PL

Plastic Surgery
Ryan Austin, Imran Jivraj and Anthony So, chapter editors Alaina Garbens and Modupe Oyewumi, associate editors Adam Gladwish, EBM editor Division of Plastic: and Reconrrtructive Surgery, Univenity of Toronto, staff editors

Basic Anatomy Review ................... 2 Skin Hand Brachial Plexus Face Differential Diagnoses of Common Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . 5 DDx of Skin Lesions/Masses Basic Surgical Techniques ................ 5 Sutures and Suturing Excision Wounds ............................... 6 Causal Conditions Principles of Wound Healing Contaminated and Infected Wounds Dressings Reconstruction Soft Tissue Infections ................... 12 Erysipelas Cellulitis Necrotizing Fasciitis Ulcen ... 13 Lower Limb Ulcers Pressure Ulcers Management of Skin Lesions ............ 14 Burns ................................ 15 Burn Injuries Pathophysiology of Burn Wounds Diagnosis and Prognosis Indications for Transfer to Burn Centre Acute Care of Burn Patients Special Considerations

Hand ................................. 20 Traumatic Hand General Management Hand Infections Amputations Tendons Fractures and Dislocations Dupuytren's Disease Carpal Tunnel Syndrome (CTS) Rheumatoid Hand Brachial Plexus ........................ 26 Common Palsies Differential Diagnosis Investigations Management Craniofacial Injuries . . . . . . . . . . . . . . . . . . . . 26 Approach to Facial Injuries Mandibular Fractures Maxillary Fractures Nasal Fractures Nasa-orbital Ethmoid (NOE) Fractures Zygomatic Fractures Orbital Floor Fractures Breast Surgery .. 31 Breast Reconstruction Breast Tissue Expanders Aesthetic Surgery ...................... 32 Aesthetic Procedures Pediatric Plastic Surgery . . . . . . . . . . . . . . . . 33 Craniofacial Anomalies Congenital Hand Anomalies References . . . 35

Toronto Notes 2011

Plastic Surgery PLI

PL2 Pladic Surgery

1'oroDio

2011

Basic Anatomy Review

Skin

F"11r 1. Split and Full (whala} Thiclmus SWn Grafts

Hand
BONES AND NERVES
't'

C."llla11 MIMIDIIIC (in order. pi'IIDnallhan d-.lrow; nadial ID ul111r aidal Some-Scaphoid Lovera- Lunate
Try- Triqlllllrum

1.

RadiUI

2. Scllllhoid 3. TnpaziiJII 4. T1111J8ZDid 5. Capiblbl

Positions-Pisiform ThBI-Trlplllilrn Thay- Trapamid Cannot- Cepillbl Hard! - HanultB

I. Ulna 7. Llllltll
8. Pilliorm

10. Hamalll 11. Mrtllearpll

boon

F"111ra Z. Carpal Ban.

Rgun1 3. Se1101J Disbiblltia1 in tile Hand

Toronto Notes 2011

Basic Anatomy Review

.....

Plastic Snrgery PL3

TENDONS

,,._ , ___________

Flexor Tendons All require OR repair. Extensor Tendons ER repair unless proximaVmultiple tendons.

DIP
Flexor digitorum profundus ] - Proximal interphalangeal joint

PIP
Extensor hood

Camper's chiasm Flexor digitorum superficialis Lumbrical } - - Metacarpal phalangeal joint Interosseous muscles

Figure 6. Testing Profundus (FDP)

j
Extensor digitorum communis
0::

.!!J
@

"

Figure 4. Flexor Tendon Insertion at PIP and DIP

Figure 5. Extensor Mechanism of Digits Palmar

Figure 7. Testing Superficialis (FDS)

Flexor retinaculum - - - - ' " \ c Median nerve - - - - . . .

Dorsal Figure B. Carpal Tunnel

1. Extensor retinaculum Compartment 1 2. Abductor pollicis longus 3. Extensor pollicis brevis Compartment 2 4. Extensor carpi radialis brevis 5. Extensor carpi radialis longus Compartment 3 6. Extensor pollicis longus (EPL tendon passes around Lister's tubercle) Compartment 4 7. Extensor digitorum 8. Extensor indicis Compartment 5 9. Extensor digiti minimi Compartment 6 10. Extensor carpi ulnaris

Figure 9. Extensor Compartments of the Wrist (dorsal view and cross-sectional view)

PIA Pladic Surgery

1'oroDio

2011

Brachial Plexus

llnchmi'IDIIIIIIH..IIIB

Thomas- Trurb
llrink8- Divillicm Cold-Cords Ba1n-

Rob-Roots

Medial

MIMI$ of arm 111d fol'llllm

BIWICHES
Flg1re 10. Brachllll Plexus AnlhiiiY

CORDS

DMSIONS

lRUNIKS

Face

10

I. IJicriiTllll bans 2. Zygomatic bona

&. Sphanaid bana 1. TempDI'III bana

3. MllCII1 4. Maidlle S.Nalllbo"'

11. Skul and

B. Pllrielll bone 8. ,o. Flunlal bo"'

fllcilll BCIIIas

'IbroDlo Nota 2011

Di&reDiial Diapo&el of Common Prele:DlalioD&/k Surgical Techniques

Plaalk Surgery PLS

Differential Diagnoses of Common Presentations

DDx of Skin Lesions/Masses
For background information, see DermatDlo&f. D3

Basic Surgical Techniques

Sutures and Suturing
ANESTHESIA inject anesthetic before final debridement and irrigation lidocaine (Xylocame) epinephrine (vasoconstrictor, limits bleeding) toxk limit and duration of action ( 1 cc of 1CJ6 solution contains 10 mg lidocaine): without epinephrine: 5 mglkg.lasts 46-60 min with epinephrine: 7 mg/kg, lasts 2-6 hours slgn8 ofumctty: CNS excitation followed by CNS, respiratory, and cardiovascular depression bupivicalne (Marcaine) epinephrine used fur longer analgesic effect toxic limit and duration of action: without epinephrine: 2 mglkg, lasts 2-4 hours with epinephrine: 3 mglkg, lasts 3-7 hours tmicity of mixtures (i.e. lidocaine + bupivicaine) is no greater than ita individual components

irrlgate copiously with a phy&iologic solution such as Ringer's lactate or normal saline to remove

IRRIGATION AND DEBRIDEMENT

surface clots, fureign material, and bacteria debride all obviously devitaliud tissue. irregular or ragged wounds must be excised to produce sharp wound edges that will assist healing when approximated SUTURES use of a particular suture IIlllterial is highly dependent on surgeon preference suture IIlllterial divided by two categories: absorbable vs. non-absorbable: absorbable materials commonly used fur deep sutures under short-term tension - also used fur akin closure in children or uncooperative adults - lose at least 5096 of their strength in 4 weeks and are eventually absorbed - aamples include Plain gut", Vlcryl, Polysorb non-absorbable materials commonly used fur skin clorure or in sites oflong term tension - lower li.kelibood of wound dehiscence - examples include nylon, polypropylene, stainlell5 steel monofilament VII. mult:ifil.ament (a.k.a twisted or bmided) monofilament sutures slide through tissue with less friction but have more memory/ stiffness - used in contaminated and infected wounds -lower likelihood ofbacterial trapping in suture material - examples include Monosof", Monocryi, Biosyn" multifilament sutures have less memory/rtift'ness making them easier to work with - increased lilcelihood of bacterial trapping, should be avoided in contaminated wounds - includes Vicryi and Silk BASIC SUTURING TECHNIQUES Basic SUb.lre Methods (F.Igure 12) simple interrupted- can be used in almost all situations intra-cutl.cula.r - good cosmetl.c result but weak. used in combination with deep IJUture8 vert1cal mattress- for areas diffi.cul.t to evert (e.g. dorsum of the hand) horizontal matt.rell5 - everting, time saving continuous over and over (a.k.a "running", "bueball stitch") - time slrving. good fur hemostasis

PL6 Pladic Surgery

Balle Suqkal Techniques/WoundJ

1'oroDio 2011

Basie Principles
minimize tissue traUDlll! fullow curve of needle, handle wound edges gently (UBe toothed forceps), use just enough tension to appr<Wmate edges (do not st:rangula.te) use the finest needle and ruture pOSiii.ble to ensure good cosmesis

evert skin edges when closing avoid tensl.on on skin (close in layers) ensure equal width and depth of tissue on both sides remove sutures within 7-10 days (5 days for the face)

Figure 13. lnclllo of l.8donl Aloll Relaxed Sldn Te...on Unea

'.

Grey regio1111 indicale areu of llkin to be ercieed

Other Skin Closure Materials tapes - may be indicated for superficial wounds and those with opposable edges. Thpe cannot be u&ed on actively bleeding wounds. When placed across the lndsion, will prevent surface marks and can be used primarily or after surface sutures have been removed.. Tape bums may occur if there is excessive tension or swelling around the incision

.. ,

skin adhealves - e.g. 2-octylcyanoacrylate (e.g. Dermabond-> works well on small areas without much tension or shearing. Advisable in children. May tattooing staples - steel-titanium ailoy5 that incite minimal tissue reaction (healing is comparable to wounds closed by suture)

IIIIU811 &ldn TIMIDn Llnll

NaturallkWwrinkle lin11 with mininal

linwta1111iD11. inciliplllllalto IISTI.s minimizes widanllgl l!wlllrlru!lhY, and helps to I*!IDulllllll

IC81'1.

Excision
incise along relaxed skin tension lines (RSTLs) to minimize appearance of scar use elliptical Incision to prevent ..dog eat(' (heaped up skin at end of Incision) ifneeded, undermine skin edges to deaeaae wound tension use layered closure Including dermal sutures when wound Is deeper than superficial (decreases

tension)

Wounds
Causal Conditions
laceration - cut or torn tissue abl'll8ian - superficial skin layer is removed. variable depth cootuaion - injury by forceful blow to the skin and soft tissue; entire outer layer ofskin intact yet injured avulsion - tlssue/Umb forcefully separated from surrounding tissue, either partially or fully; "de-gloving" puncture wounds- opening relatively small as compared with depth (e.g. needle) includes bite wounds crush injuries - caused by compression thermal and chemiall wounds

'.

,

Myofibrobluts are the cals rasp-1118 far wound conlnlction. Thev dD this Ita 1111e Df 11111 than o.75 IMV'dev.

Principles of Wound Healing

wound: disruption of the normal anatomical relationships of tissue as a result of injury
STAGES OF WOUND HEAUNG
see Figure 14 growth factors released by tissues play an important role

FACTORS INFWENCING WOUND HEALING Local (revenlble/controllable): General {often .lrrevenible): mechaniall (local trauma, tension) age
blood supply (ischemia/circulation) temperature

tedml.que and suture materials retained furelgn body infection hematoma/seroma (1' infection rate)

nutrition (protein. vit C, smoking cbronic Illness (e.g. diabetes, cancer, CVD) lmmuno9t1ppresslon (steroids, chemo, radiation)

collagen vascular disease tissue irradiation

venous hypertension peripheral vaacular disease

Toronto Notes 2011

Wounda

Plastic Surgery PL7

__________ _ ________ P_RO_C_EU ________

1. lnflllmm.taiJ Phullleactivl} pJ..p 1-6} Limits damage, prsyants further injury Debris and organisms deared viii inflammlllllry respDnse: Nautrophils {24--48 hours) Macro phages: critical to wound heeling by orchestrating growth factors for collagen production {4S-96 hours) Lymphocytes: role poorly defined {5 7 days)

Hz.
.....

