Monday, July 30, 2007

6th Week in Plastics

On Monday morning I attended the weekly resident talk. Later that day I went to Dr. Spector's office hours where I both observed and aided in patient care. Through the previous weeks I have been able to learn where much of the necessary devices and supplies are stored in the offices which enables me to better help Dr. Spector as he cares for the patients. The same patient I have spoken of before came in for a V.A.C. change as he does each week. The abdominal wound has made great progress in my time here. The first time I saw this patient his wound was 1.5-2" and extended about 7" long to about 5" wide at the widest point. The wound was pear shaped. Over the past weeks the wound has decreased to about 4" long and about 3" wide. The depth of the wound has decreased dramatically to about .5" deep. It is interesting to me that with a simple V.A.C. dressing the body is able to close over such a large open wound by itself. This week I helped in changing the V.A.C. dressing. First, we remove the old dressing and Dr. Spector cuts out in dead tissue as this will not help in wound closure. After debriding the wound, we place gauze in the wound and soak with Dakin's Solution. This is a aseptic solution for cleaning wounds what is made of sodium hypochlorite and boric acid (4 %). We allow the patient to sit our the 'rinse cycle' for a few minutes while the wound is soaked in Dakin's. Then we remove the soaked gauze and dry off the wound. The standard oval shaped black sponge is then cut to fit the wound. Often the doctor will cut the sponge half thickness and then cut out the pattern of the wound. This helps to keep the healthy tissue surrounding the wound health and increase drainage from the wound while promoting the granulation of the wound bed. A picture (from is shown that pictorially shows how the fluid in the wound bed is able to exit through the black sponge and the vacuum is able to help in wound closure. Now that the patient has seen the wound closure capabilities of the V.A.C. and the wound has greatly decreased in size, there are now other options for closure of the wound. Because the patient has also lost weight over this time period, it may be possible to simply elevate the tissue on either side and close the wound. By leaving the V.A.C. on for a few more weeks, this would certainly be possible. It would also be possible, to put a skin graft over the wound to close it. As of now, the patient has opted to keep the V.A.C. dressing on and continue to allow the wound to make progress this way.

Additionally, this week I was able to attend a unilateral mastectomy. The patient has breast cancer in her right breast and decided that removing the breast was the best option. Dr. Spector counseled her on the different reconstruction techniques that can be used and allowed her to decide what would be best for her. The two main options are to complete an reconstruction by removing a portion of her abdomen and forming a breast from that or by simply placing a tissue expander in after the breast is removed. An example of a tissue expander is shown in the image on the right. With the first option, the procedure is called a free flap where tissue is taken from one part of the body and used in another, but it is moved with its own blood supply and hooked into the blood supply around the new site. For the tissue expander, the expander is placed under the muscle and slowly expanded by adding saline ever few weeks until the desired size is reached. Once the size is correct, implants are placed. In either case, addition surgery is required to reconstruct the nipple. In the OR, first the breast team comes in and removes the cancerous breast. The day prior to the surgery, the patient is injected with a dye which then accumulates in the nodes, which can easily be seen during surgery. An incision is made around the areola and then the skin is elevated off of the underlying breast tissue. The nipple and breast tissue are then removed. The nodes are then removed and sent to pathology. Frozen sections are taken and the surgery team is informed whether the cancer is present in the nodes. The sentinel lymph node is specifically checked. This is an indication as to whether the cancer has spread to other parts of the body. Once the breast team has finished, the plastics people come to the OR and begin the reconstruction. The tissue expander is placed under the muscle with a small amount of saline in it. For the next few months the patient will come in periodically to have more saline injected into the expander. The port on the expander is labeled with a magnet so that Dr. Spector can use a magnet externally to locate the port.

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