Reconstructive techniques

Question 1

How would you close a wound?

Answer 1

• Debridement + lavage + reassess the wound
• Recategorise if necessary
• Adhere to halsted’s principles
• May need a surgical drain

Question 2

What instruments would be needed for skin reconstruction?

Answer 2

• Good quality basic instruments
• needle holders
• mayo + metzenbaum scissors
• Fine forceps e.g. Debakey / Adson forceps
• Extras =
• skin hooks
• skin pen / sterile methylene blue + Q-tips

Question 3

What are aims of skin reconstruction?

Answer 3

• Square skin edges
• Accurate apposition
• No overlapping
• Slight eversion of wound edges
• Follow Halsted’s principles

Question 4

What are different wound closures?

Answer 4

• Primary closure - clean / clean-contaminated
• Delayed primary closure - leave open for a few days + use dressing (Debride + lavage), then close
• Secondary closure - granulation bed + close after 5 days (dirty wounds)
• Second intention - just granulation

Question 5

Why would you undermine + advance skin?

Answer 5

• When wound too large for closure using tension-relieving sutures but is too small for a flap
• Frees skin from SC attachments
• Uses skin elasticity to close defect
• can blunt dissect under skin - better won’t cut vessels
• or can cut with scalpel / scissors

Question 6

What are aims when undermining + advancing skin?

Answer 6

• Maintain blood supply
• Undermine deep to panniculus layer - so skin doesn’t die

Question 7

What are tension relieving sutures?

Answer 7

• Horizontal mattress
• Vertical mattress - better
• Far-near-near-far suture
• Far-Far-near-near suture
  (far from incision / near incision

Question 8

What are cutaneous pedicle grafts?

Answer 8

• “Skin flaps”
• Portions of skin & s/c tissue moved from one area to another
• Many uses in reconstruction
• Best on head, neck & trunk (most skin)
• Good cosmetic results - Hair growth

Question 9

What should be done with flap planning?

Answer 9

• Suitable donor sites
• Appropriate flap for the wound, initially larger than the defect you wish to cover
• Avoid narrow base to flap
• Undermine below the panniculus
• Use fine suture material & initial tacking sutures to ensure that flap conforms well to recipient bed
• Ensure the recipient bed is free of infection, contamination and necrotic tissue – either a fresh surgical wound or a healthy granulation tissue bed
• Do not exceed a length-width ratio of 3:1 for unipedicle flaps and 4:1 for bipedicle flaps

Question 10

Why do flaps fail?

Answer 10

• Arterial/venous occlusion
• Thrombi
• Torsion
• Stretching
• Tension
• Direct on flap
• From haematoma/seroma
• Infection

Question 11

How would you assess flap health?

Answer 11

• Subjective measures
  -Colour
  -Temperature
  -Sensation
  -Hair growth
• Objective measures
  -Fluorescein
  -Various experimental methods

Question 12

How would you manage partial necrosis?

Answer 12

Various salvage techniques:
* Ointments
* Debridement followed by:
- Open wound management ± secondary closure
- Another flap

Question 13

What are free skin grafts?

Answer 13

Several types:
* Full thickness meshed most commonly used
* Split thickness and pinch, punch strip also used

• All survive by revascularisation from graft bed
• Requires suitable recipient bed, good contact, no movement, no infection

Question 14

Why would you insert surgical drains? What are 2 types?

Answer 14

• Remove excess fluid from wounds
• Close dead space
• 2 basic types =
• Passive drains
• Active drains

Question 15

What are principles of drain use?

Answer 15

• Place drains aseptically
• Ascending infection is a major complication
• Prepare site as for surgery
• Maintain asepsis by covering drain exit with a dressing
• Nonadherent
• Absorbent
• Do not exit drain through or place it directly along a suture line
• Promotes dehiscence

Question 16

When would you remove a drain?

Answer 16

• When consistent, small volume of serosanguineous fluid is produced