203: Excisional Surgery and Repair, Flaps, and Grafts Flashcards
(124 cards)
1
Q
What is the primary goal of excisional surgery in dermatology?
A
The primary goal of excisional surgery is to remove the lesion with appropriate margins and leave the least noticeable scar possible.
2
Q
What are the main risks associated with excisional surgery?
A
The main risks include pain and discomfort, bleeding, bruising, hematoma formation, nerve damage, wound infection, wound dehiscence, and undesirable scar or contracture.
3
Q
What are the key elements of dermatologic surgery procedures?
A
Key elements include proper patient selection and preparation, comprehension of risks and necessary precautions, obtaining effective local anesthesia, using sterile or clean technique, informed procedure design, meticulous technique in performing the incision and repair, and diligent postoperative wound care and patient education.
4
Q
What is the purpose of planning the ellipse in excisional surgery?
A
Planning the ellipse involves drawing a circle around the lesion with appropriate margins, which is crucial for ensuring the size of the surgical margin is dependent on the nature of the lesion.
5
Q
How should closures be planned to prevent distortion in excisional surgery?
A
Closures should be planned such that tension vectors are perpendicular to free margins to prevent distortion, which can be aesthetically unacceptable and may impact function.
6
Q
What is the significance of relaxed skin tension lines in excisional surgery?
A
For optimal cosmetic results and maximum scar strength, the long axis of the fusiform excision should be oriented along relaxed skin tension lines, which are generally perpendicular to the direction of the pull of the underlying muscle.
7
Q
What are the major cosmetic units of the face and how do they influence incision placement?
A
The major cosmetic units of the face include the forehead, periorbital area, nose, lips and perioral area, chin, and cheeks. Placing the incision line at the junction of these cosmetic units minimizes the appearance of scars by hiding them in natural transition zones where the eye expects to see a change.
8
Q
What is the optimal length-to-width ratio for a simple ellipse in excisional surgery?
A
The optimal length-to-width ratio for a simple ellipse in excisional surgery is 3.5:1. This ratio helps minimize redundant tissue at the apices, preventing issues such as ‘dog-ears’ or ‘standing tri-cones’.
9
Q
What is the significance of undermining in surgical closure?
A
Undermining increases the mobility of surrounding tissue, aids in wound eversion, decreases tension on wound edges, and helps diffuse scar contraction. It is performed uniformly around all edges of the wound to facilitate closure.
10
Q
What are the risks associated with undermining during excisional surgery?
A
Risks of undermining include damage to structures such as nerves and vessels, vascular compromise for flaps, and the creation of large dead spaces, which increases the chance for hematoma or seroma development.
11
Q
What are the two layers in which most wounds are closed during excisional surgery?
A
Most wounds are closed in two layers: absorbable deep sutures and nonabsorbable superficial sutures. This technique helps reduce and redistribute wound tension while minimizing permanent suture marks on the skin surface.
12
Q
What is the significance of placing the first suture in the center of a wound during closure?
A
Placing the first suture in the center of the wound helps to evenly distribute tension and allows for a more symmetrical closure. Each half of the remaining defect is then closed in a similar manner, which is repeated until a suitable number of sutures have been placed.
13
Q
What are buried vertical-mattress sutures and their benefits in wound closure?
A
Buried vertical-mattress sutures mechanically aid in wound eversion, significantly reducing tension on the wound edge. This technique produces thinner, less noticeable scars and should be used in nearly all closures.
14
Q
How does the timing of suture removal affect the risk of crosshatch marks on the suture line?
A
Removing sutures within a week of placement minimizes the risk of crosshatch marks across the suture line, as it prevents the formation of epithelial suture tracks.
15
Q
What is the purpose of using subcutaneous sutures in wound closure?
A
Subcutaneous sutures help minimize or eliminate dead space and align deep structures such as skeletal muscle or fascia, anchoring overlying tissue to underlying fixed structures to maintain proper contour and function.
16
Q
What is the clinical significance of using running subcuticular sutures for well-approximated wounds?
A
Running subcuticular sutures prevent the formation of suture tracks and are recommended for wounds that require sutures to be left in for more than 7 days, promoting better cosmetic outcomes.
17
Q
What is a Burow’s triangle and its role in surgical repair?
A
A Burow’s triangle is a technique used to repair redundant standing cones of tissue by removing an additional triangle of tissue at the tip, resulting in a linear extension of the scar and improved aesthetic outcomes.
