Granulation and grafting

Question 1

what is proud flesh

Answer 1

excessive granulation tissue

Question 2

why are limb wounds more prone to development of proud flesh

Answer 2

increase in motion and decrease in vascularity

Question 3

T/F: all granulation tissue is bad

Answer 3

false

Question 4

what does proud flesh do to healing potential

Answer 4

limits it, delays

Question 5

what type of closure is best when dealing with excessive granulation tissue

Answer 5

primary and delayed primary closure

Question 6

what type of closure is often the only option when dealing with proud flesh on distal limbs

Answer 6

second intention

Question 7

what is the mechanism leading to proud flesh

Answer 7

inefficient inflammatory phase - neutrophils stay higher and for longer = chronic inflammation
pro-inflammatory mediators leads to a profibrotic state = exuberant granulation

Question 8

what type of state created by proinflammatory mediators leads to proud flesh

Answer 8

pro fibrotic state

Question 9

what are some treatments to proud flesh

Answer 9

resection and bandage
delayed secondary closure
skin grafts

Question 10

T/F: exuberant granulation tissue is unique to equine and humans

Answer 10

true

Question 11

what is the gold standard treatment for proud flesh

Answer 11

surgical resection

Question 12

what is something to keep in mind about the properties of proud flesh

Answer 12

very vascular, will bleed!

Question 13

second intention healing of excessive granulation tissue on the distal limb requires constant care. What is the goal to reach in order to stop trimming granulation tissue away and allow the healing to continue

Answer 13

flat granulation tissue that is flush with the skin margins

Question 14

what are some pros of skin grafting

Answer 14

simple, horse can be standing/sedated

Question 15

T/F: granulation tissue has nerve endings, therefore any manipulation will be painful

Answer 15

false

Question 16

what are the characteristics of the granulation tissue bed when preparing for a skin graft

Answer 16

healthy, flat, no hematomas, no fissures

Question 17

what are indications of skin grafting

Answer 17

large wounds, open wound that cannot be sutured

Question 18

what are the two classifications of skin grafts

Answer 18

pedicle, free

Question 19

full thickness skin graft

Answer 19

epidermis and dermis

Question 20

split thickness skin graft

Answer 20

epidermis and portion of dermis

Question 21

graft acceptance steps

Answer 21

adherence –> serum imbibition –> revascularization –> organization

Question 22

adherence of graft acceptance

Answer 22

adhered by fibrin

Question 23

serum imbibition

Answer 23

nourished by plasma like fluid via capillary action

Question 24

when does inosculation and neovascularization start in a skin graft

Answer 24

48 hours

Question 25

when does revascularization start in a skin graft

Answer 25

4-5 days

Question 26

organization of skin graft

Answer 26

epidermis thickens first 2 weeks

Question 27

types of free skin grafts

Answer 27

island graft, sheet graft

Question 28

what are the types of island grafts

Answer 28

punch, pinch, tunned

Question 29

what are the types of sheet grafts

Answer 29

solid, meshed

Question 30

T/F: if doing a full thickness free skin graft, the animal needs to be under GA

Answer 30

true

Question 31

which skin graft required a dermatome

Answer 31

split thickness

Question 32

advantages of pinch/punch grafts

Answer 32

GA not required, minimal equipment, minimal expertise, failure rare (up to 75% take to the graft)

Question 33

disadvantages of pinch/punch grafts

Answer 33

poor cosmesis, little hair growth back

Question 34

where is a punch graft harvested from

Answer 34

under mane or ventrolateral abdomen

Question 35

what are you excising for the punch graft

Answer 35

SQ, fascia, and fat from dermis

Question 36

why do yo place the recipient holes first and start distally?

Answer 36

to allow hemostasis, and to not have blood running down leg where you are trying to graft

Question 37

how far apart are the punch graft holes

Answer 37

6mm, symmetrical pattern

Question 38

T/F: the punch graft holes are the same size for recipient as the donor

Answer 38

FALSE - recipient smaller

Question 39

what is the % graft survival after a punch graft

Answer 39

60-75%

Question 40

what is the best technique to use for a pinch graft of the donor

Answer 40

tent skin with burred needle and transect 3mm disc w/no 11 blade

Question 41

what do you store your pinch graft on

Answer 41

saline moistened gauze

Question 42

how do you make the recipient pinch graft

Answer 42

no 15 blade stabbed into granulation at angle to create a shallow pocket

Question 43

do you resect the granulation tissue that formed 24-48 hours after you performed a graft?

Answer 43

NOOOO

Question 44

what are the three reasons for a graft failure

Answer 44

hemorrhage (fluid accumulation), motion, and infection

Question 45

what is the most common reason for graft failure

Answer 45

infection

Question 45

to prevent fluid accumulation at the graft, what must you make sure of?

Answer 45

graft must contact the wound

Question 46

what does a hematoma/seroma prevent that lead to graft failure

Answer 46

fibrin from attaching graft to wound

Question 47

what does hemorrhage act as a barrier toward resulting in graft failure

Answer 47

new vessel growth

Question 48

why is infection the number one cause of graft failure

Answer 48

granulation tissue is a great surface to harbor infections

Question 49

what are the organisms causing graft failure

Answer 49

beta hemolytic strep and pseudomonas

Question 50

T/F: you can graft a wound bed that has signs of inflammation

Answer 50

false

Question 51

T/F: bacteria can only infect a wound once 10^5 baceria/g tissue

Answer 51

false - some at much lower concentration

Question 52

what is the most important step to ensure survival of free graft

Answer 52

prep the recipient and make sure they have a healthy, clean bed of granulation tissue (flush with skin)

Question 53

T/F: when grafting, the granulation tissue on the recipient does not need to be perfect. If you are questioning it, you are close enough and can go ahead and graft

Answer 53

false

Question 54

you will apply topical antibiotics 24-48 hours _____ (before/after) grafing

Answer 54

before

Question 55

pros of full thickness sheet grafts

Answer 55

resist trauma better, best cosmetic outcome

Question 56

what is a con of full thickness sheet grafts

Answer 56

not a readily accepted, not as robust

Question 57

what is a con of split thickness sheet grafts

Answer 57

need $$$ and training

Question 58

what are supplies needed for a split thickness sheet graft

Answer 58

hand instrument (watson knife), drum dermatomes, power dermatomes

Question 59

pro of meshing sheet graft

Answer 59

cover wound larger than itself, prevents fluid from disrupting graft from fibrinous and vascular attachments, conforms to irregular surfaces

Question 60

you have a wound on the distal limb of a horse that you have been trimming granulation tissue away. You finally get the granulation tissue flush with the skin margins, but the surface of the location is in a very irregular conformation. What graft would be best suited for this situation?

Answer 60

meshing sheet graft

Question 61

where do you secure a sheet graft on the wound?

Answer 61

at the wound margins, not in the granulation tissue

Question 62

why do you not secure a graft to the granulation tissue itself

Answer 62

granulation tissue has no holding power

Question 63

T/F: pay attention to direction of hair growth when placing a sheet graft

Answer 63

true

Question 64

T/F: you can secure a sheet graft with staples or suture and cannot use skin glue

Answer 64

false - can use glue

Question 65

what type of dressing do you apply after the graft

Answer 65

sterile, non adherent secured with sterile elastic gauze followed by routine bandaging

Question 66

how long will you not change the bandage for after a graft

Answer 66

4-5 days (or daily...depends on fluid)

Question 67

why should the horse be heavily sedated for bandage changes post graft

Answer 67

primary layer can be adhered, so you need to soak off the bandage