Principles of wound closure/reconstruction Flashcards Preview

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Flashcards in Principles of wound closure/reconstruction Deck (60):
1

How should an elective incisional wound be closed?

in the same direction in which it was made

closure in a different orientation is sometimes used in reconstruction e.g. z-plasty

2

How are elective excisional wounds closed?

closed immediately
surgeon must have an idea before excising and prep

3

What are the 2 most important things to consider when repairing traumatic wounds?

contamination
skin deficits

4

What are the 4 options for wound closure?

primary
delayed primary
secondary
second intention healing

5

What influences the method of closure that is chosen? 5

physical status
contamination
soft tissue damage
vascularity
amount of adjacent tissue available

6

What is the aim of wound reconstruction? 5

complete and durable closure
shortest time
minimise discomfort
minimise morbidity
cosmetic appearance

7

What should be evaluated when planning wound reconstruction?

inherent elasiticity (local skin)
skin tension lines and likely effects
local structures
direct cutaneous arteries
previous surgical or traumatic wounds
viability and vascularity of local skin

8

How can wound edges be closed? 2

primary
delayed primary

9

How can local skin be mobilised? 2

suture techniques
skin-stretching

10

How can adjacent skin be mobilised? 2

subdermal plexus flaps
axial pattern flaps

11

How can distant skin be mobilised? 2

distant direct flaps
distant indirect flaps

12

How can skin grafts be used? 2

partial thickness
full thickness

13

How does second intention healing work?

contraction and epithelialisation

14

List some different tension-relieving techniques - 8

maximise available skin - positioning
change local skin tension - geometric closure patterns
change regional skin tension - skin directing
mobilise local skin - undermine skin
increase local skin - skin stretching
distribute tension - walking sutures
overcome tension - tension sutures and stents
remove tension - relaxing incisions

15

What affects skin thickness, pliability and tension?

species
breed
individual
body region
BCS
certain diseases

16

What does the theory regarding dominant lines of skin tension suggest?

wounds should ideally be created and closed parallel to the lines of the greatest tension

17

If wounds are made at an oblique angle to tension lines, what shape is the wound?

rhomboid

18

T/F: wound dehiscence is much more likely when 2 suture lines intersect.

True
e.g. T, Y or X

19

What type of excision is commonly used for small skin lesions?

fusiform or eliptical
length:width ration of 4:1 recommended to avoid creating dog-ears at the apices of the incision

20

What are 'dog ears'?

triangular, raised areas of skin which may be seen following closure of a skin wound under a number of circumstances.

21

In what shape can wounds be closed?

TRIANGLE: 3 point closure (Y shaped)
SQUARE: centripetal closure (X shaped)
RECTANGLE: centripetal (double Y shaped)

begin at corners and progress to centre

22

How can 'dog ears' be dealt with?

number of techniques to remove and improve them
OR
leave in situ (natural elasticity of skin results in them flattening over 6-8 weeks)

23

How can local tension be relieved? 2

V-Y plasty or Z-plasty

24

What is the simplest technique to relieve skin tension?

undermining - the skin is relieved from its underlying attachments, thus allowing its inherent elastic properties to be used. Care is taken to avoid trauma to subdermal plexus and the direct cutaneous arteries. Undermineing proceeds undtil the wound edges approcimate without excessive tension

25

What are the correct planes for undermining skin?

cutaneous muscle present - undermine below mm
cutaneous mm not present - undermine in loose fascia below
skin associated with mm - undermine below mm fascia

26

What are vertical mattress tension sutures used for?

to imbricate normal skin either side of a cutaneous lesion e.g. skin tumour. removed after a period of time and lesion excised. simple and cheap, but requires 2 surgical procedures

27

Where can skin stretchers stretch skin? 2

adjacent too and distant from
(the ability to stretch large areas of skin not immediately adjacent to the wound allows more significant gains than pre-suturing.

28

What does a tissue expander consist of?

a silicone elastomer bag connected by a tube to a self-sealing, implantable injection port. variety of shapes/sizes. it is buried in a pocket below the skin to be stretched and the injection port is buried in adjacent tissue. periodic inflation of the expander by injecting sterile saline into the injection port is performed.

29

Why are walking sutures good?

s tatis effect distributes tension over a wide area and a dynamic effect move skin towards the wound edges

30

What are tension sutures?

they are placed to overcome tension within the wound. they may be placed a the sole suture pattern or as a secondary retention suture.

31

How long are skin stretchers left in place?

