chapter

16 Plastic and
Reconstructive Surgery

P
lastic and reconstructive surgery is a specialty concerned
with restoring, restructuring, correcting, or improving the
shape and appearance of body parts that are defective,
damaged, or misshaped by growth and development, injury, or dis-
ease. Most people are familiar with cosmetic plastic surgery, but
the specialty has a wide range with complex procedures. Many
plastic surgeons specialize in reconstructive procedures that result
from genetic abnormalities affecting children, to accidental disfig-
urements. This specialty is wide reaching and calls for the Surgical
Technologist to be familiar with multiple procedures and the anat-
omy accompanying them.

CHAPTER OUTLINE

Terminology 325
Plastic and Reconstructive Surgery 326
Burns 328
Surgical Procedures 330
Questions 333
Answers & Rationales 334
Surgery Schedule 336
Questions 336
Answers & Rationales 337

324
 CHAPTER 16 Plastic and Reconstructive Surgery 325

TIP
Answering questions about plastic surgery can be challenging because of the wide range of procedures involved in
the specialty. When faced with these questions, first you must decipher the procedure that will be performed. This
requires using medical terminology to first understand the essence of the procedure. The second step, which is
similar to the other specialties, is to remember the anatomy associated with the procedure. Once this is deci-
phered, it then becomes easier to answer these questions. Distinctions have to be made to be successful. For
example, there is a large difference in a palatoplasty and a cheiloplasty. While these surgeries are often combined,
one is much more intricate than the other. To repair a cleft lip, without the cleft palate, is much less involved and
does not involve the bones. This procedure may be done for cosmetic reasons, rather than for the survival of an
infant. These distinctions are instrumental in answering questions related to this unique specialty.
Example:
A procedure to tighten excess skin on the lower face and neck is a
a. Rhinoplasty
b. Blepharoplasty
c. Rhytidectomy
d. Rhizotomy
To answer the question correctly, the Surgical Technologist must first look at the type of procedure being per-
formed. A procedure to remove or tighten the skin of the lower face and neck is a facelift. Once that is established,
knowledge of medical terminology is all that is required to answer the question correctly. Rhizo- is the medical
term for root, in this instance; it is referring to the resection of the dorsal root of a spinal nerve, a procedure used
to relieve chronic pain. Even if the ST is unfamiliar with this procedure or term, the process of elimination can
work well for this question. Blepharo- is the combining word for eyelid, so this term would be used for a procedure
on the eye, not the lower face. Rhino- is the word meaning nose, again, not a term used for a facelift. That would
leave two possible answers: Rhytidectomy and Rhizotomy. If you recall that Rhytid- means wrinkle, you have the
answer, even if you are unfamiliar with the surgical procedure.

I. Terminology
A. Alloplasty: plastic surgery with nonhuman tissue
B. Autograft: tissue transplanted from one part of the body to another
C. Blepharoplasty (blephar/o: eyelid; plasty: mold, shape): plastic surgery on
the eyelids
D. Cheiloplasty (cheil: lip; plasty: shape, mold): plastic surgery on the lips
E. Contracture: (drawn together): a complication in the healing of thermal
burns where scar tissue prevents movement Allograft-synthetic
F. Debridement: excision of nonviable tissue Autograft-human skin
Heterograft (xenograph)-pig skin/synthetic skin
G. Dermabrasion: “sandpapering” skin by mechanical means Homograft-From another of same species
Isograft-used for twins ?
H. Eschar: scab or slough produced by thermal burns
I. Heterograft (xenograft): porcine (pigskin) or synthetic skin graft used to
protect burns during the early phase of healing
J. Homograft: graft of tissue between individuals of the same species
K. Liposuction (lip/o: fat): surgical removal of adipose tissue through a suction
cannula Mercedes Cannula used for liposuction
L. Mammopexy/Mastopexy: surgical fixation of pendulous breasts
326 CHAPTER 16 Plastic and Reconstructive Surgery