1. Hemostasis- vasoconstriction + PLT plug ChemDIIXis- migration of mecrophages and PMN

Z. Pralfllrwtin ""- {hgan1r.tiVII) (Day 4 - W.ak 3) Fibroblasts <tnncted and aclivlted by macrophage growth lilctors process: re-epithelialisalion, mlltriK synthesis, angiogenesis {relieves ischemia) Tensile strength begins to increase at days 4-5

1. Collagen synthesis (mainly typa Ill) Z. Angiogenesis 3. Epithelialillllion

I. llemadeling Phala (MIItwatian) (Week 1- 1 ytNir)

Increasing collagen organization and stronger crosslinka Typal collagen replaces Type Ill until normal4:1 ratio achiiMid Peak tensile strength at 60 days- 811% of preinjury strength

r-

1. Contraction Z. Scarring 3. Remodeling of scar

Figure 14. Stages of Wound Helling

ABNORMAL HEALING

Hypertrophic Scar scar remains roughly within boundaries of original injury red, raised, widened, frequently pruritic common sites: back, shoulder, sternum treatment: pressure garments, silicone gel sheeting, corticosteroid injection, surgical excision if other options fail (however, may still recur), typically improves with time Keloid Scar scar extends beyond boundaries of original injury frequently pruritic, often painful; collagen in whorls rather than bundles common sites: sternum, deltoid, earlobe; more common in darker skinned people treatment: pressure garments, silicone gel sheeting, corticosteroid injection, radiation therapy, surgical excision as a last resort Chronic Wound fails to heal primarily within 6 weeks common chronic wounds include diabetic, pressure and venous stasis ulcers treatment: may heal with meticulous wound care; many require surgical intervention Marjolin's ulcer: squamous cell carcinoma arising in a chronic wound secondary to genetic changes caused by chronic inflammation -+ consider biopsy of chronic wound
WOUND CLOSURE

Primary (1) Closure (First Intention} definition: wound closure by direct approximation of edges within hours of wound creation (i.e. with sutures, staples, skin graft, etc.) indication: recent (<6 hours, longer with facial wounds), clean wounds contraindications: animal/human bites (except on face), crush injuries, infection, longtime lapse since injury (>6-8 hours), retained foreign body Secondary (2} Closure/Spontaneous Healing (Second Intention) definition: wound left open to heal spontaneously (epithelialization 1 mmlday from wound margins in concentric pattern), contraction (myofibroblasts) and granulation- maintained in inflammatory phase until wound closed; requires dressing changes; inferior cosmetic result indication: when 1 closure not possible or indicated (see Primary Closure, above)

PL8 Plastic Surgery

Wounds

Toronto Notes 2011

Tertiary {3) Closure/Delayed Primary Closure {Third Intention)

definition: intentionally interrupt healing process (e.g. with packing), then wound is usually closed at 4-10 days post-injury after granulation tissue has formed and there is <105 bacteria/ gram of tissue indication: contaminated (high bacterial count), long time lapse since initial injury, severe crush component with significant tissue devitalization prolongation of inflammatory phase decreases bacterial count and lessens chance of infection after closure

Contaminated and Infected Wounds

Definitions
contamination - the presence of non-replicating microorganisms within a wound colonization - the presence of replicating microorganisms within a wound infection - greater than 105 microorganisms in a wound without intact epithelium, a wound may also be infected with small amounts of a very virulent organism (e.g. GBS)

....

Acute Contaminated Wound (<24 hr)

cleanse and irrigate open wound with physiologic solution (NS or RL) debridement: removal of foreign material, devitalized tissue, old blood surgical debridement: blade and irrigation if indicated evaluate for injury to underlying structures (vessels, nerve, tendon and bone) control active bleeding systemic antibiotics are commonly indicated for obvious infection, wound older than 8 hours, severely contaminated, immunocompromised, involvement of deeper structures (e.g. joints, fractures) tetanus toxoid (Td) 0.5 ml 1M tetanus immunoglobulin 250 U deep 1M (see Table 1 and Table2) postexposure treatment of hepatitis B, HIV, (hepatitis C iftitres confirmed at 6 months) re-evaluate in 24-48 hours for signs of deep infection open infected portion of wound by removing sutures if evidence of infection (ie. erythema, warmth, pain, discharge) Table 1. Risks for Tetanus
Tlllnui-Prone Not TlltlnuH'rone

Infection is based on: 1. V"rrulence of the infecting microorganism 2. Amowrt of bac:terill prvli8nt 3. Host resistance

lime since injury Depth of injury Mechanilll1l of Injury

>6h
>1 em
1ilough clathilg, farming injury

<6h
<1 em
Sharp cut (e.g. clean knifa, cleen glm)

Crush. bum. gun&hDt. frostbite, puncture

Present

Devitalized tissue

Not present
No No

Contammon (e.g. soil, drt, taliva,

grass) Retained ftreign body

Table Z. Tetanus Immunization Racommendations

Histurv af tetanus illnunizalian

Uncertain or <3 doses of i11111'1JJ1ization 3 doses received in immunization series
0.511'1 Dfcanminadlltl11111nd diptlwia lllxllids acalllpartullis. .. Telmls irmmeglai!Uin, 250 Ugi'llllah lili!lll'lllsitelrorn T4'Jdrp

Clean, 11inar wounds

All lither wounds

Td orTdiP

Tig
Yes
Nof

Yes
No-

No No
- V.. >10yan linea lntllclom'
5yean Iince lastboastlit

No

f Ya-. inrnUI1DCDII1prinil8d.

Contaminated Wounds (>24 hours. including ulcers)

irrigation and debridement traumatic tattooing can occur if foreign materials left in wound topical antimicrobial- avoid inhibitors of epithelialization (see Table 3) systemic antibiotics indicated if there is concern of infection (eg. redness, swelling, pain, clinically unwell) closure: final closure via secondary intention (most common), delayed wound closure (3 closure), skin graft or flap; successful closure depends on bacterial count of ::;:105 prior to closure and frequent dressing changes

Toronto Notes 2011

Wounda

Plastic Surgery PL9

BITES
Dog and Cat Bites pathogens: PasteureUa multocida, S. aureus, S. viridans investigations: same as for human bites; see below treatment: Clavulin (500 mg PO q8h started immediately- amoxicillin + clavulinic acid) consider rabies prophylaxis if animal has symptoms ofrabies or unknown animal rabies Ig {20 IU/kg around wound, or IM) and 1 of the 3 types of rabies vaccines (1.0 ml 1M in deltoid, repeat on days 3, 7, 14, 28) agressive irrigation with debridement healing by second intention is mainstay of treatment (see Emergency Medicine, ER47) only consider primary closure for bite wounds on the face; otherwise primary closure is contraindicated contact Public Health if animal status unknown Human Bites pathogens: Staph> a-hemolytic Strep > Eikenella corrodens >Bacteroides) mechanism: most commonly over dorsum of MCP from a punch in mouth; "fight-bite serious, as mouth has microorganisms/mi., which get trapped in joint space when fist unclenches and overlying skin forms an air-tight covering ideal for anaerobic growth- can lead to septic arthritis investigations: radiographs prior to therapy to rule out foreign body (tooth)/fracture culture for aerobic and anaerobic organisms, Gram stain treatment: urgent surgical exploration ofjoint, drainage and debridement of infected tissue wound must be copiously irrigated Clavulin 500 mg PO q8h, clindamycin 300 mg PO q6h + ciprofloxacin 500 mg PO q12h (if allergic to penicillin) + secondary closure (see Emergency Medicine. ER47) splint

Dressings
there is no one dressing for any given type of wound. Dressing selection depends on the wound characteristics as the wound progresses through healing it will require different types of dressings, therefore, routine inspection is recommended principles of dressings: wet vs. dry wounds - purpose of dressings should be to keep wound appropriately moist (i.e. moistening dry wounds or removing excess exudate/blood from wet wounds) - dry wounds -+ options include films and hydrogel dressings; require secondary dressing - light to moderately exudative -+ options include hydrocolloid dressing and hypertonic saline gauze - highly exudative -+ options include hydrofibre dressings, foam dressing , and hypertonic saline gauze - bleeding wounds-+ options include alginate dressings, as they have hemostatic properties clean vs. infected wounds - clean wounds can be dressed with petroleum based gauze, which is non-adhering to epithelializing tissue; requires secondary dressing - infected wounds can be dressed with iodine gauze or silver-containing dressings wide-based vs. cavitary/tunneling wounds - cavitary or tunnelling wounds (ie. through a fascial layer) can be packed with salinesoaked (non-infected), betadine-soaked (infected) ribbon gauze, or other easily retrievable one-piece moisture providing dressing

... , ,

Elwnplp of Dr...inp Films (Opsita8 )

(lnlnlsitl8 ,

Nui!1118 ,

Ouaderm} Hychfib11s (Aquacal) Hyd-ocolloid {Duoderm 8 , Teglderm 8 ) Hyper1Dnic saline gauza (Masa!t8} FOIUTI (Mepilex4', Allavyn 8 } Alginates (Sorb68n8 , Kalmmrt8) Peboleum basad gauze Silver dressings

Iodine (lodolorb8 ]

Reconstruction
SKIN GRAFTS
Definition a segment of skin detached from its blood supply at the donor site and dependent on revascularization from the recipient site Donor Site Selection must consider size, hair pattern, texture, thickness of skin, and colour (facial grafts best iftaken from "blush zones" above clavicle e.g. pre/post auricular or neck) partial thickness grafts usually taken from inconspicuous areas (e.g. buttocks, lateral thighs, etc.)

..... ,

lleeonsln1c:tion l.addtr
SICOnduy closu11 Primary cl0111n1 Skin graft

Locallllp

fliiP Free tissue 1nlnsfer

PLIO Plastic Surgery

Wounds

Toronto Notes 2011

Partial Thickness Skin Graft Survival 3 phases of skin graft "take" 1. plasmatic imbibition - diffusion of nutrition from recipient site (first 48 hours) 2. inosculation- vessels in graft connect with those in recipient bed (day 2-3) 3. neovascular ingrowth - graft revascularized (day 3-5) requirements for survival bed: well-vascularized (unsuitable: bone, tendon, heavily irradiated, infected wounds, etc.) contact between graft and recipient bed: fully immobile {decreased shearing and hematoma formation) staples, sutures, splinting, and appropriate dressings (pressure) are used to prevent movement of graft and hematoma or seroma formation site: low bacterial count (<105, to prevent infection) Classification of Skin Grafts 1. by species autograft: from same individual allograft (homograft): from same species, different individual xenograft (heterograft): from different species (e.g. porcine) 2. by thickness: (Table 3) T1ble 3. Skin Grafts
Split Thickness Skin Grift [mG]

Ful Thickness Skillhft [FTSG]

Epidennis and all of deanis Limited donor sites (full thickness skin loss, ITIJst be closed 1" or with STSG) Primary closure or thickness skin graft NIA Lower rate of suiVival(thiclcer, sloww vascularization) Greater 1 contraction. less 2 contraction Good May use on face and fingers Resists contraction, texture/pigment more nonnal

Dillinilion

Epidermis and part of dennis

..... ,

Hlilg af DilliN" Sill Ro-hlnatig

..

via dermal appendages in graft and wound edges

-10 days (faster tr1 scalp) Easier; shorter nutrient diffusion dista1ce

Primary- immediate reduction in size

Gnft Cantraction

Grift Tale

upon h11Mr1ing Secoodary- reduction in 5ize once graft placed on wound bad

Contraction
Aesthetic

Less 1 contraction, greater 7!' contraction (less with thicbr IJ8ft)

Poor Can be meshed for greater area (see below] Allow& for extrava&ation of bloD<VslliUIIl Takes well illess favourable con<itions, can cover alargar araa

Comments

Contracts sipcantly, abnonnal pigmantation. Requires well vascularized bad high &uscsptibility to trawna Must remow fat from IJlit bafore application

Uses

Large areas of skin. granulating tissue beds

Face (colour match), where thick skin or decreased contracture is dasirad (a.g.fingar)

mesh graft advantages prevents accumulation of fluids (e.g. hematoma, seroma) covers a larger area best for contaminated recipient site disadvantages poor cosmesis {"alligator hide" appearance) has significant contracture& common reasons for graft loss: hematoma/seroma, infection, mechanical force (e.g. shearing, pressure)

OTHER GRAFTS
T1bla 4. Various Tissua Grlfts

Grift Type
Bone Cartilage Tendon Nerve Vessel Deanis

u.
Repair rigid defects Restore contour of ear and nose Repair damaged tendon
for

Prmrn=d o-r SitB

Cranial, rib, iliac, fibula Ear, nasal septum, costal carliage Palmaris longus, plantaris Sural, antebrachial cutaneous, medial brachial cutaneous Foreann or foot vessels for small vessels, saphenous vein for larger vessels Thick skin of buttock or abdomen Abdomen, IIIP{ area with fat available

regeneration across nerve gap

Bridge vascular gaps Ctrltour restoration I:!: fat for bulk) Ctrltour restoration

