Surgery 250: Ambulatory Surgery

Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
recommendation is folate supplementation before
I. Reconstructive Plastic Surgery pregnancy
A. Congenital Deformities
1. Cleft Lip and Palate 
2. Craniofacial  Zinc and vitamin C? – recently have been linked to
B. Tissue Reconstruction
1. Trauma
cleft lip formation
a. Cranio – Maxillofacial  Vitamin B deficiency: latest
b. Extremity
c. Hand
2. Post-Burn Reconstruction
3. Tumor Reconstruction
4. The Reconstructive Ladder * Singapore, Taiwan & Korea have a higher
incidence of Cleft Lip/Palate because abortion is
* Please see accompanying pictotrans. not illegal.

PLASTIC SURGERY History & PE

Reconstructive Plastic Surgery 3) Birth & maternal history

o Medications
1) Congenital Deformities o Birth trauma
 Cleft Lip and Palate o Infections – previous and present
 Craniofacial 4) Family history of similar anomaly (ie. Velofaciocardiac
2) Tissue Reconstruction syndrome)
 Trauma : Cranio - Maxillofacial & Extremity 5) Previous treatment/ surgery – patients from the provinces
 Post-Burn Reconstruction may have been treated in surgical missions
 Tumor Reconstruction
 Hand (overlap w/ orthopedic surgery; about 80% 6) History of Cough and /Colds: increased vulnerability to
handled by ortho) URTI, middle ear infections and aspiration
 Recent respiratory infection infection predisposes the
Team Approach patient towards developing hyperactive airways
syndrome intraoperatively, during either anesthetic
induction or extubation
 Plastic Surgeon
 When to plan surgery: make sure no cough/colds 2
 Neuro Surgeon
weeks prior to any surgery
 ENT Surgeon
7) PE: Associated deformities
 Oral Surgeon
 Cardiac, limb, spine problems, syndactyly?
 Ophthalmologist

 Dentist
 Isolated defect or a Syndrome? (e.g. Pierre Robin
 Orthodontist
sequence)
 Pediatrician
 Speech Pathologist
Diagnostics
CLEFT LIP AND PALATE
8) Laboratory Examinations
1) CT Scan – to determine if there if brain involvement
2) CBC- check Hemoglobin
Etiology 3) CXR AP-L – very important; need to rule out PTB
4) Urinalysis- UTI
Congenital 5) Fecalysis- (aAnesthetics can stimulate parasites,
 Racial Susceptibility particularly (Ascaris), —they become mobile)
 Most common in Orientals compared to Caucasians
> (1 in 3000) and > Blacks (1 in 5000) Cleft Lip and Palate Examination
 1 in 500 births in the Philippines, in the 1980’s 
Not so much compared to > China (1 in 300) or (memorize)Assessment
India > (1 in 250)
Environmental 1) Cleft Cleft Lip
 Maternal diabetes  Unilateral vs,
 Amniotic band syndrome  Bilateral- look at columella
 Hypoxia during pregnancy, specifically during time of Complete (– extends into nasal floor) vs.
fusion of maxillary and nasal processes  Incomplete (– a bridge of tissue connects the central and
 Drugs lateral lip, p (e.g. Symonart’s band))
 Phenytoin (anti-seizure drugs)
 Alcohol
 Retinoic Acid intake: most recent
 Malnutrition
 Folate Deficiency -– major cause, showed a trend
for formation of cleft lip and palate,

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MONDAY | July 26, 201031 HAPPY BIRTHDAY, KOOKY!
January 2011 ARMANny calayan | NICki beloJoyce
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BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1

Unilateral
Incomplete Incomplete
on the Left (only up to
(central incisive
columella foramen)
connecting
with lateral
ala is seen)
Fig 2: Examples of Cleft Palate Deformities

Treatment is foh life

Bilateral
Incomplete  Lifetime Treatment
on the 1) Naso -alveolar molding – 0-3 months of age
Right  Management:
Complete on  The principal objective of pre-surgical NAM: is to
the Left reduce the severity of the initial cleft:
 End point: minimal cleft deformity
 **Maternal estrogen still circulates within the
baby’s body, hence cartilage can still be molded
by external forces.

