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Plastic surgery definition, the Greek word plastikos means to
form or mold). Not limited to the skin and its adnexa, plastic
surgery may encompass any area of the body. While the details of
various procedures are important, basic principles allow the
plastic surgeon to solve unusual problems, to apply known
procedures to other body parts, and to be innovative and change
with the times and with developing technology. These broad
principles can be applied to simple skin excisions or to complex
free tissue transfers.
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The first objective in analyzing a reconstructive problem is a
correct diagnosis. The extent and type of missing tissue are
assessed in order to formulate a plan for correction or
reconstruction (Fig. 1). Planning the reconstruction by using a
reconstructive ladder illustrates a basic principle.
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Innovations of plastic surgeryIt is now Monday and we are in the
second week of creation Peter SloterdijkMany promising new findings
will not survive forever or be rejected after a while or even
innovated by the original authors or others. Many old techniques on
the other hand have never been neglected: the ever-cited Indian
Flap e.g. The coexistence of both: old and new is the secret of
good science.
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Obtaining A Fine-Line Scar
The final appearance of a scar is dependent on many factors: (1)
the type of skin and location on the body. (2) the tension on the
closure. (3) the direction of the wound. (4) co-morbid conditions.
(5) the technique used for closure. Minimizing damage to the skin
edges with atraumatic technique, debridement of necrotic or foreign
material, ample irrigation of traumatic or contaminated wounds.
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Intrinsic Factors 1.Age. Loss of elasticity combined with
changes in the subcutaneous tissue, produce wrinkling, which makes
scars in older individuals less obvious and less prone to
stretching. 2.Type of skin should also be taken into account. Skin
that is oily or pigmented, or both, produces more unsightly scars.
Patients with fibroelastic diatheses are also prone to
unpredictable healing and scarring. 3.Certain anatomic areas
produce unfavorable scars that tend to become hypertrophic or
widened. The shoulder and sternal area are notable examples. On the
other hand, eyelid scars almost always heal with a fine-line scar.
4.Nutritional status can affect wound healing. Wounds gain strength
less rapidly in the face of protein depletion. Vitamin A reverses
the healing retardation caused by steroids. Vitamin C deficiency
has long been known to cause scurvy, characterized by a failure of
collagen synthesis. Zinc is required for epithelialization and
fibroblast proliferation. Ferrous iron and copper are necessary for
normal collagen metabolism. 5.Co-morbid conditions such as anemia
can retard wound healing. .
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Skin lines The lines of tension in the skin were first noted by
Dupuytren(1832). Langer(1861) also described the normal tension
lines of the skin, called Langers lines. Borges has written
extensively on the subject and lists 36 descriptive terms for skin
lines. He refers to the skin lines as relaxed skin tension lines
(Fig. 2). Excision of lesions is planned when possible so that the
final scar will be parallel to the relaxed skin tension lines.
Maximal contraction occurs when a scar crosses the lines of minimal
tension at a right angle. Wrinkle lines are generally the same as
the relaxed skin tension lines and lie perpendicular to the long
axis of the underlying muscles. Scars can also be hidden in contour
lines (i.e., lines of division) between body planes.
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Factors determine the severity of suture markers1.Time of
removal of stitches . 2.diameter of the suture .3. Relation to
wound edges.4. Region of the body.5.Absence of infection.6.
Propensity for keloid.
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Features of good scar1- Fine line scar 2- absence of contour
irregularities absence of pigmentary irregularities3-4- no
contracture or distortion
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Methods of Excision
1.Simple Elliptical ExcisionLesions of the skin can be excised
with elliptical, wedge, or circular excision. Simple elliptical
excision is most commonly used . Dog ears may be corrected by
extending the ellipse or removing excess tissue to close the
incision in an L or Y shape. 2.Wedge Excision Lesions located at or
adjacent to free margins can be excised by wedge excisions.