Fat

Toronto Notes 2011

Wounds

Plastic Surgery PLll

FLAPS definition: tissue transferred from one site to another with vascular supply (pedicle) intact (not dependent on neovascularization, unlike a graft) may consist of: skin, subcutaneous tissue, fascia, muscle, bone, other tissue (e.g. omentum) classification: based on blood supply to skin (random, axial) and anatomic location (local, regional, distant) indications for flaps reconstruction - replaces tissue loss due to trauma or surgery provides skin and temporary soft tissue coverage through which surgery can be carried out later improves blood supply to poorly vascularized bed (e.g. bone) main complication: flap loss due to vascular thrombosis (in free flaps), flap necrosis caused by extrinsic compression (dressing too tight) or excess tension on wound closure, hematoma, seroma, infection, fat necrosis, poor flap design Random Pattern Flaps (Figure IS) blood supply by dermal and subdermal plexus to skin and subdermal tissue with random vascular supply limited length:width ratio to ensure adequate blood supply (typically 2:1) flap choice is often a combination of available tissue and surgeon preference types rotation: cover wounds of various sizes; common use: sacral pressure sores transposition Z-plasty: used to reorient a scar, lengthen the line of a scar or to break up a scar advancement flaps (single/bipedicle, V-Y, Y-V) V-Y flaps: wounds with lax surrounding tissue; the pedicle is the deep tissue underlying the flap

...
Rotation Flap Z-plasty

Rhomboid Transposition Flap (Umberg)

Single Pedicle Advancement Flap

"' "' "'

V-Y Advancement Flap Figure 15. Wound Care Flaps - Random Pattern

Axial Pattern Flaps (Arterialized) flap contains a well defined artery and vein allows greater length: width ratio (S-6: 1) types peninsular flap- skin and vessel intact in pedicle (see Figure 16) island flap - vessel intact, pedicle is better defined (see Figure 17) free flap - vascular supply anastomosed at recipient site by microsurgical techniques can be sub-classified according to tissue content of flap: e.g. musculocutaneous/myocutaneous [e.g. Transverse Rectus Abdominal Myocutaneous (TRAM)] vs. fasciocutaneous Free Flaps transplanting expendable donor tissue from one part of the body to another by isolating and dividing a dominant artery and veins to a flap and performing a microscopic anastomosis between these and the vessels in the recipient wound survival rates >95% types: muscle and skin (common), bone, jejunum, omentum e.g. radial forearm, scapular, latissimus dorsi

Figure 16. Peninsular Axial Pattern Flap

Figure 17. Island Axial Pattern Flap

. ;

/ ;

PL12 Plastic Surgery

Wounds/Soft TIBSue Infections

Teble 5. Free Rep Cherecteristics

Toronto Notes 2011

c..ractBrillic
Colour T-..l'llln
Arlllrill Pulll (Doppler}

Nonnll
Pilk
Wa-rn

Arllnialllllllllic:ianc:y

Pale
Cool
::!:

Purple or blue
Wa-rn or cool
::!:

+
SDit, but with tissue turgor

T11111or

Decreased

Increased (i.e. tensel

Soft Tissue Infections

Erysipelas
Definition acute skin infection that is more superficial than cellulitis Etiology
typically caused by Group A Streptococcus (GABHS)

Clinical Features intense erythema, induration, and sharply demarcated borders (differentiates it from other skin infections)

Treatment
penicillin or first generation cephalosporin (e.g. cefazolin or cephalexin)

Table 6. Classification of Soft Tissue Infections by Depth

Erysipal
Superficial subcutaneous tissue ilvolvement Full thickness with subcutaneous tissue iwolvement

Calulitis
flsciilil

Fascia
Muscle

Myasitis

Cellulitis
Definition

....

non-suppurative infection of skin and subcutaneous tissues

Etiology
skin flora most common organisms: S. aureus, immunocompromised: Gram-negative rods and fungi

Clllulilia n. E,.,.._lu Cellulitis: indistinct bordm Ery$ipelal: lhlllp borde!'$

Streptococcus

Clinical Features source of infection trauma, recent surgery PVD, diabetes - cracked skin in feet/toes foreign bodies (IV; orthopaedic pins) systemic symptoms (fever, chills, malaise) pain, tenderness, edema, erythema with poorly defined margins, regional lymphadenopathy can lead to ascending lymphangitis (visible red streaking in skin proximal to area of cellulitis)

Investigations
CBC, blood cultures culture and Gram stain wound/aspirate from wound if open wound plain radiographs if suspect foreign body or abscess r/o bone invasion (osteomyelitis)

Treatment
antibiotics: first line - cephalexin 500 mg PO q6h or diclioxacillin 500 mg PO q6h x 7 days if complicated (e.g. lymphangitis, DM) consider IV cefamlin 1-2 g q8h outline area of erythema to monitor success oftreatment immobilize and splint (hands)

Toronto Notes 2011

Soft Tissue InfectionsJIDcers

Plastic Surgery PL13

Necrotizing Fasciitis
Definition
rapidly spreading, very painful infection of the deep fascia with necrosis of tissues some bacteria create gas that can be felt as crepitus and be seen on x-rays infection spreads rapidly along deep fascial plane and is limb aud life threatening
.... '
.

j .----------------.

Etiology Type 1: P-hemolytic Streptococcus

Type II: polymicrobial (less aggressive)

Soft tlun lnt.ctic11: Su&pae:t nacrotizi'lg fllsciitis with rapidly sp11111ding erythema and edema. Mpllt dmwcllteltylhematousarw on admission in order to determine amount of spread/rapidity of spread.

Clinical Features pain out of proportion to clinical findings and beyond border of erythema, edema,
tenderness, crepitus (subcutaneous gas from anaerobes) fever infection spreads very rapidly patients may look deceptively well at first, but may rapidly become very sick/toxic late findings: skin turns dusky blue and black (secondary to thrombosis and necrosis) induration, formation of bullae cutaneous gangrene, subcutaneous emphysema Investigations a clinical diagnosis CT scan only if suspect it is not necrotizing fasciitis (looking for abscess, myonecrosis, etc.) severely elevated CK: usually means myonecrosis (late sign) hemostat easily passed along fascial plane; fascial biopsy in equivocal situations

Treatment
rigorous resuscitation multiple surgical debridements: remove all necrotic tissue, copious irrigation IV antibiotics: as appropriate for clinical scenario; consider penicillin 4 million IU IV q4h or clindamycin 900 mg IV q6h urgent consultation with infectious disease specialist is recommended

Ulcers
Lower Limb Ulcers
Traumatic Ulcers (Acute) failure oflesions to heal, usually due to compromised blood supply and unstable scar
usually over bony prominence, edema, pigmentation changes, pain treatment: debridement of ulcer and compromised tissue, reconstruction with local or distant flap, vascular status of limb must be assessed either clinically or radiographically

Non-Traumatic Ulcers (Chronic)

Table 7. Venous vs. Arterial vs. Diabetic Ulcers Diabetic
Cause

Valvular incompmce Venous HlN

2" to smaii111!Vor large vessel disease Be IIWllre of risk factors

Peripheral neurapa1hy: decreased

sensation

....

'
'

Atherosclerosis: decreased regional blood flow Diabetes mellitus Peripheral n8Uillpll1hy Pressure point distribution Necrotic base Irregular or"punched out" or deep Superficial/deep Thin dry ski! hyperkeratotic border

Hislllry

Dapandant edema, 1nluma Arteriosclerosis, daudication Rapid onset throrrtophlebitis, Usually > 45 ya111 Slow progression Medial malleolus Yellow exudates GranulatiDn tissue Irregular Superficial VenDUs stasis discolouration (llrDMI) Distal locations

Anlde-brachill index IABl) in diabetics can be falsely nonnll due to incompressible arteries secondary to plaq1181/calcificlllion.

Distribution
Appiii'IRCI Wound Margins
Depth

Pale/white, necrotic base ty eschar cowring

Ewn ("punched out")

All ch1'1)11ic; ulce,. requinl VBSCullllr lludia Ifill a VIISCI.IIIIIr consult.

....

Deep Thin shiny dry skin,

cool

Sunuunding Skin

PL14 Plastic Surgery

tncers/Manasement of Skin Lesion

Tabla 7. Venous VI. Arterial
VI.

Toronto Notes 2011

Diabetic Ulcers (continuedl

c..ractBrillic

v-UI (70"4 vuc:ulllr ulcarl)

Arllrill
Decreased distal pulses

Dillllltic
Decreased pulses likEly

No111111l distal pulses

ABI >0.9

ABI <0.9

Doppler; abnonnal VIIIOUI system Pallor on elevation. rubor on dependency Delayed venous filling

ABI is ligh Usually associated with arterial disease

Painless No claudcation or rest pain

Pain

Moderately painful lnCI'I!ISed with leg dependency, decreased with elevation No rest pain

Exttemely painful Decreased with dependency, increased with lag elevation and 8X8rt:ise (claudication) Rest pain

Associated paresthesia, anesthesia

TI'IBimlllt

Lag eiiMilion, l8lt CCJ11R5Sion at 30 rrmHg (stockings or elastic bandages) Moist wound dressings topicaL systamic antibiotics skin grafts

Rsst. no aiiiVlllion, no coqnssion Moist wound dressing topical artJ/or systemic antibiotics Modify risk factors (smoking, dist. 8X8rt:ise, 1111:.) Vascular surgical consultation Treat underlying conditions (DM, proximal arterial occlusion, 1111:.)

Control diabates Careful wound care Foot care Orthotics Ell'1y intervention for infections (1apical ancVor systemic antibiotics) Vascular surgical consultation

Pressure Ulcers
Common Sites over bony prominences; 95% on lower body Stages of Development 1. hyperemia - disappears 1 hour after pressure removed 2. ischemia - follows 2-6 hours of pressure 3. necrosis - follows >6 hours of pressure 4. ulcer- necrotic area breaks down - N.B. skin is like tip of an iceberg Classification (National Pressure Ulcer Advisory Panel 2007) Stage I: nonblanchable erythema present >1 hr after pressure relief, skin intact Stage II: partial-thickness skin loss Stage III: full-thickness skin loss into subcutaneous tissue, but not through fascia Stage IV: through fascia into muscle, bone, tendon, or joint if an eschar is present, must fully debride before staging possible Prevention good nursing care (clean dry skin, frequent repositioning), special beds or mattress (Kin Air"), proper nutrition, activity, early identification of individuals at risk (e.g. immobility, incontinence, paraplegia, etc.) Treatment depends on individual patient and condition treat underlying medical issues including nutrition continue with preventative measures (pressure relief) wound debridement, moisture retentive or antimicrobial dressing, regular reassessment topical antimicrobials at treating physican's discretion, systemic antibiotics for infections assess for possible reconstruction Complications

cellulitis, osteomyelitis, sepsis, gangrene

Management of Skin Lesions

Skin Lesions see D6

Toronto Nota 2011

Plutic SIUJCIY PL15

Burns
Burn Injuries
Causal Conditions
thermal (flame contact. scald)
chemical

radiation (UY, medical/therapeutic)

elecbical

Most Common Etiology c:bildren: scald bums adults: flame bums

Table 8. Skin Fual:tion d Bum Injury

Con1nll lifluid IDII

Loss li l.ge of Wlll8r and pratan from the Kin and other body tissues

Adecr.J8II llid r811J1tibrtian is inpilllliYe

Antl:liGiic oirtrnns (S'jltemic ifsigns ol spdc infwction pnsent) Tlllllnua prophylaxi1 if nec1111ery

m:l inllllnological org1111

Mechanical bllriii'1D becterilll iiMIIion

High rilk of inlectic:rl

Pathophysiology of Burn Wounds

amount of tissue destructl.on is based on temperature. time of exposure, and specific heat of the causative agent (see Figure 18) zone ofhyperemia - VIIIIOdilation from inflammation; entirely viable, cells recover within 7 days; contributes to systemic consequences seen with major burna zone ofstula (edema) - decreased perfusion; microvascular sludging and thrombosis of vessels results in progressive tissue necrosis -+ cellular death in 24-43 hours without proper treatment factors favoring cell survival: moist, aseptic environment, rich blood 1111pply zone where appropriate early intervention bas most profound effect in minimi1Jng injury zone of coagulation (isdwnla) - no blood flow to tissue -+ irreversible cell damage -+ cellular death/necrosis

mlana of hyparamil

r lane

of msis

U lane of CG9111ion
Blood 118118IIMII naiYII
. ...._.dIn IIIII dlamls

'i

Diagnosis and Prognosis

bum size (see F.lglue 19)

Figu111 1I.Zaaes uf Themallajary

%of total body surface area (TBSA) burned- rule ofSl's for 2 and 3 bums only (children <10 ymrs old use Lund-Browder chart- see Figure 20) for patchy burns, surface area covered by patient's palm (fingels closed) represents appronmately 1CJ6 ofTBSA age: more complications if <3 or >60 years old depth: difficult to BBSess initially- history of etiologic agent and time of exposure helpful (see Table 9) location: face and neck. hands, feet, perineum are critical areas requirillg special care ofa burn unit (see further discussion on IndiaJtionsfor Thmsfor to Bum Centre) inhalation injury: can severely compromise respiratory system associated injuries (e.g. fractures) comorbid factors (e.g. concurrent disability, alcoholism. seizure disorders, chronic renal failure) can exacerbate extent of injury

PL16 Plaatic Suqp!ry

BurDI

1'oroDio 2011

....

