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ESSSxAIM presents: An Operative Approach to Anatomy - Plastic, Reconstructive & Breast Surgery

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Summary

In this teaching session, titled "Plastic, Reconstructive and Breast Surgery", medical professionals are taken through the crucial points of various surgical procedures, with a focus on pathology, anatomy, and surgical management. The session opens up with an introduction regarding the scope of practice in plastic reconstructive surgery, including topics like skin malignancies, burn treatments, skin grafts, and breast reconstruction post mastectomy. An interactive, simulated surgical case, quizzes, and questionnaires are included as part of the training materials. The unpredictable nature of the cases discussed alongside the constructive learning approach ensures that this session engages and immerse medical professionals of all levels.

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Description

👩🏻‍⚕️👨🏽‍⚕️Want to learn more about anatomy and its theatrical (by which we mean surgical) applications, but don’t know where to start? We are pleased to announce the new webinar series, in collaboration with ESSS and AIM: An Operative Approach to Anatomy!

This is the first webinar of eight and will serve as an introduction to the theatre and some of the key anatomy to look out for when observing (or assisting) in Plastic, Reconstructive, and Breast surgery.

Attendees of 6/8 sessions will receive FREE RCSEd student affiliate membership worth £15!

All medical students are welcome, we look forward to seeing you!

* Certificates will be provided to all attendees post-feedback.

Learning objectives

  1. By the end of the session, participants should be able to describe the pathophysiology, clinical features, investigations, and management of plastic, reconstructive, and breast surgery.
  2. Participants will gain an understanding of the varying presentations and types of skin cancers, including basal cell carcinoma, squamous cell carcinoma, and melanoma.
  3. Participants will learn to identify different pathologic images of skin cancers and understand their origins and development from a cellular level.
  4. Attendees will develop competence in applying anatomical knowledge in a clinical setting, such as surgical procedures related to skin malignancies and breast reconstruction following mastectomies.
  5. Participants will be able to apply their understanding of plastic, reconstructive, and breast surgery to simulated surgical cases, thereby demonstrating improvements in their clinical decision-making skills.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

I can see that. Perfect. So, as I said, guys, it's lovely to have you all here and thank you very much for coming along. Um, as you said, we're gonna cover plastic reconstructive and breast surgery. I'm Lutz. Um I've got Kayla and An and Joseph with me. Um, and hopefully we'll take you through some of the main cases that you might encounter or at least some of the interesting ones. Just a little bit of housekeeping. Please do use the chat to ask any questions. I can't see any questions at the moment, but I'm sure someone else will keep me right if something does come up, um, these sessions will be recorded. Um, and we'll put the slides out after as well. So if you do find anything particularly useful, then they'll be available to you after the session. Um Our slides do contain sensitive content. They do contain images from um real life surgeries, all of which are publicly available. So there is nothing that's kind of um, er, not anonymized. Um But we'll give you warnings before these come up. So if you do have maybe a queasy stomach, um, don't worry, we'll give you a heads up. Um, the questionnaire that I've put in, please do fill it out. It's just a short study um that we're doing to conduct how good this teaching approach is. So, hopefully we're gonna try to make it a bit more interactive and see how that compares with kind of more lecture style approaches. Um, a bit of incentive is that if you answer or in kind of the polls and at 10, 6 out of eight sessions and you get free R CSE D um affiliate membership, which is worth a whopping 15 lbs. So definitely worth it. 15 lbs can buy you a lot of other things. Um And please do follow E med all and also a um social media as well. Um To keep an eye out for our future events, a disclaimer, we are doing an SSE five which by nature means with your medical students. So we have strived to include resources from reputable sites. Um But this is pure tutoring. So if there are some mistakes and if a consultant tells you off, um we apologize. We have tried to source our materials um reliably and responsibly. Um and this should be accurate but take it with a pinch of salt. Um None of the media that's shown is owned by us and they should be credited on each slide anywhere where it's not credited. Employees assume that it's been sourced from Complete Anatomy um which is a really good resource that's freely available to at least anyone who's from University of Edinburgh. Um So I definitely recommend it to revise your anatomy even before going to surgery. So hopefully you guys have had a chance to fill out our pools and it seems like you have, which is brilliant. So, what I'll do is I'll get cracking. So our less objectives, um really, in this case, is to kind of reinforce and develop our competence in in anatomy. Um and make sure that when we are in surgery, we get the most out of the experience. The worst thing you can do is turn up and have no idea what you're looking at. So hopefully this series will help mitigate that a little bit. What we're hoping from this kind of um episode of this year specifically is that you'll be a bit more familiar with some of the things and plastics reconstruct around breast surgery, specifically excision of skin malignancies, treatment of burns of skin grafts and also know a bit about breast reconstruction following mastectomies. Hopefully, you'll have a bit of a better understanding then of what plastic surgeons do. Um And given the cases that we're doing, we've tried to include some pathophysiology, anatomy, clinical features, investigations and management, as well as some complications of surgeries that um we're gonna discuss. Ideally, you'll be able to apply this understanding um and justify our choices in surgical management through our choose your own adventure, simulated surgical case um and attendees should be able to apply your understanding of the above um to surgical and anatomy context, MC Qs. So we've got um three Mc Qs at the end and we'll see how we go. And as I say, any questions along the way, please do, just pop them in the chat. It's nice to know a little bit about the specialty. Um, before we kind of crack into these cases. So just to say plastic surgeons do both reconstructive and aesthetic surgeries. Um The majority of NHS work will be reconstructive. So restoring the function and look of affected body parts following trauma or illness. Um But many private cars um or private practices will do lots of aesthetic surgery as well. Generally, plastic surgeons have quite good attention to detail. It kind of makes sense. They have, they're associated with the aesthetic procedures. Um And that also means that they have really good manual dexterity, they do lots of things like microsurgeries and plastics. So that dexterity really does come in handy. It's definitely not a lonely specialty. And I don't think you would describe any surgical specialty as lonely. You work with anesthetists, theater nurses, other surgeons, medical students when they intrude um pharmacists, physiotherapists, and psychologists. So it's really an MDT in terms of the training pathway, it's generally um two years of core training. So, CT one and C two before you do your specialty training, which is um six years. So ST three to ST eight. and you've got some fancy exams throughout the way as well, but generally speaking, it is an eight year training course. Um Before you become a qualified um plastic surgeon, we do, as I say, often associate um plastic surgeons with aesthetic surgery. So, autoplasty liposuction, facelifts, breast reduction, et cetera. Um but they do do lots of really um cool reconstructive surgeries like hand operations, cleft, lip and palate repairs, um head and neck reconstruction, breast reconstruction as we'll talk about today, um skin and soft tissue cancer procedures as well. So, plastics is really a very varied specialty. Now, with all of that in interruption to um kind of said, let's jump into our first case because I assume that's what you're all here for anyway. And our first case will be on skin malignancy. Now, as I said, it will cover a bit of the basics around this, but hopefully focus most of our efforts on the anatomy. There's around 100 and 56,000 cases of non melanoma skin cancer in the UK per annum. So that's things like our basal cells, carcinomas or, or um um squamous cell carcinomas as we'll talk about in a second. Um But it is very frequent and there are lots of risk factors. So your age, the older you get, the more likely you are to have skin cancer, sun exposure, more sun means greater risk. Previous skin cancer is a family history of skin conditions. So things like solar keratosis, um xeroderma, pigmentosum, et cetera. Various skin conditions can expand, can increase your risk if you've been exposed to radiation in the past. Um be that through work or some other method if you've got a weakened immune system. So maybe if you got an HIV infection or you're being treated with chemotherapy or whatever else. HPV. Infection also increases your