18
Q
What is the disadvantage of using a curved ellipse in surgical excision?
A
A disadvantage is that notching or a gap can develop in the center of the defect where the two triangles peak.
19
Q
What is the purpose of S-plasty in surgical procedures?
A
S-plasty is useful on convex surfaces such as extremities, as it displaces tension over a greater length and variety of angles, preventing contracting in one direction and resulting in indentation over a convex surface.
20
Q
How does M-plasty help in scar management?
A
M-plasty allows the length of a scar to be shortened by excising redundant tissue inward, forming an M-shaped scar, which can be camouflaged in areas where rhytides bifurcate.
21
Q
What is the main characteristic of partial closure in surgical excision?
A
Partial closure is used when extensive repairs are limited by local tissue reservoirs or the patient’s health, closing the wound from the ends toward the center and allowing the area to heal by second intention if tension prevents further closure.
22
Q
What is the purpose of serial excision in surgical procedures?
A
Serial excision is used when the length of an ellipse required to excise a lesion is too long for an acceptable cosmetic outcome, allowing for staged excisions to minimize the length of the final scar.
23
Q
What are the indications for excision without closure?
A
Excision without closure is indicated for wounds that are poor surgical risks for reconstructive surgery, have minimal tissue mobility, a high risk of infection, or when the patient requests minimal downtime.
24
Q
What is the role of contraction in wound healing during excision without closure?
A
Contraction contributes 50% to 70% of the final wound closure, with scar tissue filling out the remaining wound, leading to a better cosmetic outcome if managed properly.
25
What are local skin flaps and their significance in surgical repair?
Local skin flaps are portions of full-thickness skin and subcutaneous tissue transferred from an adjacent donor site into the surgical defect, maintaining their blood supply via a vascular pedicle connected to the donor site.
26
How are axial pattern flaps different from random pattern flaps?
Axial pattern flaps depend on a named artery for their blood supply, while random pattern flaps are supported by small arterioles and capillaries of the subdermal vascular plexus found in the mid-to-superficial fat.
27
What is the primary movement involved in advancement flaps?
The primary movement in advancement flaps is one-dimensional sliding of tissue directly into a defect.
28
How does vascular perfusion pressure affect flap survival?
The greater the perfusion pressure in the flap pedicle, the longer the flap can be without undergoing necrosis. Additionally, a higher perfusion pressure allows for a narrower pedicle.
29
What are the two movements involved in repairing a defect with a flap?
1. Primary movement - action of placing the flap into the defect.
2. Secondary movement - from tissue in the donor area, which closes the secondary defect and facilitates primary flap movement.
30
What is the significance of the thickness of the flap in relation to the wound edge?
The thickness of the flap should be uniform and should approximate the thickness of the wound edge. The area around the flap should be widely undermined to ensure proper healing.
31
What is a U-plasty in the context of advancement flaps?
U-plasty is the simplest example of a pure advancement flap, involving double, parallel incisions made tangential to a round defect. The flap is undermined, advanced into the defect, and secured with sutures, creating a U-shaped scar.
32
What is the advantage of using advancement flaps in surgical repair?
The advantage of using advancement flaps is the displacement of closure lines into more cosmetically acceptable locations, which helps improve the aesthetic outcome of the surgery.
33
What is the role of cheek advancement flaps in surgical repair?
Cheek advancement flaps are used to repair medium- to large defects of the medial cheek and/or lateral nose, allowing for better aesthetic results by advancing tissue into the nasofacial sulcus.
34
What type of flap is appropriate for a defect on the cheek requiring a flap?
A cheek advancement flap is appropriate for medium-to-large defects of the medial cheek and/or lateral nose. It allows for the cheek to advance into the nasofacial sulcus, maintaining natural contours and minimizing tension.
35
What flap technique should be used for a defect on the cheek that avoids crossing cosmetic unit junctions?
A cheek advancement flap is appropriate. It allows for the cheek to advance into the nasofacial sulcus, maintaining natural contours and avoiding crossing cosmetic unit junctions.
36
What is the purpose of the helical rim advancement flap in surgical repair?
The helical rim advancement flap is used to repair defects of the helix by utilizing the tissue laxity of the lobule. It is created with a through-and-through incision inferior to the defect along the scaphoid fossa, allowing for a narrow pedicle to be advanced.