One-third of the lower lip and one-fourth of the upper lip and
eyelid can be excised with primary closure. Lesions near the rim of
the ear can be excised in a simple V shape and directly
approximated. If excisions are large, stepping the limbs of the V
at the helix will prevent notching. 3.Circular Excision When
preservation of the skin is required in areas such as the nose or
the anterior surface of the auricle, the lesion can be excised in a
circular manner and the defect closed with a skin graft or skin
flap . 4.Multiple Excision Technique Serial excision is frequently
employed for large lesions such as congenital nevi. The inherent
viscoelastic properties of skin are utilized, allowing the skin to
stretch over time. These techniques allow wound closure to be
accomplished with a shorter scar than if the original lesion was
elliptically excised in a single stage.
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Methods of suturingA. interrupted.B. Vertical mattress.C.
Transvers mattress.D. Subcuticular .E. Half buried.F.
Continous.
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skin graft
skin graft consists of epidermis and some portion of dermis that
is removed from its blood supply and transferred to another
location.
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historyReverdin 1st skin transfere Pollock autograft Theish thin
graft Wolf full thichness
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USESClose any wound with good blood supply temporary closure
control infection aesthetic replacement close donor site mucosal
replacement
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TYPESAutograft Allograft(homograft) Xenograft(heterograft)
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Skin Graft Types according to thickness
skin graft may either be full or split thickness, depending on
how much dermis is included. Split-thickness skin grafts contain
varying thicknesses of dermis while a full-thickness skin graft
contains the entire dermis. All such grafts contain adnexal
structures such as sweat glands, sebaceous glands, hair follicles,
and capillaries.
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Skin Graft Donor Sites
Skin grafts can be taken from anywhere on the body, although the
color, texture, thickness of the dermis, vascularity, and donor
site morbidity vary considerably. Skin grafts taken from above the
clavicles provide a superior color match for defects of the face.
The upper eyelid skin can also be used, as it provides a small
amount of very thin skin. Full-thickness skin graft harvest sites
can be closed primarily. The abdominal wall, buttocks, and thigh
are common donor sites for split-thickness skin grafts.
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Choice of the typeSTSG doubtful area contracture FTSG full
thickness defects no contracture
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Survival of a Skin Graft
The success of skin grafting, or take, depends on the ability of
the graft to receive nutrients and, subsequently, vascular ingrowth
from the recipient bed. Skin graft revascularization or take occurs
in three phases.1 . serum imbibition and lasts for 24 to 48 hours.
Initially, a fibrin layer forms when the graft is placed on the
recipient bed binding the graft to the bed. Absorption of nutrients
into the graft occurs by capillary action from the recipient bed.2
. inosculatory phase in which recipient and donor end capillaries
are aligned. 3 . the graft is revascularized through these kissing
capillaries. Because the full-thickness skin graft is thicker,
survival of the graft is more precarious, demanding a
well-vascularized bed.
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Four theories have been proposed for graft revascularization:
(1) There is neovascularization of the graft in which new vessels
from the recipient bed invade the graft to form the definitive
vascular structure of the graft (2) communication occurs between
existing graft vessels and those in the recipient site. (3) there
is a combination of ingrowth of new vessels and reestablishment of
flow into existing vessels. (4) the vasculature of the skin graft
is made up, primarily, from its original vessels before transfer.
To optimize take of a skin graft, the recipient site must be
prepared. Skin grafts require a vascular bed and will seldom take
in exposed bone, cartilage, or tendon devoid of its periosteum,
perichondrium, or paratenon. There are exceptions, however, as skin
grafts are frequently successful inside the orbit or on the
temporal bone, despite removal of the periosteum. Close contact
between the skin graft and its recipient bed is essential.
Hematomas and seromas under the skin graft will compromise its
survival and immobilization of the graft is essential.
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INSTRUMENTKnife Humby Watson Reese Drume type Electrical
dermatome
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Causes of failure 1 . Haematoma 2 . Inadequate immolization 3 .