likelihood to skin cancer and exposure to various chemicals through various medications can also increase your risk. So it is a higher, not a higher risk, but it, it is something that does happen to very many people because obviously age is something none of us can escape. Sun is something we escape quite often in the UK, but generally speaking, not completely. Um So those people will develop skin malignancy. So it's good to be aware. Now, I don't want to go into too much of the background, as I say, but I do think it's important that we're aware of, are aware of the three major types of skin cancer. Now, the first of these is the basal cell carcinoma. So this usually occurs on a sun exposed area. So your neck or your face usually, but it can have very varying appearances. So it might be pearly or waxy bump, it might be quite flat and flesh colored or maybe a kind of a little brown that look like a scar. It might be a bleeding or scabbing sores um that heals and then returns. And all four of these pictures, despite the fact that they all look quite different are examples of basal cell cell carcinoma. So it's worth being aware that they can have quite a varied presentation. Our other type is the squamous cell carcinoma. So again, this very often occurs in a sun exposed area, um like your neck, your face or your hands. Um There's something called Urs solar keratosis that we mentioned before or ect keratosis that people often come in with, that's actually quite benign, but it looks very similar to a squamous cell carcinoma. So um a good one to be aware of people with darker skin are more likely to have an SCC on areas that are less exposed to the sun. So, and also also a good fact, we're not all pale white beings. So um definitely worth being aware of that and it may often appear as a firm red nodule or a flat lesion with a scaly crested surface. And we can see examples of that here. And you can see all of these examples are occurring in patients that are gonna be exclusively stung quite frequently. Now, the final type of um kind of skin cancer I wanted to mention is the melanoma. Now, this most often appears on the face or the trunk of men, but usually in women, it will develop lower down on their legs. It again can have a varied appearance but tends to have um pigment to it. Um, so because melanin and things like that are included, so it can be a large brownish spot, um, spots rather with er, darker speckles, a mole that changes color size or feel it might often bleed as well. It could just be a small lesion that has an irregular border, so it's not nice and round, but it's kind of patchy like this one. So, um, it can be painful so it can be itchy or burning and people often get dark lesions on quite sensitive areas as well. Um So worth being aware of Melanomas too in terms of what this looks like in the skin. Well, it all kind of depends on which cells being affected. So a squamous cell carcinoma is gonna originate from squamous cells which you can see are kind of higher up in the skin. Whereas a basal cell um carcinomas or Melanomas will originate lower down. Basal cell. Carcinomas are, I guess nicer maybe and the fact that they're kind of well defined usually. So they've got this nice round border so you can get rid of them potentially more easily where the squamous cell carcinoma and especially a Melanoma can be a bit more invasive. Um And you can see that they're not quite as nicely um kind of circumscribed, but I won't talk too much about the skin cos someone else will a bit later on. So let's look at our patients So we know what anatomy is important to cover our patient. In this case is Mr Bloggs. He's a 75 year old chap. He's a retired tree surgeon. Um initially complaining of a groin nodule in front of his right ear, it's painful and it started to change color. So you can see in front of his ear, just kind of this patchy, um almost scar like tissue and kind of brown or mole on top. Now, when he went to his GP, his GP referred him to GERM, they took a biopsy and the biopsy confirmed that he had ABCC. So he's been referred to plastics um for surgical excision of this BCC. You are on your placement and the consultant has invited you to watch the most procedure in theater 17. Now you write down this theater number in your scrappy notebook that you keep in your pocket. Um and then you quickly revise your anatomy. So at least when I look at anatomy, there's a few things that I want to cover um kind of in the most detail. Cos it's the things that surgeons will ask you the most. Now, that's the blood, maybe the lymphatics, um it's gonna be the nerves and the musculature as well. It's the favorite question of pretty any sur pretty much any surgeon I've ever met in terms of where we're working, we're working just in front of the ear. So that's the anatomy that we want to cover Now you can see here that the vasculature is pretty extensive. It is your head. So that kind of makes sense. But some of the main kind of vessels we want to um be aware of is the superficial, superficial temporal vein, which we can see is this blue vein here. Hopefully you guys can see my mouse but I'll come up with a pointer. So this vein here in our superficial temporal vein and as you can see any other vein that I then point out is gonna be a branch of this. So our transverse facial vein for us is very important because our lesion is around about here. So we wanna keep that in mind. Um we don't have our middle temporal uh vein again, very important. These are identified drainage for the face and then up the way this is more out of our way. But again, worth knowing about you might be asked, well, what are the branches of the superficial temporal vein? And we here we can see we've got this frontal er tributary of the superficial temporal vein as well as the parietal tributaries as well. So this is our veins and on the arterial side, if we have the superficial temporal vein, it makes sense that we have the superficial temporal artery. And again, that's running alongside here, we have this zygomatic er orbital artery that's again running just alongside our middle temporal vein. So again, this one's gonna be important to us because we're performing surgery here. So we don't want to nick this artery. Then again, we have our branches. So we have the frontal branch going towards the front of the head and of the temporal artery. And then we have a parietal branch as well. And again, this is of the superficial temporal artery. So our mainstay here is the superficial temporal artery and main and its tributaries, we then also have our innervation. So our first nerve is the um auriculotemporal nerve. And again, this is the most important for us because of where we're gonna operate. Um And this is really just gonna convey your general kind of um sense information um from this prior section of your head worth knowing that there's also these um divisions of the facial nerve, not kind of very far away. So you've got your temporal branch, your Zygomatic branch and your superior division of the um the facial nerve as well. Um Now, the superior division of your facial nerve in particular, um which is where your Zygomatic and temporal branch you're gonna branch off of is gonna provide motor innervation to your face. So you definitely don't want to be doing anything funny to this um nerve. And in fact, sometimes in a mo procedure which we'll talk about in just a second, this nerve can become slightly damaged and it can affect the motor function of the face. Um And depending on the damage, um the recovery will obviously be different, but it's worth being aware. Now, finally, we have our musculature. So we have this really big temporalis muscle which um sits more deep to these three muscles that we'll chat about in just a second. Um It's involved in elevating the mandible um and also retracting the mandible at the temporomandibular joint. We've got our um auricularis anterior muscle just over here, um which elevates the auricle. So this is kind of your ear and moves it forward. We've got the um auricularis superior muscle which elevates and retracts the auricle. Um And we've got the temporoparietalis muscle, which is gonna kind of tighten your scalp basically. So, really important for chewing, this is kind of moving your ear about. So, arguably less important, but you still want to keep it intact when you're doing your surgery. And again, the one that might potentially get in our way is the auricular or superior muscle because of where we're doing the surgery. Um But we probably won't go quite so deep with this excision um in our basal cell carcinoma, as we'll see. So hopefully, that's been sort of um coherent and you guys can follow where we are. Um And some of the important structures in the anatomy, please do feel free to ask any questions. Um But whilst you're having a think and trying to keep that in mind, you're gonna rush to theater and you're gonna come to the changing rooms. Now, one of the things that I think people often panic about when they get to theater, especially for the first time is what do I do? Well, I would advise knocking on the door if the pass isn't working, usually there's someone there to let you in and then the first thing that you're gonna have to do is choose your scrubs. What color of scrub do you choose for a surgical, um, placement? Is it green or blue? Hopefully, this should come up in the chat and you guys can pick your color and we always most popular. So if anyone wants to sabotage because they know the right answer. This is your time. But, um, pick the one that you think is right. I'll give it five more seconds. Yeah, fab. Well, it seems like going for a green and that's ideal because the to go. So you grab