37
What is an H-plasty and where is it typically used?
An H-plasty involves making two sets of parallel incisions symmetrically on both edges of a defect. It is essentially a bilateral U-plasty and is used on the forehead, eyebrow, glabella, and upper lip to hide incision lines along relaxed skin tension lines and cosmetic unit junctions.
38
How does the crescentic advancement flap help in surgical repairs?
The crescentic advancement flap utilizes the removal of a small crescent of tissue to better hide the scar line or increase the length of the line to prevent distortion. It is particularly useful for repairing upper lip and perialar defects, allowing for a more aesthetically pleasing outcome by placing the superior scar line in the perinasal sulcus.
39
What are the key characteristics of the V-TO-Y flap?
The V-TO-Y flap is a variation of an advancement flap that maintains its blood supply through a subcutaneous tissue pedicle after severing connections to the epidermis and dermis. It is designed within cosmetic units, optimal for incision lines to run along cosmetic junctions, and is used in nasal and perioral closures to minimize distortion.
40
What flap technique could be used for a defect on the nasal tip with insufficient laxity for closure?
A musculocutaneous island pedicle flap can be used. It involves creating a muscular sling by releasing the muscular flap horizontally at the superior and inferior edges to advance the flap into place.
41
What flap modification could be used for a defect on the upper lip to minimize distortion of the vermilion border?
A crescenteric advancement flap can be used. Removing a crescent along the vermilion border increases the flap length and minimizes horizontal tension, reducing distortion of the lip and modiolus.
42
What flap technique should be used for a defect on the forehead to hide incision lines?
An H-plasty, or bilateral U-plasty, is suitable for the forehead. It hides incision lines along relaxed skin tension lines and cosmetic unit junctions.
43
What flap technique could be used for a defect on the nasal tip while avoiding upward tension?
A musculocutaneous island pedicle flap can be used. It involves creating a muscular sling by releasing the muscular flap horizontally at the superior and inferior edges to advance the flap into place.
44
What flap modification can be used to minimize distortion of the vermilion border on the upper lip?
A crescenteric advancement flap can be used. Removing a crescent along the vermilion border increases the flap length and minimizes horizontal tension, reducing distortion of the lip and modiolus.
45
What flap technique should be used to hide incision lines on the forehead?
An H-plasty, or bilateral U-plasty, is suitable for the forehead. It hides incision lines along relaxed skin tension lines and cosmetic unit junctions.
46
What flap technique can be used for a defect on the nasal tip to avoid upward tension?
A musculocutaneous island pedicle flap can be used. It involves creating a muscular sling by releasing the muscular flap horizontally at the superior and inferior edges to advance the flap into place.
47
What is the purpose of the East-West flap in nasal reconstruction?
The East-West flap is used for small to medium-sized defects (up to 1.5 cm) of the lateral nasal supratip. It allows for easy lateral sliding movement and closure, permitting reconstruction without significant nasal distortion or excess tension, and provides an excellent tissue match.
48
What are the key characteristics of the Rintala flap?
The Rintala flap is a superior based advancement flap for large defects on the nasal dorsum. It involves elevating a rectangular flap from the nasal dorsum and glabella in the supraperiosteal plane and advancing it downward to cover the defect. Thorough undermining must be performed to avoid nasal tip elevation.
49
How does the design of a traditional rotation flap facilitate closure of defects?
The traditional rotation flap uses a curvilinear incision along an arc adjacent to the primary defect. It recruits adjacent lax tissue while redirecting closure tension in multiple directions away from the primary defect, allowing for minimal tension on the flap's tip and decreasing the width of the secondary defect.
50
What is the significance of the arc length in a rotation flap?
The ideal arc of a rotation flap extends up to 5 times the width of the defect and makes up approximately one-quarter of the circumference of a circle. This design helps to ensure a large vascular pedicle, reducing the risk of tissue necrosis.
51
What is the Dorsal Nasal Rotation Flap used for?
The Dorsal Nasal Rotation Flap, also known as the Rieger flap, is employed to repair nasal defects involving the distal dorsum or tip. It utilizes the tissue reservoir of the nasal root and glabella to allow movement of the dorsal nasal skin superior to the defect.
52
What are the potential complications associated with the Periocular Rotation Flap?
Defects of the lower eyelid and infraorbital cheek are at high risk for ectropion. To prevent this complication, the tension must be parallel to the lid margin. Flaps like the Mustarde and modified Tenzel flaps can help prevent ectropion.
