Plastic Surgery in Trauma: What Happens After the ABCDE`s

Plastic Surgery in Trauma: What Happens After the
ABCDE’s
ASPSN 2015 Boston, MA: October 18, 2015
Branko Bojovic, M.D., F.A.C.S.
R Adams Cowley, M.D.
R Adams Cowley, M.D.
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“Every critically ill or injured person had the
right to the best medical care, according to
the state of the art and not according to
location, severity of injury or ability to pay”
“There is a golden hour between life and
death. If you are critically injured you have
less than 60 minutes to survive”
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History of the Shock Trauma Center
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1961
1967
1974
1976
1979
1982
1985
1989
1993
2013
Two bed clinical research unit
Statewide EMS system plans Med-Evac Service
MIEM/14 bed unit
22 additional beds
Hyperbaric chamber
Comprehensive rehabilitation program
MD General Assembly approves new STC Bldg.
New 7-story building
STC/UMMS
2nd STC Tower
PARC:
Primary Adult Resource Center
The only facility in Maryland with a PARC
(Primary Adult Resource Center)
designation, signifying that it provides
the highest level of trauma care in Maryland.
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Trauma Designation
A.
B.
C.
D.
E.
"PARC" is a Primary Adult Resource Center
"I" is a Level I trauma center
"II" is a Level II trauma center
"III" is a Level III trauma center
"ED" is an emergency department for
which the indicated standards are
recommended, not required
Med-Evac Helicopter Program
The Key to Statewide Capability
Regional Trauma Centers:
Golden Hour Flight Time to STC
Cumberland
43 min.
In Baltimore
24
min.
WCH
Johns
Hopkins
STC
Suburban
JH Bayview
Sinai
12 min.
Prince George’s
11 min.
Peninsula Regional
31 min.
Flight Time: 140 Knots - No Wind
RASTC:
State Mandate to provide the highest level of care for
the state’s most severely injured citizens from admission
through discharge
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7 Stories - 200,000 Sq Ft
13 Trauma Bays/26 Patients
6 Dedicated ORs
9 Post-Anesthesia Beds
24 Multi-Trauma CC/IMC Beds
24 Neurotrauma CC/IMC Beds
24 Select Trauma CC/IMC Beds
18 Acute Care Beds
10 Hyperbaric Beds
Dedicated Trauma Outpatient
Pavilion
Average Daily Trauma Admissions
22
20
18
16
14
12
10
8
6
4
2
0
20.8
8.5
6.58
4.33
2.14
2.13
4.39
4.57
4.45
R Adams Cowley Shock Trauma Approach
1.
2.
3.
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5.
State Police Aviation
Transportation
Trained Paramedics
One Central Dispatch
Trauma Center with
Helicopter Landing
Trained Personnel Transfer
to TRU
6.
7.
8.
9.
10.
Board Certified Trauma
Surgeons in TRU
CT Scan & Portable X-ray in
TRU
OR adjacent TRU
Critical Care Surgeons in SICU
Multidisciplinary Team of
Trained Physicians within
Multiple Specialties
R Adams Cowley Shock Trauma Center
Objectives
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Elucidate how the surgical management of plastic
surgery in trauma involves the use of certain basic
surgical principles.
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Realize how modern surgical approaches and materials
affect the care of these patients.
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Project how excellence in surgical care affects the
ultimate return to normalcy of the patient.
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Describe future frontiers in trauma plastic surgery.
Physical Exam: Head to Toe
Don’t forget the ABCDE’s (Basics)
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A – Airway maintenance with C-spine protection
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B – Breathing and ventilation
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C – Circulation with hemorrhage control
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D – Disability/Neurologic assessment
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E – Exposure and environmental control
Physical Exam: Head to Toe
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Soft tissue
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Entrance/exit
Vascular
Neural-facial & trigeminal
Scalp
Orbital-vision, pupils, movement,
pressure, fundus
Nasal-septal hematoma’s, csf
rhinorrhea
Ears-lacerated canal,
hematympanum, otorrhea
Torso –
avulsions/lacerations/hematomas
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Hard tissue
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Cranium
Supraorbital/infraorbital
Zygomatic arch/malar
prominence/nasal bones
Maxilla/mandible-basal and
alveolar segments
Occlusion
Long-bone injuries –
fractures/foreign bodies
“the normal human face is possibly the
most beautifully perfect structure in all
the animal kingdom”
Ralph Millard
The Avoidable Result
Goal of Surgical Management
Early Restoration of Bony Construct & Prevention of Soft Tissue Contraction
Courtesy of Eduardo D. Rodriguez, M.D., D.D.S.
MVC with “some facial trauma”
“Just a laceration”
Baseball “line-drive” to face…
“Old lip laceration…”
“Innocent bystander with GSW to face…”
“Fell onto chin while walking down stairs…”
“Fell of my bike…”
Victim of assault…
STC/UMMC – Adult
STC/UMMC – Adult
STC/UMMC – Adult
STC/UMMC – Adult
Reconstructive Ladder
REGENERATION
ALLOTRANSPLANT
Free Flap
Local Flap
Tissue Expansion
Increasing
Skin Graft
Complexity
Delayed Primary Closure
Primary Intention
Secondary Intention
A
New
Frontier
The Clinical Challenge: State of the Art
Total Facial Burn
Innovation
Necessity, who is the mother of invention.
Plato (427-347 BC)
Composite Tissue Allotransplantation:
Solution?
Transplantation of heterogeneous antigenic tissues across a
genetic mismatch
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Replace “Like with Like”- Sir Harold Gillies
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Biomechanical properties
Aesthetic appearance
Texture/shape/size
Eliminate donor site morbidity
Avoid non-vascularized tissue
Unlimited bone/soft tissue donor source
“The Right Stuff”
Frontier Surgery
Photo Courtesy of Coos Hamburger
Amir Dorafshar, Michael Christy, Eduardo D. Rodriguez, Branko Bojovic, Daniel Borsuk
Informed and Willing Patients
Surgical Plan:
Total Face, Double Jaw & Tongue Transplant
BDD Facial Soft Tissue Dissection:
3-19-2012
Completed Facial VCA Dissection:
In Situ Plating 3-19-2012
Donor Restoration:
3-19-2012
Recreating the Recipient Facial Defect:
3-19-2012
Recreating the Recipient Facial Defect:
3-20-2012
Initiating the Facial Transformation:
3-20-2012
Completing the Transformation:
3-20-2012
Richard Lee Norris
Richard Lee Norris
Transformational Surgery
Post-Injury
Post-Op Day 6
Post-Op Day 114
POD 6
POD 114
POD 332
POD 198
POD 476
“Gift of Life” Gala Celebration
(4-27-2013 POD 397)
Transformational Surgery
May 2014
We are limited not by our abilities,
but by our vision…
Thank You