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.

“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”

History of the Shock Trauma Center

1961 Two bed clinical research unit

1967 Statewide EMS system plans Med-Evac Service

1974 MIEM/14 bed unit

1976 22 additional beds

1979 Hyperbaric chamber

1982 Comprehensive rehabilitation program

1985 MD General Assembly approves new STC Bldg.

1989 New 7-story building

1993 STC/UMMS

2013 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.

Trauma Designation

A. "PARC" is a Primary Adult Resource Center

B. "I" is a Level I trauma center

C. "II" is a Level II trauma center

D. "III" is a Level III trauma center

E. "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

WCH 24

min.

Suburban

12 min.

Prince George’s

11 min.

Peninsula Regional

31 min.

Cumberland

43 min.

Flight Time: 140 Knots - No Wind

STC

In Baltimore

Johns

Hopkins

JH Bayview

Sinai

RASTC: State Mandate to provide the highest level of care for

the state’s most severely injured citizens from admission

through discharge

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

2.14 2.13

4.33 4.39 4.57 4.45

8.5

6.58

20.8

0

2

4

6

8

10

12

14

16

18

20

22

R Adams Cowley Shock Trauma Approach

1. State Police Aviation

Transportation

2. Trained Paramedics

3. One Central Dispatch

4. Trauma Center with

Helicopter Landing

5. Trained Personnel Transfer

to TRU

6. Board Certified Trauma

Surgeons in TRU

7. CT Scan & Portable X-ray in

TRU

8. OR adjacent TRU

9. Critical Care Surgeons in SICU

10. Multidisciplinary Team of

Trained Physicians within

Multiple Specialties

R Adams Cowley Shock Trauma Center

Objectives

Elucidate how the surgical management of plastic

surgery in trauma involves the use of certain basic

surgical principles.

Realize how modern surgical approaches and materials

affect the care of these patients.

Project how excellence in surgical care affects the

ultimate return to normalcy of the patient.

Describe future frontiers in trauma plastic surgery.

Physical Exam: Head to Toe

Don’t forget the ABCDE’s (Basics)

A – Airway maintenance with C-spine protection

B – Breathing and ventilation

C – Circulation with hemorrhage control

D – Disability/Neurologic assessment

E – Exposure and environmental control

Physical Exam: Head to Toe

Soft tissue

Entrance/exit

Vascular

Neural-facial & trigeminal

Scalp

Orbital-vision, pupils, movement, pressure, fundus

Nasal-septal hematoma’s, csfrhinorrhea

Ears-lacerated canal, hematympanum, otorrhea

Torso –avulsions/lacerations/hematomas

Hard tissue

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

A

New

Frontier

Reconstructive Ladder

Free Flap

Local Flap

Tissue Expansion

Skin Graft

Delayed Primary Closure

Primary Intention

Secondary Intention

ALLOTRANSPLANT

Increasing

Complexity

REGENERATION

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

Replace “Like with Like”- Sir Harold Gillies

Biomechanical properties

Aesthetic appearance

Texture/shape/size

Eliminate donor site morbidity

Avoid non-vascularized tissue

Unlimited bone/soft tissue donor source

Amir Dorafshar, Michael Christy, Eduardo D. Rodriguez, Branko Bojovic, Daniel Borsuk

Photo Courtesy of Coos Hamburger

“The Right Stuff”Frontier Surgery

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

Post-Injury Post-Op Day 6 Post-Op Day 114

Transformational Surgery

POD 6 POD 114 POD 198

POD 332 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