Fundamental Topics in Plastic Surgery E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1028

Veröffentlichungsjahr: 2018

Beschreibung

Given the wide-ranging nature of the literature one must study in plastic surgery training, a solid grounding in many fundamental principles and procedures is an absolute prerequisite to becoming a competent plastic surgeon. And yet, until now there has been no single source that collects these fundamental topics in one volume; rather, the information has had to be gleaned from the introductory chapters of multiple comprehensive textbooks. The present volume takes a new approach, and provides the trainee an opportunity to learn these fundamentals more efficiently and comprehensively through a single book.

This work will prepare the trainee to confidently advance to the more specific core topics in reconstructive and aesthetic plastic surgery.

Key Features:

• Highly efficient presentation and organization of all fundamental plastic surgical topics
• 21 chapters cover such topics as patient safety; normal and abnormal wound healing; local anesthesia and nerve blocks; soft tissue infections and antibiotics; implants and biomaterials; basic surgical techniques; grafting of fat, skin, bone, and other tissues; flaps; burns; and much more.
• Each chapter closes with a summary of key points.

Ideal for all surgeons in training, Fundamental Topics in Plastic Surgery is a complete introduction to the science and technical expertise of aesthetic and reconstructive plastic surgery.

Leseprobe

Fundamental Topics in Plastic Surgery

Diego Marré, MD

ConsultantDepartment of Plastic and Reconstructive Surgery and BurnsClínica Las CondesEmergency Public HospitalSantiago, Chile

457 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication DataNames: Marre, Diego, editor.Title: Fundamental topics in plastic surgery / [edited by] Diego Marré.Description: Stuttgart ; New York : Thieme, [2018] | Includes bibliographical references and index. |Identifiers: LCCN 2018007646 (print) | LCCN 2018008885 (ebook) | ISBN 9783132059214 () | ISBN 9783132059115 (hardcover : alk. paper)Subjects: | MESH: Reconstructive SurgicalProcedures--methodsClassification: LCC RD118 (ebook) | LCC RD118 (print) | NLM WO 600 | DDC  617.9/52--dc23LC record available at https://lccn.loc.gov/2018007646

