Plastic Surgery II

SUGGESTED READINGS

1. Current Surgical Diagnosis & Treatment, 12th Edition, Ch. 14.
2. Current Surgical Diagnosis & Treatment, 12th Edition, Ch. 6, 43, pg. 75-88, 1217-1222.

OBJECTIVES

1. Given a description of a patients’ burn injuries, calculate the percentage of body surfaced burned.
2. Demonstrate a familiarity with the Parkland formula for fluid resuscitation by using it to calculate fluid requirements for a burn injury patient, given the total body surface area of the burn.
3. Discuss the various options available for management of the burn would including topical antibiotics, biological dressings and operative debridement.
4. List the more common early and late complications of a burn injury.
5. Given a patient with a severe burn injury, present a plan for evaluation of the patient for inhalation injury. Discuss management of inhalation injuries.
6. Describe different degrees of burn injury by depth.
7. Understand differences between STSG and FTSG.
8. Describe the differences of healing by primary closure, by delayed primary closure and by secondary intention, and indication for each.
9. Recognize the various phases of wound healing and the approximate time course associated with each phase.
10. Describe the significance of epithelialization and defense against contamination.
11. Describe clinical factors that may retard healing.
12. Recognize and differentiate wounds, which have resulted in a loss of tissue and those, which have not.
13. Recognize and differentiate clean vs. infected wounds. Which can be safely closed primarily, and those, which cannot.
14. Describe the functions of a dressing.
15. Contrast “dehiscence” and “evisceration” and describe their presentation and management.
16. Assess a wound for signs of infection, attending to the local heat, erythema, and excessive pain; outline the management of an infected surgical wound.
17. Describe the factors that lead to non-healing chronic wounds.
18. Describe factors that lead to pressure ulcers and treatment.
19. Discuss the growth factors involved in wound healing.

CASE HISTORIES

1. A 26-year-old man has sustained a severe electrical burn with entry wound on his left foot and exit wounds on both hands and his back. In the emergency room the urine is noted to be reddish brown in color.

2. A 34-year-old white male sustains a circumferential third degree burn of the right forearm. Three hours later the patient loses sensation to touch in his fingers and motor function in the digits begins to deteriorate.

3. A 31-year-old white male presents to the emergency room with second-degree burns of the right arm and hand. The decision is made to manage this patient on an outpatient basis. What is your plan for emergency room care and follow-up.

4. A 42-year-old white male has undergone an uneventful repair of a direct inguinal hernia.
Based on principles of wound healing (return of tensile strength curve), provide advise on his activity over the next several weeks. When can he return to unrestricted work?
Provide patient examples for primary wound healing and healing by secondary intention. Why do we choose to perform delayed primary closure for wounds in the operating room? How do we decide when to close these wounds?

5. A 74-year-old white male underwent a subtotal gastrectomy for carcinoma five days ago. His intra-operative and post-operative course to this date has been uncomplicated. The midline abdominal wound has been dry until your exam today when you note some drainage of serosanguineous fluid from the superior aspect of the incision.
- How do you evaluate and manage this problem?
- How might such a complication have been avoided in this patient and is there a group of surgical patients at risk for this complication?

6. A 52-year-old diabetic male has a 2cm non-healing ulcer on the sole of his right foot over the head of the first metatarsal. All pulses are palpable in the extremity including dorsalis pedis and posterior tibialis.

7. A 59-yeal-old white female has a 2cm non-healing ulcer over the medial malleolus of the right foot. There is brawny edema and brown pigmentation noted below the knee bilaterally. Pulses are palpable in the foot.

8. A 59-year-old white male with a long history of vascular disease has an ulcer on the tip of the right great toe. There is a weak femoral pulse present on the right side, but no palpable pulses distally.

9. A 39-year-old white male has undergone incision and drainage of a 10cm perirectal abscess. Describe your management of the wound over the next several days.

10. A 22-year-old male is recovering from a gunshot wound to the abdomen requiring a primary repair of several small bowel perforations and two right colon perforations. On the fourth post-operative day there is redness and increased tenderness in the upper one third of his midline incision that was closed with staples. His temperature is 100.8°. Describe your evaluation and management of this problem.

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