53
What is the role of the Mustarde flap in periocular reconstruction?
The Mustarde flap is used for larger defects on the lower lid/periorbital cheek. It extends laterally from the defect, arches superiorly to the lateral canthus and temple, and ends in the preauricular area. It is undermined extensively and transposed over the defect to help prevent ectropion.
54
Which flap is the superior based advancement flap for large defects on the nasal dorsum?
The flap used for large defects on the nasal dorsum is the forehead flap.
55
Which flap is used for small to medium-sized defects (up to 1.5 cm) of the lateral nasal supratip?
The flap used for small to medium-sized defects of the lateral nasal supratip is the lateral nasal flap.
56
Which flap is considered a variation of an advancement flap that has had all of its connections to the epidermis and dermis severed?
This flap is known as a subcutaneous flap or pedicled flap.
57
What technique is used to increase mobility of the surrounding tissue and decrease tension on the wound edges?
The technique used is known as tension relieving techniques or wound mobilization techniques.
58
What are the major cosmetic units of the face?
The major cosmetic units of the face include the forehead, eyes, cheeks, nose, and mouth.
59
What is the primary function of a transposition flap in surgical procedures?
The primary function of a transposition flap is to **redistribute and redirect tension**. This is particularly useful in closing defects that would otherwise close under high tension or distort nearby anatomical structures, leading to functional or aesthetic impairment.
60
What are the advantages of using a rhombic flap in cutaneous surgery?
Advantages of using a rhombic flap include:
1. **Tension Redirection**: It creates a secondary defect that redirects the tension vector by 90°.
2. **Minimal Wound Edge Tension**: It can be closed under almost no wound edge tension.
3. **Tension Sharing**: Subsequent modifications allow for more tension sharing between primary and secondary defects, making it useful in areas with some laxity.
61
How does the design of a rhombic flap help in minimizing the arc through which the flap must rotate?
Designing the rhombic flap off the short axis of the defect helps to:
1. **Keep the flap small**: This allows for a more compact design while still filling the defect completely.
2. **Minimize rotation arc**: It reduces the arc through which the flap must rotate to fit into the defect, facilitating easier closure and better cosmetic outcomes.
62
What are the types of transposition flaps mentioned in the content?
The types of transposition flaps mentioned include:
- **Rhombic flaps**: Most common in cutaneous surgery.
- **Bilobed flaps**: Used for specific defect types.
- **Banner flaps**: Such as the nasolabial flap, which utilizes adjacent skin for better color and textural match.
63
What is a key disadvantage of transposition flaps in surgical applications?
A key disadvantage of transposition flaps is the **difficulty in completely placing the flap along a relaxed skin tension line or cosmetic unit junction**, which can affect the aesthetic outcome of the surgery.
64
A patient presents with a small partial-thickness defect on the nasal ala. Which flap would be most effective for reconstruction, and why?
The spiral flap would be most effective because it is a modified rotation flap with a 180° arc, specifically designed for small to medium-sized partial-thickness defects of the nasal ala and inferior nasal sidewall. It avoids shortening of the nasal ala and reduces the risk of alar distortion.
65
What are the benefits of using a spiral flap for nasal reconstruction?
The spiral flap is effective for reconstructing small to medium-sized partial-thickness defects of the nasal ala and inferior nasal sidewall. It avoids shortening of the nasal ala and reduces the risk of alar distortion.
66
What are the two main tension forces associated with the classic rhombic flap?
1. The first set of tension forces occurs during the approximation and closure of the secondary defect.
2. The second set of tension forces is generated at the tip of the flap when moving it into the primary defect, influenced by resistance to rotation and shortening of the flap's length.
67
What is the significance of the distal tip angle in the 30°-Angle Webster Flap?
The distal tip angle is designed to be 30°, which gives the flap a slimmer design and narrower pedicle, allowing for better tension sharing between primary and secondary defects.
68
How does the DuFourmentel flap differ from the classic rhombic flap?
The DuFourmentel flap utilizes a narrower flap tip angle and a shorter arc of rotation, allowing easier closure of the secondary defect. It bisects the angle formed by the first line of the classic rhombic flap and extends from the short axis of the rhombic defect.
69
What are the clinical applications of the Banner flap?