your, the cap on your way out of the door and you continue to model with beautiful green surgical scrubs down the theater corridor. So good job. But then the next issue is that you panicked on your way down the corridor and actually you don't really remember what the theater number was. So, what was the theater number that the surgeon is expecting you at? Not quite anatomy but an important detail fab. It seems like we're going with 17 and perfect. So you've arrived a teacher, you introduce yourself, um, which is always the best thing to do. And so here is the rest of the team. You've got your consultant surgeon. You're a specialty trainee, you're a registrar, um You're anesthetist, you're theater nurse and your nurse and all of them are absolutely lovely. Um In this case, our trainee unfortunately is gonna be a bit of a villain. He's gonna be a bit grumpy. Um but I promise everyone is usually very, very lovely. You just need to go and introduce yourself. So here is our content warning. Um We are now gonna start looking at some surgical procedures. This first one is quite tame. Um but they will get progressively more um kind of bloody, I guess as we go along. So do be do be warned. Um but we'll warn you before each case. So Mr Bloggs is now in theater. He's regressed in age and suddenly has no gray hairs, but we'll ignore that fact. Um But he's happily chatting to you. Um Whilst the DRS have in place and the surgical site has been sterilized, the anesthetist has administered some local anesthetic meniscus lidocaine and the consultant is just about to start scalpel and hand, they turn to you and they ask, what is the minimum margin of exci excision rather. So what would your guess be? And then we'll 53 that comes up, this will will vary depending on the procedure. So if you're not sure what most procedure is that will affect your answer. Good. So it seems our most popular answer is two. So let's go with that. We'll always pick the most popular choice. So good, good. This is a good margin to start off with as we'll talk through. Um, throughout the process, we'll see that we always start off with quite a small margin. It's unlikely that if we excise, just the visible tumor that we would get all of it out, we would have to go back in and take more out. But if we start with a small margin, it does mean that we're still conserving as much of the healthy tissue as possible. Um And it still makes the wound fairly easy to close afterwards, so we can excise more as needed, but we can't put stuff back in. So always start gently but equally, there's no point in doing just around the tumor to start off with. Hopefully, that makes sense good. So the BCC, at least the visible section here has been excised with a thin margin. So maybe around two millimeters. And the consultant makes sure that when she does excise the um lesion, she maintains the correct orientation. So we can see that on the paper here that anything that was here, oh, who was here is facing up the way on the kind of um little bit of paper that they put the specimen on. And that's really important because we need the orientation to know where there's tumor left. So most procedure is really gold standard and the most effective technique for removing ABCC. Um It harms the healthy tissue very minimally and it achieves very high cure rates. Once we've resected this small section of tissue, we send it off for histology. And what they're gonna do is there gonna look at under the microscope, uh they're gonna stain it with it. And e now, um Eosin is the thing that's gonna stain um the cytoplasm, it's gonna stain that pink color. Whereas the hemolin is gonna stain in the nucleus, a purple color. So anywhere where there is more basal cells, it's gonna look quite purple because basal cells have more nucleus than they do or a higher nucleus to cytoplasm ratio than the other cells surrounding them. So they end up looking quite purple. And so if we've taken our um our kind of little segment of tissue sent it to histology and what we see is actually on the border of the segment that you've taken there is still BCC. Well, we must then take a bigger um kind of bite of that skin, a bigger section of that skin in order to excise that completely. So that's what we see here. We've taken an excision, but actually, we've cut through that basal cell carcinoma, we've not completely taken out. So we know that we have to go back in. Now, the orientation becomes important because we mark it on a sheet here. This sheet tells us that actually this kind of lower um right border and this upper kind of middle, left um border still have BCC. So these sections still need to be excised further. And so that's what the consultant does. The consultant goes back in um and continues the surgery and removes a second layer of skin orientating it and sending it for histology. Whilst we wait, she asks, what nerve is it important to consider when performing surgery in this area? Now, this is not a po but an open ended question. So, can anyone remember the nerve that was really important um for this section of the er scalp? Well, temple, I should say good, very cute and plural. Perfect, very good. So the auriculo um temporal nerve or you could argue the temporal branch um of the facial nerve just because we have come a bit across, at least in this picture. So you can see we're more towards the cheek than we are the ear now. Um And that's because apparently Mister Bloggs keep muta keeps mutating, but we'll, we'll ignore that part. Um Perfect. So really important that we keep in mind um that this nerve exists here. Um especially because we don't wanna cause damage to these nerves. We don't want to alter the sensation or the motor function of someone's head um and kind of facial muscles good. So the second layer um is basal cell carcinoma free. So we know that we have excised this basal cell carcinoma completely. We sent it for histology and it came back fine. So the surgeon hands you the tools to close up and the question becomes, how do you close the wound? Oh V two. Very good. No, that's OK. Lewis, thanks for putting that through. Yeah, V two. So V two is often kind of the trigeminal um distribution as well, isn't it? But yeah, very important to consider. Um trigeminal neuralgia is potentially a complication depending on what section of the um head you're, you're operating on. Um, but really nasty. Um If it does happen, so it's quite rare with the most procedure. Um, but it can happen and it's worth worth keeping your mind. Definitely kids. Um So this is a bit of a long question. So perhaps we'll, we'll talk through it. Um, and I'll give other guys a chance to talk over there any case as well. But the point is that especially in plastic surgery, but really any surgery closing up becomes really, really important. Now, if I've created a circular excision, that's gonna be a pain to close up. So we actually need to extend this um excision to make it more of an a, a kind of eye shape really. And what that means is that this excision starts to go, um, kind of parallel to natural skin creases that exist in your face or your wrinkles. And so when you suture it up, I guess here it still looks a bit puckered and ugly. But as it heals, that scar will heal in line with lines that naturally occur on your face. And so the aesthetics of it will be much better than if I try to pull together um a circular lesion which is gonna pucker the skin quite a lot. You can see you. Well, it's kind of hard to see in this picture but you, they often um pull together in the center of a lesion like this to kind of pull everything together before you stitch the rest of it. And then you could use things like skin glue, which they use quite a lot in plastics. Um and some steri strips as well to go over the top. Perfect. So that's Mister Bloggs. He's now BCC free. Um And given that you're in a large hospital, the plastics list is very varied. So you go to theater list and you see that actually next step is a breast reconstruction. Now, the question is what do you do? But really the only answer because you are a keen, keen medical student is to hit the books and learn about breast reconstruction. So you can answer this poll but it slightly arbitrary because both answers are the same. Um So with that, if there's any questions, then please do ask and I'll try my best to answer them. Um But otherwise I'll give you guys maybe a minute or so to take a break if you wish or grab some water and whilst Kayla swapped me over and start to share her screen. Sorry, I've crashed like three times already. So I just potentially continue sharing the screen. Oh, yeah, of course. I can just let me know when you want to go next. Thumbs up every time I want the next. Wait, let me go on so I can see you and then perfect, I can see you. So give me a thumbs up whenever you wanna go next. Um But in that case, a hand over. Ok. Sorry. Are you, are you sharing the screen right now? Um I should be. Oh no, I stopped showing, didn't I? Sorry, I thought it was my thing crashing. No, no, no, it's me. Worry. There we go. That should be anything. Should I give them a bit longer for a break or is this? Yeah, we'll give them, let's give them another 30 30 seconds. I don't think we're doing too bad for now. Ok. I'll, I'll go for 733. OK. It's 733. All right then. Ok. So, hi everyone. My name is Kayla. And so the next case we'll be covering breast reconstruction. Let me see here. Ok. So the most common indication for breast reconstruction is after a mastectomy, which is the surgical removal of the breast normally for the treatment of breast cancer. Um breast reconstruction can also occur after a wide local excision, also called a lumpectomy or breast conserving