Fundamentals of Plastic Surgery

Question 1

What are the two main layers of skin?

Answer 1

Epidermis

Dermis

Question 2

What kind of tissue is the dermis?

Answer 2

Connective tissue

Also contains rich dermal vascular plexus

Question 3

What kind of cells are in the epidermis?

Answer 3

Stratified squamous epithelium

Question 4

What are the functions of skin?

Answer 4

Protection/involved in immunological response to damage by: direct trauma, chemicals, biological agents (e.g. fungi/bacteria), radiation, e.g. sunlight
Synthesis of vit D
Regulation of body temperature
Fluid balance
Sensation 
Social/aesthetic

Question 5

Define wound

Answer 5

End result of damage to the skin/other structures secondary to trauma

Question 6

Define bruise

Answer 6

Area of injury associated with escape of blood from rupture vessels underneath due to trauma

Question 7

How do the colours of bruises change over time?

Answer 7

Initially black/red –> yellow

Question 8

Why do bruises change in colour over time?

Answer 8

Due to Hb breakdown

Question 9

What is the medical word for a bruise?

Answer 9

Contusion

Question 10

What is an abrasion?

Answer 10

Graze/minor wound caused by rubbing/scraping of skin

Question 11

What will increase the change of an abrasion leaving a nasty scar?

Answer 11

If it is contaminated

Question 12

What is a laceration?

Answer 12

Tear of tissue/organ secondary to being stretched

Question 13

What are the edges of a laceration like?

Answer 13

Irregular with compromised blood supply

Question 14

What causes an incision?

Answer 14

Sharp object, e.g. knife/scalpel

Question 15

What does the edge of a incision look like?

Answer 15

Clean, well defined with viable vascularity to the wound edges

Question 16

What is a degloving injury?

Answer 16

Laceration in which skin is sheared from the underlying fascia by rotational/crushing forces

May lead to tissue ischaemia as blood vessels are torn

Question 17

What is an avulsion injury?

Answer 17

Tearing/forcible separation of a structure from its origin, e.g. a finger being pulled off

Question 18

How should any wound be initially managed?

Answer 18

1. Wound inspection +/- exploration
2. Wound lavage - wash out with 0.9% saline
3. Wound excision - excise unhealthy/devitalised tissue
4. Wound closure

Question 19

If a wound is really contaminated when should it be closed?

Answer 19

NOT after first wound management procedure
Usual for patients to return to theatre after 48h for a second look where steps 1-3 are repeated and then wound may be closed

NEVER close a dirty wound!

Question 20

What is the reconstructive ladder?

Answer 20

A ladder of ways to close wounds, from the best way to the least desirable

Question 21

What are the rungs of the reconstructive ladder (from the bottom (i.e. best) to the top (i.e. worst))?

Answer 21

Primary suture/delayed primary suture
Split thickness skin grafts
Full thickness skin grafts
Local flaps
Distant/free flaps

Question 22

What is primary suture?

Answer 22

Bringing edges of skin together with sutures at time of initial wound assessment

Question 23

What is delayed primary suture?

Answer 23

Suturing of wound at a later date, following steps 1-3 of wound management

Question 24

Where might primary suturing not be used?

Answer 24

If wound is grossly contaminated and wound closure would –> infection
Wound breakdown/extensive abrasions where no definite edges to close

Question 25

What is healing by secondary intention?

Answer 25

Not bringing the edges together by suturing

Question 26

What are the disadvantages of healing by secondary intention?

Answer 26

Unsightly wound | Prolonged healing

Question 27

What is a skin graft?

Answer 27

Piece of skin (part/full thickness) that is completely detached from its donor site and moved at a recipient site

Question 28

How does the donor site of a split thickness skin graft heal?

Answer 28

By granulation

Question 29

What do split thickness skin grafts consist of?

Answer 29

Epidermis and variable amounts of dermis

Question 30

What do full thickness skin grafts consist of?

Answer 30

Entire dermis and epidermis

Question 31

How does the donor site of a full thickness skin graft heal?

Answer 31

Requires closure

Question 32

To survive a skin graft must do what two things?

Answer 32

Gain attachment to the recipient site and gain a blood supply - known as 'taking'

Question 33

How does the graft adhere?

Answer 33

Fibrin deposition which is gradually replaced by collagen

Question 34

How do grafts receive a blood supply?

Answer 34

Vessel ingrowth from graft recipient site

Question 35

Where can skin grafts not be used?

Answer 35

``` Bone stripped of periosteum Tendon stripped of paratenon Cartilage stripped of perichondrium Exposed metalwork Open joints ```

Question 36

What makes a suitable and what makes an unsuitable bed for grafts?

Answer 36

Muscle/fascia - suitable | Fat - unsuitable

Question 37

What may cause graft failure?

Answer 37

Excessive mobility --> shearing between graft and recipient Haematoma Cross contamination of recipient site

Question 38

How can excessive mobility of a graft be prevented?

Answer 38

Plaster splint

Question 39

Why do haematomas cause graft failure?

Answer 39

Lift graft off its bed | Locus for infection

Question 40

What is a flap?

Answer 40

Transferable block of tissue that may/may not include skin and which has its own blood supply

Question 41

When are flaps used?

Answer 41

To reconstruct defects when either the recipient area has an insufficient blood supply of its own to allow healing by a technique like grafting or when some characteristic of tissue transferred is desirable, e.g. skin colour match

Question 42

How does the skin receive its blood supply?

Answer 42

Via the dermal plexus lying in the underlying fascia

Question 43

What causes a crush injury?

Answer 43

Compressive forces

Question 44

What are puncture wounds?

Answer 44

Penetrating injuries caused by sharp objects | These have a potential to damage deep structures and allow infection/FBs to be carried deep into the wound

Question 45

What is a haematoma?

Answer 45

Accumulation of blood within a tissue, organ or space which clots and forms a solid swelling

Question 46

What is the natural cycle of a haematoma?

Answer 46

Clotting and liquefaction --> gradual resorption

Question 47

What symptoms/complications can haematomas cause?

Answer 47

Discomfort Compression of nearby structures Increased risk of infection (haematomas provide ideal culture for various organisms)

Question 48

What is an ulcer?

Answer 48

Discontinuity of an epithelial surface which fails to heal spontaneously

Question 49

What are ulcers usually associated with?

Answer 49

Infection or inflammation

Question 50

What is a sinus?

Answer 50

A blind track, lined by granulation tissue leading from an epithelial surface into the surrounding structures

Question 51

What is a fistula?

Answer 51

Abnormal connection between two epithelially lined surfaces, e.g. gut and skin

Question 52

How are traumatic wounds generally categorised?

Answer 52

Clean - usually surgical/incised with no devitalised tissue | Contaminated - contains foreign material/devitalised tissue

Question 53

How can clean wounds generally be managed?

Answer 53

Primary closure

Question 54

How are contaminated wounds generally managed?

Answer 54

Must be converted to a clean wound first