The Banner flap is commonly used for repairing defects of the nasal ala or from the pre- or postauricular area to close defects on the ear. It is designed to provide optimal cosmetic results by placing the scar at the junction of two cosmetic units.
70
What precautions should be taken when securing a flap into the recipient site under high tension?
Securing the flap under high tension is not advised as it may lead to tip ischemia and necrosis. It is important to minimize shortening of the flap and subsequent tension at the flap tip by lengthening both the leading edge and the secondary limb of the flap.
71
What are the two main tension forces associated with the classic rhombic flap, and how can they be minimized?
The two main tension forces are: (1) during the approximation and closure of the secondary defect, and (2) at the tip of the flap when moving it into the primary defect. These can be minimized by lengthening both the leading edge and the secondary limb of the flap or designing the flap with a slightly more obtuse angle (greater than 120°).
72
A patient has a defect near the eyelid with insufficient laxity in the surrounding area. Which flap design is most appropriate, and why?
The 30°-Angle Webster Flap is most appropriate because it utilizes a more acute angle, allowing greater tension sharing between the primary and secondary defects. It is particularly useful for defects near free margins like the eyelids.
73
What is the primary purpose of the bilobed flap in surgical repair?
The bilobed flap is designed to fill a defect with the primary lobe while the secondary lobe fills the secondary defect, leaving a triangle-shaped tertiary defect to be closed primarily. It redirects the principal tension vector and takes advantage of tissue laxity of the donor site.
74
How does the trilobe flap differ from the bilobed flap in terms of tissue utilization?
The trilobe flap is similar to the bilobed flap but is able to use tissue that is further from the primary defect. The primary lobe should be equal to the defect diameter, while the secondary and tertiary lobes are smaller, making it useful for defects on the distal tip of the nose and nasal ala.
75
What are the key characteristics of Z-plasty in scar revision?
Z-plasty involves a transposition flap that improves the functional and cosmetic appearance of a scar by realigning it. The classic Z-plasty includes 60° angles, lengthening the scar by 75%, and consists of two incisions of equal lengths and one central incision, forming triangular flaps to redirect the tension vector.
76
What is the significance of the vascular pedicle in interpolation flaps?
The vascular pedicle in interpolation flaps is crucial as it allows for the transfer of tissue from a distant site to the defect. It must remain temporarily attached to ensure adequate blood supply during the initial healing phase before being divided in a subsequent stage of the procedure.
77
What is the primary use of the paramedian forehead flap in surgical procedures?
The paramedian forehead flap is primarily used to repair large, deep nasal defects that may or may not require cartilage grafts. It involves mobilizing tissue from the forehead based on the supratrochlear arteries to repair large distal defects.
78
What are the advantages of using a bilobed flap for small defects on the lower nose?
The bilobed flap redirects the principal tension vector and takes advantage of tissue laxity at the donor site. It is particularly useful for small to medium-sized defects of the lower nose as it redirects tension to a near-vertical vector, preventing distortion of the alar rim.
79
What is the purpose of the Nasolabial Interpolation Flap?
The Nasolabial Interpolation Flap is used to repair complex defects of the ala, particularly when cartilage grafting is also required to restore the structural integrity of the alar rim. It is harvested from the medial cheek and nasolabial fold, based on branches of the angular artery.
80
What are the key steps involved in the second stage of the Supratrochlear artery flap procedure?
1. Takes place 3 weeks after the initial procedure.
2. The pedicle is separated from the brow.
3. The wound edges are freshened.
4. The donor defect is closed.
5. The tissue is further debulked and trimmed, and the remaining edge is secured.
81
What is the Abbé Flap and its primary use?
The Abbé Flap, also known as the lip-switch flap, is reserved for the repair of large, deep defects, typically of the upper lip. It is useful for defects that involve up to half of the lip without crossing the midline and those that penetrate into the muscularis.
82
How does the design of the Nasolabial Interpolation Flap improve aesthetics when repairing defects?
The aesthetics of the repair are often improved when the defect is enlarged to include the entire alar lobule. The flap is designed around a pedicle that will be placed at the alar groove, extending as an ellipse that will be easily closed in the nasolabial fold.
83
What is the significance of the pedicle in the Supratrochlear artery flap procedure?
The pedicle is crucial as it supplies blood to the flap. It should be circumferentially wrapped with Vaseline or Xeroform gauze or Surgicel to prevent desiccation, and it is separated from the brow in the second stage of the procedure to allow for closure of the donor site.