surgery. And this involves removal of only part of the breast. For example, if the breast cancer is more localized to one quarter of it, um breast reconstruction may also be used for congenital breast disorders. For example, if there is failure for the areola nipple and or breast tissue to develop. So now I'm going to briefly talk about the different types of breast reconstruction you may encounter with the students and their advantages and disadvantages. So, implant based breast reconstruction is as a stress, the insertion of an implant, this may be a tissue expander or a silicone shell filled with either saline or silicone gel. The advantage is that the procedure is shorter and simpler compared to an autologous breast reconstruction, which we'll talk about next. However, the result is a lot less natural looking and there are complications associated with implant such as rupture infection, rippling of the breast and a small risk of something called breast implant associated anaplastic large cell lymphoma and it's a mouthful. These implants don't last forever and may need to be placed in the future. And so autologous reconstruction uses the patient's own tissue to form the new breast. This may be harvested from the abdomen, the Latin dorsi from the thigh or the buttocks because it's using the patient's own tissue. This results in a much more natural look and will gain or lose weight as the patient does. It also avoids the complications associated with implants. However, the procedure is more time consuming, more complex and the patient will get scarring at the site of the donor tissue. And depending on where the is the tissue is harp from, there may be a difference in skin tone. So lipo modeling can be used to further refine the contour volume and symmetry of the breast following either type of reconstruction. And this just involves transferring fat from, for example, the abdomen or thigh into the breast. So with the a absolute basics of breast reconstruction covered, we can now meet our patient who is Missus Dina Phillips, who's a 57 year old woman who presented with her GP with a painless hard lump on the upper outer right quadrant of her left breast, which she found incidentally on self examination. One week ago, she has a history of hypertension which she's taking amLODIPine for. I know that sounds really, I think Mr Bloggs also had this um and she had uh a liposuction liposuction sorry one year ago, which I promise is relevant. She started her period when she was 10, um went through menopause at 56 and she doesn't have a history of HRT use. Her sister has ovarian cancer and she's also an exsmoker. The GP was rightfully worried about breast cancer and urgently referred her to the breast clinic for a triple assessment where the mammogram revealed microcalcifications in the upper and lower right quadrants of the left breast and the ductal carcinoma was shown on biopsy. After counseling, Missus Phillips and an MDT, they decided early management would be a mastectomy. So let's break down the case a little. Um just briefly, very briefly cover breast cancer. Risk factors include a family history of breast ovarian or prostate cancer because you may be uh thinking about the inheritance of the BRCA one and BRCA two genes. As many breast cancers are sensitive to estrogen, um increased cumulative eastern exposure would therefore increase the risk of breast cancer endogenously. This would be if you started your period earlier and your menopause later as you essentially experience more menstrual cycles and therefore more periods of increased Estrin exogen exogenously. This may be via hormone replacement therapy and oral contraceptives. Now, the mechanism behind excess alcohol isn't too well defined, but this may be related to how it increases the levels of Oester and cigarette smoke is toxic and carcinogenic and would therefore just increase your risk of mostly anything being obese or overweight after menopause is also a risk factor. As estrogen is being produced by the aromatisation of androgens in adverse tissue ie fat instead of being produced by the ovaries. So, therefore, more fat means more androgens, which means more estrogen. So, breast cancer commonly presents with a painless lump in the breast. That's why we always emphasize the importance of self examination. You may see nipple discharge, retraction or an eczema like rash. As you can see on the left side, um picture on the left hand side, which would make you think of mammary Paget's disease, which is another condition associated with breast cancer. At the nipple, you may see dimpling in the skin of the breast, seen in the picture on the right side, assembling in orange skin, there may be a progressive increase in breast size. And if the axillary lymph nodes are involved, there may be a persistent swelling in and around the armpit. So at the breast clinic, uh Missus Phillips would have experienced something for the triple assessment. This involves a thorough history and examination, imaging and pathology. Mammogram is typically used for older women because younger women tend to have denser breasts, as you can see on the left side, these are the breasts of a 45 year old and so you won't be able to pick up the cancer as easily. The one on the right for reference um shows multiple breast cancer indicated by the white spots of micro classifications. Um an ultrasound may be used in younger women and also to differentiate between a solid lump or a cyst. The pathology of fine needle aspirate is typically done on abnormal lymph nodes and a core biopsy on any sort of breast lump. I won't go into too much detail about management either as our primary focus is reconstruction, but management depends on onco typing of the breast cancer and patient factors. For example, if they're pre or post menopausal or whether they have receptors for her two estrogen or progesterone chemotherapy may be done before surgery to shrink the tumor and radiotherapy may be done after the surgery. Um particularly after a wide local excision just to reduce the risk of recurrence. Um whether we remove the entire breast or part of the breast depends on the grading and staging of the cancer ie size and spread and how aggressive it is. The patient may choose to have reconstruction immediately after the surgery or later down the line. But that's honestly just down to the patient preference. Now, returning to the case and returning to Missus Phillips, imagine that she's already had her mastectomy. She was initially unsure about her reconstruction, but after giving it much thought she would like to have one otherwise you wouldn't have a surgical case to talk about. Um So the reconstruction of choice was like flap reconstruction as having the previous liposuction, which I told you would be relevant is a contraindication to um abdominal tissue flap because you would be concerned about that. Uh the liposuction, damaging the amen. And so there would be the risk of ischemia to the flap from reduced perfusion. Now, we'll cover the relevant anatomy needed to vaguely understand bits of the procedure and I'm gonna be throwing a lot of information at you. So please bear with me. Ok. So the latissimus dorsi is part of the superficial muscles of the back which are involved in the movements of the upper limb. It, along with the trapezius are the most superficial of the superficial muscles. You can just feel it on yourself, you touch your back. And so let's take a closer look at the let in the store side, which are now affectionately important to LD. So LD originates from the spinous processes of the T seven to T 12 vertebra, the thoracolumbar fascia, which is that gray triangle at the bottom of the diag crown. Sorry, looks, I don't know if you can get the point. I just point that little gray triangle. Yes, I think I can. Yes. Um also originates from the inferior three ribs. So ribs 9 to 12. Yeah. Yeah. And the iliac crest, which you can also point to that. Ok, which is a key landmark surface anatomy. The LD then inserts into the floor of the intertubercular surface of the humerus. So that could you also point to that. Thank you. I um and its actions are to adopt majorly rotate and extend the arm at the shoulder joint. It's innervated by the thoracodorsal nerve um and receives its blood supply predominantly from the thoracodorsal artery. So the neurovascular should be pretty easy to remember because they've both got the same lens um onto breast. So the breast is made up of mammary glands interconnected with connective tissue stroma and lies on the pectoral fascia, which is the connective tissue associated with the pectoralis major. As you can see on the diagram. The mammary glands are a network of ducts and lobules with each lobule containing a lactiferous duct. Um and they all come together at the nipple. The connective tissue streamer secures the breast to the pectoral fascia and separate and septate the lobules. I don't know that just like point to wherever I'm talking about. Sorry. Um And the breast is so I'll start with innovation. So the breast is innervated by the anterior and lateral cutaneous branches of the 4th, 5th and 6th, intercostal nerves. And regarding blood supply, the medial aspect a little bit closer to the midline is supplied by the internal thoracic artery. Whereas the lateral aspect of the outside of the breast is supplied by the lateral thoracic and thoraco a cranial branches of the ancillary artery. The lateral art, the lateral mammary branches of the posterior intercostal arteries and the mammary branches from the anterior intercostal arteries. Just remember the word mammary because it's probably going to be supplied in the breast. Now, lymphatic drainage is important to