M. Mentoplasty: (ment/o: chin; plasty: mold, shape): plastic surgery on the

chin
N. Paresthesia: prickling or tingling sensation
O. Polydactyly: excess number of fingers and toes
P. Preauricular: in front of the ear
Q. Replantation: reattachment of a structure or organ
R. Rhytidectomy (rhytid: wrinkle; ectomy: surgical removal): a face-lift
S. Stent dressing: cotton or fluffed gauze placed over a graft site and preplaced
sutures drawn across the dressing and tied
II. Plastic and Reconstructive Surgery
A. Special features
1. Patient anxiety
2. Feelings and perception of physical deformity
3. Social acceptance
B. Preparation for surgery
1. Preoperative skin preparation
a. Special attention should be paid to the fingernails of patients under-
going hand surgery.
b. Special attention should be paid to the hair of the patient having sur-
gery of the head, face, or neck (many surgeons require that the
patient scrub or shower from head to toe with an antimicrobial soap
the night before or morning of surgery).
c. Oral hygiene is essential when the procedure involves the mouth.
d. Shaving is avoided; eyebrows and eyelashes are left intact.
e. Nonstaining prep solutions are generally used; prevent prep solutions
from getting into patient’s eyes.
2. Positioning: access to all operative sites must be considered; adequate
padding is essential for long procedures.
3. Draping
a. Wide area may be required to expose both sides for comparison.
b. More than one incision site is frequently necessary.
c. Head drape: barrier sheet with two towels is placed beneath the head,
with top towel clipped around the head; diagonal towels are placed
and secured alongside the neck; full sheet is used to cover the patient
from head to foot.
d. Hand drape: two barrier sheets are used to cover the hand table,
with one forming a cuff proximally; stockinette is used to cover the
involved extremity; folded sheet is placed over the upper part of the
body to the stockinette and secured with clips around the upper arm;
additional sheets are used to cover the remainder of the body.
4. Dressings
a. Applied while the patient is still anesthetized
b. Used to immobilize, apply even pressure, collect drainage, provide
comfort, and protect the wound
c. Closed wound suction drains or catheters may be used, such as Jack-
son-Pratt, Hemovac, or butterfly cannula to rubber-tipped tube
d. Dressings include nonadherent gauze (Adaptic, Xeroform), petrola-
tum gauze, Telfa, Webril, Kling, Kerlix, adhesive bandage, skin clo-
sure tape, Coban, and plaster supplies.
e. Stent dressings: sutures tied over dressing to maintain position of a
graft
f. Biological dressings: homografts or heterografts used as temporary
cover for denuded skin to help control infection, prevent serum loss,
decrease pain, and stimulate growth of new tissue
 CHAPTER 16 Plastic and Reconstructive Surgery 327

5. Anesthesia: local, topical, regional, or intravenous sedation. Local infil-

tration anesthesia is given with 26- to 30-gauge needles.
6. Effects of aspirin and smoking: patients are asked to avoid aspirin (anti-
coagulant) and smoking (vasoconstrictor) for at least 2 weeks after surgery
because of their effects on bleeding and wound healing.
7. Use of photography: photographs may be taken and/or displayed during
surgery to assure symmetry and effective cosmesis.
8. Cosmetic wounds: cosmetic wound is enhanced by the following:
a. Marking the incision site with sterile marking pen or sterile dye (brilliant
green, methylene blue, gentian violet)
b. Making the incision along natural body lines and contours
c. Meticulous approximation of tissue
d. Adequate hemostasis
e. Small scalpel blade (#11 or #15)
f. Small suture sizes (2-0 to 7-0); for microsurgery (8-0 to 11-0); generally
synthetic nonabsorbable (nylon/polypropylene) or absorbable (Vicryl)
is used; swaged needles
9. Instrumentation, equipment, and supplies
a. Instruments: delicate, such as Iris or Stevens tenotomy scissors, mos-
quito hemostats, fine-tipped forceps (Brown-Adson), skin hooks or
Senn retractors, and Webster needle holder
b. Equipment: nerve stimulator, microscope or loupes, bipolar electro-
surgical unit, and pneumatic tourniquet
c. Implant materials: silicone (gel, adhesive, or performed), Dacron,
Marlex, Teflon, or metals (stainless steel, Vitallium, titanium, tanta-
lum), or ceramics
i. Usually come with packaged sterile
ii. Handle carefully to avoid contamination; kept lint free, oil free,
and powder free; inspected for defects
iii. Follow manufacturer’s guidelines when sterilizing is necessary.
d. Dermatomes: used for split-thickness skin grafts (STSGs)
i. Knife dermatomes
ii. Drum-type manual dermatomes (Reese and Padgett-Hood):
restricted to use on flat or open areas but provide uniform thick-
ness for STSG
iii. Motor-driven dermatomes (Brown, Padgett): have oscillating
blades that work like hair cutters with power supplied by electric-
ity or compressed air
• For use on firm areas such as the thighs
• Opened up and kept on separate sterile table
• Foot pedal is placed at surgeon’s feet when ready for use and
removed immediately after use.
• Blade is inserted into the carrier, generally by the surgeon, and
adjusted for desired thickness.
• Sterile mineral oil is applied to the donor site, and the assistant
holds tissue taut with a sterile tongue blade.
e. Skin graft mesher: enlarges graft two to three times by making multi-
ple uniform slits in the skin graft
i. Used for expanding skin to cover large denuded areas
ii. Skin, removed by a dermatome, is stretched out over plastic dis-
posable dermacarrier and passed through rollers of the skin graft
mesher.
iii. Scrub or assistant grasps edges of the skin with Adson forceps as
it is advanced.
iv. Skin is left on the carrier and kept moist with saline until the
recipient site is ready.
328 CHAPTER 16 Plastic and Reconstructive Surgery