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Contents

Foreword

Preface

Acknowledgments

Contributors

Section I Principles

1 Patient Safety in Plastic Surgery

Brent B. Pickrell, Andrew P. Trussler

1.1 Introduction

1.2 Practice-Based Safety

1.3 Patient Risk Stratification

1.4 Intraoperative Risk

1.5 Conclusions

1.6 Key Points

2 Wound Healing

Matthew G. Kaufman, Matthew R. Louis, Shan Shan Qiu, Edward P. Buchanan

2.1 Introduction

2.2 Basic Science

2.3 Factors Affecting Wound Healing

2.4 Wound Care Management

2.5 Scar Management

2.6 Conclusions

2.7 Key Points

3 Wound Management and Pressure Sores

Ricardo Roa, Cristián Taladriz, Daniel Calderón, Wilfredo Calderón

3.1 Introduction

3.2 Basic Science

3.3 Wound Assessment

3.4 Wound Debridement

3.5 Skin Substitutes

3.6 Clinical Applications

3.7 Pressure Sores

3.8 Basic Science

3.9 Classification

3.10 Treatment

3.11 Conclusions

3.12 Key Points

4 Negative Pressure Wound Therapy

Javier Buendia, Diego Marré, Marcus Castro Ferreira

4.1 Introduction

4.2 Basic Science

4.3 Dressings and Parameters

4.4 Parameters

4.5 Indications and Contraindications

4.6 Tips and Tricks

4.7 Clinical Applications

4.8 Conclusions

4.9 Key Points

5 Local Anesthetics and Common Nerve Blocks

Pablo Monedero, Ismael González, Jesús Olivas

5.1 Introduction

5.2 Basic Science

5.3 Classification of Local Anesthetics

5.4 Pharmacology

5.5 Toxicity and Complications of Local Anesthetics

5.6 Allergic Reactions

5.7 Adjuvants

5.8 Essential Regional Blocks for Plastic Surgery

5.9 Median Nerve Block

5.10 Conclusions

5.11 Key Points

6 Soft Tissue Infections and Antibiotics in Plastic Surgery

Cristina Aubá, José L. del Pozo

6.1 Introduction

6.2 Skin and Soft Tissue Infections

6.3 Alloplastic Infections

6.4 Antimicrobials for Skin and Soft Tissue Infections

6.5 Conclusions

6.6 Key Points

7 Implants and Biomaterials

Marco Romeo, Chiara Distefano

7.1 Introduction

7.2 Materials

7.3 Implantation Tips and Pitfalls

7.4 Clinical Applications

7.5 Conclusions

7.6 Key Points

8 Principles of Osteosynthesis

Pedro Bolado, Jorge Bonastre, Luis Landin

8.1 Basic Science

8.2 Fracture Repair

8.3 Complications

8.4 Distraction Osteogenesis

8.5 Conclusions

8.6 Key Points

9 Essentials of Dermatology for Plastic Surgeons

Isabel Irarrazaval, Pedro Redondo

9.1 Structure and Function of the Skin

9.2 Basic Lesions of the Skin

9.3 Skin Biopsies

9.4 Nonsurgical Treatment Modalities

9.5 Benign Skin Tumors

9.6 Fibrous Tumors

9.7 Miscellaneous

9.8 Premalignant Lesions

9.9 Nonmelanoma Skin Cancers

9.10 Conclusions

9.11 Key Points

10 Laser Therapy: Principles and Applications in Skin Diseases

Maider Pretel, Ester Moreno-Artero

10.1 Introduction

10.2 Basic Science

10.3 Therapeutic Parameters

10.4 Types of Laser

10.5 Clinical Applications

10.6 Pigmentation Disorders

10.7 Laser Hair Removal

10.8 Skin Resurfacing

10.9 Conclusions

10.10 Key Points

11 How to Set Up a Research Protocol in Plastic Surgery

Stefan Danilla, Ekaterina Troncoso Olchevskaia

11.1 Introduction

11.2 Clinical Question and Types of Study

11.3 Basic Components of a Research Protocol

11.4 Measuring the Accuracy of a Diagnostic Test

11.5 Determining the Prognosis of a Disease

11.6 Analyzing the Effectiveness of a Treatment

11.7 In Search of the Cause of Your Patient's Disease

11.8 What about the Analysis?

11.9 Key Points

Section II Techniques

12 Basic Surgical Techniques, Sutures, and Wound Closure

Diego Marré, Tomas Gantz, Alex Eulufi

12.1 Introduction

12.2 Sutures

12.3 Wound Closure

12.4 Suturing Techniques

12.5 The Unfavorable Scar: Prevention and Treatment

12.6 Common Surgical Procedures

12.7 Conclusions

12.8 Key Points

13 Grafts: Skin, Fascia, Nerve, Tendon, Cartilage, and Bone

Álvaro Cabello, Aránzazu Menéndez, Diego Marré, Bernardo Hontanilla

13.1 Introduction

13.2 Skin Grafts

13.3 Fascia Grafts

13.4 Tendon Grafts

13.5 Nerve Repair and Grafting

13.6 Cartilage Grafts

13.7 Bone Grafts

13.8 Conclusions

13.9 Key Points

14 Fat Grafting

Stefan Danilla, Ekaterina Troncoso Olchevskaia

14.1 Introduction

14.2 Basic Science

14.3 Surgical Technique

14.4 Clinical Applications

14.5 Conclusions

14.6 Key Points

15 Vascular Anatomy of the Skin and Muscles

Diego Marré, Michael Tecce, Alejandro Conejero

15.1 Introduction

15.2 Basic Science

15.3 Blood Supply to the Muscles

15.4 Regional Blood Supply

15.5 Conclusions

15.6 Key Points

16 Flaps

Diego Marré, Leigh Jansen, Sandhya Deo

16.1 Introduction

16.2 Basic Science

16.3 Principles of Flap Surgery

16.4 Flap Classification

16.5 Putting It All Together: Examples of Commonly Used Local Flaps

16.6 Fasciocutaneous Flaps

16.7 Flap Modifications

16.8 Perforator Flaps

16.9 Propeller Flaps

16.10 Conclusions

16.11 Key Points

17 Tissue Expansion

Alvaro Cuadra, Bruno Dagnino

17.1 Introduction

17.2 Basic Science

17.3 Types of Expanders

17.4 Preoperative Planning and Surgical Technique

17.5 Complications

17.6 Clinical Applications

17.7 Reexpansion

17.8 Preexpanded Free Flaps

17.9 Conclusions

17.10 Key Points

18 Burns

José Manuel Collado Delfa

18.1 Introduction

18.2 Epidemiology

18.3 Thermal Injury

18.4 Electrical Injuries

18.5 Chemical Injuries

18.6 Cold Injuries

18.7 Key Points

19 Microsurgery

Diego Marré, Pablo Zancolli, Gustavo Pérez-Abadía, Héctor Roco

19.1 Introduction

19.2 Training in Microsurgery

19.3 Basic Science of Free Flap Failure

19.4 Factors Influencing Flap Failure

19.5 Free Flap Monitoring and Salvage

19.6 Postoperative Pharmacological Therapy in Microsurgery

19.7 Clinical Applications

19.8 Conclusions

19.9 Key Points

20 Facial Trauma

Nicolás Pereira, Patricio Andrades

20.1 Introduction

20.2 Relevant Anatomy

20.3 Soft Tissue Trauma

20.4 Maxillofacial Trauma

20.5 Clinical Cases

20.6 Conclusions

20.7 Key Points

21 Hand Trauma

S. Raja Sabapathy, R. Raja Shanmugakrishnan

21.1 Introduction

21.2 Relevant Anatomy

21.3 Assessment of an Injured Hand

21.4 Identification of the Injured Structures

21.5 Management of Hand Injuries

21.6 Clinical Cases

21.7 Conclusions

21.8 Key Points

Index

Foreword

The plastic surgeon is both an artisan and an artist and aims to re-create what is lost following injury, disease, or the aging process. The medium is the living tissue, with its own fickle intrinsic power of repair and memory. At its best, the surgeon’s repair will be a replica of what was lost in form and function, with the almost invisible mending of primary healing; at its worst, it will be the scarred horror of secondary healing with contraction and deformity. How does the surgeon ensure that the pendulum is always weighted toward the former? Like all artistic pursuits, although plastic surgeons will likely boast an element of innate talent, they cannot perfect their craft until they have mastered its underlying fundamental principles. Very often in life and in our jobs, we assume we understand core principles and proceed directly to the specifics of a task. But these fundamentals may never have been learned, and instead were subliminally assumed and accreted piecemeal, often from disparate contexts, and, when challenged, we realize that our understanding is superficial and often erroneous. In plastic surgery, without a thorough grounding in these fundamentals, we are destined to flounder because they are the key to design concepts, technical mastery, and the avoidance of complications.

This book, edited by Dr. Diego Marré, is the one we all wish we had read before our entrenched habits took hold. It teaches us principles we did not even know we did not know. It is targeted at the plastic surgery trainee/resident level, but it is an excellent source for those who are not trainees as well as those who are specialists. It aims to cover all the fundamentals so that the reader, once grounded in the conceptual roots, can confidently move on to the specifics of plastic surgery. It deliberately excludes detailed surgical techniques. The authors are a balanced mix of those of the younger generation and senior specialists. The former bring new talent, their own perspective and insights as to what is important and what is not, and a refreshing contemporary feel to the work. The latter bring invaluable experience and expertise unique to senior specialists.

The book is of a digestible size, has a limited but targeted scope, avoids repetition, and is engaging and a joy to read. It collates and distills the latest information, which is not readily accessible in standard texts. The format and style are uniform and pleasing. The text is presented in two sections: Principles and Techniques. The principles presented in section 1 are interesting and eclectic. The chapters provide detailed discussion of topics that are often taken for granted or are not presented in easy format elsewhere and hence are never fully learned or understood. Examples include safety in the operating theater, antibiotics in plastic surgery, biomaterials, osteosynthesis, and statistics for plastic surgery. Section 1 also impresses on us the collaborative and interdisciplinary role that plastic surgeons play and the need to understand the fundamentals of other disciplines, as highlighted by chapters on dermatology, infections, and osteosynthesis. Section 2, Techniques, gives us the core requirements for success: blood supply, wound healing and suture techniques, and flaps and grafts, among many others.

This book offers something quite different from its contemporaries and others before it, and I very much appreciate the honor to be asked to write this Foreword. I congratulate the editor for his insight to discern the need for such a volume amid the myriad existing texts on plastic surgery, and to the multiple authors who have contributed to bring this superb book to fruition. Those who have the privilege to read it will long savor its merits.

