr. Emilia Ploplys, Surg Tech Conference 2010

Page 2: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Plastic surgery and wounds?

Don’t plastic surgeons just think about two things?

Page 3: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

a noble specialty?

Page 4: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

a problem solving specialtyPlastikos- to shape and mold

Page 5: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

all over the body

Page 6: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

for all ages

Page 7: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Plastic Surgeryencompasses many disciplines

Page 8: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

to answer one question…

Page 9: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

ProblemFell down a well. Sludge and dirt in hand required debridement of all carpal bones.

Page 10: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

GoalsIdentify. Optimize. Close.

Page 11: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

IdentifyMeasurements

Clean/Dirty

Infection

Granulation

Condition of surrounding tissues

Page 12: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

IdentifyAbsent structures

Exposed structures

Patient condition

Function expected

Page 13: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Optimize

•Wound bed

•Soilage

•Spasticity

•Cushions/beds/prosthetics

•Nutrition

•Patient condition

•Patient understanding

•Patient cooperation

•Aftercare

•Home situation

•Provider relationship

Page 14: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Close

Page 15: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Close

Flap graft

Free tissue transfer

ALT

DIEP

Secondary intention

VAC

ORAMVRAMTRAM

Delayed primary closure

Tissue expander

STSGFTSG

Tubed pedicled flap

Flap delay

Page 16: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Reconstruc

tive

Page 17: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Keep it simple

Each procedure sits on a rung

Page 18: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Goalis not to climb to the top

Page 19: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Balanceascend to just the right level of complexity to close the wound

Page 20: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

The Reconstructive Ladder

Secondary intention

Primary closure

Skin graft

Local flap

Regional flap

Free flap

Distant flap

Page 21: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

DisclaimerAll photos you see here are from real people in the Great Falls area. They have consented to the use of their photos. Please respect their confidentiality.

Page 22: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Secondary intentionYes if:

•Contaminated wound/puncture

•Will heal within 3 weeks on it’s own

•No vital structures exposed

•Contraction will not cause functional or cosmetic defect

**Works very well in small concave areas

Page 23: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Primary closure

Yes if:

• Wound is clean or can be cleaned

• Tissue approximates without undue tension

• Tissue edges healthy

Page 24: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Primary closure

Page 25: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Primary closure

Page 26: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Skin graft

Yes if:

• Clean wound

• Good granulation

• No white structures exposed

• Low shear forces

Page 27: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Full thickness burn Excision to bleeding wound bed

Graft taken at 15 one-thousandth of an inch, sewn into place with 5-0 Monocryl

Page 28: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Donor site dressings

Semi-occlusive Tegederm preferred•Faster re-epithelialization•Better pain control•Easily reinforced

Downsides•Invariably leaks on bed•Hard to place on some areas

Other choices•Silvadene•Xeroform

Page 29: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Skin graft dressings

Step 1: Conformant (shown), Mepetel or nothing over graft…

Page 30: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Skin graft dressings

Step 2: VAC sponge applied, careful not to shear on application. Set to 125 mmHg continuous suction.

Page 31: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Skin graft dressings

Step 3: Threatening note written to make sure no well-meaning person changes, unplugs, or clamps VAC.

Page 32: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Skin graft dressings

Step 4: Remove VAC sponge on day 5. Healthy graft??

Page 33: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Skin graft disaster

Two days later… dead, infected graft

Page 34: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Why does a graft die?•Poor wound bed

•Infection

•Shear

•Hematoma

•Seroma

Page 35: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Why does a graft die?•Poor wound bed

•Infection

•Shear

•Hematoma

•Seroma

Page 36: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Re-excise to fascia VAC until granulation

Re-graft Success?

Page 37: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Two weeks later…

Page 38: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Yes if:

• White structures exposed

• Unique tissue

• Local tissue laxity

• Surgeon likes geometry

Page 39: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

What is a flap?Well…

Page 40: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Flaps have a blood supply,

grafts don’t.

Random pattern

Axial pattern

Page 41: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Yes if:

• White structures exposed

• Unique tissue

• Local tissue laxity

• The surgeon likes geometry

Page 42: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Bi-lobe flap

Page 43: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

You can just pull this together,

right Doc?

Page 44: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Rotation flap

Page 45: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Rotation flap

Page 46: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Transposition flap

Page 47: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Transposition flap

Page 48: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Local flap

Transposition flap

Page 49: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Yes if:

• White structures exposed

• No local tissue laxity

• Undamaged muscle/facial flaps within area

Page 50: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Before you get to the table…

Wound care

Infection

Co-morbid conditions

Offloading

Spasticity

Soilage

Seats/beds/cushions/clothes

Nutrition

Smoking

Global assessment of patient

Page 51: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Why did this happen?And why won’t it happen again?

Page 52: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Before you get to the table… Pre-albumin

• t1/2 3 days• Acceptable > 15

Albumin

• t1/2 3 weeks• Acceptable >2.8

Nutrition

Page 53: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Before you get to the table… 1 cigarette = 90 minutes ischemia

Wound healing problems

Active smokers 67%

<4wks cessation 53%

>4wks cessation 33%

Nicotine

Page 54: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Before you get to the table…

If all factors are optimized,

the wound should be getting smaller,

not bigger!

Page 55: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Debride the ulcer and bone

Page 56: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Inferior gluteal island flap

Page 57: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Inferior gluteal island flap

Page 58: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Lots of examples…

Page 59: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Forehead flap

Page 60: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Forehead flap

Page 61: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Medial gastrocnemius flap

Page 62: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Regional flap

Medial gastrocnemius flap

Page 63: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Distant flap

Yes if:

• White structures exposed

• No local or regional tissue available

• Compliant patient

Page 64: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-
Page 65: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-
Page 66: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-
Page 67: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Distant flap

Mostly obsolete

Page 68: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Free flap

Yes if:

• White structures exposed

• Large volume needed

• No local or regional tissue available

• Intact recipient vessels

• Surgeon enjoys standing for 8+ hours

Page 69: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-
Page 70: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Free flap

Page 71: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Higher on the ladder…

Page 72: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-
Page 73: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

The Reconstructive Ladder

Secondary intention

Primary closure

Skin graft

Local flap

Regional flap

Free flap

Distant flap

Page 74: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-
Page 75: a noble specialty? 2010 Powerpoint/Fall 2010...Plastic surgery and wounds? Don’t plastic surgeons just think about two things? a noble specialty? a problem solving specialty Plastikos-

Thank you!