f. Immediately after skin is removed, the donor site is covered with

moist sponges soaked in a solution of 20 mg of Neosynephrine to
1000 ml of normal saline or sprayed with topical thrombin for
hemostasis.
g. Donor site is dressed with nonadherent gauze, moist dressings, or
covered with bio-occlusive dressing.
h. Skin may be sutured or stapled in place on the recipient site.
III. Burns
A. Types of burns
1. Thermal
2. Chemical
3. Electrical
4. Mechanical
B. Classification of burns
1. First-degree burn: involves epidermis; characterized by redness of skin
(erythema) swelling, pain; first-aid treatment is to rinse in cold water
2. Second-degree burn: involves epidermis and part of dermis; character-
ized by redness, swelling, pain, and blisters; open for infection and loss
of body fluid
3. Third-degree burn: involves injury to full thickness of the skin; charac-
terized by anesthetic surface which is dry, pearly white, and/or charred;
destroyed skin will slough and form eschar; requires skin grafts
4. Fourth-degree burn: extended beyond skin into subcutaneous tissue,
muscle, or bone; requires full-thickness grafts
C. Assessment of burn damage
1. Rule of Nines: 9% for head and neck, and each upper extremity; 18%
for anterior trunk, posterior trunk, and each lower extremity; and 1%
for perineum
2. Lund and Browder chart: percentage of burn is based on age and ana-
tomical location; useful in estimating burn damage in children, where
percentages of body surface vary greatly
D. Initial burn care
1. Open airway is ensured; smoke-induced edema of the respiratory tract
may necessitate endotracheal intubation or Tracheotomy; Bronchoscopy
is routine on patients with burns around the face.
2. Venous access for IV fluids, plasma, blood, and electrolytes is
established.
3. Urinary drainage for hourly output and urine checks is established.
4. Wound is cleansed; aseptic technique is essential, using mild cleansing
agent in warm sterile saline or water.
5. Percentage and depth of burn is estimated.
6. Patient history is taken.
E. Operative treatment for burns
1. Goal: prevent infection, promote healing, and address psychological
needs
2. Excisional therapy: debridement with scalpel, skin graft knife, der-
matome, electrosurgical knife or LASER
3. Temporary application of homograft or heterograft
4. Tangential excision: removal of burned tissue until the normal tissue is
reached; frequently used on hands, arms, and legs to minimize contrac-
tures, reduce infection and mortality, and shorten hospitalization
5. Escharectomy: excision of full-thickness eschar down to the fascia;
denuded areas are covered with a biological dressing and later grafted
with full-thickness autografts; biological dressings are not used on face,
neck, or over joints
 CHAPTER 16 Plastic and Reconstructive Surgery 329

6. Escharotomy: bilateral incisions through eschar which has produced a

tourniquet effect on an extremity or the chest; done to improve circulation
7. Fasciotomy: bilateral incision through the fascia to release a tourniquet
effect on an extremity or the chest when Escharotomy is not adequate
8. Grafts
a. Full-Thickness Skin Graft (FTSG): contains both epidermis and
dermis, causes minimal contractures, can be used near joints, adds
padding, and is more aesthetic than STSG; donor site must be closed
primarily; referred to as composite or free-tissue grafts
b. Split-Thickness Skin Graft (STSG)
i. Contains epidermis and only a portion of dermis
ii. Donor site heals more readily and can be used again as a donor
site
iii. Some postgraft contracture occurs
c. Flaps: tissue for grafting removed from one part of the body and
transferred to another location with its blood supply left intact
i. Used for recipient sites with poor blood supply or to cover exposed
bone, tendon, or nerve
ii. Retains more normal skin properties
iii. Gives bulky appearance
iv. Classification of flaps
• Pedicle flap: skin and underlying muscle rotated into distant
defects
• Advancement flaps: pedicle graft cut and advanced to recon-
struct a defect in a nearby area
• Rotation flap: pedicle flap that is widened by curving the edges
of the flap
• Omental flap: omentum mobilized from the peritoneal cavity
and rotated to cover a defect in the chest wall
• Transverse Rectus Abdominis Myocutaneous (TRAM) Flap:
single-stage breast reconstruction with a flap of the rectus
abdominis muscle
d. Tips for tissue autografts
i. Separate sterile setup for donor site.
ii. Dermatome is kept on a separate small table.
iii. Grafts must be kept moist with normal saline; avoid loss.
iv. Free flap should be placed in iced saline slush until the recipient
site is ready.
v. Recipient site is covered with a sterile towel until ready for graft
or flap.
vi. Donor and recipient sites are prepped and draped separately and
concurrently.
vii. Patient should be kept warm.
e. Environmental control for the burn patient
i. Transported to surgery in own bed, which may be a special frame
to facilitate turning with minimal pain
ii. Reverse isolation is practiced.
iii. Strict adherence to aseptic technique; anything touching the
burned area of the patient must be sterile
iv. Hypothermia is prevented by
• Raising the room temperature and lowering the humidity
• Using hyperthermia or warm blanket
• Monitoring the patient’s temperature
• Warming the IV, irrigating, and prep solutions. (Note: Some
prep solutions may be damaged by warming.)
v. Physical and emotional status of the patient is considered
330 CHAPTER 16 Plastic and Reconstructive Surgery

