Ch 77 - Tension Relieving Techniques Flashcards

1
Q

What happens to a wound under excessive tension?

A

Tissue ischaemia and pressure necrosis will result, followed by suture cutout and inevitably incisional dehiscense

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2
Q

What determines skin tension?

A

The predominant pull of the collagen and elastin fibers in dermal and hypodermal tissues

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3
Q

Which area of the body are most at risk of shear stresses at a wound edge?

A

Highly mobile areas
- Axilla
- Inguinal area
- Over joints
- Tail base
- Foot pad lacerations
- COmmisure of the lip

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4
Q

What components of the skin are central to its ability to be mobilised / its viscoelastic nature?

A
  • Collagen fibers
  • Elastin fibers
  • Lubricating extracellular matrix
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5
Q

List Halsteads Principles

A
  • Strict aseptic technique
  • Gentle tissue handling
  • Meticulous haemostasis
  • Preservation of blood supply
  • Obliteration of dead space
  • Accurate apposition of tissue planes
  • Minimisation of tension on tissue
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6
Q

When present, what layer should undermining be deep to?

A

The panniculus carnosus layer
- Cutaneous trunci
- Platysma
- Sphincter colli superficialis

Deep to this muscle to preserve the deep subdermal plexus

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7
Q

List some tension-relieving suturing techniques

A
  • Strong subcutaneous sutures
  • Stent or bolster sutures
  • Far-Near-Near-Far and Far-Far-Near-Near
  • Walking sutures
  • Horizontal and vertical mattress
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8
Q

Why are horizontal and vertical matress sutures not recommended as tension relieveing suture techniques?

A
  • Horizontal mattress may compromise the blood supply to the wound edge
  • Vertical mattress does not compromise the blood supply but causes significant eversion of wound edges.

Far-Near-Near-Far and Far-Far-Near-Near are just as functional and more cosmetically acceptable

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9
Q

What materials are NOT recommended as stents?

A

Buttons and red rubber drains - do not adequately disperse tension and can cut through the skin

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10
Q

List some methods of skin stretching techniques

A
  • Pretensioning suture
  • Posttensioning
  • Presuturing
  • Acute Intraoperative Skin Stretching
  • Chronic skin expansion
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11
Q

What phenomena of skins viscoelasticity are taken advantage of for skin stretching?

A
  • Mechanical creep - elongation under constant short-term loading
  • Stress relaxation - Delicate elastic fibers fracture and lose their tendancy to recoil once the load is removed
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12
Q

What structural changes occur to allow for mechanical creep?

A

Within the extracellular matrix, the convoulter superhelices of the coiled triple helix collagen fibers will readily straighten and realign in a more parallel orientation, releasing water molecules and increasing skin viscosity

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13
Q

List three methods of pretensioning suture application?
How often and for how long should these be tightened prior to wound closure?

A
  • Simple continuous suture line
  • Continuous horizontal intradermal running pattern
  • Extenally applies skin stretching device (Velcro)

Tightened every 8-24hr for 2-3 days

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14
Q

What can be used to maintain suture tension in pretensioning sutures?

A

Split shot sinker (used for fishing!)

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15
Q

What suture pattern is used for pre-suturing for skin stretching

A

Lembert, for plicating the skin over an area of planned excision

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16
Q

What phenomenon does chronic skin expansion take advantage of?

A

Biological creep - The creation of new dermal and epidermal components following prolonged constant loading

17
Q

What changes occur in the skin overlying an explandable tissue stretcher?
What is the recommended rate of expansion?

A
  • SQ fat and dermal thickness decrease and epidermal proliferation occurs
  • Dense fibrous capsule forms over the expander
  • Skin is not as pliable
  • However, skin perfusion is enhanced

Explanded by 10-15% of final volume every 2-3 days

18
Q

List options of relaxing incisions

A
  • Mesh expansion (1cm incision, 1cm appart in scattered rows)
  • Simple relaxing incision (Bipedicle flap) - must not exceed 4:1 length-to-width ratio
  • V-Y plasty
  • Z-plasty
  • M-plasty (at 1 or both ends of the end of a fusiform incision)
19
Q

What is the “half bow-tie technique”?

A
20
Q

What suture is recommended where multiple points of skin come together?

A

Half-buried mattress suture

21
Q

List options for closing a large circular defect

A
  • Closed in linear fashion with correction of dog ears
  • Revised to fusiform incision and closed
  • Divide into three equal arcs and performe three-point closure
  • Combined V-plasty
  • O- to S-plasty