2) Cheiloplasty (lip repair)- 3 months of age

Bilateral,
Complete
3) Palatoplasty - 12 months of age
Figure 1. Nomenclature of Cleft Lip Deformities
*There is no single, universally accepted classification.
2) Cleft Palate
 Unilateral vs. OR
Bilateral
 Laterality determined by : look at Vomer
 Incomplete (: cleft is posterior to incisive foramen) OR
vs. Complete : (cleft extends anterior to incisive
foramen, up to alveolar ridge)
 Submucous: thin mucosal connection in palate but no
muscle apposition (very rare) levator muscles don’t
come together midline, surgery still called for
4)
 Youngest patient operated on was a 7 month old
infant in MexicoMexican, done in utero,
assuming due to the assumption that healing
at this point is through regeneration; hence
tissue will heal without a scar. This
assumption was disproved; there was still a
scar
.

 Around 12 monthsThis time, the velopharyngeal
muscles are adapting for speech.
 Timing recommended to prevent hypernasal
speech (“ngo-ngo”)
 If the pProcedure is done at this age, there is a
10% chance of being “ngongo” post-
operatively; this probability dramatically rises
to 40% if the procedure is done beyond age 2.
 If not correctedUntreated?, Ppatients
compensate for defect by producing a glottal
stop.
* Sir’s oldest patient was 36 years old, but there was still
an observed improvement with his speech.
Orthodontic Treatment - 7 years old to adult
 Done tTo prevent cross-bites secondary to
gingival maldevelopment

Bilateral 5) Alveolar bone graft - 7 to 9 years old

Complete  Done by opening Open the gums and inserting a
bone graft (usually BM from the iliac crest) to
fill the cleft , such that the entire alveolus
moves as a single unit, promoting proper
tooth alignment
 Importan: if you don’t have bone, and
orthodontist will pull teeth, teeth will fall off.
Unilateral  It is at this age where permanent teeth appear.
Complete,  It is done so that teeth won’t fall off.
Right (no gap  Important for patients undergoing orthodontic
on the left treatment to align teeth, to create a better smile
side, gap is on 
 Useless if there are no teeth (teeth keeps
the right side)
pressure)