consider in understanding the sites of breast cancer nets the majority of the breasts. Lymphatic fluid drains into the axillary nodes which are the five shown in the diagram here. The lateral apical central um posterior and pectoral nodes. If mets are found, they are usually removed by an axillary lymph node. Dissection which is usually at the same time as the mastectomy. Other sites of drainage include the paracel and posterior nodes and with that we head off to see Missus Phillips for her breast reconstruction. As before you're going to be seeing some images you're not used to and you may find as a shock to the system if you're not feeling great, take a break. So before the surgery, the consultant starts marking the patient's skin, she points to one particular line and says, I've marked the anterior border of the the distance store side, what key landmark is directly inferior to it. And now this is just a free text option. So just write in the chat, what you think the answer is and we'll talk through it. Yes, Vanessa. That's right. So it is the iliac print. Um As we went for, this is where the most inferior portion of the LD inserts. So after marking the skin missus Phillips is placed under general anesthesia and put in the right lateral decubitus position, which essentially means she's lying on her, on her right side with her left facing you. So then the consultant will start by dissecting the skin paddle which I've highlighted in white in both of the pictures. On, on the right side. The dissection continues from the skin paddle and securely into the axilla. And for the tenderness, insertion of the vice do site is reached. The consultant asks, where does this tendon insert? I don't know how long we need to get that, let's say, um maybe wait until it hits like 20 responses. That's about half the people here so we can give everyone 30 seconds or so. You seem a bit torn. Yeah, maybe for the sake of time I went in the and I was gonna get ok at four. Ok. So the majority have chosen um intertubercular sulcus of the humerus. That's right. A consultant. Smiles happy with your answer. Perfect. If you think about the size. Oh, sorry, I pop up, disappeared. Sorry. That was me. I'm sorry, I don't think you affected my G drive asking me to sign back in the fine. Um So perfect. If you, if you think about the let us in the store function in the adoption and extension of the arm, it makes sense that everyone's insert in this region. Um Sorry if I didn't make it clear before because I know some people picked the greater tuberosity of the humerus. Um but that's slightly further up closer to the shoulder joint and that's where your rotator cuff muscles kind of insert like your uh infraspinatus infraspinal infraspinatus supraspinatus. I don't even know how to um pronounce it. And the minor I think insert, OK. Now that the superficial dissection of the skin flap is done. A deeper dissection of the LD flap is performed in order to elevate the muscle of the back. So here the flap is tunneled and transposed to the uh material, your chest. So next is the deva denervation of the the dismiss doors. The consultant identifies the nerve noting how the muscle twitches when the man is stimulates, stimulated and cuts it. So, what is the nerve that supplies the Vimal dorsi? Oh, sorry. Those are the free text on. So, so, right in the chat. Correct. Yeah, it is a Thoracodorsal nerve. Yeah. Perfect. Well done. And so it's cut to prevent further muscle activities as patients would be quite disturbed if they find that their breast is just twitching randomly and also reduces. I see nothing that's and also reduces the resting tone of the muscle as it would. Um So it kind of alleviates the sense of tightness that some patients complain about. Now, prior to the flap, tunneling missus Phillips in this mastectomy scar was reopened to allow the flap to be positioned within the breast pocket and held in place with staples and sutures. She is then placed in the supine position. The latissus stores like that must now be sutured to the chest wall. So what is the muscle that underlies the breast? Get back a few seconds. Ok. I think we'll stop there. So the majority of you chose pectoralis major, which is right because again, it is the most superficial muscle on the anterior anti your chest wall. And that would be directly underlying the breast. Ok. And these are the postoperative results. And as you can see a pretty good cosmetic outcome was achieved. So this is just a free text answer. There's no right or wrong answer really or maybe some very wrong answers. But these, um, so as you all know a good deal about the, the customer store side. Now, what complications do you think would arise from an LD flap reconstruction? There are some complications that are just, um, that you would get with any surgery and some sort of more specific to, uh, to the LD flat if, if that helps at all. Ok, I'll give it a few seconds. But if no one wants to volunteer and answer the, I talk at you, ok. Well, some of the complications that would arise may be something called a seroma, which is a fluid collection under the skin where, yeah. Yeah, that's right back pain infection. Yeah. So obviously because you're taking muscle from the back, um, you're gonna be, it's gonna lead to a weakness in that area. Um, it might also lead to a reduced range of motion, um, of the shoulder. And as Gemma said, yeah, you can have a wound site infection. You might also get something called a skin flap necrosis. If the skin flap isn't, you know, well, vascularized, you can get uh altered breast sensation as well. And as I was, as I was saying to before, sorry for distracted a seroma is a fluid collection under the skin where because of the incision you make, there's a bit of a dead space created and the fluid collects there, but it's usually harmless and goes up all the time. Sure, Missus Phillips, is we off to recovery, recovery and ask for what happens to her after? Um Although she was initially unsure about having a reconstruction, she's very, very pleased with her reconstructed breast and is starting to feel like her old self again. She has chosen to undergo further lipo modeling once the reconstruction has healed. So as for you, you see that a burns case is next. So you decide to have a quick trick and a snack while you cram burns management. Do you want to share your screen? And I'll stop sharing. Sure here. Can you see that? Ok. Yeah, we can see that fine. All right, I'll just give you a minute's break before we again. I guess we can start at 56. I don't want to throw off the poles or anything, but we do have some sassy registrar comments if you get it wrong. So if you got it wrong, then don't be deterred because it's more fun that way. Um But you'll see all of those when you get the slide acts anyway. So you've got that to look forward to. I kind of wish I chose the wrong one for the uh um humerous. I know you were always there. II really wanted to show you guys more response. All right. So I guess we can get going to uh I guess the earlier we finish the early you can have a rest. So, hi, I'm er Joseph. And our third and final case today is on burns. So I'm just gonna do a quick introduction to burns to start off with. So in the UK, 100 and 30,000 patients present to the emergency department every year, but burn making it the fourth most common injury. And just upon the facts view, it can take just 10 seconds of skin, ex skin exposure at 60 degree heat for full thick dispense to occur. So it's quite a common thing and it can come on quite quickly and that there are four main types of bins and that's what you might typically know as your family bs. So um your skulls, but like hot liquid and steam a flame if you directly exposed to fire or flash like an indirect, exposed to a flame. And here you can see on the image these are cigarette butts. So these are burns from uh cigarette butts. Um and then you got contact bends, these exposure to our sti sur as a stimulus. So when you're a kid, you might have touched the back of the, of an iron or might have touched something that's really hot. And this image here is supposed to be burned from a hot water bottle. Then you got chemical burns. Um These are usually due to either a strong acid um which um is due to coagulative necrosis where these cells die because the blood flow to the area is stopped. So it doesn't get enough blood and it becomes ischemic or, er, due to a strong alkali, which is due to a different process called liquefactive necrosis, um, where the cells die and turn into this liquidy, uh, fatty of pulp, I guess. And last, but not least we've got electrical burns and these usually have an entering exit wound if you get lightning that usually goes in and then out. Um, and these can cause very significant internal damage and there's a risk of cardiac arrhythmias as well. Um I guess, um, and in terms of the pathophysiology that, that burns. So, around 44 degrees, the proteins in your body start to denature. Um as the protein start to denature, it causes damage to the cells and tissues and it loses that normal er, structure and er, the, the skin loses the ability to do its normal job. Those jobs might include keeping out any bacteria or foreign objects, uh fe regulation, keeping in moisture and water and fluid inside the body. So it's unable to do all those jobs. And if you have a very large burn, then you can have a very significant inflammatory response and lots of inflammatory cells and cytokines causing the capillary to come leaky and you can get quite a lot of tissue, uh swelling and a lot of blood volume muscles as well. Well, fluid loss as well. So, if we move on to our case for today, we've got Missus Williams who is 