Wayne Morrison, MBBS, FRACSPlastic and Hand SurgeonDepartment of Plastic Reconstructive and Hand SurgerySt. Vincent’s HospitalMelbourne, Australia

Preface

Plastic surgery is one of the surgical disciplines with most presence in the media and, paradoxically, one of the most misunderstood too. Although the majority of lay public (and of course medical staff) have a very good idea of what an orthopaedic or cardiothoracic surgeon does, their knowledge about the daily practice of a plastic surgeon is generally limited to the aesthetic branch of our specialty, which, despite its great value, does not represent the whole scope of plastic surgery. In addition, the prototype of the plastic surgeon presented in advertising, television series, and movies in most cases makes the gap between illusion and reality even bigger. Furthermore, it is both surprising and demoralizing to realize every now and then how our own colleagues from other medical or surgical fields still do not understand the breadth of plastic surgery outside its cosmetic realms, a phenomenon that is highly contradictory as the roots of plastic surgery actually derive from its reconstructive legacy.

So what is plastic surgery? The name comes from the Greek word plastikos, meaning “to mold or to shape,” which, although etymologically correct, and seemingly a good and intelligent answer to give our friends or patients when they ask the question, tells us little about what we actually do as plastic surgeons. Without a system or anatomical region of its own, it is hard to box plastic surgery into one specific definition or scope of practice. For example, how is a complex craniofacial reconstruction related to the tangential excision and grafting of a burn or to a flexor tendon repair in the hand? In the very broad sense, plastic surgery could be thought of as the surgical specialty in charge of repairing what is wounded, replacing what is missing, restoring what is altered, and reshaping what is deformed.

At the start of our training, most of us had an idea of what we were getting ourselves into, though probably for most, it was rather vaguely so, with very little interconnection between these fascinating things we started seeing every day, a lot of them for the very first time. And so, in this whirlwind of new concepts and techniques, we started digging into specific flaps for specific needs or reading on specific procedures and classifications, in an effort to prepare ourselves in the best possible way for the next case, studying on a case-by-case basis rather than on a principles-based approach. Not surprisingly then, trainees may sometimes know all about the anatomy and the technical aspects of the deep inferior epigastric perforator (DIEP) flap, but have a hard time describing the different ways in which flaps can be classified. And so the obvious becomes clear: in order to build our knowledge we need to start from the basics. But then comes the issue of where to begin the study from. Where do I find a good chapter on flaps? Where is tissue expansion described in detail? And again we start diving through pages of numerous textbooks, one with a good chapter on a specific topic but falling short on another one that is equally important, all of which renders difficult the study of these essential issues. This is especially the case during the early years of training, in which time is limited and thus going through different textbooks becomes frustrating and ineffective. In this context, Fundamental Topics in Plastic Surgery would help the reader as it has been designed and written to provide trainees with a solid foundation and a detailed description of the basic principles of our specialty.

The book is divided in two sections: Principles and Techniques. The first section, Principles, comprises 11 chapters, including topics such as patient safety, wound healing, dressings, and negative pressure wound therapy, among others. In addition, this section incorporates topics such as infections and antibiotics in plastic surgery and principles of osteosynthesis, which despite being part of our everyday practice, are sometimes hard to find in reference books. The second section, Techniques, describes the theoretical and technical aspects of procedures that are common to virtually the whole scope of plastic surgery, starting with basic techniques and local flaps and then navigating through grafts, flaps, tissue expansion, and microsurgery, the latter including a detailed description on the necessary elements for a successful laboratory training as well as the physiological and clinical features of microsurgical tissue transfer. In addition, chapters on burns, facial trauma, and hand trauma have been included in this second section to provide the basic theory and principles of treatment of these conditions, commonly seen by trainees in the emergency department.

In all, Fundamental Topics in Plastic Surgery has been devised as the starting point for anyone interested in pursuing this fascinating specialty. In addition, senior trainees, fellows, and consultants might also find it useful as a reference resource and as a teaching resource as well. The concepts and information provided throughout the following pages should help the reader build a solid foundation of the core topics of plastic surgery, and then be able to move confidently forward into more specialized reading.

Diego Marré, MDConsultantDepartment of Plastic and Reconstructive Surgery and BurnsClínica Las CondesEmergency Public HospitalSantiago, Chile

Acknowledgments

First and foremost I want to thank my beloved wife, Isabel, and our children, Juan Diego and Agustin. Not only has Isabel been the pillar of our family throughout my years of residency and fellowship, but she has managed to do so while being a resident and fellow herself, which has led her to become the accomplished dermatologist she is today. Her help and sage advice have been vital for this book to come to fruition, by making me see things in different ways at times of frustration and despair, by bringing new and fresh ideas that have really enhanced the work, and by contributing with a fabulous chapter. But above all, I thank her for being a wonderful wife and a loving mother.

I would like to thank my parents for encouraging me to study medicine and supporting me in every step of the way. My mother, who always managed to find time away to come and visit and stay with us no matter how far we were, and my father, for his example of hard work. And, very especially to Juan and Maribel, without whom our life overseas would not have been possible.

This book represents the culmination of the generous contributions from several authors. I am indebted to each of them for their participation in this wonderful project.

I offer sincere thanks to my mentors and friends in plastic surgery. A special recognition goes to Dr. Wilfredo Calderon and the whole Burns and Plastic Surgery Unit at Hospital del Trabajador during my stay there many years ago. Many thanks to Alex Eulufi, Patricio Léniz, and Álvaro Cuadra for their friendship and support, and Dr. Hector Roco, who became my role model very early in my career and with whom I took my first steps in reconstructive surgery and microsurgery. I am deeply grateful to Bernardo Hontanilla and Cristina Aubá, my tutors in Spain, for being my teachers and surgical mentors and for showing me the value of and passion for research. I thank all my colleague residents—we shared such wonderful moments throughout our training. A special thanks to my colleague and close friend Alvaro Cabello, a skillful surgeon and one of the most virtuous people I know. My deepest gratitude to Professor Wayne Morrison, a true master, a person whose door and mind are always open to new ideas, and with whom I had the privilege to share thoughts, projects, and countless hours in theater during my 2 years in Melbourne. To everyone at O’Brien Institute, I really enjoyed my research time there! Thanks to Mr. Tim Bennet, Eldon Mah, and the whole Plastic Surgery Unit at St. Vincent’s Hospital Melbourne for an amazing year as your reconstructive surgery fellow; that period has left an indelible mark in my career and my life. To my new colleagues and team members at Hospital de Urgencia de Asistencia Pública and Clinica Las Condes, I really enjoy working with you.