IV. Surgical Procedures

A. Cosmetic and reconstructive procedures
1. Blepharoplasty: excision of redundant skin or fat from the eyelids
a. Indications
i. Blepharochalasis: loss of elasticity of the skin of the eyelids
ii. Dermatochalasis: hypertrophy of the skin of the upper eyelids
iii. Protrusion of infraorbital fat into the eyelids
iv. Hypertrophy of the orbicularis oculi muscle (horizontal bulge at
the lower lid margin)
b. Anesthesia: local
c. Performed by plastic surgeon or ophthalmologist
2. Otoplasty: correction of external ear deformities
a. Indications
i. Microtia: small ears; prosthesis is available
ii. Macrotia: large ears are reduced
iii. Trauma
iv. Malignancy
3. Rhinoplasty: restructuring or reshaping the nose
a. Indications
i. Cosmetic alteration
ii. Defects following excision of malignancy
4. Mentoplasty: restructuring the shape and size of the chin; prosthesis is
available
5. Liposuction: removal of adipose tissue for cosmesis with a blunt hollow
metal cannula connected to suction
6. Abdominoplasty: excision of excess skin and adipose tissue with tighten-
ing of the abdominal wall
7. Augmentation mammoplasty: insertion of prosthetic implants under
breast tissue or underlying muscle
a. Implants
i. Inflatable silicone sac—filled with sterile saline
ii. Contoured sac of silicone gel
b. Incisions: periareolar, transaxillary, or inframammary
c. Bilateral augmentary mammoplasty for cosmesis; unilateral for
replacement following Mastectomy
8. Reduction mammoplasty: excision of excess skin and glandular and adi-
pose tissue of the breast
a. Indications
i. Hyperplasia, gigantomastia, or macromastia, which causes back
pain and deep grooves in the shoulder from the weight of the breast
ii. Asymmetry following Mastectomy
9. Gynecomastia: enlarged male breast tissue
10. Cleft Lip Repair (Cheiloplasty): rearrangement of the tissue of the lips
of an infant due to a congenital anomaly
a. Indications: cosmesis, sucking difficulties
11. Cleft Palate Repair (Palatoplasty): performed on toddlers with a con-
genital defect in the midline of the palatine bone to prevent the escape of
air through the nose during speech, keep food and liquids out of the
nose, and facilitate sucking and eating
12. Repair of Syndactyly: surgical separation of webbed fingers or toes
13. Dermabrasion: “sandpapering” of acne scars; performed with high-
speed dermabrader with a rotating tip
14. Scar revision: excision of scars with realignment of tissue to improve
appearance
15. Excision of skin lesions: sometimes associated with flap or grafts
a. Verruca: wart
b. Nevus: mole
 CHAPTER 16 Plastic and Reconstructive Surgery 331