Proplil blllt determined bV bum Iilii !lBSAI. age of patiaJL llblanca of ilhllation injury.

... ,

blnllll*! rwtrict mpntory m:ursion Mrllar blaod flaw Ill IIKinlmiti88 and I'ICJ!irl 88chlrDimnV.

....

,.

TBSA d not include areu with 1

f"IIIIIFI 11. R1l1 af 1'1 fDr TGtllllady S11rf'llce Anll (liSA)

Anlll
A= I'. head-

AgaD

Afe1
814
314

Afel

Agllll

Ap15
41'.

Mill
31'.

B = Y.llll!lh 1M C='AiltaiiH

'"'
414

414

4'Ai 314

4% 31'.

Z'Ai

ZY.

F"11111ra ZO. Llnd-8rowd Diagram

Tabla I. B11m IJeptll (1st. 2nd, 3nl dear)

Painlui,IIIISBtian inlll:t. arythama.
bhn:llllllle

Secanddep!

lniD lllpllficiJI d1m1is

Painful. SIIISIItion inlll:t. erythema. blisle!s with clall'lluid, blenc:lllllle, hlir

folliclas pre&ant

DIIIP"PIItiiiTblcb Secand dep!

lniD deep (relicdar) dennis

Insensate, dilfiwlt ID distincrJjsh fl1lm ful thiclinasl. does not billdl. acme t.ir folliciBIIII allachad. IIOfta" then ful
11icknass bum

Ful Tllicbell

Tlnugh apidannis and damis lnsamall (IIIIVIIR!ings dastroyadl.lwd Injury ta tissue le&thery eschar lhllt is Iiiii, grey, while. 8ll\lciJns (e.g. mUlde, bn) ar cllany lid in colour, hlin do nat ll8y IUiclled, may a111D!R10&8d wins

Toronto Notes 2011

Burns

Plastic Surgery PL17

Indications for Transfer to Burn Centre

American Burn Aaociation Criteria
total2 and 3 burns> 10% TBSA in patients <10 or >50 years of age total2 and 3 burns >20% TBSA in patients any age 3 bums/full thickness >5% TBSA in patients any age 2, 3 or chemical bums posing a serious threat of functional or cosmetic impainnent (i.e. circumferential bums, bums to face, hands, feet. genitalia, perineum, major joints) inhalation injury (may lead to respiratory distress) electrical bums, including lightning (internal injury underestimated by TBSA) bums associated with major trauma/serious illness

Acute Care of Burn Patients

adhere to ATIS protocol resuscitation using Parkland formula to restore plasma volume and cardiac output 4 cc Ringer's/kg/% TBSA over first 24 hours ( 1/2 within first 8 hours of sustaining bum, 1/2 in next 16 hours) extra fluid administration required if bum >80% TBSA 4bums associated traumatic injury electrical bum inhalation injury delayed start of resuscitation pediatric burns monitor resuscitation urine output is best measure -maintain at >0.5 cc/kglhr (adults) and 1.0 cclkg/hour (children <12 years) maintain a clear sensorium, HR <120/minute, mean BP > 70 mrnHg bum specific care relieve respiratory distress- intubation and/or escharotomy (see sidebar) prevent and/or treat bum shock- 2large bore IVs identify and treat immediate life-threatening conditions (e.g. inhalation injury, CO poisoning) determine BSA affected 1st, since depth is difficult to determine initially (easier to determine after 24 hours) tetanus prophylaxis if needed all patients with bums> 10% TBSA, or deeper than superficial partial thickness, need 0.5 ml tetanus toxoid also give 250 U oftetanus Ig if prior immunization is absent/unclear, or the last booster >lOyrs ago baseline laboratory studies (Hb, U/A, BUN, CXR, electrolytes, ECG, cross-match, ABG, carboxyhemoglobin) cleanse, debride, and treat the bum injury (antimicrobial dressings) early excision and grafting important for outcome

.... _._

, ______________

Coma

Headache Conluaion

"Arrhyllwnias

....

..

lnhmtion lnjpr-101 l.lndicaiDrs of lnhlllstion Injury Injury in 1 closed space

Facial bum

Singed nasal hair/eyebrows

Soot around n.rarloral cavity
HOirMIIHII

Conjunctivitis Carbon particles in sputum El.vmd blood CO IMs (i.l. brighter red I 2. Suspected ilhalation injury requires immediate due ID impending airway adema. FaiiUIIIID dilgnou inhalation can rnult in aifway swelling and obstruction, which, can lead ID death. 3. Nllilher CXR or ABG can be uud ID rull out inhallltion injury. 4. Oirvct broncho&copy now used for diagnosis

Tachypnu

Respiratory Problems
3 major causes bum eschar encircling chest distress may be apparent immediately perform escharotomy to relieve constriction carbon monoxide (CO) poisoning may present immediately or later treat with 100% 0 2 by facemask (decreases half-life of carboxyhemoglobin from 210 to 59 minutes) until carboxyHb <10% smoke inhalation leading to pulmonary injury chemical injury to alveolar basement membrane and pulmonary edema (insidious onset) risk of pulmonary insufficiency (up to 48 h) and pulmonary edema (48-72 h) watch for secondary bronchopneumonia (3-25 days) leading to progressive pulmonary insufficiency intubate patient with any signs of inhalation injuries

PLIB Plastic Surgery Burn Wound Healing

Table 1D. Burn Shock Ruscitlltion (Parkland Fonnulal

Burns

Toronto Notes 2011

Table 11. Bum Wound Healing

Dl!plll Hilling No scarring. Complete healing Spantaneously in 7 to 14 days from retained epidermal structures residual skin discolouration Hypartrojtlic scarring uncommon. Grafting nnly required R&-epithelialize in 14-35 days from retained epidennal structures Hypartrojtlic scarring frequent Grafting recommended to expedite healing R&-epithelializa from 1ha wound edge Grafting necessary to replace dermal integrity, limit hypertrophic scarring R&-epithelialize from 1he wound edge Grafting necessary to replace dermal integrity Must ensure viable bed to graft onto

Hour W4

4 cc

TBSA

Fim degll!e
Second degree (Superficial partial) Deep second degree (Deep partial) Third Degree (Full thickness)

with 112 of total 0-8 h llld 1/2 of tcrtal 11-24 h

Hour 24-30 0.3&-0.5 cc

>Hour 30 D5W at rate to maintain

normal serum sodium

* da nDtforgBIID add TlllliriBIIIIDfUd ID

IISIISCi1mJn

Fourth Degree

8lmr ZOO&;

MIINnllflil IIEII!r Wililnfllllrll

l'lllfiii:TDIIIIblilhilllltyiiiiCilianMdgllfting il IUJ)IIiJr !Dr equillllntj to CGIIIIrvaMJIIItmR llld dlllyad gllfting Dlllll tile lull 81Chlr IIJ)Irllad. M....,..._AillrQ!re!Mw prDip8C1M ntndDnillld cuabulud lllll:ililn JIDII-81ChltlllpRtiaa. AIIQII md lun -as were ilcUded.lldcames Wile mDrtllty. biODd lrlniWu5. WDOOd hudng 1iJw ll1d ilngtll gf
lloepimlslly.

I<7 dlysl IIIII irnmiCiats grafting IQiilst lnil1ment v.itllchaings foi1Dwe1111 Piing

._..:A1ulll of361 plllisiQ fTom 71Mdomiz8d cuabulud lrilil Wlfl inlildld in 111111"1111-nlylia.
180 pllierG!Qiwd allty

181

l'llllivld coRIIMiive nwnagemant. Tlwl WI! AD si,ificlnt dlnlce il mDrtaily in Pltilllll wilb irlllllllillllll injury. Ellty acili110 IIIII grafq
in pMients Mhaut im.tiDIIII ijly IIUIId in Rlllic:ad mD!IIIily IRR 0.36, p<0.051 llld decreued length of holpblizllillll by 8.89 days IP<D.051- The runter of patiarq ntePring biDod 111111fusili MIS lignilicmly wilb lilt;' aciliD111111'11nagvmeul ISMO 1.65, p<0.051. There WI! no lidtlli clllalaca '-ing tima betweea the two ifDups. CIIIIIAIIill1: &tvacilioo of bums I<7 dlysl is beaeticial in reducing mDrtah in patilllll Mhaut n.latiooal injury, abagwilh llllb:ing . . . of time spent in bDIJiiml.

Treatment 3 stages 1. assessment - depth determined 2. management- specific to depth of bum 3. rehabilitation first degree treatment aimed at comfort topical creams (pain control, keep skin moist) aloe oral NSAIDs (pain control) superficial second degree daily dressing changes with topical antibiotics, pol)'5porin, may use a temporary biological or synthetic covering to close the wound; leave blisters intact unless circulation impaired deep second degree and third degree prevent infection and sepsis (significant cause of death in bum patients) most common organisms: S. aureus, P. aeruginosa and C. albicans - day 1-3: Gram-positive - day 3-5: Gram-negative (Proteus, Klebsiella) topical antimicrobials: prevent bacterial infection (from skin flora, gut flora or caregiver) and secondary sepsis (Table 12) remove dead tissue surgically debride necrotic tissue, excise to viable (bleeding) tissue
Table 12. Topical Antibiotic Tharepy
Antililllic
Silver nitrate (0.5% solution) Silver sulfadiazine (cream) (Sutn.nyiooGt) Mafanida acstate (sDiutionlcreem) (Silvadene4')

Pain with Appication

None Minimal Moderate

Pllnllrllion
Milimal Medium. does not penetrate eschar Wall, panetratas eschar May cause methemoglobinemia, stains (black), leaches sodium from wounds Slowed healing, leukopenia, mild of epithelialization Mild inhibition of epithelialillllion, may causa matabDiic acidosis with wide application

important to obtain early wound closure initial dressing should decrease bacterial proliferation indication for skin graft: deep 2 or 3 bum > size of a quarter prevention of wound contractures: pressure dressings, joint splints, early physiotherapy

Other Considerations in Burn Management

r----.Aitand
Vaicullll' Purm811bility and Edema +-----,
1

CO, 1' SVRI

I
I

lmmunoliUpprenion

SEVERE BURN

r r----

Hyp111111u!llboli&m

Progressive Pulmonary Insufficiency

Renal Failure (2" to ..V Renal Blood Flowl

L----+lncraased Gut Mucosal Purmaability (GI Bleed Risk)

Figure 21. Systemic Effects of Severe Bums

Toronto Notes 2011

Burns

Plastic Surgery PLHI

nutrition hypermetabolism: TBSA >40% have BMR 2-2.5x predicted calories, vitamin C, vitamin A, Ca, Zn, Fe immunosuppression and sepsis must keep bacterial count <105 bacteria/g of tissue (blood culture may not be positive) signs of sepsis: sudden onset ofhyperlhypothennia, unexpected CHF or pulmonary edema, development of ARDS, lleus >48 hours post-bum, mental status changes, azotemia, thrombocytopenia, hypofibrinogenemia, hyper/hypoglycemia (especially ifbum >40% TBSA} gastrointestinal (GI) bleed may occur with bums >40% TBSA (usually subclinical) treatment: tube feeding or NPO, antacids, H 2 blockers (preventative) renal fallure secondary to under resuscitation, drugs, myoglobin, etc. progressive pulmonary insufficiency can occur after: smoke inhalation, pneumonia, cardiac decompensation, sepsis wound contracture and hypertrophic scarring largely preventable with timely wound closure, splinting, pressure garments and physiotherapy

Special Considerations
CHEMICAL BURNS major categories: acid burns, alkaline burns, phosphorous bums, chemical injection injuries common agents: cement, hydrofluoric acid, phenol, tar mechanism of injury: chemical solutions coagulate tissue protein leading to necrosis acids -+ coagulation necrosis alkalines -+ saponification followed by liquefactive necrosis severity related to: type of chemical (alkali worse than acid), temperature, volume, concentration, contact time, site affected, mechanism of chemical action, degree oftissue penetration burns are deeper than initially appear and may progress with time Treatment {general) ABCs, monitoring remove contaminated clothing and brush off any dry powders before irrigation irrigation with water for 1-2 h under low pressure inspect eyes, if affected: wash with saline and refer to ophthalmology inspect nails, hair and webspaces correct metabolic abnormalities and tetanus prophylaxis if necessary local wound care after 12 hours initial dilution (debridement) wound closure same as for thermal bum beware of underestimated fluid resuscitation, renal, liver, and pulmonary damage ELECTRICAL BURNS depth of bum depends on voltage and resistance of the tissue (injury more severe in tissues with high resistance} often presents as small punctate burns on skin with extensive deep tissue damage which requires debridement electrical burns require ongoing monitoring as latent injuries can occur watch for system specific damages and abnonnalities: abdominal: intraperitoneal damage bone: fractures and dislocations especially of the spine and shoulder cardiopulmonary: anoxia, ventricular fibrillation, arrhythmias muscle: myoglobinuria indicates significant muscle damage -+ compartment syndrome neurological: seizures and spinal cord damage ophthalmology: cataract formation (late complication) renal: acute tubular necrosis (ATN) resulting from toxic levels of myoglobin and hemoglobin vascular: vessel thrombosis -+ tissue necrosis (increased Cr, K and acidity}, decrease in RBC (beware of hemorrhages/delayed vessel rupture} Treatment ABC's, primary and secondary survey, treat associated injuries monitor: hemochromogenuria. compartment syndrome, urine output wound management: topical agent with good penetrating ability (silver sulfadiazine or mafenide acetate) debride non-viable tissue early and repeat pm (every 48 h) to prevent sepsis amputations frequently required FROSTBITE see Emer.genc.y Medicine, ER45

.....

