3-14 Advanced Dermatological Procedures Flashcards Preview

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Flashcards in 3-14 Advanced Dermatological Procedures Deck (47)
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1

What are the general steps of dermatologic procedures?

  1. „Evaluation of the wound or the area of the procedure
  2. „Cleansing of the area
  3. „Anesthetizing the area
  4. „Complete the procedure or biopsy
  5. „Follow up care and suture removal

2

How are wounds evaluated?

The wound is evaluated for damage to underlying structures, including:

nerves, tendons, vessels, joints, and bones,

as well as the presence of foreign bodies or body cavity penetration (e.g., peritoneum, thorax).

 

Failure to recognize these complications is one of the most significant errors in wound management

3

How are possible nerve injuries evaluated?

„Suggested by sensory abnormality distal to the wound; suspicion is increased for lacerations near the course of significant nerves.

 

„Examination should test light touch and motor function. Two-point discrimination is useful for hand and finger injuries.

 

„Normal varies among patients and by location on injuries of the the hand; comparing findings on the identical site of the uninjured side is the best control.

4

How are possible tendon injuries recognized?

„Complete tendon laceration usually causes a resting deformity (e.g, foot drop from Achilles tendon laceration, loss of normal resting finger flexion with digital flexor laceration) because forces from antagonist muscles are unopposed.

„Resting deformity does not occur with partial tendon laceration, which may manifest with only pain or relative weakness on strength testing or be discovered only on exploration of the wound.

5

How should a tendon injury be evaluated?

„The injured area should be examined through the full range of motion; the injured tendon may sometimes retract and not be visible on inspection or wound exploration when the injured area is in the resting position.

6

What are the SSXs of a vascular injury in a wound?

„Suggested by signs of ischemia, such as pallor, decreased pulses, or perhaps delayed capillary refill distal to the laceration (all compared with the uninjured side).

„Vascular injury is occasionally suspected in the absence of ischemia when a laceration traverses the territory of a major artery and is deep or complex or results from penetrating trauma.

„Other signs of vascular injury can include a rapidly expanding or pulsatile mass or a bruit.

7

When should a bony injury be suspected?

„Should be suspected particularly after penetrating trauma or when injury occurs over a bony prominence. If the mechanism or location of injury is concerning, plain x-rays are taken to rule out fracture.

8

When should foreign bodies be suspected in a wound?

„Sometimes present in wounds, depending on the mechanism. Wounds involving glass are likely to have foreign bodies, lacerations from sharp metal rarely do.

„Although not very sensitive, a patient's complaint of feeling a foreign body is fairly specific and should not be ignored.

„Localized pain or tenderness in a high-risk wound also is suggestive, particularly if pain worsens with active or passive motion.

9

How can possible foreign bodies in a wound be appreciated by a physician?

„Wound examination and exploration are not sensitive for small foreign bodies unless the wound is superficial and its full depth is visible.

„Imaging studies are recommended for all wounds involving glass and for other wounds if a foreign body is suspected because of the mechanism, the symptoms, or an inability to examine the wound's full depth.

10

What imaging studies are good for evaluating different types of foreign bodies?

If glass or inorganic material (eg, stones, metal fragments) is involved, plain x-rays are taken; „glass bits as small as 1 mm are usually visible.

 

„Organic materials (eg, wood splinters, plastic) are rarely detected with plain x-rays

(although the outline of larger objects may be visible because of their displacement of normal tissue);

various other modalities have been used, including xerography, ultrasonography, CT, and MRI.

11

What are the contraindications to primary wound closure?

Concern about wound infection is the main reason not to close a wound primarily. If infection develops, the resultant deformity may be worse than that caused by the initial injury alone. The following circumstances are associated with an unacceptably high risk of infection:

„An acute wound > 6 hours old (with the exception of facial wounds)

„Foreign debris in the wound that cannot be completely removed e.g., a wound with a lot of embedded dirt that you cannot clean completely

„Active oozing of blood

„Dead space under the skin closure

„Too much tension on the wound

12

What is delayed primary closure?