Misevaluation of the wound 4 . Epidermal upside down 5 . Dependent
position
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character of skin graft Primary contraction is the immediate
recoil of freshly harvested grafts as a result of the elastin in
the dermis. The more dermis the graft has, the more primary the
contraction that will be experienced. Secondary contracture, the
real nemesis, involves contraction of a healed graft and is
probably due to myofibroblast activity. A full-thickness graft will
contract more on initial harvest (primary contraction) but less
upon healing (secondary contracture) than a split-thickness skin
graft. The thinner the split-thickness graft, the greater the
secondary contracture. Granulating wounds left to heal secondarily
demonstrate the greatest degree of contracture and are most prone
to hypertrophic scarring.
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The number of epithelial appendages transferred with a skin
graft depends on the thickness of the dermis present. The ability
of grafted skin to sweat depends on the number of glands
transferred and the sympathetic reinnervation of these glands from
the recipient site. Skin grafts are reinnervated by ingrowth of
nerve fibers from the recipient bed and from the periphery.
Full-thickness grafts will have the greatest sensory return because
of a greater availability of neurilemmal sheaths. Hair follicles
can also be transferred with the graft. Full-thickness skin grafts
will contain more hair follicles than split-thickness skin
grafts.
character of skin graft
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Unwanted squealsScaling Milia
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Special TechniquesMesh graft Indication Contraindication Dermal
graft Application Mucosal graft Composite graft
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SKIN FLAPSUnlike a graft, a flap has its own blood supply.
Although the skin graft is often simpler, there are cases in which
a flap is required or may be more desirable. Flaps are usually
needed for 1 .covering recipient beds that have poor vascularity; 2
.reconstructing the full thickness of the eyelids, lips, ears,
nose, and cheeks 3.padding body prominences (i.e., for bulk and
contour). 4 .Flaps are also used when it is necessary to operate
through the wound at a later date to repair underlying structures.
5. muscle flaps may provide a functional motor unit or a means of
controlling infection in the recipient area. 6. controlling of
infection.
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Disadvantages1.Bulky. 2.Carry hair. 3.Multiple operations
4.Masked facial expression.
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TYPES1.Skin 2.Muscle 3.Omental 4.Fascial 5.Chondral 6.Periostial
7.Mixed
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A skin flap consists of skin and subcutaneous tissue that are
transferred from one part of the body to another with a vascular
pedicle or attachment to the body being maintained for nourishment.
Proper planning of a flap is essential to the success of the
operation. All possible sites and orientations for the flap must be
considered to be certain that the most suitable one is
selected.
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Blood Supply of the skin1.Segmental 2.Anastimosing axial vessels
3.cutaneous vessels A.Musculocutaneous perforators B.Direct
cutaneous vessels
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Classification of skin flapsA. According to vascular anatomy
1.Random flaps 2.Axial flaps a. peninsular b. island c. free
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B. According to mobilization1. Local a. Moved around fixed point
1.rotation 2.Transposition Rhomboid,dufourmental 3.Z plasty 4.
Interpolated b. Advancement 1. single pedicle 2. bipedicle 3. V-Y
plasty
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Advancement Flaps
All advancement flaps are moved directly forward into a defect
without any rotation or lateral movement. Modifications are the
single-pedicle advancement, the V-Y advancement, and the bipedicle
advancement flaps. The single-pedicle advancement flap is a
rectangular or square flap of skin and subcutaneous tissue that is
stretched forward. Advancement is accomplished by taking advantage
of the elasticity of the skin (Fig. 20A) and by excising Burows
triangles lateral to the flap (Fig. 20B). These triangular
excisions help to equalize the length between the sides of the flap
and adjacent wound margins. The V-Y advancement technique has
numerous applications. It is not an advancement in the same sense
as the forward movement of a skin flap just described. Rather, a
V-shaped incision is made in the skin, after which the skin on each
side of the V is advanced and the incision is closed as a Y (Fig.