I want to thank all the people at Thieme for their invaluable support. It has been a true honor to publish this book with you and become a Thieme author.

Lastly, I would like to pay tribute to and honor the memory of two very special people, Dr. Ernesto Medina Lois and Dr. Ana María Kaempffer, two outstanding physicians, leaders in their respective fields, but more than that, my two loving grandparents. Their contributions to Chilean medicine and the World Health Organization are countless, as are the number of students that had the privilege to attend their lessons. They were the first couple to ever receive the Professor Emeritus distinction from Universidad de Chile, and my grandmother was one of the few women to be honored with such a remarkable recognition. Every memory I have of them is a joyful one, and I am sure they would have been proud to see this book published.

Contributors

Cristina Aubá, MD, PhDConsultantDepartment of Plastic, Reconstructive and Aesthetic SurgeryUniversity Clinic of NavarraPamplona, Spain

Patricio Andrades, MDConsultantDepartment of SurgeryUniversity of Chile Clinical HospitalHospital del TrabajadorSantiago, Chile

Pedro Bolado, MDResidentDivision of Plastic and Reconstructive SurgeryLa Paz University HospitalMadrid, Spain

Jorge Bonastre, MD, PhDConsultantDivision of Plastic and Reconstructive SurgeryLa Paz University HospitalMadrid, Spain

Edward P. Buchanan, MDAssistant ProfessorDivision of Plastic SurgeryTexas Children’s HospitalMichael E. Debakey Department of SurgeryBaylor College of MedicineHouston, Texas, USA

Javier Buendia, MDConsultantDepartment of Plastic and Reconstructive SurgerySan Carlos Clinical HospitalMadrid, Spain

Álvaro Cabello, MD, PhDConsultantDepartment of Plastic and Reconstructive SurgeryUniversity Clinic of NavarraPamplona, Spain

Daniel Calderón, MDInstructorDepartment of SurgeryUniversity of ChileSantiago, Chile

Wilfredo Calderón, MDProfessor of Plastic SurgeryChief of Plastic and Reconstructive SurgerySalvador HospitalSantiago, Chile

Marcus Castro Ferreira, MD, PhDFull Professor of Plastic SurgeryUniversity of São PauloSchool of MedicineCoordinator of the Complex Wound CenterSyrian-Lebanese HospitalSão Paulo, Brazil

Alejandro Conejero, MD, FACSFacultyDepartment of Plastic and Reconstructive SurgeryAssistant Professor of SurgeryAlbert Einstein College of MedicineMontefiore Medical CenterNew York, New York, USA

Álvaro Cuadra, MDFacultyDepartment of Plastic and Reconstructive SurgeryUniversity HospitalPontifical Catholic University of ChileSantiago, Chile

Bruno Dagnino, MDAssistant ProfessorHead of Plastic Surgery DivisionDepartment of SurgeryUniversity HospitalPontifical Catholic University of ChileSantiago, Chile

Stefan Danilla, MD, MScConsultantPlastic Surgery UnitDepartment of SurgeryClinical HospitalUniversity of ChileSantiago, Chile

José Manuel Collado Delfa, MDChief of Burn UnitDepartment of Plastic and Reconstructive Surgery and BurnsVall d’Hebron University HospitalBarcelona, Spain

Sandhya Deo, MDPlastic and Reconstructive SurgeonWellington Regional Plastic, Maxillofacial and Burns UnitHutt HospitalLower Hutt, New Zealand

Chiara Distefano, MDPlastic SurgeonPrivate practiceCatania, Italy

Alex Eulufí, MDConsultantDepartment of Plastic and Reconstructive SurgeryClinica AlemanaSantiago, Chile

Tomas Gantz, MDConsultantDepartment of SurgeryPadre Hurtado HospitalSantiago, Chile

Ismael González, MDConsultantIbermutuamurMadrid, Spain

Bernardo Hontanilla, MD, PhDProfessor of Plastic SurgeryChief of Plastic and Reconstructive SurgeryUniversity Clinic of NavarraPamplona, Spain

Isabel Irarrazaval, MDConsultantDermatology DepartmentUniversity Clinic of Los AndesExequiel Gonzalez Cortes HospitalSantiago, Chile

Leigh Jansen, MD, MSc, FRCSCPlastic SurgeonVancouver, British Columbia, Canada

Matthew G. Kaufman, MDResidentDivision of Plastic SurgeryBaylor College of MedicineHouston, Texas, USA

Luis Landin, MD, PhDConsultantDivision of Plastic and Reconstructive SurgeryLa Paz University HospitalMadrid, Spain

Matthew R. Louis, MDResidentDivision of Plastic SurgeryMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, Texas, USA

Diego Marré, MDConsultantDepartment of Plastic and Reconstructive Surgery and BurnsClínica Las CondesEmergency Public HospitalSantiago, Chile

Aránzazu Menéndez, MDConsultantDepartment of Plastic and Reconstructive SurgeryUniversity Clinic of NavarraPamplona, Spain

Pablo Monedero, MD, PhDConsultantDepartment of Anesthesiology and Critical CareUniversity Clinic of NavarraPamplona, Spain

Ester Moreno-Artero, MDDermatologistDermatology DepartmentUniversity Clinic of NavarraPamplona, Spain

Jesús Olivas, MDResidentDepartment of Plastic and Reconstructive SurgeryUniversity Clinic of NavarraPamplona, Spain

Nicolás Pereira, MD, MScAssistant Professor in Plastic SurgeryDepartment of Plastic and Reconstructive SurgeryHospital del TrabajadorClínica Las CondesSantiago, Chile

Gustavo Perez-Abadía, MDAssistant Professor of Physiology and BiophysicsDirector and Instructor of Microsurgery Teaching CourseUniversity of LouisvilleLouisville, Kentucky, USA

Brent B. Pickrell, MDResidentHarvard Plastic Surgery Residency ProgramBoston, Massachusetts, USA

José L. del Pozo, MD, PhDConsultantDivision of Infectious DiseasesUniversity Clinic of NavarraPamplona, Spain

Maider Pretel, MD, PhDConsultantDermatology DepartmentUniversity Clinic of NavarraPamplona, Spain

