Plastic Surgery Pearls for IPAS Fall CME 2016 JKeith Word - Plastic Surgery Pearls for IPAS Fall CME 2016 JKeith.docx Created Date 9/30/2016 8:18:58 PM

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JerrodKeithMDClinicalAssistantProfessorPlasticandReconstructiveSurgery

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! Nodisclosures! Unbiased! Evidencedbasedmedicine

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! Woundhealing! Patientcare! Woundcare! Debridement! Dressings! Postoperativewoundcare! Scarmanagement

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Fanetal.Plast Reconstr Surg.127(suppl):44s,2011.

! $25billionperyear! 2.5millionAmericans! 2millionworkdayslostperyear

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! Damagedbloodsupply! hypoxia" Decreasedactivitybyneutrophils" Releaseproteasesandtoxicoxygenmetabolites

! Medicalcomorbidities" Heartdisease" Peripheralvasculardisease" Tobaccouse" Radiationdamage" Chronicinfection

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! Presenceofbacteriaprolongtheinflammatoryphase! Increasedmetabolicdemand! Increasedproteaselevels

! >105colony-formingunitspergramoftissue! Exudate,odor,pain,changeincolor,rapidonsetofslough,failedhealing

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! Immunosuppression! Corticosteroids! Diabetes! Livercirrhosis! Malnutrition! Foreignmaterials

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! Diabetes(HgA1C<7 g/dl)! Malnutrition(checkalbuminandprealbumin)! Anemia(correctableforms– ironsupplementation)

! Immunodeficiency(CD4counts,viralloads,systemicsteroidmodulation)

! Maintainnormothermia! Activesmokers

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! Scientificbasisfordiminishedwoundhealinginactivetobaccouse! Leukocyte,macrophage,fibroblast,andplateletdysfunction

! Microvascularinjury! Thrombogenic! Decreasedoxygendelivery! Diminishedoxygenutilization! Impairedwoundepithelialization

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! Recommendations! Avoidtobaccoandnicotinecontainingproducts(includingpatchesandgums)for▪ 4weekspre-op▪ 4weekspost-op

! Cancelorpostponesurgeryfornoncompliance

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! Increases#ofmonocytesandmacrophagesinwound

! Stimulatesfibroplasia! Increasescollagensynthesis! Improvesepithelialization

! VitAdefdelayswoundhealing,supplementationinnondeficient animalshaslittleifany+effect

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! Give15,000IUdailytocombatnegativesteroideffectsonwoundhealing! Dosenotexact

! Repletionsdosage– 2000IUdaily! Trauma,sepsis,catabolicstate

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! Involvedincollagensynthesis! Improvesneutrophilfunction! Increasesangiogenesis! Depletedinstressandsevereinjury

! Supplementationenhanceswoundhealingindeficientsubjects,butnotshowntohelpthosewhoarenondeficient

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! Antioxidant! Anti-inflammatory! Inhibitscollagensynthesis! Decreasestensilestrengthofwounds

! Doseshigherthan1000mg/daycanimpairwoundhealingandinhibitclotformation(inanimals)

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! Requiredforcellulargrowthandreplication! Deficiencycandecreaseproteinandcollagensynthesis! Canseedeficiencyinthosewithfistulas,stress,sepsis,diarrhea,orpregnancy

! Nobenefitseeninnon-deficientindividuals

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MechanicalAutolyticEnzymaticBiologicSurgical

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! Maintainstissuehydration/temperature! Preventsescharformation! Promotesrapidepithelialization! Decreasespain! Softennecroticdebris

! “Adrywoundisadeadwound”

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! Providesbettervascularsupplyandmaintenanceoftissueviabilitytoresistinfection

! CausesslightlyacidoticpH(betterbecausethisisnormalfortissue)

! Permitsgrowthfactorstobefunctional

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! Makeacleanwound! Reducesbioburden

! Decreasesbacterialcounts! Lowerinfectionrate

! Removesendotoxins! Necrotictissue

! Improveshealingrates! Shouldseeanimprovementof10%perweek

Falanga.Wound2002

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! Wet-to-drydressings! Tearsnecrotictissuefromthewoundinarandomandpainfulmanner