42. Er, she attended the emergency department after a large burn on her right hand and her forearm after she tripped over and spilled some boiling water from the kettle directly onto her hand. Um, she has a past medical history of type two diabetes. Um, she doesn't take any medications at the moment. So I guess her diabetes is properly managed with, uh, lifestyle. So, uh, diet and exercise, uh, in terms of a social history, she's slightly sleep deprived. Um, and she's got three Children as you are, I guess, uh, um, Children and she has to work at home and she's never smoked or drink. So, um, after seeing your previous surgeries, you can decide to see if there are any interesting cases in the S department and you find Missus Williams in one of the babies who has just been admitted. So, the ed Registrar spots and ask how you approach, assessing this unwell patient or any, er, unwell patient in general. So this is ok, I guess a free text answer. So, is there an approach or a structure you would use to assess any unwell patient? I'll give it 10 seconds or so. And now, uh, yup. Exactly. Right. And ABCD E approach. Um, so the consultant comes back and says, in my opinion, it helps if I have a structured approach, er, to deal with any of my patients that, that miss anything. So, the most common one, that you use in A&E and in most medicine is the ABCD approach. So you don't miss, er, problems, um, such as airway problems, problems with situation and sepsis and it just works the same in burns, um, which we'll find out on the next slide. So in terms of the ABCD approach, uh, a stands for airways, so you Eva evaluate the airways, see if there's any airway obstruction and especially if there's been, um, a fire or something. Uh they might have get a bit of inhalation injury. Uh and um the airway might be obstructed due to that. So, if there is signs of inhalation injury, uh you should really seek urgent uh senior anesthetic review as soon as possible as you might need to intubate. Uh the patient, um BB in this case, test for breathing. Um So in all burns, er, patients would want to miss 100% oxygen by a non rebreed mass, er, no matter what the sacs are um as 100% oxygen helps to speed up that recovery process, er, from the burns. And you also want to obtain ABG and check the carboxyhemoglobin levels if there are concerns of carbon monoxide poisoning, CC stands for circulation. So you would want insert two white bull Cannulas um for cannulation. You want to take ur blood, so you maybe a full blood count your e knees, uh take a grip and say that's uh just in case um the patient needs a blood transfusion uh later on a coagulation screen uh to see if any clotting disorders and creatinine kinase. And you also want to insert a urinary catheter er to monitor their fluid balance. Um as in burns, they can lose a lot of fluid um from the area of skin that's burned and they might need aggressive IV fluid therapy. So it's very important to monitor their fluid balance to make sure they're not going to hypervolemic territory. Uh D uh D stands for disability. Uh So check the temperature G CSI C with O A&E E stands for exposure. So you would assess the er burn severity using a percentage of total body surface area, er burn and depth of the burns. Uh You, they might need a tetanus booster as well. So, er in terms of how you assess the total body surface area bur um there's two main methods at the moment. So in a, as you can see here, it's the rule of nines. So each um body area is 9% but you just add them up depending on which body area is burned. So like head and neck is 9% each arm is 9%. Um But the more accurate method I guess is the uh is this one here? And B this is the little row diagram. So you can see uh each arm is actually split up. So the um the top of the arm is 2%. And then if you go down, it's 1.5% and it's also good because it, it can be a, just, it, depending on the age of the patient as well. And so you just out of the different areas that are being burned to give you a total uh, body surface area burned. Er, and before we move on to looking at burn depth, I think it's very important um, to, um, look at skin anatomy. Um First of all, so, um yes, this top, the skin is made up of three main layers. The epidermis, which is its top layer, the dermis, this middle layer and the hypodermis or the subcutaneous tissue, which is this bottom layer, sorry. So this epidermis. Um so this is to be superficial layer, it's just formed with these layers of keratinocytes. And so let's do keratin and that's what forms like the barrier function of your skin. And then in, in terms of other cells you might find in the epidermis. You've got melanocytes which are responsible for melanin production as well as er langer cells, which are these dendritic cells to use. Um Yes, cells are sensing if there's any foreign bodies or any infections in that area. Um in terms of the dermis, it's this this middle layer, it's formed of various cells. You got fibroblasts, you got mast cells, you got these tiny cutaneous uh blood vessels and nerves in this area. You got hair, hair follicles, you got sebaceous glands which are really sebum, uh the oily um substance. And you also might find some sweat glands as well in the dermis. And then as you move down into the hypodermis here, the subcutaneous tissue, that's your major body store of er fatty tissue, adipose tissue as well as your more bigger er blood vessels as well. So, before we begin, uh there, there'll be a con this is a content warning and we might see some images which um you might, you might not like or might be a bit gruesome. So this is your content one, if you don't feel great, uh just take a break, grab a snack and some water and come back when you feel ready, I guess. All right. So now we are assessing burn depth. So there's four major categories of burns um ranging from superficial to full thickness. So the superficial burns or your first degree burns only affects the epidermis. So that's that top layer of the skin. And these are usually dry, they're red, they're angry looking as you can see here. Um Usually they're painful and usually heal in between 5 to 10 days about scarring. And then as you move down, you move on to your superficial partial burns. These are the second degree burns and these affect the epidermis and the upper part of the dermis. And as you can see here, you're very likely to get blister formations. Um They might be red, they might be wet and they are pretty painful as well and they take a bit longer to heal so they take, er, they heal around within three weeks and then as you move on to the next step of burns, you've got deep partial burns and these affect the epidermis and, er, most of the dermis. And as you go down here they're usually maybe dry, yellow, white and, um, you start to get decreased sensation, I guess as you start to affect those cutaneous er, nerves and these usually heal um, in 3 to 8 weeks and they're likely to scar. And the most serious, er, type of burns is your full thickness burn. So, these third degree burs affect the epidermis, the dermis and the subcutaneous tissue underneath it as well. So, as you can see here, they're dry lea waxy white and as you affects more, they usually get no sensation here and they're pretty, uh painless and they usually have to heal in, um, they take a while to heal. You might need um, further management to help it as well. All right. So after assessing the burn, er, the ed registrar turns to you and us before we look at initial management, we should properly think of potential complications. Er, which of the following do you think are complications of burns? Er, is it hypervolemic shock, hypothermia cellulitis or all of the above? Um, just a note, um, and this picture isn't quite accurate for an acute wound as this picture is, er, two weeks, post healing after, um, a, a wound, I guess. So, I'll give you, uh, 30 seconds, I guess to answer that poll. All right. And it seems like the most popular answer is all of the above, which is correct. So, yes. Um, all the above are complications of burns. Um, so they often hypervolemic because as you think this, uh one of the major functions of the skin is to keep moisture in. So, if you lose that barrier function, um a lot of water might evaporate and that's why people in birds might need aggressive fluid therapy as well to um counteract the hypervolemia. And they say um and the function of the skin is as a barrier against uh bacteria and other foreign bodies. And so they might get infected now and get cellulitis and other complications of burns will include gi side effects. You can get AK I get secondary to the hypervolemia and you also don't forget about the psychosocial impact as well. And some patients might get PTSD, especially if they're um being in a situation with fire and they've been stuck in, er, stuck near fire for quite a long time and the appearance of the skin after the burn, it can be distressing to some patients that might feel depressed about it. So, psychosocial impacts as always in medicine is incredibly important to explore the patient as well. So I guess remember to exer explore the ice um with your patients in terms of further management. Um you would do a little bit of wound management, so you'll er cool the wound with cool tap fossa for 20 minutes and clean the wound with saline and cover loosely with cling film. And as I mentioned before, you would probably need to do uh fluid resuscitation. So you correct any hypervolemic shock and then er the probably need additional flu requirement as well. And um there's this part formula that you can use to calculate this uh additional fluid requirement. So it's four meals times, uh the body weight of the patient