Shan Shan Qiu, MDConsultantDepartment of Plastic and Reconstructive SurgeryMaastricht University Medical CenterMaastricht, The Netherlands

Pedro Redondo, MD, PhDProfessor of DermatologyUniversity of NavarraConsultant Dermatology DepartmentUniversity Clinic of NavarraPamplona, Spain

Ricardo Roa, MDChiefDepartment of Plastic and Reconstructive Surgery and BurnsHospital del TrabajadorSantiago, Chile

Héctor Roco, MDChiefDepartment of Plastic and Reconstructive SurgeryChilean Air Force HospitalSantiago, Chile

Marco Romeo, MD, PhDConsultantDepartment of Plastic and Reconstructive SurgeryJiménez Díaz Foundation University HospitalMadrid, Spain

S. Raja Sabapathy, MS, MCh, DNB, FRCS(Ed), MAMSChairmanDivision of Plastic Surgery, Hand andReconstructiveMicrosurgery and BurnsGanga HospitalCoimbatore, India

R. Raja Shanmugakrishnan, MDSenior FellowDepartment of Plastic Surgery, Hand andReconstructiveMicrosurgery and BurnsGanga HospitalCoimbatore, India

Cristián Taladriz, MD, MScConsultantDepartment of Plastic and Reconstructive Surgery and BurnsHospital del TrabajadorSantiago, Chile

Michael Tecce, MDClinical Research FellowDivision of Plastic SurgeryUniversity of PennsylvaniaPhiladelphia, Pennsylvania, USA

Ekaterina Troncoso Olchevskaia, MD, MScPlastic Surgery ResidentDepartment of Plastic and Reconstructive SurgeryUniversity of ChileSantiago, Chile

Andrew P. Trussler, MDPlastic SurgeonPrivate practiceAustin, Texas, USA

Pablo Zancolli, MDMicrosurgery FellowKleinert Kutz InstituteLouisville, Kentucky, USA

To our god-daughter, Maria, our angel looking after us every day from above

Section IPrinciples

1 Patient Safety in Plastic Surgery

2 Wound Healing

3 Wound Management and Pressure Sores

4 Negative Pressure Wound Therapy

5 Local Anesthetics and Common Nerve Blocks

6 Soft Tissue Infections and Antibiotics in Plastic Surgery

7 Implants and Biomaterials

8 Principles of Osteosynthesis

9 Essentials of Dermatology for Plastic Surgeons

10 Laser Therapy: Principles and Applications in Skin Diseases

11 How to Set Up a Research Protocol in Plastic Surgery

1 Patient Safety in Plastic Surgery

Brent B. Pickrell, Andrew P. Trussler

Abstract

This chapter provides a brief overview of the topics most pertinent to patient safety for the busy practicing surgeon and advanced trainees. It is organized to provide a longitudinal account of the patient encounter, beginning in the clinic (“Practice-Based Safety”), where patients are often first evaluated and their consent is sought for the recommended procedure. The discussion moves to a discussion of risk factors (“Risk Stratification”), with particular emphasis on smoking and patient safety. Finally, safety topics are outlined, with current supporting evidence from the literature (“Intraoperative Patient Safety”).

Keywords: informed consent, intraoperative risks, preoperative risk assessment, venous thromboe mbolism

1.1 Introduction

Patient safety has become a national focus in recent years, since the Institute of Medicine published To Err Is Human (2000), alerting the public to the serious and potentially deadly dangers posed by medical errors occurring in the health care setting. The authors estimated that approximately 44,000–98,000 Americans die annually secondary to preventable medical errors costing approximately US $79 billion. Thereafter, initiatives and guidelines have evolved to define, measure, and improve patient safety practices and culture.

Despite perceptions of the lay public, even in the elective office-based setting, plastic surgery is not without risk to the patient. Although plastic surgery often poses less risk than procedures of other surgical subspecialties, the risk of surgical complications should not be minimized. Even though the majority of complications from plastic surgery include scarring, infection, and bleeding, more serious complications, such as venous thromboembolism, do occur and can have devastating consequences.

1.2 Practice-Based Safety

1.2.1 Informed Consent

Opportunities to obtain patient consent abound in clinical practice, and physicians are required to obtain the informed consent of their patients before initiating treatment. That is, valid informed consent is premised on educating competent patients with the appropriate information so that they may make a conscious, voluntary choice. When patients lack the competence to make a decision about treatment, substitute decision makers must be sought if the scenario is nonemergent. If a surrogate decision maker must be sought, it is the physician’s responsibility to follow the given state’s statutes and contact family members in the correct order of priority.

Patient education begins preoperatively with a clear explanation of the procedure, along with the risks, benefits, and alternatives, if available. This necessary counseling can help avoid surprise and confusion if a complication arises postoperatively. Indeed, failure to inform patients is a common secondary claim in malpractice lawsuits. For specific procedures, the surgeon should consider providing standardized preoperative and postoperative patient education.

Informed consent should include the type of surgery and its potential risks, including anticipated outcomes, benefits, and possible consequences and side effects. When discussing risks with patients, one should avoid a recitation of statistics because they are frequently misunderstood or misinterpreted. Documentation of the informed consent should be noted in the medical record and revisited by the surgeon on the day of the operation.

Note

Spending time informing patients in the preoperative period can increase patient satisfaction and potentially lead to fewer claims in malpractice suits.

1.2.2 Reporting Adverse Events

It is important that a medical system has a standardized process for reporting adverse events that is valid, reliable, and actionable. Historically, many physicians have abstained from reporting their errors for fear of liability. To this end, the protocol should encourage honest reporting without fear of ramifications; an in-depth, comprehensive review of adverse events is key to improving the culture of patient safety. In 2002, the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation and the American Board of Plastic Surgery collaborated to create the “Tracking Operations and Outcomes for Plastic Surgeons,” a web-based database that compiles plastic surgery procedures and outcomes information. This database, which is compliant with the Health Insurance Portability and Accountability Act, serves as an internal quality control mechanism for the sole purpose of reducing morbidity and mortality and improving patient care. Because this information is not discoverable or admissible as evidence in a court of law, physicians need not fear liability for reporting their adverse events.

1.3 Patient Risk Stratification

Identification of preoperative patient risk factors is essential during initial consultation. It is appropriate for plastic surgeons to maintain a low threshold for primary care referrals for medical evaluation if a patient is over the age of 40 and wishes to undergo an elective procedure. Screening should be evidence based to avoid unnecessary use of patient and health care resources.