„Delayed primary closure is a compromise between primary repair and allowing an acute wound to heal secondarily. It may be considered for a wound over 6 hours old even though primary closure is preferable such as a large wound or a wound near a skin crease

„In delayed primary closure, you initially treat the wound with wet-to-dry dressing changes for a few (2–3) days with the hope of being able to suture the wound closed within 3–4 days.

13

How is a wound treated in delayed primary closure?

„In delayed primary closure, you initially treat the wound with wet-to-dry dressing changes for a few (2–3) days with the hope of being able to suture the wound closed within 3–4 days.

„During the few days of dressing changes, the reasons for not closing the wound initially may resolve. The dressings should clean the wound, the tissue swelling caused by the trauma may subside, and all bleeding may be fully controlled.

„If the wound shows no signs of infection and can be closed without tension, it may be possible to close the wound primarily within a few days.

14

When should you seek a surgical consultation for laceration repair?

  1. „Deep wounds of the hand or foot
  2. „Full-thickness lacerations of the eyelid, lip, or ear
  3. „Lacerations involving nerves, arteries, bones, or joints
  4. „Penetrating wounds of unknown depth
  5. „Severe crush injuries
  6. „Severely contaminated wounds requiring placement of a drain
  7. „Wounds leading to a strong concern about cosmetic outcome

15

How are wounds initially cleansed? Irrigated?

„Saline or tap water may be used for wound irrigation, whereas povidone/iodine, detergents and hydrogen peroxide should be avoided.

„Evaluating and cleansing a wound can hurt; remember pain control.

16

What agents are used for pain control? What are they good for? Contraindications?

„Injectable lidocaine or bupivacaine should be used.

„For wounds of the face or scalp, the addition of epinephrine decreases bleeding caused by the placement of sutures.

„The effects of lidocaine last approximately 1 hour; the effects of bupivacaine last 2–4 hours

„Epinephrine, which is used to decrease wound bleeding through vasoconstriction, should be avoided when wounds involve anatomic areas with end arterioles, such as the digits, nose, penis and earlobes.

17

How is pain control administrated?

„Inject the anesthetic with as small a needle as possible.

„A 25 gauge needle is acceptable, but use the smallest needle that you have.

„Inject slowly. It is acceptable to inject into the wound after it has been cleaned. If the tissues are dirty, however, inject into the skin surrounding the wound to prevent foreign material from being pushed into the uninjured surrounding tissues.

„Inject enough anesthetic to make the tissues swell just a little.

„If the injury is in an area where a nerve block can be done (e.g., on the finger), do a nerve block. It provides better anesthesia.

„Allow 5–10 minutes for the anesthetic to take effect.

„The sting from a local anesthetic injection can be decreased by slow administration and buffering the solution.

18

To achieve the best cosmetic result, what should you consider in addition to technique?

Lines of Langer

•Consider the wound’s location in relation to Langer’s line before deciding the method and orientation of the closure

19

What is the composition, uses, pros/cons of silk?

Silk - non-absorbable

Composition - natural product

Pros - ease to handle and tie

Cons - lowest tensile strength of any nonabsorbable suture

Uses - rarely used for suturing of minor wounds because stronger synthetic materials are now available

20

What is the composition, uses, pros/cons of nylon?

Nylon (Dermalon, Ethilon) - non-absorbable

Composition - synthetic

Pros - popular due to its high tensile strength, excellent elastic properties, minimal tissue reactivity, and low cost

Cons - prominent memory that requires an increased number of knot throws (3 to 4) to hold a suture in place

Uses - 

21

What is the composition, uses, pros/cons of polypropylene?

Polypropylene (Surgilene, Prolene)  - non-absorbable

Composition - plastic, synthetic suture

Pros - low tissue reactivity and high tensile strength similar to nylon

Cons - slippery and requires extra throws to secure the knot (4 to 5)

22

How does prolene react to wounds? What are the advantages and disadvantages?