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MONDAY | July 26, 201031 HAPPY BIRTHDAY, KOOKY!
January 2011 ARMANny calayan | NICki beloJoyce
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BLOCK 28
 Surgery 250: Ambulatory Surgery
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department
6) Orthognathic Surgery 16 - 18 to 21 years old
 Movement of teeth and axilla
 Le Fort Maxilla Advancement and Sagittal Split
Mandible bleh- Cleft PGS
 To prevent occurrence of class III malocclusion
where growth of maxilla is defective and
mandible grows faster, leading to maxillary
retrusion/maxillary hypoplasia
 whMaxillary retrusion is explained by?
(a) inherent congenital defect in maxillary
growth and
(b) devascularization of a portion of the
maxilla during prior surgery (orthodontic
treatment & alveolar bone graft)- periosteum
is lifted from bone- , causing impaired growth.
 Restoration of the alignment of the mandible
and maxilla
* AGE DOES NOT PRECLUDE SURGERY
a. Palatoplasty may be done even on older patients with
some improvement in speech, but will never reach
100%
b. Older than 2, 5, 12, 18, palatoplasty may still be done.
c. Improved intelligibility: listener can now understand
what speaker is saying despite hypernasal speech
 Good Dental Hygiene and Health of pPrime iImportance-
very important, alongside dentist
RULE OF TENS
- For safety. Not all hospitals equipped with anesthesia that’s safer
to use in neonates/infants * they use halothane, isofluorane,
which puts patient at risk of malignant hyperthermia
- Old 1970’s rule devised in the 1970’s which is still used today,
wherein operation is done on infants who satisfy the following
criteria:
 Age: 10 weeks (3 months)
 Weight: 10 lbs. (5 kgs.)
 Normal Hemoglobin (Hgb): 10 mg/dL
d. Operation on cleft lip and palate may be pursued
regardless of the age of the patient, even until
adulthood; however it will not guarantee 100% return
of good speech.
9) Velopharyngeal Closure >5, can already talk
- Superior and posterior movement of the palate
against the posterior pharyngeal wall to separate
the oral and nasal pharynx, during speech
Fig 3: During speech, the velum (soft palate) moves superiorly and
posteriorly against the posterior pharyngeal wall, thereby separating the
nasopharynx and oropharynx and facilitating the production of explosive
consonants.
10)Velopharyngeal Insufficiency (VPI)- “Ngo ngo speech”
- Improper closing of the velopharyngeal sphincter (soft
palate muscle) during speech characterized by an
acute nasal quality of the voice
- Characterized by hypernasal speech- difficulty in
proper articulation of the plosive consonants
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January 2011
BLOCK 28
Bernard U. Tansipek, MD
EXA
M
1
"p," "b," "g," "t," and "d" (and “k”) “s”: PaBiGaT
Ka Daw! (supposedly no air coming out of nose
when these letters are pronounced)
* Why are children with cleft palate prone to recurrent otitis
media?
Deficiency in the midline tissues leads to defective attachment of
muscles around the eustachian tube. Thus, there is difficulty in
the closure of the tube, promoting a nidus for the growth of
pathogenic organisms.
CRANIOFACIAL CLEFTS
CRANIOFACIAL CLEFTS
1) Facial Clefts – Tessier’s classification
 clefts that originate from oral cavity, goes up to the
brain? or eye

 not as common as cleft lip or palate

 entails more surgery
 Tessier’s classification 0-14
Craniofacial Dysostosis or Craniosynostosis Syndromes
(Crouzon’s, Apert’s, Treacher Collins) – disordered or early
closure of sutures in the cranium may cause potential
problems in brain growth
2) Naso-Ethmoidal Meningocoeles
 – failure of closure of anterior cranium where a part of
the brain is sticking out the cranium; the protrudinged
part of the cranium may contain dura, CSF or brain
tissue which is sometimes atrophied/gliottic

 surgery: open the cranium, take out excess part, and
close the defect;
 intracranium repair (neurosurgeron), extracranium repair
(plastic surgeon)
 pathogenesis –theories
 Defective closure of the anterior neuropore
 Faulty tissue induction during the initial phase of
gestation
 Form of facial cleft involving both soft and bony
tissue
 Faulty formation of bone and soft tissue in the
anterior cranial fossa

 Other assosicated anomalies
Hydrocephalus, microphthalmia, agenesis of
the eye globe, arachnoid cyst, porencephalic cyst,
microcephaly, seizure disorders
Tx: intracranium repair, extracranium repair
3) Non- cleft related
o Ex. Skeletal class 3
 molars of mandible more anterior than molars of
maxilla
 open bite; can’t eat sandwich
 Tx: cut maxilla, bring it forward