1.3.1 Smoking Cessation

The risks associated with smoking in the surgical patient are well documented. In particular, perioperative pulmonary complications have been shown to be four times more frequent in current smokers than in people who have never smoked. In a multicenter, randomized, controlled trial, patients who were randomized to receive preoperative smoking intervention (i.e., counseling, nicotine replacement, and either cessation or reduction of smoking) 6 to 8 weeks before surgery had fewer complications than control patients who did not receive the intervention.

A number of studies have linked tobacco use with complications following plastic surgery operations, most frequently in the context of the deleterious effects on wound healing. Chang et al. found an increased risk of mastectomy flap and abdominal wall necrosis following free transverse rectus abdominal myocutaneous flap reconstruction. Rees et al reported that smokers undergoing face-lifts were more likely to suffer skin slough. Coon et al. reported significantly higher overall complication rates, tissue necrosis rates, and the likelihood of reoperation. In a retrospective review of 1,881 patients, smoking was found to correlate with decreased skin graft survival.

Deciding whether to operate on a smoking patient is ultimately up to the surgeon, but the current literature supports an increased risk of complications that may be unacceptable for elective operations. Even so, a large survey by Rohrich et al. in 2002 suggests that many plastic surgeons elect to operate on patients who are known smokers, but the majority refused to offer skin flaps or procedures with extensive undermining.

Caution                                                                                                                                                             

Smokers will often misrepresent their tobacco status in the doctor’s office. Use of preoperative cotinine levels may help avoid tobacco-associated complications in these patients.

1.4 Intraoperative Risk

1.4.1 Patient Positioning

Complications arising from patient positioning are an underappreciated source of intraoperative morbidity. The risks of improper patient positioning include peripheral neuropathies, brachial plexopathies, myopathies, compartment syndromes, and pressure ulcers (Fig. 1.1). Given that plastic surgeons will often require unusual positioning in the operating room (OR) for adequate exposure, it is extremely important that the surgeon takes the appropriate precautions to prevent these complications.

Eighty percent of operations take place in the supine position. The two most common postoperative neuropathies, brachial and ulnar plexopathy, result from improper positioning and padding. These complications may be avoided by abducting the arms < 90 degrees to avoid traction on the brachial plexus. Additionally, the arms should remain supinated while abducted to avoid pressure on the ulnar nerve as it passes posterior to the medial epicondyle. Members of the surgical team should also be discouraged from leaning on extremities during the case. Similarly, cachexia may produce bony prominences and predispose the patient to compressive neuropathies or pressure ulcers.

Fig. 1.1 Common patient positions and safety considerations.

Prone positioning is the second most common position in plastic surgery. Aside from respiratory and cardiovascular concerns, complications related to prone positioning include vertebral artery occlusion causing stroke, brachioplexopathy, and pain from shoulder impingement. Most complications are related to excessive pressure on the head and neck, including blindness secondary to ischemic optic neuropathy. As such, a well-padded headrest should be used for every prone case. The neck should be stabilized in a neutral, nonextended position, avoiding neck rotation and accelerated movements. Bilateral chest rolls placed lengthwise should support the patient’s weight on the clavicles and iliac crests to lessen compressive forces that have the potential to negatively impact cardiopulmonary status. Lastly, female breasts and male genitals should be free from pressure and torsion.

Note

Postoperative neuropathies are a common source of malpractice claims and can be avoided through proper patient positioning and arm board padding.

1.4.2 Hypothermia

Hypothermia, defined as a body temperature lower than 36°C, is a risk factor for coagulopathy, cardiac events, and wound infection. A meta-analysis that pooled the results of 14 randomized trials found that even mild hypothermia (35–36°C) was associated with a 16% increase in blood loss and a 22% increase in the relative risk of transfusion. In another study, hypothermic patients undergoing plastic surgery were found to have an 8.3% prolongation of activated partial thromboplastin time as compared with those patients with mild intraoperative hypothermia. Additionally, Coon et al. found that lower OR temperatures were associated with an increased risk of seroma formation following postbariatric body contouring procedures.

Hypothermia is most frequently caused by cold OR temperatures, infusion or irrigation with temperate fluids, and anesthesia-induced impairments of thermoregulatory mechanisms. Procedures with a large surface area exposed, such as multisite or large body-contouring cases, large-volume liposuction, and cases lasting longer than 2 hours, are associated with an increased risk of hypothermia.

Proactive methods to decrease the risk of intraoperative hypothermia include using only warm infiltration/irrigation fluids and applying cutaneous warming devices or forced-air warming blankets. The surgeon, anesthesiologist, and OR staff should ensure that the temperature of the OR remains at a level that allows the patient to remain normothermic throughout the case.

1.4.3 Malignant Hyperthermia

Malignant hyperthermia is an inherited myopathy that presents as a hypermetabolic reaction to certain anesthetic gases, including halothane, enflurane, sevoflurane, desflurane, and isoflurane, and the depolarizing muscle relaxant succinylcholine. Desflurane and sevoflurane are less potent triggers, producing a more gradual onset of clinical signs. The onset may be dramatic if succinylcholine is used in genetically susceptible patients.

A variety of unusual conditions (e.g., sepsis, thyroid storm, pheochromocytoma) may resemble malignant hyperthermia during anesthesia and eclipse the initial diagnosis. Classically, an impending episode is heralded by a rising end tidal carbon dioxide level in the anesthetized patient. Hyperthermia is most often a late sign.

Given its autosomal dominant inheritance pattern with variable penetrance, careful preoperative screening can identify susceptible individuals, who should then undergo the caffeine halothane contracture test. Even then, susceptible patients may actually undergo anesthesia several times before a clinical event occurs.

Initial management of malignant hyperthermia should include immediate discontinuation of all volatile anesthetic agents and succinylcholine, followed by administration of dantrolene, given as a 2.5 mg/kg rapid bolus through a large-bore IV, with repeated administration every 10 minutes until the initial signs of the episode have ceased. Pediatric dosing is the same as for adults. Stopping all surgery, hyperventilating with 100% oxygen, volume resuscitation, and correcting hyperkalemia are also important. In the acute scenario, rapid dantrolene administration is of the highest priority; thus it is critical that perioperative staff are aware of its treatment role in this disease process. A continuous administration of 10 mg/kg/d should then be started for at least 24 hours, during which the patient should be transferred and observed in an acute care facility due to the risk of recrudescence (Table 1.1). It is important to ensure that all surgical suites be ready and able to handle a malignant hyperthermia emergency.

