plastic surgery in trauma: what happens after the abcde's
TRANSCRIPT
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