4)
 Rare Case: 1 mandible, 2 tongues.
 Non-cleft related malocclusion:
ARMANny calayan | NICki beloJoyce
beloJoyce and Cedes
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
 Anterior open bite: teeth in front don’t close at > Ophtha exam
all because mandible molars more anterior  Visual
than maxilla molars acuity
 Cut maxilla, bring it forward and
diplopia
 EOMs,
CRANIO-MAXILLOFACIAL TRAUMA Pupillar
y light
Recently iIncreasing in prevalence with the advent of cheap reflex
scooters and the infrequent and improper helmet use of most > Dentoalveolar exam- patient can aspirate on loose teeth patient
Filipinos. > Maxillofacial exam
-  Malocclusion – change in the
- Involves soft tissue and bone apposition of the tooth
-  Check for TRISMUS
- BONE FIRST RULErule: Bone must be > Midfacial exam
corrected first (e.g. fixation of fractures) 1) PALPATE INFRAORBITAL RIDGE FROM THE ZYGOMA GOING
followed by the soft tissues. Since the bone MEDIALLY
is the foundation of the face, repairing the 2) CHECK FOR CREPITATION ON THE NASAL BRIDGE.
soft tissue first will cause it to follow the - Crepitation of the nasal bridge is indicative of nasal
unstable bone wherever it goes; thus bone fracture.
rendering the earlier correction futile. 3) DRAWER SIGN. PULL MIDFACE OF THE PATIENT FORWARD.
e.g. plate broken bones by Titanium 2.0, 2mm - 1-2 fractures on the midface may enable the it to be pulled
forward, as in LeFort fractures I, II, and III. Pull on maxilla,
parang drawer. Loose teeth? Fractures?
Team Approach - Do this if the patient is GCS 15 and can understand instructions.
Before doing the procedure, assess for Glascow Coma Scale
Usually plastic surgeon comes last; the patient is stabilized first. (GCS) due to the possibility of being bitten.
1) Trauma Surgeon 4) PUT FINGER NEAR THE ALVEOLAR RIDGE AND TRY TO PALPATE.
2) Orthopedic Surgeon - Alveolar fracture or tooth fracture may cause
3) Neurosurgeon malocclusion & aspiration.
4) Plastic Surgeon- 4th level, stabilize patient before any 5) TRY TO TORQUE THE MANDIBLE.
pagka-plastic - Pain and/or crepitations may indicate the presence of
5) Ophthamologist mandibular fracture may be present
6) Dentist 6) PALPATE THE INFERIOR BORDER OF MANDIBLE.
- Smooth surface with sudden step-off or pain may
indicate mandible fracture.

Advanced Trauma Life Support protocol

Primary survery History & PE
Airway and cervical spine stabilization
Breathing  DOI / TOI /POI / MOI
Circulation and control of hemorrhage

Disability and neurologic evaluation
 Symptoms
Exposure of patient and environmental control
a. Headache / vomiting – head trauma
b. Loss of consciousness
Secondary Survery for maxillofacial injuries
c. Malocclusion - change in the apposition of the
> Cranial and cervical spine injuries
toothteeth; may be evaluated by asking “Tama o may
>Maintain stability of cervical spine
pagbabago ba sa lapat ng ngipin mo?”
Diagnostics
d. Trismus – pain and/or difficulty in mandibular
 Lateral cervical spine x-rays (all 7 vertebra should
movement, either in opening or closure of the jaws
be visualized)
e. Temporo-mandibular joint pain
 Open mouth water’s view (sees atlas and axis
f. Visual acuity changes – may occur with fracture of the
bodies)
orbital floor
 CT scan
g. Rhinorrhea / otorrhea – may indicate CSF leak
> Neurologic exam
 Associated injuries
 GCS exam score

 Assessment of 12 intracranial nerves
 Previous treatment /surgery done
 History of headache and vomiting

 Loss of consciousness
 Co-morbidities
> SKIN: Integument examinations (medico-legal purposes)

 Assessment of abrasions, contusions, lacerations
 Part affected
of the face has to be listed down. Be very
a. Size & shape of defect
thorough. Location, size.
 Assess injury to facial nerve
b. Location of injury
 Assess for injury to salivary ducts (Stensen’s can
be transected) if indicated
c. If in extremities affected, assess for fullness of pulses
o Cannulate with 22 gauge venocatherer
& identify any motor/sensory deficits.
 Introduction of radio-opaque dye. Spillage?
 Drawer’s sign – assessment of midface stability
(+) transection

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BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
 Associated injuries
- Extremity fractures
-
- Visual acuity deficits
-
- EOM limitation/ diplopia
 Neurologic exam
PALPATE INFRAORBITAL RIDGE FROM - GCS Coma Scale
THE ZYGOMA GOING MEDIALLY.
Diagnostics
CT scan is best, easiest. But some don’t have it. So back to x-ray!
Radiographs
- Towne’s, Water’s view
-s
Mandible APO

