Chapter 77 Tension-Relieving Techniques Flashcards
What determines tension in the skin?
Pull of collagen and elastin fibres in dermal and hypodermal tissues
List 3 dermal changes with age
- Less pliable
- Thinner
- Less well perfused
What are the three primary aims of reconstructive surgeon?
Broadly speaking, what factors shoudl be considered when deciding wound closure technique (4 factors)
- Minimise tension and motion of primary suture lin e
- Return function to area
- Ensure final outcome is free of morbidity
Wound factors
Patient factors
Owner factors
Surgeon factor (i.e. experiece)
What are Halsted’s prinicples
- Strict aseptic technique
- Gentle tissue handling
- Presevation of blood supply
- Meticulous haemostasis
- Obliteration of dead space
- Accurate apposition of tissue planes
- Minimise tension
List 4 broad tension relieving techniques
- Undermining
- Tension Relieving Sutures
- Skin Stretching Techniques
- Relaxing Incisions
List 5 types of tension relieving sutures
Tension Relieving Sutures
- Strong subcutaneous sutures
- Stent/Bolster sutures
- Far-near-near-far or Fra-far-near-near
- Walking sutures
- (Horizontal/vertical mattress sutures- not recommended - adv far…instead)
List 5 types of skin stretching techniques
Skin Stretching Techniques
- Pre-tensioning sutures: Simple continuous suture + split shot, continuous horizontal intradermal + button, externally applied skin strechers e.g. velcro
- Post-tensioning
- Presuturing (basically the same as pre-tensioning but placed before planned excision cf e.g. wound closure)
- Acute (intra-op) skin stretching: towel clamps/skin hooks/stay sutures for 30+ mins during prep/op
- Chronic skin expansion: inflatable or expandale
List 5 broad types of relaxing incision
Relaxing Incisions
- Mesh expansion
- Simple relaxing incision (i.e. –> bipedicle flap)
- V-Y plasty
- Z-plasty
- M-Plasty
How long should bolster/stent sutures stay in place?
3-4d
What is mechanical creep:
What is stress relaxation?
What is biological creep?
Mechanical creep: Phenomenon of skin’s viscoelasticity that allows it to elongate under constant short ter loading. In ECM of loaded dermis, coiled triple helix collagen fibres straighten and realign in parallel orientation + delicate elastic fibres break.
Stress relaxation: Loss of tendency to recoil
Biological creep: Creation of new dermal and epidermal components following prolonger constant loading.
Breifly describe the method for using an inflatable skin expander
What happens to the overlying dermis?
- Expander placed in sc tissue
- Allow initial healing period, at least several days
- Expand by 10-15% volume q2-3 d until final volume reached
Dermis thinner, epidermal proliferation, dense fibrous capsule forms over implant –> skin not as pliable but perfusion enhanced. Recommend a several week ‘maintaining period’ to improve quality of expanded skin
List 4 demonstarted effects of NPWT
- Earlier formation of granulation tissue
- Less oedema
- Increased blood flow
- Increased early systemic cytokine levels
List 3 recommendations when meshign skin (for tensioon releiving incisons)
- 1cm incisions, 1cm from wound edge, 1cm apart from each other.
- Staggered rows
What is the max length of a bipedicle flap (i.e width to length ratio)
1:4
Relative to the area of tension, where is the V shaped incision of a V-Y plasty made?
Point of V facing away from area of tension
What is the effect of a Z-palsty?
How is the direction of a Z-plasty positioned relative the the line of tension/cicatrix?
Changes the direction of tension (e.g. along cicatrix/scar or adjacent to a wound)
Central arm of Z positioned along line of tension in cicatrix.
If used to allow closure of neighbouring wound then central arm of Z made perpendicular to the line of tension of the wound
List 2 potential areas for use of M-plasty
Where end of a fusiform incision is limited e.g. lip commisure, proximal bilateral mastectomy
List 4 techniques for closure of a cresent shaped wound
- Fudging (i.e. slightly divergent sutures onthe longer side)
- Suture from edges in and excise resultant central dog ear
- Suture from centre outwras and excise dog ears at either end
- Half bow tie technique of large wound
List 5 methods for closing a circular wound
- Linear closure and excise dog ears
- Convert to fusiform/eliptical wound
- Three point closure i.e. mercedes sign
- ‘combined v-plasty’
- ‘O- to S- plasty’
Large circular defects on the trunk can be closed by developing two adjacent flaps through a combined V-plasty (A) or an O- to S-plasty (B-E). It is critical to make the flaps large enough to cover the defect without undue tension (C-E).