c. Basal-Cell Carcinoma (BCC): spreads but does not metastasize

d. Squamous-Cell Carcinoma (SCC): capable of distant metastasis
e. Malignant Melanoma: begins with a nevus which has changed in
color and appearance
f. May be performed by plastic surgeon or dermatologist
g. Accomplished by
i. Excision with scalpel; closed with sutures, flaps, or grafts
ii. Electrosurgical curettage and electrodesiccation
iii. LASER surgery
iv. Cryosurgery
v. Radiation therapy
16. Rhytidectomy (facelift): excision of redundant facial and neck skin;
hypotensive anesthesia and meticulous hemostasis help decrease inci-
dence of hematoma formation; closed-wound drainage frequently used
17. Excision of pressure sores (decubitus ulcer): removal of the ulcer and
underlying bony prominence, followed by a skin graft (local flap) to the
denuded area
a. Occurs most frequently over the sacrum, greater trochanter, and
ischial tuberosities
b. Occurs in paraplegics or patients who lack normal sensation and lie
or sit in one position for prolonged periods of time
B. Hand surgery
1. Purpose: restore function
a. Replace lost tissue
b. Restore bony structure
c. Restore motor unit (tendon repair, graft, or transfer)
d. Replant severed digits
e. Repair severed nerves
2. Surgical anatomy
a. Metacarpals: bones of the hand
b. Phalanges: bones of the fingers and thumbs
i. MP joint: metacarpophalangeal joint
ii. DIP joint: distal interphalangeal joint
iii. PIP joint: proximal interphalangeal joint
c. Carpals: wrist bones (scaphoid, lunate, triquetrum, pisiform, trape-
zium, trapezoid, capitate, and hamate)
i. Radial side: lateral aspect
ii. Ulnar side: medial side
iii. Dorsal: back
iv. Volar or palmar: anterior
d. Muscle and tendons: provide for flexion, extension, abduction, and
adduction
e. Nerves: motor and sensory; radial, median, and ulna
f. Blood supply: radial and ulnar arteries form the palmar arch
3. Special equipment
a. Pneumatic tourniquet
b. Hand table; surgeon and assistant sit during surgery
c. Disposable sterile system for lavage and debridement of tissue
4. Anesthesia: intravenous regional—Bier block
a. Pneumatic tourniquet with double cuff (along with control valves and
tubing) is needed.
b. Esmarch bandage is used to exsanguinate the extremity; proximal cuff
of the tourniquet inflated; Esmarch is removed and 0.5% lidocaine is
injected IV; prepping and draping is done.
c. Second cuff is inflated and proximal cuff is deflated to reduce patient
discomfort.
332 CHAPTER 16 Plastic and Reconstructive Surgery

5. Dressing and immobilization

a. Wound healing is enhanced by elevation and immobilization
b. Support and splinting is provided by proper immobilization of the
entire hand (fingers, wrist, and distal two-thirds of the forearm) for
3 to 4 weeks postoperatively
c. Dressing and immobilization secured while the patient is still
anesthetized
d. Steps in applying the hand dressing
i. Assistant supports affected hand.
ii. Nonadherent gauze is applied over the incision.
iii. Gauze sponges (thin and of uniform thickness) are placed
between the fingers, and a thicker sponge is placed between the
thumb and the index finger.
iv. Soft bulky material is placed in the hand to support PIP and DIP
joints and placed across the volar and dorsal surface.
v. Rolled gauze is wrapped around the hand and forearm with
MP joints in 90° flexion, and PIP and DIP joints are extended.
vi. Fingertips are left exposed.
vii. Adhesive tape is applied vertically to prevent a tourniquet effect.
6. Surgical procedures
a. Open Reduction and Internal Fixation (ORIF): for treatment of
fractures
i. Need plastic hand instrument set, Kirschner wire, mini or maxi
driver, marking pen, and Esmarch bandage
ii. Procedure: incision site is marked; tourniquet is inflated; incision
is made to expose the fracture; fracture is reduced; Kirschner wire
is driven into the bone; x-ray is taken; Kirschner wire is trimmed
and twisted with needle-nosed pliers, and skin is closed; hand
dressing is applied.
b. Tendon repair: 3-0 or 4-0 double-armed nonabsorbable suture on
Keith needles commonly used.
c. Flexor tendon graft: palmaris longus tendon in the wrist and forearm
is used as free graft to repair flexor tendon.
d. Peripheral nerve repair and grafting: need jeweler’s forceps, Castro-
viejo scissors and needle holder, von Graefe muscle hook, microsurgi-
cal blade, nerve stimulator, Esmarch bandage, marking pen, loupes or
operating microscope, and very fine nonabsorbable nylon sutures
(7-0 to 10-0)
e. Implant arthroplasty: for traumatic or rheumatoid arthritis; diseased
area of joint is reamed out using Swanson burrs; prosthetic joint is
placed, joint capsule is repaired, skin is closed, and dressing is applied
f. Palmar fasciectomy: Z-plasty incision is made to lengthen the
involved skin of the finger and palm; part of the palmar fascia is
excised; tourniquet is released, and incision is closed; full-thickness
skin graft may be required. Indications: Dupuytren’s Contracture
(progressive disease of the palmar fascia which causes severe flexion
contractures—“trigger finger”).
g. Microsurgery: operating microscope and special instruments are used
for tissue replantation; this is a long procedure, requiring microvascu-
lar sutures.