5-7 days (as with tension sutures)

32

What is a relaxing or a release incision?

a skin incision created parallel to the long axis of a wound to facilitate its closure.
single/double/multiple
generally heal by second intention
if local skin mbility following undermining of the skin allows it, the secondary defect may also be closed primarily. In this respect, the single relaxing incision is a bipedicle advancement flap.

33

When are relaxing incisions indicated?

when it will allow primary closure of the main wound (in some cases, the inherent elasticity of the skin will also allow the closure of the secondary wound).

34

What are multiple punctate relaxing incision?

multiple small stab incisions made in staggered rows parallel to the primary wound. they release the tension in the skin adjacent to the wound and allow the primary wound to be closed. The stab incisions are left to heal by second intention and, being small the cosmetic appearance is generally acceptable. They are indicated primarily for closure of wounds on the extremities.

35

What are the different types of skin flap?

advancement
transposition
rotation
flank fold

36

When are advancement flaps used?

where there is loose skin
They are developed so they will advance parallel to the lines of skin tension.
Unless created carefully, theis skin tension may promote wound dehiscenc eor may distort the recipient wound, which is important if this wound is to close a natural orifice or other mucocutaneous junction.

37

What is a transposition flap?
Features?

a rectangular lap within 90 degrees of the long axis of a defect. one long edge is to be shared by the defect to be closed.
most versatile of local flaps and additonal skin is moved into the wound

38

What is a rotation flap?

an arc of skin which shares a common border with a triangular defect. if planned with care, no secondary donor site defect is created.

skin for closure is provided by a combination of stretching (advancement) and moving adjacent skin (transposition)

no real advantage over a transposition flap, but is useful for the local closure of triangular defects

39

What are flank folds used for?

the loose skin of the axilla and flank fold may be used for reconstruction in these regions. The fold may be left attached to the limb and used for reconstruction of the limb or may be left attached to the flank and be used for reconstructions of the flank.

40

What is the deep paniculus mm closely associated with?

deep or subdermal plexus

41

What is an angiosome?

a region of her tissue that is supplied by a specific group of veins and arteries

42

Name 1 disease that can cause fragile skin

Hyperadrenocorticism

43

Name 3 ways to control wound dead space

suture it closed
apply external dressing
use a drain
(first two often together)

44

What is local undermining?

go deep to the cutaneous trunci mm

45

What is a SDPF?

subdermal plexus flap

46

What are axial pattern flaps planned around?

planned around the direct cutaneous vessels

47

What are the thoracodorsal landmarks?

scapula spine
depression between triceps and deltoids
dorsal midline

48

Where is a reverse saphenous conduit used?

useful in distal HL (distal metatarsal region)

49

What is a compound or composite flap used for?

to create skin and muscle coverage

50

When should distant direct subdermal plexus flaps be used?

distal limb injuries
fresh wound, healthy GT or omentalised wound
single or bipedicle
requires at least 2 anaesthetic episodes
needs tolerant patient

51

When are free skin grafts indicated?

distal limb injuries
fresh wound, healthy GT or omentalised wound
not over exposed bone/tendon/ligaments
not if infection/movement
not if chronic GT

52

What terminology describes free skin grafts? 4

split vs full thickness
full sheet or meshed (expanded or not)
pinch or punch
line grafting

53

What dictates homograft survival? 4

adhesion
plasmatic imbibition
vascular ingrowth (inoscultation)
maturation

54

What is plasmatic imbibition?

the initial way a homograft is nourished, it describes how the graft 'drinks' plasma

55

How is a homograft nourished after plasmatic imbibition?

by capillary inosculation (this should happen within 36 hours of the transplant)

56

Outline the basic technique for performing a homograft transplant

Prepare recipient wound (no haemorrhage)
make template of recipient wound
wrap recipient wound
make outline of graft at donor site
excise graft, clean and place directly into recipient
suture periphery (direct or overlap)
protect with bandage - non adherent
change dressing (under GA) in 48 hours

57

Outline the use of silicon mesh as a non adherent and low/non-absorbent passive dressing.

Example?

expensive
soft
easy to apply
stick to dry skin
need secondary absorptive layer
re use

EXAMPLE = Mepitel

58

What is omentalisation?

the placement of omentum around organs or within cavities to improve vascularisation or drainage. Also used to help reconstruct infected skin wounds.

59

List some examples of omentalisaiton

repair of diaphragmatic defects
augment thoracic wall reconstruction
augment suture lines (GIT, bladder)
prostatic abscessation
wound reconstruction
chylothorax

60

What should you do if a wound that you repair falls apart?

don't panick!
manage the wounds open until they are healthy enough to undergo another reconstruction.

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