21). This V-Y technique can be used to lengthen such structures as
the nasal columella, eliminate minor notches of the lip, and, in
certain instances, close the donor site of a skin flap.
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2. Distant FlapsA. Direct B. Indirect carried either by 1.
carrier 2. migration eg.caterpillar
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Delay PhenomenonIt is a method of augmenting the surviving
length of a flap by: 1. increase tolerance to ischemia 2. increase
vessel no. &size
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Requirement for survival1. Size &location 2. presence of
large bl. Vessel 3. delay method 4. absence of arteriosclerosing
changes 5. absence of smoking absence 6. absence of trauma
,infection &radiation.
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Causes of failureA. Intrinsic factors 1.inadequate bl. 2.AV
shunts B. Extrinsic factors 1.infection 2.hypotention 3.compression
4.hematoma 5.smoking
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Monitoring ViabilityA. Clinical test 1.color &temp 2.
capillary refilling 3.dermal bleeding 4.atropin absorption
5.histamin test B. Chemical Flourescin dye injection C.
Instrumental 1.doppler 2.photoplethysmography 3.tissue
PH,PO2,PCO2.
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Measures to improve circulation1. Postural assistance 2. Cooling
0-20`C 3. Leeches Hirudo Medicinalis 4.Dextran 5.Hyperbarric O2
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SKIN CANCERSSkin cancer is the most common ca. in USA. it
account for 1% of all ca. death.Etiology: 1. Radiation 2.Chemical
3.Inherited
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Premalignant Lesions1. Actinic keratosis:20-25% 2. Bowen disease
:intraepidermal SCC 3. Erythroplesia of Querate 4.
Leakoplakia:15-20% 5. Keratoacanthoma :self-limiting SCC 6.
Radiation Dermatitis 7. Xeroderma Pigmentosum
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Basal Cell Ca.. Consist of 65-80% of all Ca. . 85% of them found
on head& neck . It is slowly growing but with massive silent
penetration . It arise from basal layer of epithelium
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TYPES1. Nodular ulcerative 2. Superficial 3. sclerosing(morphea
) Fire Feild 4. Pigmented (fibroma like) Rodent ulcer
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Syndroms with multiple BCC1. Xeroderma Pigmentosum 2. Basal cell
nevus syndrome(Gorlin Syndrome) palmar pits, sensetivity to
light&bone cyst. 3. Bazex Syndrome
(atrophoderma,anhidrosis)
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Treatment1. Surgical depend on many factors 2. curettage&
desiccation 3. cryosurgery 4. radiation 5. dermabrasion &
chemical peel. 6. interferon alpha & 5 flurouracil 7. laser
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Recurrent Basal Cell Carcinoma
Definite clinical signs that alert the physician to the possible
presence of a recurrent skin cancer are as follows. 1Scarring with
intermittent or nonhealing ulceration scar that becomes red,
scaled, or crusted 3. An enlarging scar with increased
telangiectasia in the adjacent area 4. Development of papule or
nodule formation within the scar itself 5. Tissue destruction
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Squamous Cell Ca.. Originate from atypical keratinocytes .
Predisposing factors 1.sun exposure UVB&UVA 2.radiation
3.arsenic 4.immunosupresion 5.HPV 6.tars&polycyclic
hydrocarbons
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TYPES1. Slowly growing (Verrocous ,Exophytic) 2. Rapidly growing
(more nodular &indurated )
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Differential Diagnosis1. Actinic keratosis 2. Keratoacanthoma 3.
Seborrhic keratosis 4. Wart or horn 5. BCC
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Syndromes with SCC1. Xeroderma Pigmentosum 2. Epidermodysplasia
verrusiformis 3. Muirr-Torre syndrome.
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Moh Micrographic Surgery. By fixing the skin with ZnCl .
