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Flashcards in Principles of wound reconstruction Deck (38):

elective incisional wound

shouldn't present problem in closure is wound is closed the same direction it was made
closure in different orientation sometimes used in reconstruction e.g z-plasty


elective excisional wound

can cause large skin deficit, can be a challenge to close
usually closed immediately following the excicion + plans for reconstruction needed prior to surgery for preparations to be made


traumatic wounds

potential for contamination must be addressed
need plans for reconstruction before surgery


options for wound closure

primary closure
delayed primary closure
secondary closure
second intention healin


choice of technique for wound closure - factors

patients physical statues
wound contamination
soft tissue damage
vascularity of tissues
amount of adjacent tissue available for closure


aim of wound reconstruction

complete + durable wound closure
wound healing in shortest possible time
minimal discomfort
minimal morbidity e.g adequate limb function
cosmetic appearance


planning wound reconstruction

evaluate inherent elasticity of local skin
identify skin tension lines + their likely effect
position + importance of local structures
location of adjacent direct cutaneous arteries
previous surgical or traumatic wounds in the region
evaluation of viability + vascularity of local skin


closure of edges

delayed/primary closure


mobilisation of local skin

suture techniques


mobilisation of adjacent skin

subdermal plexus flaps
axial pattern flaps


mobilisation of distant skin

distant in/direct flaps


use of free skin grafts

partial/full thickness graft


second intention healing

contraction + epithelialisation


tension relieving techniques

maximise available skin - patient 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 + stents


excessive tension

compromised circulation
slow wound healing
distortion of anatomic areas


effect of tension on closure of skin wounds

wounds made parallel to tension lines close + have minimal tension
wounds perpendicular to tension lines gape + have greater tension
wounds made at oblique angle to tension lines form rhomboid wound


patient positioning

patient should be suitably positioned depending on the site of surgery
ease of access to loose, available skin


management of dog-ears

raised areas of skin after wound closure
can be removed to improve cosmetics of the wound but flatten over 6-8 weeks naturally


triangle wound

3-point closure - Y shaped


square wound

centripetal closure - X shaped


rectangular wound

centipetal closure - double Y shaped wound


undermining skin edges

simplest technique to release tension
skin is relieved from underlying attachments - allow inherit elastic properties to be used
care taken to avoid trauma to subdermal plexus + direct cutaneous arteries


planes for undermining skin - cutaneous muscle present

undermine below muscle


planes for undermining skin - cutaneous muscle not present

undermine in loose fascia below


planes for undermining skin - skin associated with muscle

undermine below muscle fascia`


skin stretching - pre-suturing

vertical mattress tension sutures used to imbricate normal skin either side of a lesion
sutures removed after time+ lesion excised using extra skin to achieve wound closure
simple + cheap but needs 2 operations


skin stretching - skin stretchers

externally applied, non-invasive, adjustable devices that can stretch skin adjacent to + distant from the wound
stretching not immediately next to the wound allows for more gains than pre-suturing
cables crossing the wound can also hold dressing in contact with the wound


skin stretching - skin expanders

silicone elastomer bag connected by tube to self-sealing implantable injection port
put under skin and slowly expanded with sterile saline


walking sutures

simple + effective adjunctive method
static effect distributes tension over wide area
dynamic effect moves skin towards wound edges


tension sutures

overcome tension in a wound
can be sole suture pattern or secondary retention sutures
retention, stay or echelon sutures consist of second suture line at distance from primary incision to reduce tension


tension-relieving incisions - relaxing or release incisions

incision created parallel to long axis of a wound to ease closure
incisions may be singe, 1 either side of wound, double, or multiple
if skin mobility allows, secondary defect may be closed primarily


relaxing incision for primary closure

incision placed adjacent + parallel to primary wound to allow intervening skin to close the defect
indicated when allows primary closure of main wound
in some cases skin elasticity will allow closure of secondary wound also


multiple puncate relaxing incisions

multiple stab incisions in staggered rows parallel to primary wound
release tension + allow primary wound closure
left to heal by 2nd intention
indicated primarily for closure of wounds on the extremities


relaxing incision for skin flaps

tension may prevent skin flap from being used
incisions in flap or adjacent tissue may be used to relieve this tension
incisions in adjacent skin are preferred as vascularity of flap not compromised
careful to avoid regional direct cutaneous artery
other procedures(V-Y + Z-plasty) should also be considered


advancement flaps

limited to areas where there's lose skin
additional skin made available for wound closure by making use of skin elasticity - no new skin moved into the wound
these flaps developed so that they advance parallel to lines of skin tension
skin tension may cause dehiscence or distort recipient wound


transposition flaps

rectangle flap made within 90 degrees of long axis of defect
1 long edge of the flap shared by defect to be closed
loss of length of flap + incr likelihood of dog-ear development with incr are of rotation
90 degree transposition most useful + 180 dgree is max possible
measurements critical for closure of both sites
90 degree flap aligned parallel to lines of greatest tension which aids development of larger flap + helps transverse closure of donor site


rotating flaps

arc of skin which shares common border with triangle defect
if planned properly, no secondary donor site defect created
skin from stretching (advancement) + moving adjacent skin (transposition)
no advantage over transposition flap but good for triangle defects
length of incision needed approx 4x length required to rotate the flap to cover the defect
incision progressively developed with undermining until flap cover defect


flank folds

loose skin of axilla + flank fold used for reconstruction in these regions
fold of skin can be left attached to the limb + used for reconstruction of the limb, or can be left on the flank + used on the flank