SURGERY HINT
Always test the mini or maxi driver before handing to the surgeon. Face the driver away from the field and any
personnel in the room when testing. Be familiar with the Jacobs chuck and key before loading wires.
 CHAPTER 16 Plastic and Reconstructive Surgery 333

Show What You Know

Directions Each of the numbered items or incomplete statements in this section is followed by answers or by
completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

1. When tissue is taken from one part of the body 8. Tissue transfer from one part of the body to
and grafted to another, it is called a/an: another with the graft tissue’s blood supply left
A. xenograft intact is called a/an:
B. autograft A. split-thickness skin graft
C. allograft B. pedicle graft
D. heterograft C. full-thickness skin graft
2. The scab or slough produced by a thermal burn D. xenograft
is called: 9. Blepharoplasty would be indicated for a patient
A. contracture with:
B. plume A. microtia
C. paresthesia B. macromastia
D. eschar C. hypertrophy of the orbicularis oculi
3. The medical term for a facelift is: D. strabismus
A. Rhytidectomy 10. Special fine-tipped forceps used in plastic surgery
B. Lipectomy include:
C. Mentoplasty A. Senn
D. Rhizotomy B. Brown-Adson
4. All of the following are hand procedures C. Webster
except: D. Stevens
A. Release of Dupuytren’s Contracture 11. Which of the following skin closure materials
B. Carpal Tunnel Release would be most appropriate for use in hand surgery?
C. Palmar Fasciotomy A. staples
D. Le Fort III B. 0 chromic gut on a cutting needle
5. Homografts or heterografts used as temporary C. 5-0 nylon on a cutting needle
coverings for denuded skin are called: D. 2-0 Vicryl on a taper needle
A. biological dressings 12. What supplies would be needed for a STSG?
B. stent dressings A. heparin, 5-0 chromic suture
C. hand dressings B. Marlex mesh, Lugol’s solution
D. flaps C. methylene blue, cryoprobe
6. The removal of devitalized tissue is: D. mineral oil, wooden tongue blade
A. dermabrasion 13. The device used to expand a skin graft by mak-
B. escharotomy ing multiple uniform slits is a:
C. fasciotomy A. Reece dermatome
D. debridement B. Marlex mesh
7. A burn patient is brought to the OR with an C. skin graft mesher
arm greatly charred and distended with cyanotic D. dermabrader
fingers. Which of the following procedures 14. A TRAM flap would be used for which type of
would you anticipate? surgery?
A. full-thickness skin graft A. Breast Reconstruction
B. escharotomy B. Repair of Syndactyly
C. dermabrasion C. Palatoplasty
D. conization D. Cheiloplasty
334 CHAPTER 16 Plastic and Reconstructive Surgery

15. Release of a “trigger finger” due to contraction of C. Mastopexy

the palmar fascia is technically referred to as a/an: D. Mentoplasty
A. Metacarpal Arthroplasty 21. Burns are assessed using which of the following
B. Dupuytren’s Contracture Release assessment techniques?
C. Carpal Tunnel Release A. Rule of Nines
D. Bankart Procedure B. Brown and Sharp
16. During Peripheral Nerve Repair, which of the C. STSG
following sutures would commonly be used? D. ORIF
A. chromic gut 22. Brown and Padgett are examples of which type
B. silk of equipment used for skin grafting?
C. nylon A. knife dermatome
D. stainless steel B. drum dermatome
17. Another name for an intravenous regional C. motor dermatome
anesthetic block is: D. mesher
A. Bier Block 23. Otoplasty is performed for which of the follow-
B. Le Fort Block ing diagnoses?
C. TMJ Block A. otosclerosis
D. Esmarch Block B. microtia
18. Another name for a “mole” is a: C. blepharochalasis
A. verruca D. syndactylism
B. nevus 24. Which of the following bones is NOT one of the
C. microtia carpal bones?
D. dermatochalasis A. pisiform
19. A burn that involves the epidermis and part of B. hamate
dermis layers of the skin and is characterized by C. scapula
redness, swelling, pain, and blisters is called a: D. scaphoid
A. first-degree burn 25. A xenograft for human skin replacement most
B. second-degree burn commonly comes from which animal?
C. third-degree burn A. horse
D. fourth-degree burn B. cow
20. Surgery to change the shape of the chin is called: C. goat
A. Rhytidectomy D. pig
B. Cheiloplasty

Answers & Rationales

1. B. Rationale: When tissue is grafted from one part of Dupuytren’s Contractures, Carpal Tunnel
of the body to another, it is called an autograft. Release, and Palmar Fasciotomy are all
2. D. Rationale: Eschar is the scab which is pro- approached from the volar surface of the hand
duced from devitalized tissue which is or wrist.
sloughed from thermal burns. 5. A. Rationale: Biological dressings are composed
3. A. Rationale: Rhytidectomy is derived from two of homografts or heterografts used as tempo-
words, rhytid/o = wrinkles, and !ectomy = to rary dressing on denuded areas of skin to con-
remove surgically. The general term used for trol infection, prevent loss of serum, decrease
rhytidectomy is facelift. pain, and stimulate growth of new tissue.