„Prolene is especially noted for its plasticity, allowing the suture to stretch to accommodate wound swelling. When wound swelling recedes, the suture will remain loose. The cost of Prolene is approximately 13 percent more than nylon [5]. Prolene can be purchased in a blue color, which can be advantageous in localizing sutures in the scalp and dark-skinned individuals.

23

What are the non-absorbable suture materials?

silk

nylon - Dermalon, Ethilon

polypropylene - Surgilene, Prolene

cotton

stainless steel

24

What are the absorbable suture materials?

catgut - plain or chromic

 

25

What actually is catgut? What is the difference between plain or chromic?

„Catgut — Catgut is a natural product derived from sheep or cattle intima.

 

Plain catgut retains significant tensile strength for only five to seven days.

 

Chromic gut is treated with chromium salts to resist body enzymes, thus delaying absorption time.

Chromic gut retains tensile strength for 10 to 14 days.

26

What is the main use of chromic gut? Why? Where is it not used?

„The main use of chromic gut is to close lacerations in the oral mucosa.

Chromic gut is more rapidly absorbed in the oral cavity than most synthetic sutures, making it ideal for this environment.

It is less optimal for use in dermal (subcutaneous) and muscle layer closures because of increased tissue reactivity.

27

What is a good absorbable suture for epidermal sutures?  How is it treated and used?

Fast-absorbing gut is a newer primarily for epidermal suturing, where sutures are only required for material not treated with chromic salts.

It is heat-treated to accelerate tensile strength loss and absorption.

It is used five to seven days, absorbs in 4-6 days.

Fast-absorbing gut is ideal for suturing facial lacerations when tissue adhesives cannot be used or suture removal will be difficult. However, care must be taken to be gentle with tying knots when using the smaller (6-0) fast-absorbing gut, due to its low tensile strength. It is reasonable to reinforce this suture with skin tapes

28

What is Vicryl? What is the composition, uses, pros and cons?

„Polyglactin 910 (Vicryl) — absorbable

Composition - lubricated, braided synthetic material with excellent handling and smooth tie-down properties

Pros - retains significant tensile strength for three to four weeks. Complete absorption occurs in 60 to 90 days. It has decreased tissue reactivity compared with catgut as well as improved tensile strength and knot strength.

Uses - Vicryl is an ideal choice for subcutaneous sutures.

29

What is the composition, uses, pros/cons of poliglecaprone?

Poliglecaprone 25 (Monocryl) - absorbable

Composition - monofilament suture

Pros - monofilament quality gives it a theoretical advantage over braided sutures for contaminated wounds requiring deep sutures.

Uses - facial lacerations closed with subcuticular running sutures

Cons - All of its tensile strength is lost by 21 days postimplantation

30

What is the composition, uses, pros/cons of Dexon?

Polglycolic acid (Dexon) - absorbable sutures

Composition - first synthetic absorbable suture to become available, braided polymer

Pros - less reactive than gut sutures, and has excellent knot security. It maintains at least 50 percent of its tensile strength for 25 days

Cons - high friction coefficient causing "binding and snagging" when wet. Newer forms of this suture have been developed, Dexon Plus and Dexon II, which have an added synthetic coating to improve handling properties while maintaining knot security

31

What are the advantages of an interrupted suture?

•Easy to learn and do

• Allows for removal of only some of the sutures in cases of infection

•Better for wounds that are jagged or irregular

•If a suture breaks, the remaining sutures remain in place

32

What are the pros/cons of a continuous technique suture?

•Also called a baseball  stitch

•Closes the wound quickly

•Generally gives a better cosmetic result since tension is spread uniformly along the wound edges

•If the suture breaks the entire wound opens

33

What kinds of wounds are subcuticular running stitches good for?

A subcuticular running suture is ideal for low-tension, cosmetically important wounds.