and times the percentage of total body surface area burns. So it's, it's usually three meals instead the four meals in Children and the fluid that's usually given is Hartman's solution. So you get 50% of that fluid within the first eight hours and then the other 50% in the remaining 16 hours, er, these burns er, can be quite painful. So you would want adequate analgesia, er, and you would pro er need to refer to a specialist burn service. So you would refer to a specialist burn service if more than 3% of total body surface area burned in adults and more than 2% total body surface area burned in Children and all deep partial or full fitness burns. Same ask you fellow Mr Williams to the fer and the specialist Ben Skin, the surgeon there tells you, they are going to do a quick procedure first before they start the skin graft. They ask you what procedure do you think we are going, er, we are going to do first? Is it ear a debridement or ma surgery? So, example of what's happening is in this picture, they're sort of peeling away the necrotic tissue, um, from the wound. So I'll give you, I guess, 30 seconds again to answer that question before we move on. All right. Um It looks like the most popular answer at the moment is uh debridement, which is exactly correct. So, yeah, uh the consultant smile are not exactly right. Uh So, debridement allows you to remove all the oh Tommy, sorry, quite hard to pronounce. Um What that is is uh if you have a full thickness burn um as it heals as it rehydrates um because it's a very tough Levery tissue er because of the full thickness, but it can cause pressure to build up in that area. And if pressure keeps on building up, it can cause um it can cause ischemia to the area as it starts blood flow to the area and you can get, you can get some sort of compartment syndrome. So in an erect toy, a cut is made in the bone to relieve that pressure and help blood flow to return to that area. And in terms of the other option, may surgery, that was what the first case was about. So that's how you would remove most of your B CCS and your S CCS. So now I'm gonna pass on to a, he will talk through the rest of the one you been. Great. Thank you. Uh Can I check people can hear me? Yeah, we can. Uh Yeah, great. Yeah. Uh My name is Anna. I'm just gonna take over from Joe for the rest of case three. I'm not going to be so kind as everybody else to give you an introduction to my health. So you'll have to answer a question first. Uh As soon as you start to bear, get your bearings, the surgeon finishes debriding the wound and starts taking out some new tools to start the surgical repair. And you're curious to see what the device they're bringing out is, but they interrupt you, you and ask you what are the four stages of cutaneous wound healing? Is it option A or option B option A being hemostasis, inflammation, proliferation, remodeling or option B, primary intention, secondary intention, hemostasis and scarring. I'll let a couple more answer before picking the most popular. No. So yeah, that is a bit of a hint that the second half will be more focused on the reconstruction side and the wound healing. Oh, it's a very tight pole. I'm glad I feel like everybody's got everything right so far. So let me be one more person. Ok. Oh, 5050. Can I ask whoever hasn't voted to maybe be the tiebreaker. It's ok. It doesn't seem that we're gonna have a 21st. Uh, let's just go for option B since everybody's got everything right so far and we'll let the specialty registrar actually come and say something. Oh, there's something never mind. Uh, let's assume you got it wrong. And the specialty registrar chimes in and says you evidently don't grasp the concept of primary and secondary intention. If you think it's one of the stages of wound healing, you need to go find a textbook on this and set up. So you quickly go and learn about it and then it's going to show you the good things which is up to move forward. Yup. So you start learning about wound healing and you're going to quickly learn that there is two types of wound healing that you generally deal with when it comes to surgery and it's primary intention and secondary intention. We'll get to the stages of wound healing in just a second. But it's very important that you grasp these two types first. And mm for both of these, what you're generally focused on is the dermal edges. So in primary intention, the dermal edges, which is just the edges of the skin, you can think of it as the walls of the cut. It's quite neat and it's geometrical so it can nicely close. Uh There's a very good diagram there from teach me surgery that just visualizes it. You can see how in the primary intention it's a clean narrow incision and it can be stitched together or it can just close by itself very cleanly. Whereas in secondary intention, these dermal edges won't fit together again the same way that it was before the injury. So what happens is the wound has to now heal from the bottom up as opposed to sealing itself from the sides. Now, this has some very important practical considerations for surgery because most of us will eventually uh end up being in theater and have the chance to future. And wound closure is very important for the way that the wound will heal. Because if you were to make it too tight, this will make it so that the blood supply is compromised and you'll have poor wound healing. Whereas if you make it too loose, then you, you won't be able to make any use of primary intention or secondary intention because the edges won't align. Can you move on? Great and now to touch on the four stages of wound healing. Now, now that you understand what primary and secondary intention is, it's important to then remember that these are the main four stages. It's hemostasis, inflammation, proliferation and remodeling. And although the general idea stays the same for both primary and secondary intention, there are some slight differences. So I'll go through primary intention first, which is highlighted here in blue for hemostasis and primary intention. It's mainly platelets and cytokines doing the work. It'll cause vasoconstriction. And the purpose of that is to limit any blood loss, any extra blood loss from the wound to the outside. And this will also help to prevent infections as it's going to be the mechanism that scabs the wound over you. This is followed by inflammation which is very important in terms of removing any unwanted stuff from the wound, all of the the dead cells and any pathogens that was introduced when uh you had the wound, either to burn or a cut. This is followed by the most important step potentially, which is proliferation. So, proliferation is where fibroblasts and the granulation tissue forms. And this is what allows for angio angiogenesis to occur, which is the formation of new blood vessels. And through this process of all sorts of new things forming and a new blood, uh new vasculature forming, you'll also be able to close the wound itself and this will be helped along by the f uh the collagen fibers being deposited and the remodeling that occurs in the last stage. Now, in secondary intention, you can follow the same structure. However, in hemostasis, the main thing that's going on is the fibrin mesh. So you need the fibrin mesh in order to just fill up the wound as much as you can, it's not going to be very nicely shaped. So you need something to take up that space. The inflammation is going to be the exact same, but it's just going to be much more intense because there's a larger surface area of, of dead cell of cell debris and potentially pathogens to remove and proliferation is going to be the same except where it goes from the bottom up. As previously mentioned. Once everything has been filled up with from the hemostasis, the fibrin mesh, as well as the granulation tissue. This is where a new epithelia can form over the wound and then it'll be covered. And the last step for secondary intention is where the inflammation comes down and then the whole wound contract. And I'm just going to highlight how important the cell myofibroblasts are in the step because without it, you wouldn't have any good remodeling of a wound that healed by secondary intention. So we'll move on from here that we've understood the basics of wound he healing. The surgeon is asking is about to start cutting off a layer of skin. But before that, they ask you what type of skin graft you think that this patient needs. So there's three options here, you could put in a skin flap, you could put in a full thickness skin graft or you can put in a po a split thickness skin graft and bonus points for anybody who can name the fancy tool that you see on the screen and put it into chat. It's theoretical bonus points. You don't actually win anything, but we will favorably look upon you if your name shows up again. Amazing. It is a dermatol. Great, good job J and good job. I'll wait for some more responses in the poll before continuing in the interest of ending this on a timely manner. I'll move on and go with the most popular answer which is a split thickness skin graft, which is correct. Uh The surgeon is delighted and tell says that is correct. We are using a dermatome to harvest a split thickness graft since we're covering a relatively large surface area. So we'll move on and look at the different types. But before that, let's look at the relevant anatomy. Now, Joe has already done a great job telling you all about skin anatomy and all of the structures inside when it comes to skin graft, the main uh skin anatomy that you need to focus on is understanding the layers and some of the more key structures of the layers and what's in them. So the epidermis is the top layer of the