Remember                                                                                                                                                      

Rising end-tidal CO2 is often the first sign of a malignant hyperthermia episode.

1.4.4 Duration of Procedure

Increased surgery length has been correlated with increased rates of hypothermia, wound infection, postoperative nausea and vomiting, and hospital admission in the outpatient surgery setting. In a study that examined 35 different procedures, long-duration procedures (> 95% upper confidence limit of expected operative time) had significantly greater risk of mortality, acute renal failure, cardiac arrest requiring cardiopulmonary resuscitation (CPR), superficial/deep surgical site infection, deep vein thrombosis, prolonged intubation, pneumonia, progressive renal insufficiency, sepsis/septic shock, unplanned intubation, urinary tract infection, and wound disruption.

Table 1.1 Management of malignant hyperthermia in the operating room

• Discontinue volatile anesthetic agents and triggers.

• Halt procedure as soon as possible.

• Administer 100% O2, high flow 10L/min.

• Increase minute ventilation (hyperventilate).

• Administer dantrolene 2.5 mg/kg intravenous (IV) bolus, then give 1–2.5 mg/kg every 10 minutes until signs of episode have resolved and the patient is stable.

• Actively cool the patient with ice packs, cooling blankets, and cool nasogastric lavage.

• Treat hyperkalemia: calcium chloride 1 g IV; D50 1 Ampule IV (25 g dextrose) + regular insulin 10 units IV; sodium bicarbonate 1 Ampule.

• Treat cardiac arrhythmias (most often from hyperkalemia). Consult Advanced Cardiac Life Support (ACLS) guidelines as needed.

• Send labs for arterial blood gas, myoglobin, creatine kinase, prothrombin time/partial thromboplastin time, and lactic acid.

• Place a Foley catheter for monitoring urine output.

• Admit the patient to the intensive care unit for postoperative care and monitoring.

• Continue dantrolene 1 mg/kg every 4–6 hours for 24–36 hours.

• Call Malignant Hyperthermia Hotline with questions: 1–800-MH-HYPER (1–800–644–9737).

Plastic surgery operations lasting longer than 6 hours should be evaluated critically for close post-operative monitoring and an overnight stay for observation, depending on the time of day at which the operation ends and any confounding patient risk factors.

1.4.5 Venous Thromboembolism

Venous thromboembolism (VTE) has a varying range of incidence within the field of plastic surgery. The literature states that incidence ranges from 1 to 2% of all patients undergoing plastic surgery, although there is significant variance among the breadth of procedures. Among plastic surgical procedures, the risk of symptomatic pulmonary embolism is highest in liposuction, with a reported maximum incidence of 23%. Breast reconstruction is second, with a maximum incidence of 6%, followed by thermal injuries (4.4%), abdominoplasty (0.3–3.4%), and oncological head and neck reconstruction (0.1–0.4%).

Patients most at risk for VTE include those undergoing combined procedures, belt lipectomy, and abdominoplasty. Keyes et al found that 13 of the 23 deaths in the outpatient setting were caused by pulmonary embolism, and 12 of the deaths were associated with abdominoplasty alone or in association with one or more surgical procedures. Similarly, Grazer and Goldwyn reported a deep vein thrombosis incidence of 1.1% and a pulmonary embolism incidence of 0.8% in abdominoplasty patients.

Despite the severe consequences of VTE, a 2007 survey of members of the American Society of Plastic Surgeons found that only 43.7% of surgeons performing liposuction, 48.7% performing face-lifts, and 60.8% performing a combined procedure used VTE prophylaxis all the time. Until recently, there had been no data that addressed either risk stratification or thromboprophylaxis in plastic surgery patients. Recognizing the void of plastic surgery–specific literature, Seruya et al devised a VTE prophylaxis algorithm tailored specifically to plastic surgery patients. The authors provide an overall score for patients to stratify them into one of four risk groups (Fig. 1.2): low, moderate, high, or highest. For each group, the authors recommend a VTE regimen, including early ambulation, positioning, intermittent pneumatic compression stockings, and/or low-molecular-weight heparin (LMWH). Importantly, Seruya et al dem onstrated that the appropriate use of chemoprophylaxis did not result in statistically significant increased rates of hematoma among the highest-risk patients. Similarly, Pannucci et al showed that postoperative enoxaparin does not produce a clinically relevant increase in observed rates of reoperative hematoma.

There are certain preoperative factors known to increase the risk of VTE (Table 1.2); these should be explored on initial consultation for risk category assignment. Ideally, patients with an inherited bleeding disorder are identified preoperatively; however, some patients may not know their family history or may not think to disclose this information to the surgeon. As such, a thorough history and exam, including familial history, is imperative to gaining key information to identify potentially high-risk patients.

Caution                                                                                                                                                             

Patients most at risk for venous thromboembolism include those undergoing combined procedures, belt lipectomy, and abdominoplasty.

1.4.6 Surgical Site Infections

It is estimated that as much as 40–60% of surgical site infections may be preventable. The indications for the administration of prophylactic antibiotics are limited to clean-contaminated and contaminated procedures, although the significant morbidity that ensues from the infection of implants should warrant their use in clean procedures. Choice antibiotics include a first-generation cephalosporin (e.g., cefazolin), typically 1 g given intravenously (IV), or 2 g in the patient who weighs at least 160 pounds. Patients with a β-lactam allergy can be given clindamycin (600–900 mg IV) or vancomycin (1–1.5 g IV).

Antibiotic administration should be completed at least 30–60 minutes before incision. Additional administration should be performed every 3 to 5 hours until the wound has closed or if a significant amount of blood loss has occurred. Numerous studies have shown that continued administration of antibiotics after the completion of surgery is not indicated, and current Surgical Infection Prevention Project panel recommendations dictate the discontinuation of antimicrobial prophylaxis within 24 hours from the completion of surgery.

Fig. 1.2 Venous prophylaxis form for plastic surgery patients devised by Seruya et al.

Table 1.2 Factors that increase risk of venous thromboembolism

• Older age

• Underlying malignancy

• History of spontaneous miscarriage

• Pregnancy

• Oral contraceptive use

• Previous venous thromboembolism

• Heart failure

• Obesity

• Paralysis

• Presence of thrombophilic abnormalitya

a Factor V Leiden, prothrombin variant 20210A, antiphospholipid antibodies, protein C or protein S deficiency, antithrombin deficiency or dysfunction, hyperhomocysteinemia, heparin-induced thrombocytopenia, dysfibrinogenemia, and polycythemia vera.