84
A patient requires a flap for a large, deep nasal defect. Which flap is recommended, and what artery is it based on?
The paramedian forehead flap is recommended for large, deep nasal defects. It is based on the supratrochlear artery, which is located at the medial border of the eyebrow, approximately 1.5 to 2 cm from the midline.
85
What are the key considerations when designing a nasolabial interpolation flap for alar defects?
The flap should be harvested from the medial cheek and nasolabial fold, based on branches of the angular artery. The defect may be enlarged to include the entire alar lobule for better aesthetics. The flap must account for through-and-through nasal defects, including mucosal repair.
86
What is the purpose of the flap in surgical procedures?
The flap is designed to be full-thickness to fill the enlarged defect and is rotated upon a vascular pedicle that makes up the lateral aspect of the flap.
87
What are the three basic types of skin grafts?
The three basic types of skin grafts are:
1. **Full-thickness skin grafts (FTSG)** - consist of epidermis with full-thickness dermis and preserved adnexa.
2. **Split-thickness skin grafts (STSG)** - consist of epidermis with partial thickness dermis with loss of adnexa.
3. **Composite grafts** - are full-thickness skin grafts with cartilage attached to the graft.
88
What is the significance of the revascularization stage in graft healing?
During the revascularization stage, which occurs 4 to 7 days after grafting, there is growth and proliferation of vessels from the base. This is crucial as blood and lymphatic flow begin, leading to the reestablishment of full circulation, which is essential for graft survival.
89
What are the potential complications that can affect graft healing?
Potential complications that can affect graft healing include:
- **Mechanical shear forces**
- **Hematoma**
- **Seroma**
- **Infection**
These factors may prevent essential vascular growth and increase the rate of graft failure.
90
What is the role of autografts in dermatology?
Autografts, which are skin grafts taken from the donor site of the same individual, are most commonly used in dermatology for reconstructive purposes, as they provide the best compatibility and healing outcomes.
91
How does the Abbé flap address large upper lip defects, and what artery is it based on?
The Abbé flap, also known as the lip-switch flap, is harvested from the ipsilateral lower lip and is based on the inferior labial artery. It is rotated superiorly to fill large, deep defects of the upper lip, aligning the vermillion borders carefully.
92
What are the three basic types of skin grafts, and how do they differ?
The three basic types are: (1) Full-thickness skin grafts (FTSGs) include epidermis and full-thickness dermis with adnexa; (2) Split-thickness skin grafts (STSGs) include epidermis and partial-thickness dermis without adnexa; (3) Composite grafts are FTSGs with cartilage attached.
93
What are the stages of wound healing in grafts, and what occurs during each stage?
The stages are: (1) Plasma imbibition (first 24 hours): graft affixes to the recipient bed via fibrinous material; (2) Inosculation (48-72 hours): anastomosis and proliferation of vessels; (3) Revascularization (4-7 days): growth of vessels and reestablishment of circulation; (4) Reinnervation (2 weeks to 1 year): sensory reinnervation occurs.
94
What are the advantages of using Full Thickness Skin Grafts (FTSGs) over Split Thickness Skin Grafts (STSGs)?
FTSGs are preferred because they have a similar thickness and texture to surrounding skin, leading to better aesthetic outcomes. They also have a relative lack of significant wound contraction compared to STSGs, which often result in depressed, hypopigmented scars without normal epidermal texture. FTSGs are reserved for smaller defects that cannot be covered with STSGs.
95
What factors should be considered when determining a donor site for Full Thickness Skin Grafts?
The donor site should match the defect in terms of:
1. **Thickness**: Thin (eyelids), medium (preauricular), or thick (supraclavicular).
2. **Texture**: Similarity to surrounding skin.
3. **Sun Exposure**: Similar exposure to ensure healing.
4. **Adnexal Structures**: Presence of sebaceous glands and hair follicles.
Common donor sites include preauricular, nasolabial fold, and conchal bowl skin.
96
What is the importance of harvesting technique in Full Thickness Skin Grafts?
The harvesting technique is critical for graft survival. It involves:
1. **Creating a Template**: To ascertain the size and shape needed for the defect.
2. **Oversizing the Graft**: Recommended to be 10-20% larger to accommodate contraction.
3. **Defatting the Graft**: Trimming away yellow fat to expose shiny white dermis is essential for ensuring a good match to the recipient site.