skin, which is not going to come into question a lot of the time in skin grafts because regardless of what type of uh skin graft or skin flap, you use, the epidermis will always come along. But then the dermis is where things change. So in a partial thickness or a split thickness, skin graft, you're only taking a variable amount of the dermis, which is that second layer that you're seeing. The one where the hair follicles are in. However, in a full thickness, skin graft, you take the epidermis as well as the entire thickness of the dermis. So you can already start to visualize the differences because you can tell that in one in a full thickness, you're going to be taking the entire hair follicle along with you. So this may have some implications. However, and with the split thickness, it can be variable depending uh variable thickness, depending on what you set the dermatome to and how thick you want the graft to be. But a key thing to take away from the anatomy is where are the blood vessels? You can see from the diagram that the larger blood vessels supplying the skin are all underneath both of those layers and they sit within the subcutaneous uh layer. So in neither of these grafts, are we actually taking any blood vessels with us? So this is a key key point when it comes to understanding skin graft is that the graft itself has no innate blood supply. It's going to rely on the wound that you put the graft onto to provide its new blood supply and for it to heal through that. Can we move on to the next slide? Thank you. So, understanding that we can now look at the two types of skin grafts in a bit more detail. I'm not going to cover skin flaps in too much detail. That's that can get quite complex in terms of the different types. But these two are the more important things to take away from this. So as I've mentioned, split thickness, skin grafts only contain the epidermis and a variable part of the dermis. Whereas full thickness contains the entire dermis as well as the hair follicles. Now, the good thing about split thickness skin grafts is that it can be used to cover very large defects. It's easy to harvest because you can use special tools like the dermatome, which is a great mention. There's a couple other options. But most of the time nowadays, you'll see the dermatome being used. And this uh putting on this blood thickness, skin graft will allow for rehab at the donor site, which is the formation of a new epithelium, uh the top layer. And as opposed to that with full thickness skin grafts, the main thing to take away from this is that, oh oh sorry, your n it's just a question before. So I thought I would tell OK, skin that is correct. So uh I'm sorry if I cause any confusion in that in terms of tech is, yeah, you're, you are 100% correct of it is not technically either primary or secondary intention. I was just covering the two pro main types of wound healing. And because it's important to understand it for understanding the rest of wound healing and it wasn't the correct answer for the first question. Does that make sense. I'm sorry if I cause any confusion. So I wa I actually wasn't saying that this is a secondary. Uh Yeah, sorry. I hope that makes sense. I think I minced my words a bit there, but I'll keep going with the explanation of full thickness skin graft. So the main thing you do need to take away from understanding full thickness is that since you're I uh putting on a thicker layer, you'll have to make sure that the place that you implant it onto is able to support it. And that means putting it choosing areas that have very good vasculature. Um So this will allow for, for that area to then support the higher energy needs of full thickness grafts. Another thing to keep in mind is that since you're removing so much more uh layers of skin, you will have to close the donation site. S as in which sutures. If you don't have to do this with foot thickness skin graft, it will reep it by itself. And you also can't use a dermatome for full thickness skin grafts, you'll have to use a scalpel and your finger de dexterity. A benefit is that you get better co cosmetics, but you are very limited in where you can take and place full thickness skin grafts because it's difficult to find these areas and you won't be able to cover a large place with it. And also it's going to be limited where Uh Do you have a good enough blood supply? So the key takeaway from this slide is blood supply. Blood supply is incredibly important for skin grafts without it, you won't get ve very far. Let's move on. Yeah, great. Uh So, contraindications for skin grafts, we'll just brief by this. The absolute contraindications are active infection in infection, skin cancer and uncontrolled bleeding. If you have any of these things, you can't really be considered for a skin graft at all before these are first addressed. Now for relative contraindications such as smoking and comorbidities such as poorly controlled type two diabetes and immunosuppression. These will weigh into the discussion of whether you think a skin graft is viable and the reason for this once again comes down to blood supply because as you can imagine, poorly controlled diabetes will affect your microvasculature and it may make it so that uh skin graft failure is more likely. Let's move on. Great. So next question, we've placed the graft on it should adhere and go through the four stages of graft incorporation. Now, of those stages, what's the most important step of? Mm mm uh of these that determine whether the graft has failed or not? Stage one is adherence. Stage two is plasmatic inhibition which is a great word. Stage three is revascularizations and stage four is remodeling of scar tissues. Yeah, it seems like revascularization is the most popular answer. And I would argue that that is correct. Uh it is key, revascularization is key, all steps are important but without blood into the graft tissue, there is no chance of success. I apologize. This is a little bit of a subjective question. But the point of it was to really emphasize the importance of vasculature and giving your graft a good blood supply. Let's go ahead. And the reason for this is because you always have to think about graft failure. So before I talk about graft failure, let's just quickly touch on how graft tape works. So the four steps are adherence, um plasmatic intubation, revascularization, and remodeling. So in adherence, what's basically happening is is being stuck together, you have fibrin bonds that quickly fall in between the two plasmatic inhibition is a fancy way of saying fluid or serum or whatever just moves into the graft. You, everything needs fluid to work in your body. So does the graft? So fluid is gonna have to move from your wound site into the graft. And then this will allow for the vascular network to begin forming. You'll have anastomosis uh between the vessels and this will allow for the graft to survive. Hopefully for remodeling in terms of failure. This is always going to be when you have no blood supply forming. And then the question is why did no blood supply form? It could be a failure and adherence. So it might be a hematoma or a seroma forming under the graft. It could be infection. It could be shooting forces tearing the graft off the wound bed that you put it on, just might not have been able to support it or it could have been a human error. All the things that you have to consider. But the main point here is uh that you always have to be thinking about vasculature and always think about how the graft will contract afterwards as well. So grafts will contract go under primary contraction, which is as soon as you take it off the skin, the skin will recoil and budge into itself that's normal. And that will depend on whether it's uh a split skin graft or a full thickness skin graft. And once you put it onto your donor site and it heals, it's gonna contract again, that secondary contractor once again, it will depend, but it's something to keep in mind for healing. Let's quickly go ahead cause I'm conscious of time. The last thing I'm just gonna touch on is the reconstructive ladder. This is essentially just a framework that you have in the back of your mind in the future. For somebody's come in with a wound, it doesn't seem like it's going to be able to heal if you leave it alone by either primary or secondary intention. So then you need to think about what kind of reconstructive options do I have. And this is just a stepwise ladder that gives you all of the options. So it goes all the way from secondary intention and primary closure, all the way up to the many different kinds of flaps you can put in. Last point, I'll say about flaps since I'm not covering it is skin grafts have no innate vasculature flaps do flaps means that you're taking whatever skin is along with the big vessels underneath that supply it and you're moving it somewhere else. It gets much more complex than this, but that's the main thing you should understand about it. And if you do remember that you'll be in good stead. Let's move on. Great. You've had a long day of seeing three different surgeries. You're feeling tired, hungry and you just decide to call it a day at 5 p.m. You head home, you heat up your premade meal and binge watch Cra's Anatomy before falling into a nice long sleep. Contemplating whether to pursue plastic in the future. Um, Joe, if you don't mind just keeping sharing. So I don't have to reha um, I'm gonna put three really quick M CMC Qs in the chat. I appreciate. We're already slightly over time. So if you guys stay back for like two more minutes, we're almost done. Um, let me just put these in and then I'll finish up. So we got one from each case just to see. Um, if