Plastic Surgery Plastic Surgery Survival GuideSurvival Guide

A guide to help you survive A guide to help you survive nights and weekendsnights and weekends

Outline of TopicsOutline of Topics

General overview of serviceGeneral overview of serviceExpectationsExpectationsPlastic surgery “Emergencies”Plastic surgery “Emergencies”HandHandFaceFaceSoft tissue injuriesSoft tissue injuriesDecubitus ulcersDecubitus ulcersV.A.C. systemV.A.C. system

General OverviewGeneral Overview

Plastic surgery at the VA and Elmhurst is a Plastic surgery at the VA and Elmhurst is a relatively small service staffed soley by the relatively small service staffed soley by the plastic surgery chief resident or senior residentplastic surgery chief resident or senior residentA general surgery junior resident is responsible A general surgery junior resident is responsible for covering the service during off-hours and for covering the service during off-hours and weekends. This includes the in-patients (which weekends. This includes the in-patients (which are rare) and the ED consultsare rare) and the ED consultsYOU ARE NOT ALONEYOU ARE NOT ALONE – the plastic surgery – the plastic surgery resident is always reachable by pager or phone, resident is always reachable by pager or phone, and ALWAYS available to come in to assist you and ALWAYS available to come in to assist you with complex questionswith complex questions

VA is a light service and most ED consults VA is a light service and most ED consults are facial lacerations or hand injuriesare facial lacerations or hand injuriesElmhurst is significantly busier especially Elmhurst is significantly busier especially during “hand” weeksduring “hand” weeks– Plastic surgery and Ortho alternate hand Plastic surgery and Ortho alternate hand

coverage weekly. You should know what coverage weekly. You should know what service is covering when you are on callservice is covering when you are on call

– Plastic surgery/ENT/OMFS alternates “face” Plastic surgery/ENT/OMFS alternates “face” call. You should refer to the call schedule for call. You should refer to the call schedule for the coverage detailsthe coverage details

ExpectationsExpectations

You are not expected to know everything about You are not expected to know everything about plastic surgeryplastic surgery

YOU SHOULDYOU SHOULD::– be competent in the basic physical exam (hand, face)be competent in the basic physical exam (hand, face)– Be able to assess severity of injuriesBe able to assess severity of injuries– Be able to clearly describe injury to the plastic surgery Be able to clearly describe injury to the plastic surgery

residentresident– Be able to identify plastic surgery “emergencies”Be able to identify plastic surgery “emergencies”– Be comfortable with digital nerve blocks, splinting, Be comfortable with digital nerve blocks, splinting,

and suturingand suturing– Know when to call for helpKnow when to call for help

Plastic Surgery “Emergencies”Plastic Surgery “Emergencies”

Hand/Extremity:Hand/Extremity:– amputation, near amputation, vascular amputation, near amputation, vascular

compromisecompromise– compartment syndromecompartment syndrome– Uncontrolled bleedingUncontrolled bleeding

Face:Face:– Entrapment of ocular musclesEntrapment of ocular muscles– Septal hematomaSeptal hematoma– Complex multifacial traumaComplex multifacial trauma

HandHand

Includes soft tissue distal to the elbow and Includes soft tissue distal to the elbow and bones on wrist and distalbones on wrist and distalRadius/Ulnar fractures are always orthopedicsRadius/Ulnar fractures are always orthopedicsMost common injuries include:Most common injuries include:– FracturesFractures– LacerationsLacerations– Tendon injuriesTendon injuries– Nerve injuriesNerve injuries– Nailbed injuriesNailbed injuries– CellulitisCellulitis– IV infiltrateIV infiltrate

““Hand History”Hand History”

Specifics about “hand history”Specifics about “hand history”– Mechanism of injury (crush, laceration, fall)Mechanism of injury (crush, laceration, fall)– Right-handed or left-handedRight-handed or left-handed– Occupation (piano player, construction)Occupation (piano player, construction)– Tobacco useTobacco use– DiabetesDiabetes– Injury at work or at homeInjury at work or at home

AmputationsAmputations

This is an emergency - This is an emergency - the clock is ticking…the clock is ticking…Call the plastic surgery residentCall the plastic surgery residentAlso, facilitate the following in the ED:Also, facilitate the following in the ED:– Tetanus, IV ABxTetanus, IV ABx– Xray of hand (yes this is important)Xray of hand (yes this is important)– Pre-op labs – results should be printed and sent with patientPre-op labs – results should be printed and sent with patient– Let the ED attending know that patient shold be transported to Let the ED attending know that patient shold be transported to

SinaiSinai

Packaging of part – place in plastic bag, then place that Packaging of part – place in plastic bag, then place that on ice. on ice. NEVER PUT PART DIRECTLY IN ICENEVER PUT PART DIRECTLY IN ICEIf part is “hanging” by small skin bridge, If part is “hanging” by small skin bridge, NEVER NEVER COMPLETE THE AMPUTATIONCOMPLETE THE AMPUTATION. Wrap bag of ice . Wrap bag of ice around hand and secure with ace bandage.around hand and secure with ace bandage.