- Panorex: – Panoramic X-ray of the Mandible

Important for those who underwent
CHECK FOR CREPITATION ON THE orthodontic treatment
NASAL BRIDGE.
Crepitation of the nasal sSpecific for plastic surgery
bridge is indicative of Facial CT with axial and coronal cuts
nasal bone fracture.
CBC
BUN, Crea, electrolytes

PULL MIDFACE OF THE PATIENT

FORWARD (DRAWER SIGN).
1-2 fractures on the
midface may enable the it to
be pulled forward, as in
LeFort fractures I, II, and III.
Do this if the patient is
GCS 15 and can understand
instructions. Before doing the
procedure, assess for Glascow
Coma Scale (GCS) due to the
possibility of being bitten.

PUT FINGER NEAR THE ALVEOLAR

RIDGE AND TRY TO PALPATE.
Alveolar fracture or
tooth fracture may cause
malocclusion & aspiration.

TRY TO TORQUE THE MANDIBLE.

Pain and/or
crepitations may indicate
the presence of
mandibular fracture may
be present.

PALPATE THE INFERIOR BORDER OF

MANDIBLE.
Smooth surface with
sudden step-off or pain
may indicate mandible
fracture.

 Fig 8: Midface Examination. Though not shown in the following

photographs, gloves should have been worn during the entire Radiographs
procedure. (Topher, ikaw ba to? Hehe.) 1) Fig 9: Water’s View, actual radiograph & diagrammatic
representation.

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BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
2)
3) Towne’s View
- Patient’s head flexed; plate placed in front of
the patient’s head; beam from behind from
position higher than patient’s head
- Important structures
 Condylar process of mandible: should appear
straight
 Ramus of mandible

4) Water’s view
- Patient’s head flexed; plate placed in front of
the patient’s head; beamcoming from behind
at a position higher than the patient’s head
- Important structures TOWNE CR.
 Condylar process of mandible: should appear
straight
 Ramus of mandible

Water’s View
- For visualization of the zygoma, infraorbital
& supraorbital areas; the sinuses
-
- If there is a white area blood

Fig 11: Mandible Oblique View, actual radiograph

and diagrammatic representation.

Fig 10: Towne’s View, actual radiograph & diagrammatic representation.

Fig 12: CT scan. (Left) Infraorbital rim fracture
5) Mandible Oblique
located almost at the zygoma. (Right) Le Fort I
Fracture from one side of the maxilla extending to
the other side.(maxillary area separated from
head part)

Examples of Cranio-Maxillofacial Trauma

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MONDAY | July 26, 201031 HAPPY BIRTHDAY, KOOKY!
January 2011 ARMANny calayan | NICki beloJoyce
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BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1

Fig 4: Waters’ View showing fracture of the Right Fig 7: Waters’ View showing Blowout Fracture.
Zygomatic Arch. (after reduction, titanium plates seen)

Advanced trauma life support protocol

Primary survery
Airway and cervical spine stabilization
Breathing
Circulation and control of hemorrhage
Disability and neurologic evaluation
Exposure of patient and environmental
control

Secondary Survery for maxillofacial injuries

Cranial and cervical spine injuries
Fig 5: Coronal CT scan showing fracture of the Maintain stability of cervical spine
Right Zygomatic Arch. Diagnostics
 Lateral cervical spine x-rays (all 7
vertebra should be visualized)
 Open mouth water’s view (sees atlas
and axis bodies?)
 Ct scan
Neurologic exam
 GCS exam score
 Assessment of 12 intracranial nerves
 Headache and vomiting
 Loss of consciousness
Integument examinations
 Assessment of abrasions,
contusions, lacerations of the face
Fig 6: Sagittal CT scan showing fracture of the  Assess of any injury to the facial
Right Zygomatic Arch. nerve if indicated
 Assess for injury to salivary ducts if
indicated
 Cannulation with 22 gauge
venocatherer
 Introduction of radio-opaque dye
Ophtha exam
 Visual
acuity
and
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MONDAY | July 26, 201031 HAPPY BIRTHDAY, KOOKY!
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BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
diplop
ia
 Pupill
ary
light
reflex
Dentoalveolar exam
Maxillofacial exam
 Malocclusion – change in
the apposition of the tooth