! Insufficientforadequatewoundbedpreparation:▪ Removesvitaltissuesinadditiontonecrotic,causingreinjury ofthewoundbed

! Painful▪ Attributedtoexposureanddehydrationofsensorynerves

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! Wet-to-drydressings! Allowsevaporationoffluidsfromthewound! Coolsthewoundsurfacetoapproximately10degreeslessthanbodytemp▪ Localvasoconstriction,hypoxia,diminishedcellactivity▪ Susceptibilitytoinfection

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! Wet-to-drydressings! Providesnophysicalbarriertothepenetrationofbacteriaorcontaminants

! Laborintensive! BIDorTIDchanges

! Advantage! Cheapandeasy

LawrenceJK.AmJSurg.1994;167.

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! Usesthebodiesinherentabilitytodigestandriditselfofnecrotictissueandenhancesgranulationtissueformation! Occlusivedressings! Hydrocolloids! Moistinteractivedressings

! Usedaloneorincombinationwithotherdebridementtechniques,includingsurgical

Steed,DL. AmJSurg.2004.187.

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! Necrotictissueliquefied! Painless! Potentialforinvasiveinfectioninwoundswithpersistentnecrotictissue! Woundmustbemonitored

! Bestforpatientswithminimalnecroticloadwhocannottoleratemoreaggressivedebridement

LewisR.HealthTechnol Assess.2001.5.

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! Papainwithurea! Collagenase

! Enzymesselectivelydigestdevitalizedtissue! Lesstraumatohealthytissuethansurgicaldebridement

! Forwoundswithsmallamountofnecrotictissue

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! Disadvantages! Time-intensive! Labor-intensive! Canbepainful

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! Leptospermumhoney! Broadspectrumantibioticandantifungal! Anti-inflammatory! Accelerateswoundhealing,debridementandgranulation

! Noadversesystemicorlocaleffects

GMSKrankenhhyg Interdiszip.2006;1(1):Doc18.

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! Macrostrain! Drawswoundedgestogether! Totalwoundbedcontactforevendistribution! Removesexudateandinfectiousmaterials

! Microstrain! Reducesedema! Promotesperfusion! Promotesgranulation

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! Goldstandard! Decreasebioburden withinthewound! Immediatelyprovidesahealthywoundbed

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PassiveActive

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! Controlwoundmoisturelevels! Occlusivedressings! Acute,superficialwounds

! Moisture-retainingdressingsspeedepithelialization

! Chronicwounds! Lesspain! Autolyticdebridement


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! Developmentstemsfromthealteredbiologyofthechronicwound! Increasedbacterialload! Excessproteaselevels

! Antimicrobial! Proteaseinhibitors! Collagendressings


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! Scaffoldfortissueingrowth! Bindhighlevelofproteases

! Protectgrowthfactorsfromdestruction! Neutralizefreeradicaldamage

! Studiesmixedonefficacy! Diabeticandvascularulcers


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! Absorbable! Deeplayers! Intraoral! Monocryl– clear! Vicryl- braided

! Permanent! Remove5-7days! Nylon- black! Prolene- blue

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! SkinAdhesive! Dermabond

! TrackMarks

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! Nosutureorstapleremoval! Spontaneouspeeloff! Goodtensilestrength! Microbialbarrier! Decreasedpain! Shorterapplication! Increasedeconomicbenefitcomparedwithsuturing

Richter.Plas ReconSurg.2012,10.