4. D. Rationale: Le Fort III is a procedure classifica- 6. D. Rationale: Removal of devitalized or nonvia-

tion given to facial fractures in which both ble tissue, or debridement, may be accom-
zygomas, maxillae, nasal, ethmoid, sphenoid, plished by a scalpel, skin graft knife,
and other orbital bones are fractured. Release dermatome, electrosurgical knife, or LASER.
 CHAPTER 16 Plastic and Reconstructive Surgery 335

7. B. Rationale: An escharotomy is a bilateral inci- breast reconstruction following Mastectomy.

sion through eschar, which completely encir- 15. B. Rationale: A Dupuytren’s Contracture Release
cles an area such as an extremity or chest, is the technical name for the release of a “trig-
causing a constricting or tourniquet effect and ger finger” due to contraction of the palmar
cutting off circulation. An escharotomy fascia.
relieves the constricting effect, and the wounds
are left open. 16. C. Rationale: Nylon suture is the material com-
monly used to repair peripheral nerves. Stain-
8. B. Rationale: A pedicle graft is a transfer graft of less steel is too difficult to work with and
tissue from one part of the body to another might damage the nerve; silk is braided and
with the graft tissue’s blood supply remaining would drag on the delicate tissues, and chro-
intact. mic gut causes adhesions to form due to the
9. C. Rationale: Blepharoplasty, revision of the eye- reaction of the tissue to its presence.
lids, is indicated when the orbicularis oculi 17. A. Rationale: A Bier Block is a method for the
muscle is overdeveloped (hypertrophied), the delivery of intravenous regional anesthetic.
skin of the eyelids has lost its elasticity
(blepharochalasis), the skin of the eyelids 18. B. Rationale: Nevus is another name for a mole.
hypertrophies (dermatochalasis), and infraor- A verruca is a wart.
bital fat protrudes into the eyelid. 19. B. Rationale: A burn that involves the epidermis
10. B. Rationale: Brown-Adsons are fine-tipped for- and part of dermis layers of the skin and is
ceps used in plastic surgery. Senns are rake characterized by redness, swelling, pain, and
retractors, Websters are needle holders, and blisters is called a second-degree burn.
Stevens are tenotomy scissors. 20. D. Rationale: A Mentoplasty is a surgical proce-
11. C. Rationale: A small-gauge nylon suture with dure that involves changing the shape of the
a cutting needle is preferred by plastic sur- chin (ment/o = chin).
geons because it is monofilament (less wick- 21. A. Rationale: The rule of nines is used to assess
ing action), has elasticity (stitches stretch as burns; there are 11 sections, each of which
tissue swells during the inflammatory comprises 9% of the total adult body surface.
phase), and provides better cosmetic results. The perineum comprises the last 1%.
A cutting needle is essential in suturing the 22. C. Rationale: Brown and Padgett are motor der-
skin of the hand. matomes used for skin grafting.
12. D. Rationale: During a split thickness skin graft, 23. B. Rationale: Otoplasty is performed for the
mineral oil is applied to the donor site, and the diagnosis of microtia (micro– = small, ot/o =
skin is held taut with a sterile wooden tongue ear, !ia = condition of).
blade when taking the graft.
24. C. Rationale: The pisiform, hamate, and scaphoid
13. C. Rationale: The skin graft mesher expands a are all carpal bones. The scapula is a bone of
skin graft by making multiple uniform slits. the shoulder girdle.
14. A. Rationale: A Transverse Rectus Abdominis 25. D. Rationale: Porcine (pig) grafts are xenografts
Myocutaneous (TRAM) Flap is used during commonly used for human skin replacement.
336 CHAPTER 16 Plastic and Reconstructive Surgery

Part II: Deciphering a Surgical

Schedule
The following mock surgery schedule will be used to answer several questions pertaining to
plastic and reconstructive surgery. The same schedule, or a similar one, will be used in sub-
sequent chapters to ask questions about the content of the chapter.

Rm. # Rm. #
time Surgeon Procedure Anest. time Surgeon Procedure Anest.
Rm.00 Rm07
OC Dr. Z STSG Gen. 7:00 Dr. M Laparoscopic Gen.
OC Dr. C Craniotomy Gen. TF Dr. M appendectomy MAC
OC Dr.Z Angioplasty Gen. Lipoma removal
Rm.01 Rm08
7:00 Dr. X Hemorrhoidectomy Gen. 11:00 Dr. E Abdominoplasty MAC
TF Dr. X Colostomy Gen.
TF Dr. X Bowel resection Gen.
Rm02 Rm09
7:00 Dr. B Reduction mammoplasty Gen. 8:30 Dr. T FTSG Gen.
TF Dr. B Breast augmentation Gen. TF Dr. T Palatoplasty Gen.
Rm03 Rm10
7:00 Dr. A Cystoscopy MAC 7:00 Dr. K Nephrectomy Gen.
TF Dr. A Cystoplasty Gen. TF Dr. K Choledocholithotripsy MAC
12:30 Dr. F Pyleogram MAC TF Dr. K Hepatic resection Gen.
3:00 Dr. F Cystocele repair Gen.
Rm04 Rm11
7:00 Dr. Y Carpal tunnel release Gen. 7:00 Dr. L Rhytidectomy Gen.
TF Dr. Y Whipple Gen. 12:00 Dr. L Blepharoplasty Gen.
Rm05 Rm12
7:00 Dr. G z-plasty for Dupuytrens Gen. 7:00 Dr. W Trans-metatarsal Gen.
TF Dr. G contracture TF Dr. W amputation
TF Dr. G TRAM Gen TF Dr. W Osteotomy Gen.
Bletharoplasty Gen. Arthrocentesis Gen.
Rm06 Rm13
7:00 Dr. R Lumbar Laminectomy Gen. 7:00 Dr. O Hysterectomy Gen.