4. **Suturing Technique**: Proper insertion and placement of sutures minimize graft movement and ensure good contact with the recipient bed.
97
What are the signs of graft viability and necrosis after a Full Thickness Skin Graft procedure?
Signs of graft viability include:
- **Pink Color**: Indicates healthy graft.
- **Purple Color**: Suggests relative hypoxia, but many will survive.
Signs of necrosis include:
- **White Color**: Indicates maceration; if full thickness, it may represent necrosis.
- **Black Color**: Indicates necrosis; gentle wound care without debridement is recommended for necrotic grafts.
98
What are the advantages of full-thickness skin grafts (FTSGs) over split-thickness skin grafts (STSGs)?
FTSGs are preferred for their similarity in thickness and texture to surrounding skin, lack of significant wound contraction, and better aesthetic reconstruction. STSGs are reserved for larger wounds and result in a depressed, hypopigmented scar.
99
How should a donor site for a full-thickness skin graft (FTSG) be selected?
The donor site should match the defect in terms of thickness, texture, sun exposure, and adnexal structures. Common sites include preauricular, postauricular, nasolabial fold, and forehead skin.
100
What is the purpose of a necrotic graft in wound healing?
The necrotic graft acts as a biologic wound dressing, promoting dermal healing and generally avoiding contraction. Antibiotics should also be started to minimize the risk of infection.
101
What are the characteristics of Burrow's/Regional Graft?
Burrow's/Regional Graft utilizes the Burow's triangle or dog-ear technique, often from a partial linear closure, to act as a Full Thickness Skin Graft (FTSG). It eliminates the need for removing tissue from a separate donor site and generally provides excellent tissue match. The design must resemble a V-to-Y advancement flap for larger surface area coverage.
102
What are the advantages and disadvantages of Split Thickness Skin Grafts (STSGs)?
Advantages of STSGs include increased survivability due to less rigorous vascular support requirements, ability to cover large defects, and better wound bed surveillance. Disadvantages include appearance more like scar tissue, being depressed and hypopigmented, suboptimal cosmetic outcome with absent appendages, and frequent wound contracture.
103
What is the significance of meshing in Split Thickness Skin Grafts?
Meshing expands the donor tissue, allows wound exudate to drain preventing seroma and hematoma formation, and has been found to increase graft survival. However, it is associated with increased wound contraction and decreased cosmesis.
104
What are Punch and Pinch Grafts used for?
Punch and Pinch Grafts are useful for accelerating the healing phase of a chronic ulcer. They involve harvesting several grafts from a donor site and placing them in the wound bed, with a good survival rate if meticulous postoperative care is provided.
105
What are Composite Grafts and their key considerations?
Composite Grafts consist of one or more adjacent tissues, often involving a Full Thickness Skin Graft (FTSG) with underlying cartilage. Key considerations include: they should remain less than 2 cm² to ensure sufficient nutrient supply, they have the highest metabolic demand and therefore the highest rate of failure, and oral antibiotics are recommended due to the high bacterial load in the area.
106
What is the purpose of meshing a split-thickness skin graft (STSG), and what are its drawbacks?
Meshing expands the donor tissue, allows wound exudate to drain, and increases graft survival. However, it is associated with increased wound contraction and decreased cosmesis.
107
What are the advantages and disadvantages of split-thickness skin grafts (STSGs)?
Advantages: STSGs survive in poorly vascularized locations, allow early tumor recurrence detection, and reepithelialize rapidly. Disadvantages: They lack appendages, have poor color match, and result in frequent wound contracture.
108
What are composite grafts, and where are they commonly used?
Composite grafts consist of full-thickness skin with underlying cartilage. They are commonly used for small defects of the nasal ala and helical rim.
109
What are the main types of skin substitutes used in dermatologic surgery?
The main types of skin substitutes are: 1. Epidermal 2. Dermal 3. Composite (combination of epidermal and dermal). They can be further categorized as autologous, allogenic, or xenogenic.
110
What is the importance of meticulous postoperative care after excisional surgery?
Meticulous postoperative care is crucial to ensure optimal outcomes, including limiting postoperative bleeding, applying a pressure dressing for 24 to 48 hours to minimize bleeding and promote healing, and keeping the wound clean, moist, and covered until suture removal to prevent complications.
111
What are the early complications associated with dermatologic surgery?
