77. tension relieving

Question 1

halsteads 7 principles

Answer 1

1. asepsis2. gentle tissue handling3. meticulous hemostasis4. maintain blood supply5. obliterate dead space6. accurate apposition7. tension free closure

Question 2

two consequences of skin closed with approximation and too tight of sutures

Answer 2

1. suture cut out2. biologic tourniquet

Question 3

recommendation for closing wound in relation to tension lines

Answer 3

PARALLEL to tension lines/ Langer lines

Question 4

skin properties inherent to its viscoelastic nature

Answer 4

1. pliability2. returns to original shape (plasticity) when load is removed3. ability to adapt when prolonged stress is applied (mechanical creep and stress relaxation)

Question 5

list techniques to alleviate tension

Answer 5

1. undermine2. tension relieving sutures 3. skin stretching4. relax/releasing incisions

Question 6

at what level should undermining tissues occur at

Answer 6

DEEP to cutaneous trunci muscle to preserve to subdermal plexus (deep plexus) which arborizes and perfuses the dermis

Question 7

principle behind tension relieving sutures

Answer 7

to alleviate tension on the primary suture line and to distribute it over a larger areaminimizing “cut out suture”

Question 8

types of tension relieving suture patterns

Answer 8

1. strong SQ interrupted sutures (FFNN, FNNF, cruciate)2. stent sutures (bolster, perpendicular to incision 2 cm away placed before closure of primary defect–NOT BUTTONS)3. FFNN, FNNF (relieves-F and approximates-N)4. mattress (horizontal–may compromise blood supply, vertical–better with stents, may evert)

Question 9

skin stretching techniques

Answer 9

Allow for creep of skin (elongate) over time will lose it tendency to recoil (stress relaxation)1. pretensioning sutures and pre suturing 24-72 hrs before sx (mechanical creep)2. acute intraop skin stretching skin hooks, towel clamps, stay sutures3. intraop walking sutures (dermis to underlying fascia)4. skin expanders for chronic skin wounds (biologic creep)5. relaxing incisions (1 cm spacing, parallel, single/multiple/V-Y/Z/M)

Question 10

difference btwn pretension and presuture

Answer 10

pretension is over an existing woundpresuture is over an area of planned excision

Question 11

ways to pretension/presuture

Answer 11

1. continuous suture line with monofilament2. continuous horizontal intradermal3. skin stretching with velcro4. lembert interrupted sutures over areacan add lead spit shot compressed over suture ends of deep loop when suture loosens from stress relaxation and need to tighten for pretension

Question 12

skin expanders to relieve tension

Answer 12

NOT for acutely traumatized skin but rather for chronic or delayed recon effortutilizes biologic creepinflatable or expandable silicone device placed in SQ and expanded by 10-15% q48-72 hours (total 100 ml)

Question 13

T/Fa simple relaxing incision is also called a bipedicle flap

Answer 13

trueincision created parallel to long axis of defectlength and width equivalent to length and width of woundlength to width ratio should NOT exceed 4:1relaxing incision will heal via second intention

Question 14

types of relaxing incision

Answer 14

1. multiple mesh2. single or double simple (bipedicle flap)3. V-Y (V points away from defect)4. Z plasty (central arm perpendicular to long axis defect)5. M plasty (close in Y)