Treatment

1) Barton’s Bandage – (usually in Filipino movies, Fig 13: Motorcycle abrasion injuries, treated and covered with a skin graft.
hehe) controversial- most patients not GCS 15. If History & P.E.
they vomit, can aspirate. since it carries a risk of
aspiration when patient vomits especially in cases
ABC’s of trauma
of mandible and maxillary fracture. Refrain from
Part affected
doing this!
a. Size & shape of defect
- Fixing the
b. Location of injury
mandible against
c. Full pulses? Motor/sensory deficits
the maxilla
Make sure no Aassociated injuries before you handle extremities,
like abdominal trauma.
2) Intermaxillary Fixation - done together with the
Neurologic exam
dental department to fix the occlusion
d. GCS Coma Scale
intraoperatively; when patient has malocclusion.
usually indicated for LeFfort I fractures. (Correct
occlusion is based on the wear and tear of the
teeth.) Bite is restored.
Specific Injuries
* Do we need to wait for edema to subside before we fix the
1) Pneumatic Tire Injury PNEUMATIC TIRE INJURY
fracture to the face?
- when a patient’s leg is caught under tire of moving vehicle
- No. Fractures should be fixed as early as possible (within 24
- no outward sign of injury- but skin and soft tissue avulsed
hours) as long as there are no life-threatening conditions.
from blood supply
Anecdotal evidence says that edema resolves faster upon fixation
- Mechanism of Injury
of bones. See BONE FIRST 1st, remember? RULE.
 Shearing effect on the skin, dermis and fat  shears
- Also, faster onset of healing once bones back in place!
and cuts off blood supply causing necrosis of a
3) Address other associated life threatening injuries.
portion of skin and devascularization of soft tissues
**Titanium is usedEXTREMITY
because it is rigid INJURIES
but light-weight.
 Initial presentation of edema becomes necrotic after
several hours
 Within 24 hours, avulsed stuff DIE, and you’ve to
remove them.
- Management
 Debridement of necrotic tissues
 Early Coverage (with skin graft or flap) once wound
is clean

2) COMPARTMENT SYNDROME
- Occurs when a patient’s leg is caught under the tire of a
moving vehicle
Mechanism of Injury
Shearing effect on the skin, dermis and fat  shears and cuts
off blood supply causing necrosis of a portion of skin and
devascularization of soft tissues
Initial presentation of edema becomes necrotic after several
hours
Management
Debridement of Necrotic Tissues
Early Coverage (with skin graft or flap) once wound is clean

Compartment Syndrome
Seen most often in burns/ and closed crush injuries (no
external signs of injury, e.g. naipit sa machinery)

- Mechanism of Injury

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BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
 Fluid exudation at the capillary level in a tight
and confined fascial space/plane, leading
ultimately to obstruction of arterial inflow.
- Untreated Sequelae?
 Muscle and nerve DIE. changes become irreversible
 Volkmann’s Ischemic Contracture (muscle and
nerve die and becomes scar tissue; irreversible)
 Progression of Signs and Symptoms (in order of
occurrence)
i. Pain
ii. Pallor
iii. Paresthesia Fig 15: Sensory distributions of the hand.
iv. Pulselessness
v. Paralysis
Severe pain leads to pallor and parethesis, eventually losing pulse 2. Motor
- Management - Check both the extensor and flexor muscles.
Fasciotomy (Compartment Decompression): cutting open  Shoulder motion
until edema subsides. Let muscle pop out, remove fluid  Elbow motion
 Pronation and supination of the forearm
HAND
 Check active and passive range of motion for
discrepancies.
 It is iImportant: to determine differences in grip strength
and pinch strength differences between the two hands.