Advantage 1. preservation of normal tissue . 2. precise delineation
of tumer
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Malignant Melanoma (MM). 2nd killer Ca. in male . Arise from
neural crest derived cells
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Types1. Superficial spreading (50-70%) 2. Nodular melanoma
(10-20%) 3. Amelanotic melanoma . 4. Lentigo Maligna (Hutchison
freckles) .
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Indication of biopsyA. Asymmetry B. Border C. Color D.
Diameter
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Prognostic Factors1. Depth (Clark Level). 2. Thickness (Breslow
level). 3. Ulceration. 4. Type of primary lesion. 5. Satellistosis
6. Site a. Grave AGE b. Poor Border.
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Differential Diagnosis1. Dysplastic nevi 2. Pigmented BCC 3.
Seborrhic keratosis 4. Blue nevi 5. Dermatofibroma 6. pyogenic
granuloma 7. Kaposi sarcoma
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Premalignant pigmented lesions1. Large no. of nevi >100. 2.
Gaint congenital nevus >10cm. 3. Dysplastic nevus
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STAGESStage 1 :localize to skin Stage 2 :spread to regional LN
Stage 3 :2& metastasis to distant skin
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Management1. Surgery 2. ERND elective regional LN dissection 3.
Regional perfusion 4. chemotherapy 5. Interferon alpha 2b
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Embryology.CL :failure of mesenchymal fusion of nasofrontal
&lateral processes at 4-7 weeks . CP : failure of mesenchymal
fusion of 2 palatine processes at 7-12 weeks
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Classification (Stark-Kernahan)A. Cleft of primary palate
.unilateral .bilateral .median for each. complete .incomplete
.microform B. cleft of secondary palate .complete .incomplete
.submucous C. Cleft of primary & secondary palate
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Etiology1. Family history 2. reduction of facial mesenchyme 3.
increase facial width 4. high position of tongue 5. oligohydramnion
6. drugs 7. infection, radiation ,alcohol
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Early consideration1. Feeding 2. airway Peirre-Robin syndrome 3.
middle-ear disease 4.speech consideration 5.teeth problem 6.
psychological 7. associated anomaly
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Time of repairCL Rule of 10 10 weeks 10g Hb 10 pounds(4.5Kg)
10,000 WBC CP 12-14 months
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Aim of Rx1. Normal appearance 2. Aligned teeth 3. swallowing
4.speech 5. hearing
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Pressure sores The terms pressure sore, decubitus ulcer, and
bedsore have been used synonymously to refer to the tissue
ulceration commonly seen in debilitated patients. The term
decubitus comes from the Latin word decumbere, which means to to
lie down. Although this term may be appropriate for patients who
are bedridden, it does not correctly describe the ulcers in
patients who are mobile (i.e., ischial ulcers in wheelchair-bound
patients).
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TABLE 1. Pressure sore staging StageDescriptionStage ISkin
intact but reddened for more than1 hour after relief of
pressureStage IIBlister or other break in dermis infectionStage
IIISubcutaneous destruction into muscle infectionStage
IVInvolvement of bone or joint infection
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Epidemiology In general, approximately 9% of all hospitalized
patients develop pressure sores. The occurrence seen in the acute
care setting is as high as 11%. Commonly cited in all studies was
their association with other medical problems, including
cardiovascular disease (41%), acute neurologic disease (27%), and
orthopedic injury (15%).
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Pathophysiology1. Pressure 2. infection 3. edema
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Preoperative care1. Nutrition. 2. Infection. 3. Releive of
pressure mattress systems are designed to relieve pressure,
including foam, static flotation, alternating air, low-air-loss,
and air fluidized beds. The purpose of these beds is to more evenly
distribute the patients weight to minimize pressure in any one
area. The Clinitron bed is designed with medical-grade optical
beads fluidized with a constant flow of warm air. 4. spasm valium
baclofen dantrolene rhizotomy 5. Contacture
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Surgical Rx1. Debridment 2. ostectomy 3. closure
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complications1. Recurrence 2. Carcinoma. Marjolin ulcer
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