Flashcards in Skin Surgery Deck (21)
What are some skin surgery considerations?
- Suture techniques
- Suture placement
- Wound drainage
- Wound tension
- Blood supply
- Reconstruction techniques
- Skin flaps
- Skin grafts
- Wound management
What are the two main blood supplies to the skin?
1. Myocutaneous vessels
2. Direct cutaneous vessels
Describe the myocutaneous blood supply?
These are the small vessels that come up from the skeletal muscle
Describe the direct cutaneous blood supply...
Key vessels that come up between muscle bellies and feed directly into the panniculus etc. muscle
Describe the deep subcutaneous plexus...
Terminal vessels that branch from the direct cutaneous vessels form this plexus
- Most of the blood comes from here to feed up to the skin
Why do you have to be careful when stretching tissue to apposition?
If the tissue is over-stretched, there won't be a blood supply
- the wound won't heal
At what angle/ direction do you want to make a skin incision to the lines of tension in the body?
A parallel incision
- this reduces the size of the wound
What is dehiscence?
When the wound ruptures along the surgical suture
What will push the limits of tissue viability?
- Bacterial contamination
When do wound generally (if at all) start to break down?
After 3-5 days
- The blood supply terminates and the tissue begins debriding
- Sutures have "given up" and the wound is taking over
What happens if you get premature failure of sutures?
The tissue loses its own strength and the wound will debride
What are some problems with sutures?
- Too tight
- Too many
- Too big
- Use of irritant materials
What is the effect of excessive skin tension?
- Pain (chew at sutures)
- Ugly scar
- Wound dehiscence
What is important about fascia?
- It is where blood supply is (subdermal plexus)
- Sutures must engage underlying fascia to manage any wound tension
- Fascia is most tolerant to tension
When suturing a wound, what should the skin be like once it comes together?
Skin edges should come into apposition without tension
- The tension is obtained within the deeper tissues where there is better blood supply!
What are some options for good control of tension?
- Geometric closure
- Tension relieving sutures
- Tension relieving incisions
- Advancement flaps
- Pre-surgical techniques
- Advanced procedures
What is geometric closure?
Large or irregular defects can be closed using V, Y or Z plasty instead of a straight line
What is undermining?
One method of reducing skin tension
- Scissors are used to separate skin and/ or panniculus muscle from the underlying tissue
- Releases skin from underlying tissue so its full elastic potential can be used to stretch over the wound
Describe tension relieving incisions...
An incision is made nearby the wound the same length as the original wound
- Undermine the new incision and move the elastic skin over to the original wound
" borrowing" skin
- In most cases the new wound can be left open to heal by second intention
What are the two rules of undermining?
1. Deep to fascia/ panniculus
2. Maintain elevation within established limits so as not to exceed local perfusion limits
- Size of flap depends on location
- Two small flaps better than one big one
- Wider base to flap
- Avoid subdermal plexus injury