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! Debatable! 1%lidocainewithepinephrine

! Taketimetowork– 7min! Dryfield! Stillpatient

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! Ointmentsarelesssensitizingthancreamsorlotions! Nopreservatives,emulsifyingagents,orsolvents

! Averageantibacterialactivitylasts12hours! Woundreepithelializesin24hours

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! Bacitracin! Neomycin! Neosporin(Bacitracin,PolymyxinB,Neomycin)

! Polysporin(BacitracinandPolymyxin B)! Petrolatum

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! 2nd mostcommonlypositiveallergeninNorthAmerican

! Sensitivity1-6%inthegeneralpopulation(highestofalltopicals)! Higherinthosewith:▪ Stasisulcers(30%)▪ Chronicotitisexterna(15%)▪ Chroniceczematousconditions(5%)

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! Foundinointmentswithoutprefix“Neo”also(“tripleantibioticointment”)

! Canbesystemicallyabsorbedifappliedtolargesurfaceareasofdamagedskin! Burnpatients! Ototoxicityandnephrotoxicity

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! Raresensitivity(0.9%)! Cansee“co-reactivity”withNeomycinwhenusedtogether

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! Bacitracinvs.Petrolatum! Randomized,double-blind,prospectivetrial! 922patients(440whitepetrolatum,444Bacitracin)

! Smack,DP.JAMA276(12):972-7,1996.

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! Post-opinfection! 2%vs.0.9%(petrolatumvs.Bacitracin)p=0.37▪ 8of9infectionsinpetrolatumgroupfromS.aureusvs.0of4inBacitracin(p=0.004)

! Contactdermatitis! 0%vs.0.9%(petrolatumvs.Bacitracin)p=0.12

! Woundhealing! Nodifferencesondays1,7,or28(p=0.98,0.86,0.28)

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! “whitepetrolatumissafe,effectivewoundcareointment…incomparisontoBacitracin,whitepetrolatumpossessesanequallylowinfectionrateandminimalriskforinductionofallergy”

! Cheaper

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! Contactdermatitis! Neomycin>Bacitracin>Petrolatum

! Cost

! Mypreference! Petrolatum>Bacitracin>Neosporin

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! Siliconegelsheeting! Pressure! Topicals

! Mederma! VitaminE

! Intra-lesional steroids! Radiation! Surgery

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! OTCtopicalgel! Activeingredient:AlliumCepa(onionextract)! Quercetinisderivativeofalliumcepa

! anti-inflammatory/antihistamineeffects

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! Clarkeetal.(CosmeticDerm1999)! “significantimprovement”inscarsoftnessinMedermagroupvs.placeboaccordingtopatientsafter2monthsoftreatment

! However,blindedplasticsurgeon’sphotoevaluationofscarsize/appearancewasNOTabletodetermineadifference

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! Saulis etal(PRS2002.July;110(1).)! Rabbitearmodel▪ Increasedcollagenorganizationinthescardermiscomparedwithplacebo(p=0.05)

! Nodifferenceinscarheightorerythema

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! Chungetal.(DermatologicSurg 2006.Feb;32(2).)

! Randomized,double-blind,split-scarstudy▪ Scardividedequally▪ HalftreatedwithMederma,otherhalfwithAquaphor▪ Evaluatedbyblindedinvestigatorsforoverallcosmeticappearance,erythema,hypertrophy▪ Patientsalsoindependentlyratederythema,pruritus,burning,andpain

! Nostatisticallysignificantdifferencebetweenthe2treatmentgroupsinanyoutcomestudied(p>.1)

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! Thoughttoimprovescarring,butnotsupportedinscientificliterature

! Noprovenbenefitonscarthicknessorcosmeticappearance

! Massageismostlikelybenefit! Cancausebothdelayedallergiccontactdermatitisandimmediateallergicurticariain15%ofpatients

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! Convertchronicwoundstoacutewounds! Wounddebridementiskey! Maintainmoistureandavoideschar! Overallpatienthealthiscriticalforwoundhealing

! Ointmentscancausedermatitis! Expensivescarcreamshavenotbeenshowntobeeffective

! Keepitsimple!

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! Optimizethepatient! Nutrition,DMcontrol,andsmokingcessation! Pressureoff-loading

! Debridement! Enzymaticandsurgical

! Wounds– petrolatum! Scars

! Glue"Aquaphor withgentlemassage! Brownpapertape

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Plastic Surgery Pearls for IPAS Fall CME 2016 JKeith Word - Plastic Surgery Pearls for IPAS Fall CME 2016 JKeith.docx Created Date 9/30/2016 8:18:58 PM