Fig 14: Examples of hand conditions.

History

Trauma-related
- DOI/TOI/POI/MOI

- Posture of the hand at the time of injury Fig. 16: Movements of the hand.
Handedness
Associated injuries or lesions
Previous treatment / surgery

Congenital
Non-Trauma Related
- Work Related

- Functional or structural limitations- namo-move?

- Effect on activities of daily living

TRIVIA: 40-50% of the function of the hand comes from the thumb.
This increased dependence o thumb function separates humans
from the primates. -
Activities that make the pain/condition worse?

Physical Examination Fig 17: Movements of the thumb.

Examine the entire upper extremity, up to shoulder. Expose and 3. Circulation

evaluate the entire upper limb for: - Allen’s Test for radial and ulnar artery function

1. Sensory (Nerve Function)

- Distribution of the radial, ulnar and median nerves

- Two Point Discrimination

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BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
- Permanent tightening of the scar tissue that may affect the
underlying muscles and tendons that limit mobility
- Normal elastic connective tissue is replaced with inelastic fibrous
tissue (scar)

Fig 19. LEFT): Extensive post-burn contractures, especially of the axilla.

RIGHT: After surgery.

Fig 18: Allen’s Test. This test eEvaluates the patency of both radial and
ulnar function. Blood
flow is halted in either vessel one at a time by manually
external pressure on the vessel. Adequacy of delivery in
the isolated artery or the arters held in consideration is
thus performed.
Fig 20. Burn contraction of the antecubital fossa; Surgery of
4. Watch out for COMPARTMENT SYNDROME
contractures of the right arm.
5. Splinting of hand or any injured part, using thermoplast or
Plaster of Paris, straightens the tendon and prevents History
contracture. However contracture may also develop
during the time of splinting; thus the splinting position DOI / TOI /POI / MO
must be designed to allow optimal functioning once How long has is the contracture been around?
contractures indeed develop. For the hand, the - More than 1 month (scar tissue develops at this
following characterize the “safe” position: duration)
 Wrist in mild extension
 MCPJ at 70°-90° - Sometimes, with the chronicity of the contracture, the
 IPJ in extension joints themselves become subluxed.
 Thumb in palmar ABDduction Functional or structural limitations
Associated injuries
Diagnostics Previous treatment / surgery
Co-morbidities
Hand APO
CT Scan Physical Examination

Part affected
- Extent: Bone? Soft tissue? Viable joint?
POST-BURN RECONSTRUCTION
- Bony involvement in the setting of burn contractures in
PEDIATRICS.
> Results in results in mmaladaptive bone regeneration
and subluxation. Bone grows, scar pulls it back. Subluxed
joints due to pulling of scar.

> Bone examination is essential in pediatric burn

patients
Limitation of range of motion
Handedness: very important consideration
Fig 17. Burns on the hand > If both hands are contracted, surgery is done on the
dominant hand first
Team Approach
1. Diagnostics
2. Plastic Surgeon / Burn Surgeon
3.
4. Rehabilitation Medicine Specialist X-rays of involved area
5. CBC
6. Physical Therapist BUN, Crea, electrolytes

Burn Contracture Treatment

Early Mobilization (after release of contraction)

Page 10 of 12
MONDAY | July 26, 201031 HAPPY BIRTHDAY, KOOKY!
January 2011 ARMANny calayan | NICki beloJoyce
beloJoyce and Cedes
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 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
Physical therapy Radiologic exam of involved area
Splints o X-rays
Jobst garments or Pressure Garments: exerts pressure on o CT scan
scar to blunt hypertrophic scar. o MRI
Skin graft – take top 0.12 mm of skin; very thin so the CBC
skin where it came from heals very well with only BUN, Crea, electrolytes
discoloration; usually harvest from the scalp where CXR
healing rate is 2x as fast due to adnexal structures
THE RECONSTRUCTIVE LADDER
TUMOR RECONSTRUCTION