Speed is essential in the m-aement of chemical blms 1111 chemicals cen conti1111e to cause damage untlthey are IVIIIOVlld or neLmllizlld.

.,
..

.-----------------,

.....

Tu: remove with repeated applicidiiJil of petroiiUIII-based antibiotic ointments

(e.g. Polysporin ).

.....

...-----------------.

TI'MIIIIIIIC(speclic]

Acid br: dilute sokrtion of sodium bicarbonate folowing wmr iniiJIItion llydrvl-": acid: water irriglltion;
calcium gel injection of calcium gklconate 10"' calcium gluconab!IV depending on 1rn0unt of

fingtmails to avoid acid 1npping; topical

axposura and pain Wfuric Kid: treat with

to irrigation, u di111ct wmr axposure

prior

produces extreme heat

....

T - a.sistMCII te EIIICiriclll Cunallt: nerva < VIISS&liblood < muscle < lkin

.,

< tendon < fat < bone

PL20 Plastic Surgery

Hand

Toronto Notes 2011

Hand
Traumatic Hand
Tabla 13. Kay Faaturaa of tha Hiatury and Physical Exam of tha Injured Hand in the Emergency Department

HISTORY

AQe
Hand oomilllllce Occupation lime and place of accident Mechani5m of injury Tetanus status PHYSICAL EXAM

High pressure injection inj-.y is dacllplivlly b111ign-looking (1111aU pinpoint hole on finger pad] often with few clinical signs. Intense pain and tenderness, along the
cour1a tha fllraign mamriallrlvalad, is pmant a faw hours an. th1 iljury. Definitive 1rHiment is EDCpQsure and ramoval of foraign mamrial.

....

. .

On.v.tian

Position of finger

Dafonrity
Bruising or sweling Sweating pattern Ana!Dmicel strucbues beneath

Abnormal cadence (fingen normally slightly ftaxed), scissoring Bony or apacific (e.g. Mallet. Swan Neck) May indicate underlying skl!lellll i;ury May indicate denlli!Mition If open laceration, need to 8llj)lore within wound (under sterile Allen's Test (see sidebar) Capillary refill ( <2-3 &ac) For each test. need to CCJ11118re bolh sides Dorsal redial tip of index finger Dorsal ulnar tip Ill little finger Dorsal web space Ill the thwnb 2point discriminalion crf each finger Exlrinsic muscles: Rex DIP Ill index finger ("OK sign") Intrinsic muscles: Thwnb to ceiling with palm up Extri115ic musclee: Flax DIP of little finger Intrinsic muscle&: Abduct index finger ("Peace sign") or patient able to hold piece of paper between adducted fingers and resist pulling Extrill5ic muscles: Exland thumb ("Thumb's up1 and wrist Stllbilize PIP joint in extension, ask patient to flex fingers (II DIP) (see Figure 6) Stabilize non-exam fingers in extension (neutralizes FDP) and ask patient to nex examination finger (see Figure 7) Focal tenderness or abnonnal alignment Instability may indicate igamentous injury or dislocation

Radial and ulnar wries Digital arteriee Temperature and skin turgor SaniHIIY (IIefer to Figum 3) Median nerve Ulnar nerve Radial nerve nerves Median nerve

,, I

Allen' Tnt: while patienfs hand is finnly l:lolad, m:luda both radial and

ulnar arteries. Once fist is open, release aithar artary and llSSBSS con.teral flow.

Matur Functio1

It' Appnw:h ID Hand Llcllionl

Ulnar nerve

TIN AX Tanus prophylaxis

Irrigate with NS

Antibiotic prophylaxis
X-rays

NPD

Radial narva Flexor Digitorum Profundus (FDP)

Flexor Digitorum Superficialis (FDS)

Bones
Joints

I

General Management
Nerves direct repair fur a clean injury within 14 days and without concurrent major injuries -+ otherwise secondary repair epineural repair of digital nerves with minimal tension post-operative: dress wound, elevate hand and immobilize Tinel's sign (cutaneous percussion over the repaired nerve) produces paresthesias and defines level ofnerve regeneration a peripheral nerve regenerates at 1 mm/day after the first 4 weeks as a result ofWallerian degeneration paresthesias felt at area ofpercussion because re-growth of myelin (Schwarm cells) is slower than axonal re-growth --+ percussion on exposed free-end of axon generates paresthesia

,.}-----------------,

Nevw blindly clamp a bleading viSSII as nerves are often found in close IISSIIcillion with vnuls.
,, I

Arterial bleaclinu from a volar digilal laceration may indicate nerve lacellllion (fiiiMII in digits ara suparficial to
arteries].

Toronto Notes 2011

Hand

Plastic Surgery PL21

Vessels
often associated with nerve injury (anatomical proximity) control bleeding with direct pressure and hand elevation if digit devascularized. optimal repair within 6 hours dress, immobilize, and splint hand with finger tips visible monitor colour, capillary refill, skin turgor, fingertip temperature post-revascularization

... ,

Tendons
most tendon lacerations require primary repair many extensors are repaired in the emergency room. flexors in the operating room within 2 weeks avoid excessive immobilization (specific protocols for flexors, 2-3 weeks for extensors) to minimize stiffness and facilitate rehabilitation

Co11putmenl Syndrome Watd1 out for these signs with doled or opan injury: tiiiiSI, peinful fiXtrwnity on paHive lilrulch), dilllll pulsaiiiSIIKISs {oftan lata in process). and contracture {irTIIVaraible ischamia). lnti'IICompartmental pressum can be menurad, but a clinicel diagnosis is an indication for an emergent fasciotomy. If untr8111ed, end 1'88Uit is ischemic af the extremity {Volkmann's

Hand Infections
Principles
trauma is most common cause 5 cardinal signs: rubor (red), calor (hot), tumour (swollen), dolor (painful) and functio laesa (loss of function) 90% caused by Gram-positive organisms most common organisms (in order) - S. aureus, S. viridans, Group A Streptococcus, S. epidermidis, and Bacteroides melaninogenicus (MRSA becoming more common)

TYPES OF INFECTIONS Deep Palmar Space Infections

uncommon, involve thenar or mid-palm. treated in OR

Felon
definition: subcutaneous abscess in the fingertip that commonly occurs following severe paronychia or a puncture wound into the pad of digit; may be associated with osteomyelitis treatment: elevation, warm soaks, cloxacillin 500 mg PO q6h (if in early stage); if obvious abscess then I&D and PO cloxacillin

Flexor Tendon Sheath Infection Staph> Strep >Gram-Negative Rods

definition: acute suppurative tenosynovitis commonly caused by a penetrating injury and can lead to tendon necrosis and rupture if not treated clinical features: Kanavel's 4 cardinal signs: 1. point tenderness along flexor tendon sheath (earliest and most important) 2. severe pain on passive extension of DIP (second most important) 3. fusiform swelling of entire digit 4. flexed posture (increased comfort)

treatment
OR incision and drainage, irrigation, IV antibiotics, and resting hand splint until infection resolves

Herpetic Whitlow HSV-1, HSV-2 definition: painful vesicle(s) around fingertip

often found in medical/dental personnel and children clinical features: can be associated with fever, malaise and lymphadenopathy patient is infectious until lesion has completely healed

treatment: routine culture and viral prep protection (cover), consider oral acyclovir

Paronychia acute = Staph; chronic = Candida definition: infection (granulation tissue) of soft tissue around fingernail (beneath eponychial fold) etiology acute paronychia - a "hangnail': artificial nails, and nail biting
chronic paronychia - prolonged exposure to moisture

treatment
acute paronychia - warm compresses and cephalexin 500 mg PO q6h drainage if abscess present chronic paronychia- anti-fungals with possible debridement and marsupialization, removal of nail plate

PL22 Plaatic Suqp!ry

Hand

1'oroDio 2011

Amputations
Hand or Finger

emergency management: injured patient and amputated part require attention patieDt: .x-mys, NPO, clean wound and irrigate with NS, dress stump with nonadherent, cover with dry sterile dressing, tetanus and antibiotic prophylaxis (cephal.oaporin/ erythromycin) amputated part: J:-rays. gently irrigate with RL. wrap amputated part 1n a NSIRL soaked sterile gauze and place inside waterproof plastic bag, place in a. container, then place container on ice indkalions 1Dr replamation ap: children often better results than adults level of injury: pronmal. thumb and multiple digit amputations are higher priority nature ofinjury: guillotine injuries have a better potential; avulsion and auab injuries are relative contraindications to replant Ifreplant contraindicated manage stump with revision amputation would only allow a fingertip injury to heal by secondary intention

Tendons
Common Extensor Tendon Deformities
Table14. Exl:eiiiOI' Tendon Daformltlea
IIjury

Dllililian
Df llaxad 1Mth loss tA active IIICialsian (s&a Fi!1118 23)

llna

EtiDIIIIf/tinicll fteluNI
Fal:ad flaxian of1ha axtendad DIP joint to axllln&ar tand111 ruplln at DIP jairt (e.g. sudd111 blow to tip li1be fingel)

Trlllnat Splint liP in axtansian fa&was fallawad 11y 2 wea1a1 ol night splinq. If inadeqUIIII

MllletFiiiJII"

.......
Dafadr

6 weeks.. check aplinting routine and 18C11111111111d 4 men waab tA Clllllilaus spliting

Pf flaxad. DIP hyperaxtendld (see Fue 24)

Figure 22. Zone of Extensor r ..dDn Injury {Odd n1111bered zones fall over a jaint)

Splint PIP in axtansian IIIII !Iaw Injury ardis- exllmsar tenlan insatian i!G 1he active DIP motian dlllllll bala Dl tha midde phlln Assacialad with dlaumad IWthritis (RA) ar tnune will" di!lacation, BCUte fmzful lleiOOn of PIP)
val plata

Swa Macl Dafadr

Pf hyperadaldad, DIP flaK8d (588 Fijr.lre ZS)

Assacialad with RA 111d aid, Ull1r8Bt8d ..... dnmity

Splint ta pravant PF llypalvmnsianar Ill' flaxian

Cansid a11radasiWarthrapllmy

Z3. Millet Finger Dafomity

Da Quervaln's Tenosynovltls(zone 7; most common cause of radial wrtst pain) de:finl.tion: inflammatl.on in 1st extensor compartment (APL and EPB) cllnl.aal features: +ve Finkelstein's teat (pain over the radl.al styloid induced by making fist, with thumb in palm, and ulnar deviation of wrist) pain l..ocallzed to the 1st extensor compartment tenderness and aepitation over radial styloid may be praent diffe:rentiate from CMC joint arthritis (CMC joint artlutti& will have a positive grind test, whereby crepitus and pain are elldted by axial pressure to the thumb) treatment: mllcl: NSAIDs, spllnting and steroid injection into the tendon sheath (succeasful. in over 60%
ofcase.)
&eYere: surgical release of stenotic tendon sheaths

(APL and EPB); remember there may be

2 or more sheaths

Figure 24. BaiiiDnniara Dafunrity

DIP Fltxion

Ganglion Cyat (zone 7)

definition: fluid-filled synovial lining that pratru.dcs between carpal bones or from a. tendon sheath; most commonly carpal in origin most common soft tissue tumour ofhand and wrist (6096 of masses)

PIP Hyp--.si111

Figure 25. Swa Naclc: Dafarmity

cllnl.aal farturea: most common around scapbolunate ligament junction 3 times more common in women than in men more common in younger individuals can be luge or small -may drain internally so size lllll)' wax and wane often non-tender although tenderness increased when cyst smaller (from increased pressure within amall.er cyst sac)

'IbroDlo Nota 2011 trcablleDt:

Hand

Plutic Surgery PL23

conservative treatment: watch and wait aspiration (recurrence rate 6596) consider operative acision of cyst and stalk (recurrence is po88ible) steroids ifpa1nful Common Flexor Tendon Dvformities (see Figure 26) fiemr tendon zones (Important for prognosis of tendon lacerations) "no-man's land":
between distal palmar crease and mid-middle phalanx zone where superficialis and profundus lie ensheathed together recovery of glide very dlfficult after Injury

A2and A4 pulley5 n most importlfll lor flrlction; pwwent bowstmgWig of bindo..