34

What kind of wound is a vertical mattress suture good for? What about it is so good?

A vertical mattress suture is best for everting wound edges in anatomic locations which tend to invert

35

What is a horizontal mattress suture good for?

A horizontal mattress suture is usually best for high-tension wounds or wounds with fragile skin.

36

What are the layers that are needed to close a wound? What happens if the wound is wide or under a lot of tension?

„Although most wounds require only skin closure, sometimes it is necessary to close the wound in layers.

„The layers may involve:

„muscle

„fascia 

„dermis

„If the wound is widely separated or the closure will be under some tension, a few buried dermal sutures are useful. Such sutures are placed just below the epidermis and should be made of an absorbable material.

37

How do tissue adhesives compare with stitches? What are the pros/cons?

„Suturing is the preferred technique for skin laceration repair however tissue adhesives such as 2-octylcyanoacrylate (Dermabond), are comparable with sutures in cosmetic results, dehiscence rates, and infection risk.

„However, tissue adhesives can be applied more quickly, require no anesthesia, and eliminate the need for follow-up because they slough off spontaneously within five to 10 days.

„Tissue adhesives’ low tensile strength makes them inappropriate for high-tension areas, such as over joints, unless the area is immobilized.

38

What are some contraindications of tissue adhesives?

„Tissue adhesives are contraindicated in patients at higher risk of poor healing:

„Immunosuppressed patients

„Diabetics

39

What kinds of wounds should tissue adhesives NOT be used in?

„They should not be used in lacerations that are:

„Contaminated

„Complex

„Jagged

 

„They should also be avoided on mucosal surfaces and areas that maintain moisture, such as the groin or axillae.

40

What is the purpose of a biopsy? What kinds of biopsy are there?

„The purpose is to sample tissue.  It is not a curative procedure

Incisional or excisional biopsy types

41

What are the types of incisional biopsy?

„Incisional biopsy

„Shave biopsy—The superficial portion of the suspect area is removed.

„Punch biopsy—A small cylinder of tissue is removed using a punch tool.

42

What are the 3 phases of wound repair after an injury? What actually happens in the real world?

„Inflammation

„Proliferation

„Maturation

„Although didactically useful, this separation is highly artificial, for the course of cutaneous wound healing is more like a cascade of events that are highly interdependent and have considerable temporal overlap.

„Initially, hemostasis and cross-linked fibrin formation occur.

43

Check out  this graph on wound repair:

44

What is the aftercare in sutures?

„After suturing the wound closed, apply a small amount of antibiotic ointment over the suture line and cover the area with a dry gauze.

„After 24 hours, remove the original dressing.

„The patient can wash the area with gentle soap and water the day after the repair. A shower is fine, but if the patient wants to take a bath, the injured area should not be allowed to soak in the water for more than a few minutes.

„A small amount of antibiotic ointment can be applied daily for the first few days; then leave the area open to air.

„If the injured area is on the hand, foot, or calf, have the patient elevate the affected extremity. Elevation decreases swelling in the injured area and thereby improves healing.

„Applying white petrolatum to a sterile wound to promote wound healing is as effective as applying an antibiotic ointment although neither is necessary and may delay wound healing.

45

What is the timing of removal of sutures to:

face

scalp

arms

trunk

legs

hands or feet

palms or soles

„Wound location       Timing of removal (days)

  Face                           Three to five

  Scalp                          Seven to 10

  Arms                          Seven to 10

  Trunk                          10 to 14

  Legs                           10 to 14

  Hands or feet           10 to 14

  Palms or soles          14 to 21

46

How is scarring decreased with suture removal?

„To decrease scarring, skin sutures are removed while the scar tissue is still relatively weak compared with the final scar strength (which is not attained for several months).

„To help maintain the wound closure, it is useful to place Steri Strips (if available) across the scar once the sutures have been removed. These strips fall off on their own, and the patient can wash the area, even with the strips in place.

47