FracturesFractures

95% of time will simply advise to place in 95% of time will simply advise to place in splintsplint

Splint options:Splint options:– Phalanx, metacarpal, carpals- volar splintPhalanx, metacarpal, carpals- volar splint– ““boxer” fracture, 4boxer” fracture, 4thth/5/5thth metacarpal - ulnar metacarpal - ulnar

gutter splintgutter splint– Thumb- thumb spica splint.Thumb- thumb spica splint.

NO CASTSNO CASTS

Thumb spica

Basic Splinting

Position of “safety”

Flexor TenosynovitisFlexor Tenosynovitis

Infection in flexor sheathInfection in flexor sheath

4 classic Knavel Signs4 classic Knavel Signs– Pain with passive motionPain with passive motion– Fusiform swellingFusiform swelling– Fixed in flexionFixed in flexion– Pain along tendon sheathPain along tendon sheath

Treatment is operative Treatment is operative drainagedrainage

Tendon InjuriesTendon Injuries

You are not expected to know how to You are not expected to know how to repair theserepair these

You must be able recognize the injuryYou must be able recognize the injury

Know anatomyKnow anatomy– FDP flexes at DIP jointFDP flexes at DIP joint– FDS flexes at PIP jointFDS flexes at PIP joint

FDS tendon – flexes PIP joint

FDP tendon – flexes DIP joint

Extensor tendon

Nerve InjuryNerve Injury

Must have high degree of suspicion given Must have high degree of suspicion given location of lacerationlocation of lacerationMost of the time, patient will say that it Most of the time, patient will say that it feels “a little weird at the tip”. This is more feels “a little weird at the tip”. This is more common then complete numbness. common then complete numbness. Repair not emergent. Should be fixed in 7-Repair not emergent. Should be fixed in 7-10 days for optimal results.10 days for optimal results.Important to test BEFORE giving Important to test BEFORE giving anesthesiaanesthesia

LacerationsLacerations

Close in 1 layer with 4.0 nylon suturesClose in 1 layer with 4.0 nylon suturesNot too tight – it will swellNot too tight – it will swellBacitracin/xeroform/dry dressingBacitracin/xeroform/dry dressingMay place splint for comfortMay place splint for comfortElevationElevationABx – 1 dose IV in ED and 5-7 days oralABx – 1 dose IV in ED and 5-7 days oralTetanus boosterTetanus boosterSutures remain for 2-3 weeksSutures remain for 2-3 weeks

Digital BlockDigital Block

1% lidocaine – 1% lidocaine – NO EPINEPHERINENO EPINEPHERINE

2 nerves – must block both for each finger2 nerves – must block both for each finger

2 techiques:2 techiques:– Individually block each nerve (in web space)Individually block each nerve (in web space)– Trans-thecal – inject into tendon sheath and Trans-thecal – inject into tendon sheath and

anesthetic diffuses out sheath into nervesanesthetic diffuses out sheath into nerves

You can always inject directly into woundYou can always inject directly into wound

Individual Nerves – inject in each web space

Trans-thecal – inject in tendon sheath at A1 pulley

Nailbed injuryNailbed injury

Typical injury is “crushed finger in door”Typical injury is “crushed finger in door”

Remove nail-plateRemove nail-plate

Assess nail-bed injury (below plate)Assess nail-bed injury (below plate)

Nail-bed repaired with 6.0 chromicNail-bed repaired with 6.0 chromic

Nail-plate replaced under eponychial fold Nail-plate replaced under eponychial fold and secured in place with a sutureand secured in place with a suture

If no nail-plate, may use foil from suture If no nail-plate, may use foil from suture wrapperwrapper

Sub-Ungal hematomaSub-Ungal hematoma

Hematoma under nail plateHematoma under nail plate

Should be drained if > 50% nail surfaceShould be drained if > 50% nail surface

Drain by boring a hole in nail with 18 Drain by boring a hole in nail with 18 gauge needle. This should not be painful gauge needle. This should not be painful to patient.to patient.

