Basic Plastic Surgery Flashcards
What are the aims of wound management?
Early healing
Avoid infection
Minimise long-term scarring
How do you assess a wound?
Mechanism of injury
Extent of skin loss
Underlying structures
Any impairment of wound healing
What are some causes of wound healing?
Arterial insufficiency Venous insufficiency Pressure Infection Diabetes Nutritional deficiency Radiation Drugs; eg: steroids Smoking
What are the principles of wound management?
Assessment of wound and patient
Tetanus prophylaxis
Debridement
Wound closure
What does debridement involve?
Physical removal of all dead tissue and foreign matter
Lavage to reduce bacterial count
What is the management for bite wounds?
High risk of infection! Thorough debridement Antibiotics Determine type of closure or secondary intention healing Never suture close a human bite wound
How do pressure sores occur?
Impairment of blood supply due to pressure of body on wound > occludes vessels
What is the management for pressure sures?
Assess overall health
Pressure care
Debridement to healthy tissue
Skin graft/flap when underlying causes have been corrected and good pressure care in place
What is the aim of wound dressings?
Debridement Reduction of bacterial count Maintenance of favourable environment Protection/splinting of wound Apply pressure to reduce bleeding Reduce pain
What is negative pressure wound therapy?
Open cell sponge applied directly to wound
Clear, occlusive plastic dressing
Tubing connected to negative pressure pump
Removes fluid from wound
What is a hypertrophic scar?
Exaggerated normal remodelling response
Stays within margins of original wound
What is a keloid scar?
Extends beyond original wound
Which racial groups do hypertrophic and keloid scars affect?
Hypertrophic - all racial groups
Keloid - African and Asians most common
Which areas of the body do hypertrophic and keloid scars affect?
Hypertrophic - some areas more common
Keloid - any part
How do hypertrophic and keloid scars change over time?
Hypertrophic - improve
Keloid - progress
What is the response of hypertrophic and keloid scars to steroid injections, and pressure?
Hypertrophic - respond well
Keloid - less responsive
What is a graft?
Transferred tissue dependent on recipient site for nutrition
Develops vascular network from recipient bed
What is a flap?
Transferred tissue independent of recipient site for nutrition
Carries own vascular network
What is a split skin graft?
Harvest epidermis and part of dermis
Leaves wound like deep graze > heals > pale scar
What are the advantages of a full thickness skin graft compared to a split skin graft?
Less contraction
Better appearance
Better function
Compare and contrast split skin and full thickness skin grafts
Area - Split skin: large area - Full thickness: size limited by need to close donor site Adnexal structures - Split skin: none - Full thickness: present Contraction - Split skin: significant - Full thickness: less Cosmetic appearance - Split skin: poor - Full thickness: better outcome Ease of harvest - Split skin: easier take - Full thickness: needs optimal recipient bed
What are the indications for a flap over a graft?
Bed not sufficiently vascularised to support graft
Need to cover prosthetic material
Better appearance
What are the types of single stage local skin flaps?
Transposition
Rotation
Advancement
What is primary skin closure?
Immediate
What are different types of suture material?
Prolene - non-dissolvable Monocryl - dissolves in 8 weeks - Used to suture in sub-cuticular areas Cat gut Vicryl
What is a free flap?
Flap taken from one part of body to another part
Anastomose microvasculature
What sort of rotation flap is used on the face for a small area?
Limberg
What sort of advancement flap is commonly used on the forehead and back of the ear?
Double advancement H flap
What is an island flap?
Cut out all the way around
Most commonly seen at nasolabial fold
What sort of flap is a keystone flap?
Island flap
What is healing by secondary intention?
Closed by dressings
What is the proportion of different skin cancers?
BCC - 70%
SCC - 25%
Melanoma - 5%
What are some of the subtypes of BCCs?
Ulcerating Nodular Superficial Multifocal Morphoeic
What is the treatment for BCCs?
Excision
2-3 mm margin
Do BCCs metastasise?
No
What factors contribute to poorer outcomes in melanoma?
Nodular Higher Clark's score Male Smokers Truncal vs on periphery Ulcerated
What is the treatment for melanoma?
Excision
Clear margin has to be 10x depth
May also have sentinel node biopsy
Vemurafenib for secondary melanoma
What are the Clark’s levels?
I = in epidermis II = invasion into papillary dermis III = invasion to junction of papillary and reticular dermis IV = invasion into reticular dermis V = invasion into subcutaneous fat
What is the vermilion line?
Line where mucosa of lip meets skin
What is the technique to excise a skin lesion on the ear?
Below equator - remove as wedge and suture
Above equator - flap
What area should you avoid when excising under the eye?
Ectropion, as pulls eye down > can’t control tear duct
What are the possible causes of Dupuytren’s contracture?
Alcohol
FHx
Manual labour; eg: jackhammer
What is Dupuytren’s contracture?
Fatty-fibrous change in palmar fascia > attaches to other structures on hand > contracts
Which digits does Dupuytren’s contracture affect, in order of most to least common?
4th 5th Thumb 2nd 3rd
What is the treatment for Dupuytren’s contracture?
If painless - do nothing
Limited fasciotomy - most common treatment
Radical fasciotomy - take out fascia of whole hand
Amputation
What is a pilonidal sinus?
Abnormal nest of hair in blind-ended tract
Where is a pinonidal sinus most commonly found?
Sacrum
What is the treatment for pilonidal sinus?
Excision
Heal with secondary intention