Stenosing Tenosynovitis (trigger Dnger/thumb) definition: inflammation ofsynovium Cllll8e8 size discrepancy between tendon and sheath/ pulley (most commonly at A-1 pulley) = locking of tbumb or finger in timon/extension
etiology: idiopathic or associated with RA, diabetes, hypothyroidism and gout clinic:al fnlara: thumb, ring and long fingers most commonly affected patient complains of catching, snapping or locking of affected finger tenderne88 to palpation/nodule at palmar aspect ofMCP over A1 pulley women are 4 times more l.ikdy than men to be affected conlenative treatment:

injectiomlesslikely to be ruccessfu.l in patienb with DM or symptoms greater than 6 months aurglcal treatment: incise A-1 fluor tendon pulley to permit unrestricted, full active finger motion

NSAIDs steroid injection surgical flexor tendon release

Figura 26. lanes af tla Flexar

T811donS

Fractures and Dislocations

for fracture prindples, see OrthQ,paedljJb ORS
FRACTURES

about 90% of hand fractures are stable in fl.exl.on (locklprevent extension) polition of fandloo. (like a band holding a pop can) (see Figure 27):
wrist extension 15

MCP fl.mon 45 IP fial.on (slight) thumb abduction/rotation contraindicatlons: post repair offlexor tendons, medlanlulnar nerve injury polition ofsafety (see Figure 28): wrist extension 45 (position most beneficial for hand function ifimmobilized) MCP flmon 600 (maximal collateral ligament stretch) PIP and DIP in full atension (m.ui.mal volar plate origin stretch) thumb abduction and opposition (functional position) stiffness secondary to immobilization is the most Important complli:ation; Tx = early motion Distal Phalanx Fractures subungual hematoma is common and must be decompressed ifpamful or nail removed treatment consists of3 weeks of dJgital splinting (with IP joint movement preserved) Proximal and Middle Phalanx Fractures check for: rotation, sd88oring (overlap of fingers on making a fist), shortening of digit undispla.ced or minimally displaced- closed reduction (ifextra-articular) buddy tape to neighbouring stable digit, elevate hand, motion in guarded fa&hion 10-14 days post injury displaced, non-reducible or not stable with closed reduction- percutaneous pins (K-wires) or ORIP, and splint Metacarpal Fractures generally accept varying degrees of deviation before reduction required: up to 10" {D2),
20" (D3), 30 (04), or 40" (D5) Boxer\ fraaure (ema-artl.cul.ar): acute angulation of neck of metacarpal of little finger into pelm (see Figure 29) mechanism: blow on the distal-dOI88l upect of closed fist loss of prominence of metacarpal head, volar displacement ofhead check for scissoring offingers on making a :fist

Figura 27. Positian af F1111ction

most commonly fractured bone in the hand usual mechanism Is crush injury and thus accompanJ.ed by soft tissue injury

Figura 21. Positian af Slfety

PL24 Plaatic Suqp!ry

Hand

1'oroDio 2011

up to 30-40'> angulation may be acceptable closed reduction should be considered to decrease the angle ifstable ulnar gutter splint x 3 weeks with PIP and DIP joints free Bennett's fraaare (intra-artkular): fracture/dislocation of the base ofthe thumb metacarpal (see Figure 30) unstable fracture abductor pollicis longus pulls MC shaft proximally and radially causing adduction ofthumb treat with percutaneoue pinning. thumb spica x 6 weeks Rolando' fraaare (intra-artic:ular): T- or Y-shaped fracture ofthe base of the thumb metacarpal (see Figure 31) treat with open reduction, internal :fixation (ORIF) with K-wire
DISLOCATIONS

must be reduced as soon as possible

PIP and DIP Dislocations (PIP more common than DIP) usually dorsal dislocatl.on (commonly from hyperexteD!Iion) ifclosed dlslocation: closed reduction and splinting (30 flal.on for PIP and full extension for DIP) or buddy taping and early mobilization (prolonged immobilization causes stiffness)

open injuries are treated with wound care, closed or open reduction and antibiotics

I I
:I!

MCP Dislocations (relatively rare)

. . 31. RollllldDs Fnelu18

dorsal di&locations much more common than volar dislocations dorsal di&location ofprmimal phalanx on metacarpal head; most commonly index finger (hyperenension) two types of dorsal dislocation: simple (reducible with manlpulation) - treat with 2 weeks ofsplinting at 30" MCP tlai.on compla: (volar plate blocks reduction)- treat with open reductionand Al pulley release+
cxb:nsion-blocking splint at 30" tlenon (2 weeks) then 100 ftenon (2 weeks)

Ulnar Collateral Ligament (UCL) InJury forced abduction of thumb (e.g. ski pole injury) Lllier"s thumb: acute UCL injury pmekeepen thumb: chronic UCL injury mdaaticm: radially deviate joint in full extension and at 3Qa flexion and compare with noninjured hand. UCL rupture is presumed ifinjured side deviates more than 30" in full extension or more than tsa in flexion Stcner'sle&ioD: the UCL ha8 bony attachments to the adductor aponeurosis and the piOJdmal ligament can displace while the dirtal attachment remains deep to the aponeurosis, forming a

barrier that blocks healing and leads to chronic instability; requires surgery

Dupuytren's Disease
Definition

contraction oflongitudinal palmar fascia. forming nodules (usually painless), fibrous cords and eventually flexion contractures at the MCP and interphalangeal joints (see Figure 32) flexo.r tendons not involved Dupuytren's diathesis - early age of onset. strong family history, and involvement ofsites other than palmar aspect of hand
Epidemiology

genetic disorder (unusual in patients from Afrkan and Asian countries, high inddence in northern Europeans), men> women, often presents in 5th-7th decade oflife, assodated with but not caused by alcohol use and diabetes
Clinic.l FHtures
order of digit involvement (most common to least common): ring :> little :> long :>thumb :> index may also involve feet (Lederhosen's) and penis (Peyronie's - see UroloBY. U29)

''..,

Treatment

AccurHJ rlth fir C.rlllllmllllynd.,.IH Hilmi SU1pty 1916; p.223 1. Phalen's: SenaiiMty: 0.75 Specificity: 0.47
2. lira's:

SenaiiMty: 0.60 Specificity: 0.67 3. IMpel Tumel Compnaion Test: SenaiiMty: 0.87 Specificity: 0.90

stages: 1. palmar pit or nodule - no surgery 2. palpable band/cord with no llinitation of atension of either MCP or PIP- no ru.rgery 3. lack of extension at MCP or PIP - smgical fasciectomy indicated 4. irreversible periarticular joint changesfscarring - smgical tn:al:ment possible but poorer prognosis compared to stage 3

Toronto Notes 2011

Hand

Plutic Surgery PL25

indications for percutaneous release: functional impairment MCP joint contractures >30 any PIP contracture rapidly progressive disease may recur, especially in Dupuytren's diathesis

Carpal Tunnel Syndrome (CTS)

Definition median nerve compressed by nearby anatomic structures Etiology median nerve entrapment at wrist primary cause is idiopathic secondary causes: space occupying lesions (tumours, hypertrophic synovial tissue, fracture callus, and osteophytes), metabolic and physiological (pregnancy, hypothyroidism, and rheumatoid arthritis), infections, neuropathies (associated with diabetes mellitus or alcoholism), and familial disorders job/hobby related repetitive trauma, especially forced wrist flexion Epidemiology female:male = 4:1, most common entrapment neuropathy Clinical Features sensory loss in median nerve distribution i.e. radial3.5 digits (see Figure 3) discriminative touch often lost first classically, patient awakened at night with numb/painful hand, relieved by shaking/dangling/ rubbing decreased light touch, 2-point discrimination, especially fingertips advanced cases: thenar wasting/weakness Tinel's sign (tingling sensation on percussion of nerve) Phalen's sign (wrist flexion induces symptoms) Investigations a clinical diagnosis nerve conduction velocities (NCV) and EMG may confirm, but do not exclude, the diagnosis Treatment avoid repetitive wrist and hand motion, wrist splints when repetitive wrist motion required conservative: night time splinting to keep wrist in neutral position medical: NSAIDs,local corticosteroids injection, oral corticosteroids surgical decompression: transverse carpal ligament incision to decompress median nerve indications for surgery: numbness and tingling sensory loss, weakness muscle atrophy, unresponsive to conservative measures complications: injury to median motor branch, palmar cutaneous branch or superficial transverse vascular arch, local pain (pilar pain), scar

Calfll TAll StWDllllplli: trilldllar JilllldSIIg,111J6. YGI31 No.6 p.911 To dMgp

CIIPII tunlllll1lihrrl tt.lllllllllld till clniclll

dilgnolti: piiCii:lll rl axpartl.
57 cinicllllildings -cillsd l"lidiCTS, eight were mild 1 pnlrl aplll clinicilnL lhing Z!i6 -lilmrill.l pal rl mcperts decided wheller a case did did nat I'Md.-riCTS. ,_d. ...--. the .,dentmiable Ill! alogistic regralioa model. 111 wflicll tilleigbt cinicallildings wn IIIPhd. 1111 modiiWII dwiwldllld l(lliRII till C01118111US of IIICOIIII J*IGI on 1118 dillgnosis af CTS forU. C8l8 hillllriM. blulll: The-- between the problblty rl CTS pl'llliclld by tillllgllllion lllldllllld till pnlrJcliicin-0.71. filii lilt ofUIIIWigiDd cmcal rilgnonc Clitlria tt.l OIJIIribulld slgnificlndv bl111e 1. illiWlilfl IIIIW dillrillllian

,.._e:

3. w.knaa lr4'GIIIIIolil rl tilllillall 4. f111f111ign

2. rtlct!Jmlll"llrilnasl

5. PIMI(stest &. 1.os1 rl Z.paid dilcrimmon

Rheumatoid Hand
General Principles non-surgical treatments form the foundation in the management of the rheumatoid hand surgery only for patients whose goals (improved cosmesis or function) may be achieved Surgical Treatment of Common Problems synovitis: requires tendon repair if ruptured; can lead to carpal tunnel syndrome and trigger finger ulnar drift: MCP arthroplasty, resection of distal ulna, soft tissue reconstruction around wrist thumb deformities: can be successfully treated by arthrodeses (surgical fixation of joint to promote bone fusion

....