If hematoma and nail-plate is partially If hematoma and nail-plate is partially avulsed, you can simply remove the nailavulsed, you can simply remove the nail

Facial lacerationsFacial lacerations

Rule out other injuries based on locationRule out other injuries based on location– Lacrimal ductLacrimal duct– Parotid ductParotid duct– Facial nerveFacial nerve– Vascular injuryVascular injury

6.0 nylon or prolene6.0 nylon or prolene

Sutures removed in 3-5 daysSutures removed in 3-5 days

Bacitracin ointment, keep dryBacitracin ointment, keep dry

Facial FracturesFacial Fractures

CT scan – axial and coronal with fine cuts CT scan – axial and coronal with fine cuts through orbits (3mm)through orbits (3mm)Protect airway if multiple fractures or Protect airway if multiple fractures or mandible/maxilla fracturesmandible/maxilla fractures10 % incidence of C-Spine injury in setting 10 % incidence of C-Spine injury in setting of mandible fracture or multiple facial of mandible fracture or multiple facial fracturesfractures– All patients need spine cleared if significant All patients need spine cleared if significant

facial injury.facial injury.

Orbit FractureOrbit Fracture

Opthamology must see the patientOpthamology must see the patient

Assess gross visionAssess gross vision

Assess occular musclesAssess occular muscles– Entrapment is emergencyEntrapment is emergency

Check for forehead parathesia (supra-Check for forehead parathesia (supra-orbital N.) and cheek parathesia (infra-orbital N.) and cheek parathesia (infra-orbital N.)orbital N.)

Nasal FractureNasal Fracture

Look for septal hematomaLook for septal hematoma– Must be drained if present to prevent septal Must be drained if present to prevent septal

necrosisnecrosis

Is fracture stable or unstable (“crunches” Is fracture stable or unstable (“crunches” when palpated)when palpated)

Septal Hematoma

Complex Soft Tissue InjuriesComplex Soft Tissue Injuries

Assess woundAssess wound

Irrigate copiouslyIrrigate copiously

Xray to rule out fractures or foreign bodiesXray to rule out fractures or foreign bodies

Most do not need “coverage” or “repair” in Most do not need “coverage” or “repair” in the acute settingthe acute setting

Priority is bone/vascular/nerve injuriesPriority is bone/vascular/nerve injuries

Must assess neurologic function Must assess neurologic function beforebefore injecting local anestheticinjecting local anesthetic

Decubitus UlcersDecubitus Ulcers

Only “emergent” if source of sepsisOnly “emergent” if source of sepsis

If wound is open and draining, very If wound is open and draining, very unlikely to be septic sourceunlikely to be septic source– Look for other sources (urine, lungs, etc.)Look for other sources (urine, lungs, etc.)

If “boggy” and fluctuant, need to open If “boggy” and fluctuant, need to open wound and allow drainagewound and allow drainage

V.A.C. systemV.A.C. system

Know how to troubleshoot system if called Know how to troubleshoot system if called because it is “beeping”because it is “beeping”Usually it is a leak in the dressing. Can patch Usually it is a leak in the dressing. Can patch leaks with Tegadermleaks with TegadermIf machine says cannister is full…but clearly it is If machine says cannister is full…but clearly it is not, most likely because clogged tubingnot, most likely because clogged tubing– Change cannister firstChange cannister first– If still not working, change tubing on dressing next. If still not working, change tubing on dressing next.

Can simply replace “disk”and tube without removing Can simply replace “disk”and tube without removing sponge. Cut out disk, replace it, and patch over top of sponge. Cut out disk, replace it, and patch over top of it.it.

Clinic ScheduleClinic Schedule

ElmhurstElmhurst– Plastic surgery – Tues 1 PM, Friday 9 AMPlastic surgery – Tues 1 PM, Friday 9 AM– Hand – Friday 1 PMHand – Friday 1 PM

VAVA– Plastic/Hand – Thursday 1 PMPlastic/Hand – Thursday 1 PM

Plastic Surgery Pager numbersPlastic Surgery Pager numbers

Matt Schulman PGY 6 – 917-457-0594Matt Schulman PGY 6 – 917-457-0594

Elie Levine PGY 6 – 917-457-0593Elie Levine PGY 6 – 917-457-0593

Marco Harmaty PGY 5 – 917-457-0597Marco Harmaty PGY 5 – 917-457-0597

Henry Lin PGY 4 – 917-457-0599Henry Lin PGY 4 – 917-457-0599

Tommaso Addona PGY 4 – 917-457-0613Tommaso Addona PGY 4 – 917-457-0613