Final Flashcards
What are Langer’s Lines? What are two advantages of using this knowledge when doing minor surgery?
Topological lines that correspond to the natural orientation of collagen fibers and parallel to the orientation of the underlying muscle fibers. Incisions made parallel to these lines minimize wound tension, heal faster, and produce less scarring than those cut across.
What are the “problem areas” of the body for increased risk of scarring/keloids?
Upper chest
Back
Shoulders
How do Kraissl’s lines compare to Langer’s lines?
Kraissl’s lines are based on observations in living people
When a wound occurs what, essentially, is the body’s only interest?
Survival
What are the three phases of healing?
Inflammatory (2-5 days)
Proliferative (5 days to 3 weeks)
Maturation (3 weeks to 2 years)
What is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?
5-6%
Understand the difference between clean, clean-contaminated, dirty/contaminated and infected wounds.
Clean - free from microorganisms
Clean-contaminated - non-significant contamination and less than 6h elapsing until medical care
Contaminated - without local infxn and more than 6h elapsing until medical care
Infected - intense inflammatory reaction and frank infectious process
Is there a “Golden Period” of time for closing lacerations?
Not really
What are the four “Goals of Surgery”?
- Close the wound efficiently
- No infection
- As small a scar as possible
- No loss of function
What factors involving the patient and surgeon affect wound repair?
Surgeon’s responsibility is in the areas of aseptic and quality technique. The patient’s is their overall health status.
Understand the concept of “Healing by First (Primary) Intention”. What are the goals and outcomes of this method?
A clean wound that is closed promptly with no complications during healing leaving a minimal scar.
What are the two possibilities that lead to a wound “Healing by Secondary Intention”? Can it be reasonable choice made by the patient or surgeon?
- Wound fails to heal via primary intention due to excessive tissue trauma/loss or imprecise approximation
- Wound is left open on purpose because it is small or drainage needs to occur
Describe the steps in “Delayed Primary Closure (DPC)”.
- Debride
- Leave open
- Pack with sterile dressing
- Cover with bandage and redress often
- When healthy granulation tissue has developed, suture close
What are the advantages of using a “running” stitch? Where on the body is this a good stitch to use?
Faster to perform.
Valuable on eyelids, neck, and scrotum (places of loose skin)
What are the advantages and disadvantages of letting a wound heal by secondary intention?
Pros: Simplicity and low risk of infection
Cons: Length of time needed to heal and larger scar
When should DPC be used? What are its advantages?
Recommended for heavily contaminated wounds where there is extensive tissue loss and a high risk of infection
Know the various steps to performing an I and D of an abscess (10 steps)
- Anesthetize
- Lyse with #11
- Let contents drain
- Gently express contents
- Break up any pockets
- Pack cavity with iodine gauze
- Dress wound daily
- Return in 3 days to change drain and remove any new pus
- Repack with less
- Repeat daily dressings
What are the possible pitfalls of attempting to drain an abscess before it has formed?
Bleeding without obtaining drainage
Potential of spreading the infection
Why use a cruciate incision?
Helps prevent premature wound closing during drainage/healing
What does it mean to “advance the drain”?
Patient gradually pulls out the drain an inch or so a day, and trimming off the end
What ratio and angles should ellipses be at?
3:1 at a 30 degree angle at the ends
Why is the goal to cut skin edges perpendicular to the surface when doing elliptical excisions?
It allows for better eversion and closure
Know the options for treatment when a wound dehisces.
Let heal by secondary intention for partial
For larger, resuture if no sign of infection and less than 24hrs has passed
What are the two options as methods of anesthesia for removing part/all of a finger/toenail?
Digital block
Block at the proximal end of the proximal carpal between the digits
Name two reasons for/advantages of using a running lock stitch.
If you need a watertight seal
Gathering of loose skin
Name the several different ways to deal with “bleeders” that may appear in a surgical wound or traumatic laceration.
Wait for them to clot Apply pressure Clamp Cauterize Tie-off
What is Quikclot? When should you consider using it?
Gauzy wound pads infused with Kaolin - a mineral known to activate the coagulation of blood. Useful in emergency situations.
What is SURGICEL? When should you consider using it?
Absorbable hemostat that is bacteriocidal. Use as an adjunct to ligation or other conventional methods.