Early complications of dermatologic surgery include: Bleeding, which occurs in the first 24 hours and must be addressed promptly; Pain, commonly experienced post-surgery; Infection, with signs including increased pain, erythema, heat, purulent drainage, and fever. Prompt intervention is necessary to manage these complications effectively.
112
What are the characteristics of dermal allogenic skin substitutes?
Dermal allogenic skin substitutes are characterized by being developed from cadaver skin or neonatal foreskin-harvested allogenic fibroblasts, helpful in replacing the dermis in a defect, minimizing wound contraction, and can be covered by a split-thickness skin graft (STSG). They are used for treatment of full-thickness non-healing ulcers and chronic wounds.
113
What is the role of cartilage grafts in reconstructive surgery?
Cartilage grafts provide structural support to prevent nasal valving and maintain facial contours, are harvested from areas like the ear or nose, with elastic cartilage being preferred for recontouring, and are placed under flaps to ensure proper healing and integration with surrounding tissues.
114
What are free cartilage grafts, and what is their primary function?
Free cartilage grafts consist of cartilage and perichondrium, used to reconstruct defects on free margins like the nasal tip and ear. They provide structural support and retain natural facial contours.
115
What are the three main types of skin substitutes, and how are they categorized?
The three types are: (1) Epidermal, (2) Dermal, and (3) Composite (epidermal and dermal). They are further categorized as autologous, allogenic, or xenogenic.
116
What are the key steps in postoperative care for skin grafts and flaps?
Postoperative care includes meticulous wound cleaning, application of pressure dressings for 24-48 hours, use of bland ointments, and limiting activity for 1-2 weeks. Signs of infection or hemorrhage should be monitored.
117
What are the common causes of scarring in surgical patients?
Common causes of scarring include: Hypertrophic scars that tend to flatten and soften over time; Administration of intralesional steroids or 5-fluorouracil can hasten this process; Areas under tension or motion, such as the upper back and arms, may lead to scar spread or atrophy; Erythema and telangiectasia can form around scars during healing and may persist for extended periods, especially in highly vascular areas.
118
What are the potential complications of flap repair in the early postoperative period?
Potential complications of flap repair in the early postoperative period include: Partial or complete flap necrosis due to inadequate blood supply from the wound bed; Vascular compromise from flap design issues, such as a pedicle being too narrow, excessive torque or tension at the flap's leading edge; Areas of partial necrosis may heal secondarily, leading to less appealing scars.
119
What is a trapdoor deformity and how can it be managed?
A trapdoor deformity occurs when the center of the flap becomes elevated while the suture line is depressed. It may resolve spontaneously over 6–12 months. If persistent, management options include: Intralesional steroids, 5-fluorouracil, flap elevation with thinning, and fractional ablative lasers or dermabrasion. To minimize the risk of trapdoor deformity, proper undermining, thinning, and geometric shaping of the flap are recommended.
120
What are the complications associated with grafting in the early postoperative period?
Complications associated with grafting in the early postoperative period include: Graft failure due to inadequate nutrient supply to the tissue; Poor vascular health of the wound bed, especially in smokers or diabetics; Inadvertent shearing forces, trauma to the graft, hematoma, seroma formation, or infection.
121
What follow-up measures should be taken after surgical procedures involving sutures?
Follow-up measures include: Patients with nonabsorbable epidermal sutures should return for suture removal at the appointed time; If the defect has been left to heal secondarily, the wound should be checked in approximately 4 weeks; The surgical site should be evaluated 3 to 4 months postoperatively to ensure proper healing; Patients treated for malignancy should receive counseling for follow-up skin examinations to monitor for new or recurrent skin cancers.
122
What are the early complications of dermatologic surgery, and how can they be managed?
Early complications include bleeding, pain, and infection. Bleeding can be managed with compression or suture removal for hematomas. Infections require culture, antibiotic susceptibility testing, and broad-spectrum antibiotics.
123
What is trapdoor deformity in flap repairs, and how can it be minimized?
Trapdoor deformity occurs when the center of the flap becomes elevated and the suture line depressed. It can be minimized with wide undermining, proper thinning and sizing of the flap, and using sharp geometric shapes.
124
What are the causes of graft failure in the early postoperative period?
Graft failure can result from inadequate nutrient supply due to poor vascular health, shearing forces, hematoma or seroma formation, or infection.