The following questions should be answered using the surgery schedule above

1. The TRAM scheduled in Room 5 will utilize which muscle to reconstruct the
patient’s breast?
A. Internal oblique
B. Pectoralis
C. Transverse Rectus
D. External oblique
2. Dr. T has scheduled a FTSG. Why would he opt for this instead of STSG?
A. It will be grafted near a joint
B. It will heal more quickly
C. It will cause more contracture
D. It contains less padding tissue than STSG
3. There is a STSG on call. What instrument should the Surgical Technologist
have available for the surgeon to enlarge the graft?
A. Adson forceps
B. Mesher
C. Dermatome
D. Iris scissors
 CHAPTER 16 Plastic and Reconstructive Surgery 337

4. Dr. G will be performing a z-plasty. What is the reason for this procedure?
A. To lengthen the skin
B. To repair a tendon
C. To repair the flexor tendon
D. To shorten the skin
5. Dr. B has scheduled a reduction mammoplasty. What will the Surgical Technol-
ogist do with excess breast tissue?
A. Send it to pathology
B. Dispose of it in the kick bucket
C. Pass it off to the circulator
D. Place tissue from each breast into a separate container to be weighed
6. All of the following incisions may be used for the breast augmentation
EXCEPT
A. Periareolar
B. Transaxillary
C. Inframammary
D. Midline
7. The most likely suture to be used in the augmentation skin closure will be
A. Silk
B. PDS
C. Chromic Gut
D. Monocryl
8. There is an Abdominoplasty scheduled for Room 8. What are the prep param-
eters for this procedure?
A. Nipple to groin
B. Neck to groin
C. From the umbilicus to pelvis
D. From umbilicus to knees
9. What is going to be used to prepare the skin during the skin graft?
A. Betadine
B. Alcohol
C. Mineral oil
D. Chlorohexidine
10. Room 11 has a Rhytidectomy. What position will the patient most likely be in
for this procedure?
A. Lounge chair
B. Lateral
C. Prone
D. Supine

Answers & Rationales

1. C. Rationale: A TRAM flap is a common recon- 2. A. Rationale: Using a full-thickness skin graft
structive procedure following a mastectomy. It allows for more padding and is commonly
uses the transverse rectus abdominal muscle to used near a joint. The other statements are
reconstruct the breast. This may be followed by true of the split thickness grafts.
tattooing of the aereola for cosmetic reasons.
338 CHAPTER 16 Plastic and Reconstructive Surgery

3. B. Rationale: While all of these instruments may 7. D. Rationale: Plastic surgery skin closures tend to
be used during a STSG, the Mesher is the be made with the goal of minimal scarring.
instrument that will be used to enlarge the Chromic gut would be an unlikely choice, as
graft before placement. would PDS and silk.
4. A. Rationale: Z-plastys are performed to lengthen 8. A. Rationale: The parameters of the skin prep for
skin area. They are commonly used in scar an Abdominoplasty should incorporate the
revision and to reduce the appearance of scars. incision site, as well as a large area surround-
5. D. Rationale: The surgeon may request that ing the site.
excess breast tissue be weighed to ensure that 9. C. Rationale: Regardless of the skin prep solution
the same amount of tissue is being removed used, the surgeon will most likely prep the
from each breast. The Surgical Technologist donor skin with mineral oil before it is har-
must ensure that he or she does not contami- vested.
nate the glove or arm of the gown when plac- 10. A. Rationale: This procedure requires the surgeon
ing the tissue into the container. to have several views of the operative site.
6. D. Rationale: Most surgeons use a specific inci- Generally, the preferred position is a lounge
sion based on individual patient needs. Gener- chair or modified beach chair position with
ally, they will be an Inframammary, the head in a Mayfield or doughnut.
Transaxillary, or Periareolar incision.

PEARSON

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choice of disciplines. Find this book and click to enter.