Rldlorlrllhlc Evolution of tile Rh-lltoid Hlllll Eullest sign: 1111sion of lh1 uln11r
5tyloid
PrOgr811i. .: chracterized by

symmetrical joint space narrowing IUid arolions oftha CllrJIIII bones. MCP and PIP (with DIP r.IIIIMiy sparld)
deformities

._... st.ge: Swan neck IUid 8outomiara

PL26 Plastic Surgery

Brachial PleiUsiCraniofadallnjurlea

Toronto Notes 2011

Brachial Plexus
Etiology common causes of brachial plexus injury: complication of childbirth and trauma other causea of injury: compression from tumours, ectopic ribs

Common Palsies
Tabla 15. Named NaDnlltlll Palsies Df tha Brachial Pinus
Lacation ullnjwy

Machlniun ullnjury
HaacVshouldar distraction (e.g. motorcycle)

Faaturea
Waiter's tip dlllormity (shoulder internal rotation. elbow extension, wrist flexion)

DucllenneEIII Pllly

Upper brachial pi8XliS (C5-C6)

Lower brachial plexus (C7-T1) Traction on abducted arm

May include Homer's syndrome {"claw hand")

Differential Diagnosis
trauma (blunt, penetrating) thoracic outlet syndrome neurogenic - associated with cervical rib; compression of C8/Tl vascular - pain or sensory symptoms without cervical rib; cessation of radial pulse with provocative maneuvers tumour schwannoma- well-defined margins makes it easier for total resection neurofibromas- associated with neurofibromatosis type I (NF-1) other- e.g. Pancoast's syndrome (apical lung tumour) neuropathy (compressive, post-irradiation, viral, diabetic, idiopathic)

Investigations
EMG
MRI - gold standard for identifying soft tissue massea CT myelogram - better than MRI for identification of nerve root avulsion and identification of pseudomeningocele. hnportant for preoperative identication of patients likely to require neurotisation procedures (esp. for patients with blunt trauma)

Management
Tabla 16. Management Df Brachial Plaxuslnjuries
Type Non.flnllrlling Tra111111
Concussivalcomprassive

Trennent
Usualy improves (unless expanding mass, e.g. hamlllllma)

TractiorVstretch
Obstetric palsy

Hno continued insult. follow for 3-4 months for improvement Surgery if no significent and/or residual paresis at 6months Df age Explore immediately in OR

Sharp or vascular injury

Craniofacial Injuries
low velocity vs. high velocity injuries determine degree of damage fractures cause bruising, swelling and tenderness -+ loss of function frequency: nasal > zygomatic > mandibular > maxillary management can wait 5-10 days for swelling to decrease before ORIF required

Toronto Notes 2011

Craniofacial Injuria

Plastic Surgery PL27

Approach to Facial Injuries

ATLS protocol inspect, palpate, clinical assessment for injury to underlying structures (e.g. facial nerve) visual assessment tetanus prophylaxis radiological evaluation wound irrigation with NS/RL and remove foreign materials conservative debridement of detached or nonviable tissue repair when patient's general condition allows (soft tissue injury: <8 h preferable)

... , ,

l'lllilnts with majorfllcilll iljurin ara at risk ol developing upper airway obstruction (displaced blood clots, 1eelh or haclure frllgmenl$; swelling of pharynx 11111 latyruc; loss of support of hyomandibular complex-+ of tongue). Also at risk of ocLJar injury.

Investigations (see Table 17) CT: Axial and Coronal (specifically request 1.5 nun cuts) - for fractures of upper and middle face (not good for mandible) indicated for high velocity trauma, complex facial fractures, orbital floor, panface fractures, pre-op assessment panorex radiograph - shows entire upper and lower jaw; best for isolated mandible fracture as patient must be able to sit

....

,,

Tabla 17. Imaging oftha Craniofacial Skalaton

Suspect C-spine iljury with any facial C-spine evaluation before

radiographs n onlmd_

N11albona MaxiIll
'llalt inlging rnstf1od

CTKilll Water's view (accipitomental, A-P "fnm below"l, Town's. AP No x-ray rvquired- clinical

... ' ,
....

CT scan - axial and caranaJ

Cor\lider inlnlcranialtrauma; rule out skul fncturl.

Treatment consultation when indicated (dentistry, ophthalmology) re-establish normal occlusion pursue normal eye function restore stability of face and appearance Complieations diplopia/enophthalmos/blindness intracranial pathology such as cerebrospinal fluid (CSF) leak, bleeding and SIADH sinusitis functional abnormalities (i.e. malocclusion) infection - extremely rare poor cosmesis; need for 2 surgery

',

Sips af IJual Skull Fractur 1. 8Btlle's sign (bruised masiDid proce55} 2- Hemotympanum
3_ Raccoon eyes [periorbital blllising) 4_ CSF otormaa

... '...-----------------, ,
Facial bona injuries with orbit involved r.quin ophthalmology consult

Mandibular Fractures
always two points ofinjury since it is a ring structure (includes fractures and dislocations) commonly at sites of weakness (condylar neck, angle of mandible, region of 3rd molar or canine tooth)

Etiology anterior force: bilateral fractures lateral force: ipsilateral subcondylar and contralateral angle or body fracture note: classified as open if fracture into tooth bearing area (alveolus}

Clinical Features pain, swelling, difficulty opening mouth ("trismus") malocclusion, asymmetry of dental arch
damaged. loose, or lost teeth palpable "step" along mandible numbness in V3 distribution intra-orallacerations or hematoma (sublingual) chin deviating toward side of a fractured condyle

PL28 Plaatic Suqp!ry

Craniofadal.lnjuries
Classificlltion

1'oroDio

2011

Tabla 18. Mandibular Fnctura ClassilicatiDns by Anata11ic Ragi... (rmr ta Figun 33)

mrior border of111! IIIIIRJie

Midln. d the 1111111dibll; bai.WIIII the clldnll R:isars frrm tha aiVIIOI!w J11DC8SS lllwgh the

Fmn the &yl1lllyliB ta the lislllllveollr bardfl' af the 111ird malar

""an batwaan tha anllriar bardar of tha riiiiS88tar and tha postarasuperia" inurliln of1ha miiiS8bir lislllm tha third niJiar

Pllrt olthe

that 8ldands poalariaaupericlly illo the CDII!yllr caranid praca

Araa of CIJIIdo,W jnC8IIS ofllllllldibla

Figura 33. Maalihlllar flllcbn
Area below lila cmdylar nack (i.e. &Vnaid natdl) of the mild!!a

Araa of the Cllllnlid pnJC8SS d llllllldibla

Treatment muillary and mandibular arch bars wired together (int:ramaDllary fixation) or ORIF antibiotics to cover against S. aureus and anaerobes Complications

malocclusion, mal.unlon
tooth loss, and possible sensation loss temporomandibular joint (TMn ankylosis

Maxillary Fractures
Tabla 19. La Fort Clatiliclllion

Allin.._ Nan
TyJe of lracbn

t.I'Gitl
frlcbn

La Fllltll
Pyrwlidal frlclllre Pynmdal Nasal banes Medial arbittll wall Mada Plarygcid plltal
Madery18eth l8l)8l1ll8d from face

La Flllt Ill l:raliollcill dyljiiiCtian

TIIIIISIIa18
Nlsafnmlllllllnl

Slrur:llns imhad

Horizontal PiriDrm apa11n Maxilllry sinus PtErygoid plates

Maxilla dividld inta 2. aapants

ZygarnatGfnlntalmre Zygomatic 8ICh

Ptalygaidplltel

Anltlnal...-t

DBtach entiremdflcill akllaton frrm cnnial basa

i
La fait I Fradlns La Flllt II Fncllnl La Flllt II Flldlnl

.II

Toronto Nota 2011

Cnmiofadal.lajurics

Plutic SIUJCIY PL29

Nasal Fractures
Etiology lateral force -+ more COlMlOil, good prognosis anterior force -+ can produce more serious injuries most common facial fracture

Clinical Features epistaxislhemorrhage, deviationlflattening of nose, swelling, periorbUal ecchymosis, tenderness over nasal dorsum. crepitus, septal hematoma, respiratory obrtrw:tion. subconjunctival hemorrhage depression and splayiDg ofnasal bones causing a saddle deformity important to clinically assess for naso-orbital-ethmoid (NOE) fractures
Treatment nothing always drain ICpta1 hematomu as this is a cause ofseptal necrosis with perforation (saddle nose
deformity)

closed reduction w.lth Asch or Walsbam forceps under anesthesia, pack nostrils with Adaptic", nasal splint for 7 days best reduction immediately (<6 hours) or when swelling subsides (5-7 days) rhinoplasty may be necessary later for residual defunnity (30%)

Naso-orbital Ethmoid (NOE) Fractures

Etiology
fractures of the nasal and ethmold bones of the medW. orbit problematic and may lead to greatest change in facial appearance

Markowitz-Manson classification:
Type 1: Single, central fragment. medial canthal ligament intact Type 2: Comminuted central fragment. medial canthal ligament intact lYPe 3: Severe comminution of central fragment and disrupted medial canthalllgament

telecanthus (increased intercanthal distance secondary to medial canthal ligament disruption) orbital rim step-off

Clinical Presentation

s1mJlar to nasal fractures (see above)

Treatment
surgkal repair to restore intercanthal distance. nasal projection and orbital anatomy

Zygomatic Fractures
3 categories (see Figure 34) L fracture restricted to zygomatic arch 2. depressed fracture of zygomatic complex (zygoma) 3_ unstable fracture of zygomatic complex (tetrapod fracture) - sepanrtions occur at maxilla, frontal bone. temporal bone and orbital rim
1

Clinical Features flattening ofmalar prominence (view from above)

pain over fractures on palpation numbness in V2 distribution (infraorbital and superior dental nerves) palpable step deformity in bony orbital rim (especially inferiorly) often usociated with fractures of the orbital floor ipsllateral epJstuis; trismus (lock Jaw)

0..:

)r-\'\
\.. ":

, .

'}'ntuzygumatic
Zyprullie an:h

Treatment ifundisplaced, stable and no symptoms, then soft diet; no treatment necessary ophthalmologic evaluation ifsuspected orbital injury uncomplicated zygomatic arch fractures can be elevated using Gillies approach: leverage on the anterior part of the zygmnatic arch via a temporal incision; stabilization often unnecessary ORIF for displaced ar unstable fractures ofzygomatic complex

PL30 Plaatic Suqp!ry

Craniofadal.lnjuries

1'oroDio 2011

Orbital Floor Fractures

see Qphtha1moloK)Io OP43

Definition
fracture of floor of orbit intact infraorbital rim (see Figure 35) may be assodated with naaoetbmoid fracture

Etiology blunt force to eyeball -+sudden increase in intra-orbital presmre (e.g. baseball or fist)
daeck ruual ftel.ds and acuity fur injury to Blobe

Clinical Features

F'111.. 35. Blnv-0.. Fractu..

.... 1

Di!llopia Cll1 out liactinl.

IIIII illllllillll blow-

periorbital edema and bruiaing. subconjunctival hemorrhage ptosis, exophthalmos. exorbitism. or enophthalmos orbital rim step-off's with possible Infraorbital nerve anesthesia vertical dystopia (abnormal displacement of the entire orbital cone in the vertical plane); diplopia looking up or down (entrapment of inferior rectus), limited EOM orbital entrapment: clinical diagnosis that is a mrgical emergency diplopia with vertical gaze: limited EOM severe pain or nawea and vomiting with eye movement requires urgent ophthalmology evaluation and mrgical repair

cr (diagnostic) -axial and coronal views

Investigations

diagnostic manoeu.vre for entrapment is Fon:ed Dudion test (pulling on inferior rectus IIIIlScle with forceps to ensure full ROM) under anesthesia

Trelltment surgical repair indicated if: urgent repair for entrapment, floor defect > l em, any size defect with enopthalmus or persistent diplopia (>10 days) reconstruction of orbital floor with bone graft or alloplastic material ophthalmologic evaluation suggested Complications persistent diplopia enopthalmos Superior Orbital Fl88ure (SOF) Syndrome fracture ofSOP causing ptosis, proptosis, anesthesla In Vl distribution. and painful

ophthalmoplegia (paralysis ofCN III. IV; VI) uncommon complication seen in LeFort II and m fractures (1/130) recovery time reported as 4.8-23 weeks fullowing operative reduction offractures
Orbital Apex Syndrome fracture through optic canal with involvement of CN II at apex of orbit symptnms are the same as SOP syndrome plus vision loss treatment is urgent decompression offracture in optic canal or steroids (emergency)

Toronto Notes 2011

Breut Surgery

Plastic Surgery PL31

Breast Surgery
Breast Reconstruction
integral part of breast cancer treatment two basic methods: implants (I stage or 2 stage) or autologous tissue (see Table 20) may also require breast balancing procedure and nipple areola reconstruction
Pre-Reconstruction Considerations radiation: treatment before and after mastectomy is a relative contraindication to alloplastic reconstruction recipient tissue: skin sparing mastectomy allows for the use of implants without tissue expanders ( 1 stage process) donor tissue: limited availability of suitable donor tissue (lack of tissue, scar, previous surgery that interferes with blood supply) may prevent the use of autologous tissue reconstruction timing (immediate vs. delayed) contralateral breast: may not be possible to reconstruct a breast of the same size or shape as the contralateral breast. Breast reduction or mastopexy may be considered in opposite breast (see Table 21) other considerations: patient's age and co-morbidities, prognosis, body weight, characteristics of chest wall and patient's attitude
Table ZD. Options for Breast Reconstruction

......_._

, ______________

l'lltiflnlll may r1quin 1 balancing

proc8Wra Dl1 conlnllltar&lside.