Team Approach Processes Arranged in Description

Increasing Complexity
Oncologic Surgeon Healing by Secondary No Surgical Intervention. Let it heal
General Surgeon Intention on its own.
Plastic Surgeon
Healing by Primary Suturing Involved Areas. Indirect
Burned scalp? Put tissue expander, inflate every week 50-100 cc Intention closure.
Delayed Primary Deferring Suturing until
Closure Histopathologic fFindings aAre
History aAvailable
Skin Graft Use of One Area of Autologous Skin
Onset to Cover Skin Gap
Changes
 Size What happens to donor site? Heal on
 Shape its own. You just get a very thin part of
 Consistency dermis.
Previous treatment/surgery Local Flap Use of Adjacent Tissue to Fill Skin
Exposure to environmental agents Gap, cover other area
Associated symptoms Random: no sp. blood supply
Pedicled: specific BS

E.g. MR Mastectomy. From stomach

and rectus abdominis to make breast
Important Question tissue. Pedicled. Artery running down
“Would the quality of life be affected by the surgery?” R. Ab muscle, transferred to breast
Free Flap Microvascular Transfer
- (anastomosis of involved vessels
Physical Examination from distant sites to another area
,
Part affected (Tumor Staging) e.g. from tibia fibula to face, along
 Size with peroneal artery and vein;
 Shape anastomose to facial artery and
 Depth external jugular vein)
Extension to adjacent areas
 Projected margins of defect Involves basically harvest of
 Lymph node involvement autologous distant tissue
Involvement of other organs

- Important Question - Aesthetic Surgery

Anything (mole, mass, cyst, suspicious lesion) that leaves
patient’s body: What is the pPathologic dDiagnosis? For you,
for your patient, future medico-legal purposes. History & PE

All resected masses must be sent for pathologic evaluation
prior to any surgery. To determine if benign (treatable by
surgery or therapy alone? Lymphoma can be treated by
chemotherapy alone) or malignant – will determine mgt. Also
for protection of patient and doctor
(Sir’s example: doctor MD performs a mole excision. and patient Pt
returns several years later with a diagnosis of squamous cell CA.
Without the pathologic diagnosis of the initial lesion, i.e. mole, the
doctor cannot prove that the initial lesion was just a mole and not SCC
that eventually presented due to incomplete excision.)
Diagnostics
It is important to talk to patients before surgery!
 Patient expectations & objectives for surgery
 Previous surgery
 Allergies & co-morbidities
 Psychological concerns- e.g. unrealistic: I want to look like
______, breast augmentation because husband is cheating
on me
 Realistic goals- aesthetic, should help in psychological
acceptance, betterment
 History of Smoking – one of the causes of morbidities post-
op
- Problems of aseptic surgery
- Smoking decreases blood supply to the area involved
in surgery which can cause chronic non-healing

Page 11 of 12
MONDAY | July 26, 201031 HAPPY BIRTHDAY, KOOKY!
January 2011 ARMANny calayan | NICki beloJoyce
beloJoyce and Cedes
BLOCK 28
 Surgery 250: Ambulatory Surgery
Bernard U. Tansipek, MD
Lecture 1: Introduction to Plastic Surgery Outpatient
Clinics and the Emergency Department EXA
M
1
infection, especially in surgeries needing elevation of
flaps. Smoking increases chance of necrosis of flap.
Advise the patient to stop smoking 1 month before the
surgery and 1 month after surgery.
 Area of Concern
- Size & shape of original breast

- Symmetry

- Some degree of asymmetry commonly persists in the

breasts, even after aesthetic surgery.

- Measurements
 Masses or any palpable abnormality in the area
- Nodularities
- Polyps
- Infections
- (+) Mammography warranted

Page 12 of 12
MONDAY | July 26, 201031 HAPPY BIRTHDAY, KOOKY!
January 2011 ARMANny calayan | NICki beloJoyce
beloJoyce and Cedes
BLOCK 28