1.4.7 Hypertension

Management of perioperative blood pressure control is largely unstandardized in the field of plastic surgery, even though hypertension is known to correlate significantly with hematoma rate and bleeding. It is well known that perioperative hypertension is the most significant risk factor in the development of hematoma after face-lift. To date, several studies have shown that the incidence of hematoma formation after face-lift can be reduced with close blood pressure control. Specifically, Ramanadham et al. use a transdermal clonidine patch on every patient undergoing rhytidectomy at their institution, and they report a postoperative hematoma rate of 0.9%. Although there is still a lack of consensus regarding treatment thresholds, perioperative hypertension requires consideration and careful management by the surgeon.

1.4.8 Liposuction

Liposuction is considered to be one of the most frequently performed plastic surgery procedures in the United States. Infiltration solutions containing up to 35 mg/kg of lidocaine are considered safe, provided that they are injected into the subcutaneous fat and contain epinephrine. Epinephrine doses between 1:100,000 and 1:1,000,000 are generally administered, with maximal doses not to exceed 0.07 mg/kg. Epinephrine is a critical additive in infiltrate solutions because it provides hemostasis and delays the rate of local anesthetic absorption from infiltrated tissue (Table 1.3).

In 1990, the dermatologist Klein demonstrated that the systemic absorption of lidocaine after tissue tumescence is equivalent to a slow, continuous infusion of the drug. Through this, he established a conservative maximum dose of lidocaine for tissue tumescence at 35 mg/kg. Klein also demonstrated that, when the total dose of lidocaine and infiltration time were held constant, the more-dilute solutions delay systemic absorption. By effectively slowing down the rate of absorption by using dilute lidocaine, rapid absorption from highly vascularized tissue or inadvertent intravascular injection is less likely to result in toxicity.

As a more potent local anesthetic, the toxic dose of bupivacaine (2.5 mg/kg) is far less than the toxic dose of lidocaine. Additionally, bupivacaine has a much longer duration of action (up to 10 hours) compared to that of lidocaine (up to 3 hours) due to higher protein binding. Toxicity of bupivacaine was originally noted to cause a therapy-resistant and nearly universally fatal cardiovascular collapse due to irreversible heart block. The first case of successful human rescue from refractory cardiac toxicity from bupivacaine was published in 2006. Intravenous 20% lipid emulsion (Intralipid, Baxter) has been shown to reduce mortality and should be stocked in facilities using bupivacaine.

Table 1.3 Commonly used local anesthetics

Agent

Recommended dosage (mg/kg)

Duration of action (min)

Lidocaine

Without epinephrine: 4.5 With epinephrine: 7

30–60

120–360

Procaine

7

15–60

Prilocaine

8

30–90

Bupivacaine

Without epinephrine: 2.5 With epinephrine: 2.5–4

120–240

180–420

Caution                                                                                                                                                             

Intralipid is used to treat bupivacaine toxicity and should be stocked appropriately.

1.4.9 Lidocaine Toxicity

Toxic effects of local anesthetics result from inappropriately high dosages or accidental intravascular injection. Signs and symptoms of lidocaine toxicity include light-headedness, restlessness, drowsiness, tinnitus, metallic taste in the mouth, slurred speech, and numbness of the lips and tongue. Plasma lidocaine levels peak 10–14 hours after infiltration into most fatty body areas when epinephrine is present in the wetting solution. Levels peak more quickly when the working area is highly vascularized, such as in the neck (6 hours). As such, the surgeon must be aware that tumescent anesthesia in the head and neck and other well vascularized tissues may show signs of toxicity sooner and at lower doses compared to the trunk (12 hours).

Cessation of administration, ensuring adequate oxygenation, and close electrocardiogram monitoring should be prompt, with supportive care in the form of IV fluids and vasopressors as needed, usually in the form of small doses of epinephrine. Seizure control is most appropriately managed with benzodiazepines (e.g., diazepam, midazolam).

Caution                                                                                                                                                             

Different anatomical sites have different rates of local anesthetic absorption.

1.4.10 Operative Room Fires

There are approximately 100 OR fires per year in the United States, responsible for an average of two deaths annually. The vast majority of all fires occur during facial, neck, and tonsil surgery. Aside from fiberoptic lights, lasers, and electrocautery devices, supplemental oxygen has traditionally been a lesser-known risk for surgical fires among OR personnel.

For surgical fires to occur, the classic triad must be present: a spark, flame, or heat source to cause ignition; a fuel source (a flammable item); and an oxidative material (e.g., oxygen). Further, the likelihood of fire depends on (1) the oxygen flow rate, (2) the power of the heat source (e.g., Bovie device), and (3) the distance between the heat source and the supplemental oxygen.

To mitigate the risk of surgical fires, some have advocated for techniques that reduce facial oxygen concentrations to ambient levels through use of a nasopharyngeal tube in lieu of a nasal cannula. Under this design, the two cut ends of the nasal cannula are placed down the nasopharyngeal tube. Others use an 8-French feeding tube to ensure oxygen delivery to the posterior pharynx. Indeed, one of the most critical elements in preventing OR fires involves communication between the surgeon and the anesthesiologist in cases where electrocautery is used in the head/neck or oropharynx in the presence of supplemental oxygen.

1.5 Conclusions

The culture of patient safety has undergone significant change in recent years and continues to make strides to improve the safety of health care delivery. Given the astounding breadth of plastic and reconstructive surgery, the surgeon must remain current on not only the expanding technology and surgical techniques but also the processes that make these procedures safe for our patients.

1.6 Key Points

• Patient safety begins preoperatively with patient education and proper consent.

• Active smoking can limit surgical options and should be addressed on initial consultation.

• Improper patient positioning in the OR can seriously harm patients.

• Close intraoperative monitoring can limit the risk of hypothermia.

• All surgical suites should be equipped to handle an episode of malignant hyperthermia.

• VTE prophylaxis should be considered in all procedures, especially combined operations.

• Surgical site infections can be limited by proper antibiotic administration 30–60 minutes before the operation.

• Reducing facial oxygen concentrations can limit the risk of OR fires.

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2 Wound Healing

Matthew G. Kaufman, Matthew R. Louis, Shan Shan Qiu, Edward P. Buchanan

Abstract