Ch09. Recon Surgery Flashcards
How much bone can you get from fibula?
Up to 40 cm
Disadvantages of using fibular free flap?
Variable and tenuous blood supply to skin paddle
Septocutaneous perforators make for a precarious skin island
Skin graft may be required at donor site for osseocutaneous harvest (skin paddle >6 cm)
Artery, vein, nerve for fibular free flap?
Peroneal (fibular) artery
Peroneal vein
Lateral cutaneous branch of peroneal nerve
Normal occlusion in Angle’s classification
The mesiobuccal cusp of the upper first molar occludes with the buccal groove of the lower first molar. If anterior to buccal groove then class II (retrognathic); if posterior then class III (prognathic)
What is the epidermis?
Outer layer, predominant cell is the keratinocyte (epidermis rarely referred to as cuticle)
Epidermis layers
Crazy layers give skin bulk
- Stratum corneum
- Stratum lucidum
- Stratum granulosum
- Stratum spinosum
- Stratum basale
What is stratum corneum?
Most superficial, dead cells (no nucleus), loosens then desquamates
What is stratum lucidum?
Second most superficial, absent in thin skin
What is stratum granulosum?
Middle layer. 3-5 layers thick, flattened, keratohyalin granules
What is stratum spinosum?
4th layer (prickle layer) initiates keratin synthesis, basophilic cells
What is stratum basale?
single layer of cuboidal cells above basal lamina; continuously divide to renew outer layers
How are cells connected?
Desmosomes form cell-to-cell
Hemidesmosomes form cell-to-basal lamina
What is epidermal-dermal junction?
“blueprint” for overlying skin, must be re-established in repair
What are epidermal-dermal junction elements?
- Rete pegs: epidermal projections into dermal layer
2. Papillae: dermal, vascularized projections into epidermal layer
What is the dermis?
Inner layer, predominant cell is the fibroblast (dermis rarely referred to as subcuticle, as in subcuticular stitch, which is simply intradermal)
What are the dermal layers?
- Papillary
2. Reticular
What is the papillary layer?
Lies immediately deep to the epidermis, made of loose connective tissue, contains small blood vessels and nerve endings
What is the reticular layer?
Made of dense connective tissue; contains blood vessels, hair follicles, sweat glands, nerves and sebaceous glands
What is Fitzpatrick scale?
a numerical classification schema for human skin color developed by Thomas Fitzpatrick
What is hypodermis?
The subcutaneous layer deep to skin and contains fat and fibrous tissue
What are the methods of wound closure?
- Primary (first intention)
- Secondary (second intention)
- Tertiary (third intention, delayed primary)
What is the primary/first intention wound closure?
Skin edges are approximated within hours, optimal cosmesis, typically for clean wounds
What is the secondary/second intention wound closure?
Wound is left open, wound bed granulates, contracts -> increased scar, typically for contaminated or very small wounds
What is the tertiary/third intention/delayed primary?
Delayed closure after initial secondary healing (and possible debridement)
What is the definition of chronic wounds?
> 4-6 weeks old
What are the stages of cutaneous wound healing?
- Inflammatory/Substrate Phase
- Proliferative Phase
- Remodeling (maturation) phase
What are the steps of inflammatory/substrate phase of cutaneous wound healing?
- Hemostasis
2. Inflammatory (cellular)
What is the first step of hemostasis in the inflammatory/substrate phase of cutaneous wound healing?
Initial vasoconstriction for 10-15 minutes (thromboxane A2) followed by vasodilation (histamine, serotonin [platelets], and nitric oxide [endothelium])
What is the second step of hemostasis in the inflammatory/substrate phase of cutaneous wound healing?
Endothelial cells contract
- > expose collagen, fibronectin, and laminin
- > forms platelet plug with fibrin from coagulation cascade
What is the third step of hemostasis in the inflammatory/substrate phase of cutaneous wound healing?
The coagulation and complement cascades, along with activated platelets, release biologically active substances including prostaglandins, growth factors, and cytokines (chemotactic and proliferative factors), which active their target cells
What are the roles of neutrophils (PMNs) in inflammatory/substrate phase of cutaneous wound healing?
Appear by 6 hours, maximum cellular influx at 24-48 hours (not critical for wound healing); clean wound for debris and bacteria by phagocytosis
What are the roles of macrophages in inflammatory/substrate of cutaneous wound healing?
Essential for wound healing (regulatory function); predominant cell type by 48-96 hours; attracted by PDGF; transition wound into stage of repair; attract fibroblasts via PDGF; secrete TNF-alpha, TNF-beta, IGF-1, and IL-1
What are the roles of fibroblasts in inflammatory/substrate of cutaneous wound healing?
Appear by 48 hours, maximum cells at 15 days; predominant producer of collagen, elastin, and fibronectin (differentiate into myofibroblasts, which are important for wound contraction, disappear by apoptosis once a scar is formed)
What are the steps in the proliferative phase of cutaneous wound healing?
- Reepithelialization
- Neovascularization
- Collagen deposition
What is the first step in reepithelilization of proliferative phase of cutaneous wound healing?
Begins within hours with basal epithelial cell differentiation and separation from basement membrane (may be stimulated by epidermal growth factor), collagenease and plasmin begin dissolution of eschar matrix, matrix metalloproteinases also imporatant for degradation and remodeling
What is the second step in reepithelization of proliferative phase of cutanoeus wound healing?
Initial cellular detachment from loss of desmosomes, pseudopod formation, and migration of fibroblast from dermis into woudn bed
What is the third step in reepithelization of proliferative phase of cutaneous wound healing?
Migration in “leap frog” pattern with fibronectin and others at 12-21 micron/hr (moist environment aids in migration)
What is the first step in neovascularization of proliferative phase of cutnaneous wound healing?
Granulation tissue begins to form ~day 4. Scaffold for cell migration made of fibrin, fibronectin, and hyaluronic acid in matrix.
What is the second step in neovascularization of proliferative phase of cutaneous wound healing?
Angiogenesis involving migration of epithelial cells into perivascular spaces, forms channels, and capillary buds
What is the third step in neovascualization of prolifeative phase of cutaneous wound healing?
Increases delivery of neutrophils, macrophages, and fibroblasts
What is the fourth step in neovasculaization of proliferative phase of cutaneous wound healing?
Modulated via vascular endothelial growth factor (VEGF)
What is are the types of collgen deposited in collagen deposition during collagen deposition of proliferative phase of cutaneous wound healing?
Initial deposition of type III collagen, later forms type I collagen
What is the maximum deposition of collagen duration?
Maximum deposition at 2-3 weeks
Describe collagen synthesis pathway during collagen deposition during proliferative phase of cutaneous wound healing
Polypeptide chains -> hydroxylation of proline and lysine (requires vit C and iron) -> combine into a helix -> glycosylation -> secreted by fibroblasts as procollagen -> cleavage to tropocollagen -> aggregates into fibrils -> combines into collagen fiber
What increases local tissue strength during collagen deposition during proliferative phase of cutaneous wound healing?
Collagen fiber cross-linking
When does the tensile strength increase during collagen deposition during proliferative phase of cutaneous wound healing
tensile strength begins to increase at 4-5 days