Procedun
Implant

Definition
Use of synthetic material (siicone or saline in1)1ml

Surgical Detail
Wi!h 8ICp8lldets (Z Stagesl: Use tissue expanders before replacement with implants to help facilitatu breast ptosis. (see further discussion on 1issue belawl Without expanders (1 Stagal: In skinspiring mastactomy, anough skin is available far immediate placement of implant Reconstruction with implants requns a 1ubmuscular placement of devices
CorrtJiications: capsular contraction (foreign body to implantsl. rupture or leakage of in1)1ant, increased risk of infection, 35% revision rate ovar 5years

Aulologou T111ue Use of patient's awn tissue

Many flap options: DIEP (deep inferior Offers reduced long-18rm epigastric parfonrtorl. TRAM (trensvarse morbidity and natural consistency rectus abdorninusl,l.atissimus SIEA (superfical ilferior epigastric ateryl, SGAP gluteal al'lllry perforatorl, and IGAP (inferior gluteal artery parlonrtorl Usually tilttooing far areDia Usualy performed 3 months reconstruction post-reconstruction Local vs. distant flap/graft 1. Local: fish tail Dr skate ftap mDst common; theseilap5 allow siooltaneous nipple and areola reconstruction Z. Distant: opposite nipple, abdDminal skin, costal cartilage, labia

Nipple Areola

Recollltnlction

Final stage of breast R!Construction

Breast Tissue Expanders

types: textured w. smooth, both with integrated port placement: sub-pectoral, total submuscular (pecoraUserratus) size: depends on contralateral breast and desired size generally over-expanded to facilitate ptosis timing of expansion: begins when wound fully healed {usually 2 weeks post-op), and implants are expanded weekly or bi-weekly until complete (up to 3 months). Expanders are exchanged for implants after another 3 months for consolidation of expanded skin

PL32 Plaatic Suqp!ry

1'oroDio

2011

Aesthetic Surgery
Aesthetic Procedures
T1bl1 21. Alltlurtic Pracadres

HaatWeck Hair lln"'nts

ompasty
Bmw lit
fla

Aasthalic impravarrulll of hai" growth pattBms using SIIJiicsl carecliJn of prulndng ears

of flaps

SIIJiicll procad.ua to it low brows Sllgicll procad.lra to rallce WliiliQ IIIII sagging af lhl flce111d nact. "'flee lift"" Sllgical procad.lra to shape or mocly lhl fat pads lnt11111181 flllgiceii'8CDIIIbuction of lhl111118
Chin llll!rnantatian vii Dlt8olomy or synthetic
of ..,.lids by 1111111VirJ axcess svalid skin

Rhytidac:tDmy

Bla!Droplasty
Rhinopllly

Genio!Btv

contour

injeaions, fat transhmd !ram other body parts, or implantabla matnls

Procedure Ia CI8IIIJ fUIIips 111d 1D

wrirtles around lhl nmll using collagen

Sllil

Cheni:al peel

AAJ!ication of ooe ar 111111! exfoliating agem to 1he skin resulting in des1ruction of portions of the apidarmillllll/or darmil with aubaa-1inua raganaretian Skin ra-1urfcing by Slllding wi1h a111pilly rota1D;I abRI&iva 1DDI. Often used 1D racb:a scars, imaglilr skin .races and fila lines AAJ!ication of laser to the ski! wlich ullimalely reslJbl in collagen recrig1.1111ian 101 skin DitiJg 101 Often used ID reduce seers IIIII wmdes

Dermllx'asian
Laser

l._ectlbla filn

satn:es incllda colagen. fat. hyat.uonic acid and catium

An injeclatile Ulbn:a il used 1D daCIIIS8 fnrMIIinee, wrinkiBI end

tuck""

Dill

Removal of lllCC8SS skin and rapai" of rectus muscle laidly (rectus diastasis).
Breaslaug111e1Dtian SIIJiicsl breast erllllncement 1Mth siiCillll! ar die (see Figure 36)

c aug111e1Dtian

Alvnenlllion of 131 nusde with

SIIJiicllraJIOVII of llipal81islualor body cadauring (nate weight 111111 pracad.lra) Sllgicll breast lift to eiiVIta breast maund IIIII lil#elllhl skin envaq,. in ptDtic InaIlls Sllgical breast nadlll:lian for ral&f af physic:all'l'"p1Dms
lnjiiCiion with a sclaramt to 1IIBt !Jiangilr:lllllias llld varicas1 wins

Subpac:lcnl

Bnlllll ndJctian
SclarathiiiiPY

Figure 3&. Augmantation Mmoplally: lncilia Una 1nd

lmpl11f: PIIC811111f:

Toronto Notes 2011

Pediatric Plastic Surgery

Plastic Surgery PL33

Pediatric Plastic Surgery

Craniofacial Anomalies
Table 22. Pediatric Craniofacial Anomalies Definition Cleft Lip Failure of fusion of maxillary and medial nasal processes M:F = 2:1 Cleft Palate Epidemiology 1 in 1000 live births (1 in 800 Caucasians, increased in Asians, decreased in Blacks) More common on the left (cleft of left lip/palate in boys has hereditary component) Clinical Features Classified as incomplete/ complete and uni/ bilateral 2/3 cases: unilateral, left sided, male Classified as incomplete/complete and uni/bilateral Isolated (common in females) or in conjunction with cleft lip (common in males) Syndromic- assoc. with genetic mutation Secondary (to microcephaly, hyperthyroid, rickets, etc.) Dx: irregular head shape, craniofacial abnormalities, x-ray Treatment Cleft lip team; Surgery (3 months): Milliard or Tennison-Randall; corrections usually required later on (esp. for nasal deformity) Special bottles for feeding Speech pathologist Surgery (69 months): Von Langenbeck or Furlow Z-Piasty ENT consult - often recurrent OM, requiring myringotomy tubes Multidisc. team (incl. neurosurg, ENT, genetics, dentistry, peds, SLP) Early surgery prevents secondary deformities 1' ICP is an indication for emergent surgery ICU bed may be req'd post surgically

Failure of fusion Isolated Cleft Palate: 0.5 per of lateral palatine/ 1000 (no racial variation) median palatine F> M processes and nasal septum

Craniosynostosis Premature fusion of 1+ cranial sutures Primary - abnormal suture, no known cause This may limit brain perpendicular to the suture and cause compensatory growth parallel to the fused suture

1 in 2000 live newborns; M:F = 52:48 Syndromic includes: Crouzon's, Apert's, Saethre Chotzen, Carpenter's, Pfeiffer's Jackson-Weiss and Boston-type syndromes

Incomplete Cleft Palate

Complete Cleft Palate

Cleft lip and Palate

Defects of Soft Palate Only

Defects of Soft and Hard Palate

Defects of Soft Palate to Alveolus, Usually Involving Up

Complete Bilateral Cleft

Figure 37. Types of Cleft Lips and Palates

PL34 Plastic Surgery

Pediatric: Plastic Surgery

Toronto Notes 2011

Congenital Hand Anomalies

Tabla 23. Americen Society for Surgery of the Hand (ASSH) Clauificetion of Congenital Hand Anomalies Clllificati111 A. Failure d fonnrtion

Exmpla
Trensverse Absence (congenital amputation) Longitudinal Absence (phocomelia) Radial Dsficiency {radial club hand)

FaIlium
Al any level (often below elbow/Wrist) Absent humerus ThalidomidHSSOc. Radial deviation lllJmb hypoplasia M>F

Tl'llllmlnt
Early prosthesis

Physic + splirting Soft tissue splinting fails Distraction osteogenesis (llizarov) :t wedge osteotomy Tendon transfar Pollicization

lllJmb Hypoplasia

Dagrue ranges from small Depends on dagrue - may involw thumb with all C0f11)01lents to no treatment. webspace deepening. complete absence tendon transfer, or pollicization at index finger Rare, compared to radial dub hand Stable wrist Splinting and soft-tissue stretching therapies Soft-tissue ruleasa abova fails) Correction of angulation (llizarov distraction) First web space syndactyly release OSI8atomy/tendon transfer of 1hlmb (if hypoplastic)

Ulnar Cub Hand

Cleft Hand

Autosomal dominant Often functionally nonnal {dependiiW,l on degree)

B. Failure !I diffarentiationl separation

Syndactyly

Fusion of 2+digits Surgical separation before 612 months at age 113000 live birth& M:F=2:1 Usually good result Classified as partiaVcomplete Simple (skin only) vs. complex (osseous or cartilaginous tridgBB) Short fingers with short nails at fingertips CDIW,lenital flaxion contracture {usually at PP. esp. 5th digit) Radial or ulnar deviation Often middle phalaRK Digital separation (more difficult) Webspace deepening

Symbrechydactyfy Carnptodactyly

Early aplinting Volar release Arthnoplasty (rarely)

None (usually). If severe, osteotomy with grafting

Clinodactyly C. Duplication
Polydactyly

Congenital duplication of digits Al11)utation of least functional digit May be radial {increased i1 Usually > 1yr of age {when functional Aboriginals ll1d Asians) or status can be assassed) central or ulnar (increased in Blacks) Rare Short phalqes None (if mild) Soft tissue/oony recllction Removal of non..functional stumps Ostaotomiatltendon transfers Distraction ostaogenasis PhalaiW,lealltree IDe transfer As above + syndactyly release Urgent release for acute, progressive edema dislal to band in newborn Other reconstruction is caseoipecific Treatment depends on etiology

D. Overgrowth
E. Undergrowth

Macrodactyly Brachydactyly

Symbrechydactyfy {Brachysyndectyly)

Short webbed fingers

Variety at presentations

F. Constriction band syndrome

G. Generalized skeletal abnormality

AKA amniDiic (annular) band syndrome Achondroplasia, Marian's, Medelung's

Variety at presentations

Toronto Notes 2011

References

Plastic Surgery PL35

References
Gl'lll Plastio Sul'l'l'f Concepti Bruwn Dl, Bortdlul GH. Mielligln manual of ]ilutic IIIITillllY Plilldlllphia: SIIUIId111, 21104. Dmr BM, Antii NH, Fumu liN. H111dbook of plu1ic 111g1111 far the genmluQean seclrlld editilln. New Delhi: Oldord University Pless. 1995. Gaorvilda GS. Rielblll R, Levin LS. Guorgiade pll$tic. lllllilkllacialllld turvery third edition. llallinole: Willia111$llrld Wilkils. 1m. Hunt TK. Wound Heatv.ln: Doherty G'lll, Wrt LW, eels. Cllnent surgical &lrellmenl twellh edition. Norwalk. CT: McGmv-HI, 2006. Jaril JE. of Pllllic Surv111Y: AUT Sautlrwlslim Medical C111111' HIIIIIW. St lolis, MD: lblty 211Jl. Noble J. Tllldbook. of primery CUll medicine thi'd editi:JA. St. LDui&: 2001. Dng YS, Samuel Mand S1111g C. Mellilnaly&i of lll!ly IIXl:ision of bum&. Bum&. 2006; 32: 145-50. Plastic Simi illY Educational Fllmllation. Plntic end riCCnlltruc1iva IIIITil&ry ..ntiall fer studlllll. Arlington Hlig!D, IL: Plastic Surv-ry Educa1icnl Fa.mdatian, 2007. _ prolwlionait'pliblication.&ential!.for-&udlllll.c:fm. Rimuds AM.Key rns ill Great BrUin: Blacllwell Science Ltd. 2002. S.. Ill. Practical pllllic surgery lor non-surQIOIIL Philedalplia: Hsnley &Bellus Inc. 2001. Snith llJ. Brown AS, Crull CW at II. Plllltic and recgnltructiw IIIIQIIY. ChiRgo: Plastic &r!liiY Educatinl Fudrlill, 1987. Stiml C.l'lutic llflllly. IKII. l.Dndon: Graanwiell Medical Medii Lid. 2001 TIMII!Hnd CM. SalisiDn 1lDdlloci rl surgary- the bioiiiQiCII bllis rl mod am llfllical p!ICiica six!aenth aditiarl. Phillldelpllia: W.B. Sudars 2001. Yasoonez HC. RBI, V.sconez 1.0. Plastic & reconslrul:live surgery. In: Doherty GM, Wrt LW, eels. Cllnent surgical dilglais &lrellmenl twellh edition. No!wal CT: McGn.w-llill 2006. W8inzwaig J. Plllltic :ugary SICtllls. I'MIIdalphil: Hanley snd Belfuslnc, 1919.
lt.d Am8rican Societyfor Surgvry rl tha Hand. The hand: l!XIminlltion and diiiiJIOSis third edition. Philad81phia: 1190. Beredjik111r1 PK. Bozenikll DJ. Rft'iew of band ugery. Philadelphia: Suders. 2004. Graham B, llegehr G. Naglie G. Wright J. Devalopment andvaidation of diagnostic critlril forcarpellunnllsyndrome. J Hand 2006; 31[6): 919.tl-919.e7.

PL36 Plastic Surgery

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