Contrast the treatment of an area of skin loss up to 1sq. cm. in a fingertip vs. a larger wound.
If 1sq. cm. refer to plastic surgeon
What are particular concerns about palm wounds?
Worried about damage to nerves and tendons
Be familiar with tetanus and tetanus immune globulin administration guidelines.
If uncertain wether the patient has received a tetanus shot in the past 10yrs, give shot. Give tetanus immune globulin if patient has had fewer than two doses in lifetime and wound is heavily contaminated.
What are the controllable and uncontrollable issues that affect wound healing?
Controllable: tissue handling, careful cleaning, splinting
Uncontrollable: mechanism of injury, location, age and race, patient’s ability to heal, patient’s tendency toward abnormal scar formation, patient’s nutritional status
Before applying anesthesia, what should you do?
Assess the wound site for tissue damage, contamination and possible underlying nerve, tendon, muscle or bone damage
Where should anesthetic be injected for a wound?
Inside or center of the laceration
What is so concerning about human bite wounds?
Contamination - dirty mouths
What is tattooing, and how do you prevent it?
When foreign material gets embedded it must be removed and the wound washed thoroughly
If there is question about the vitality of the tissue, should you remove it anyways?
No. If the tissue is in question, it is best to minimize debridement.
Do we shave hairy regions before surgery?
No! Causes micro-trauma that can increase infection risk. Never shave eyebrows!
What is the goal of trimming a wound edge?
To produce an opening wider at the base than the surface which helps with eversion
Is there a “golden period” of 12-24 hours after which a wound should not be surgically closed?
Not really. Best results are within 6hrs, but can be longer if there are no complicating factors
Steri-strips and glue are usually not sufficient for repairing what three types of wound?
Lacerations into deeper dermal layers
Wound missing tissue
Wound with increased tension
Name the 7 wound closure technique basics.
- Handle tissues gently
- Ensure hemostasis
- Use as fine a suture as feasible
- Enter needle into skin at 90 degrees
- Evert
- Keep skin edges relaxed
- Remove sutures as early as reasonably possible
What are the closure options for clean vs. contaminated/dirty wounds?
Clean - primary intention (if small); larger wounds that can’t be closed either secondary intention or skin graft
Contaminated - secondary intention (if small); large use DPC
Should a drain be inserted into a traumatic laceration?
Only if there is anticipated infection
Removal times for sutures placed on various body parts.
Face: 3-5 days Scalp: 5-7 days Extremity (low tension): 6-10 Extremity (high tension): 10-14 Abdomen: 6-12 Chest and back: 6-12
When and where on the body would you choose to use a three-point corner stitch?
For better closer of 3-point lacerations
To reduce chance of compromising circulation
Advanced specialty and plastic surgery procedures
Name the 6 goals of wound care.
- Reduce ecchymoses
- Reduce “dead space”
- Prevent hematoma and seroma formation
- Prevent infection
- Preserve function
- Preserve appearance
What are the 7 complications of wound healing?
- Ecchymoses
- Hematomas
- Seromas
- Infection
- Wound dehiscence
- Bad scarring
- Loss of function
What are the causes of ecchymoses? How can we reduce their severity?
Blood leaking into the skin or subQ fat.
Can be reduced by careful handling, avoid excessive local anesthesia, proper pressure, ice pack
What causes hematomas?
Post-op sustained capillary bed leakage or venous/arterial bleeding within a traumatic lesion
What pre-operative steps can be taken to reduce the occurrence of hematomas?
Assessing hx of coagulopathies, screen for alcohol abuse, medication use
T/F: Aspirin, Alka-Seltzer, ibuprofen, and plavix have been shown to increase risk of hemorrhage more than warfarin.
True
T/F: All prescribed and non-prescribed anticoagulants must be stopped 1 weeks prior to dermatologic surgery.
True
What intraoperative steps can be taken to reduce bleeding and hematomas?
Produce careful hemostasis
What post-op management steps can be taken to reduce bleeding and hematomas?
Pressure bandaging
Ice packs
Consider prolonged use of drains and “suction” drains
Contrast the treatments for expanding or clotted hematomas compared to fluctuating ones.
Expanding: partially or completely re-open, identify any oozing vessels, stop bleeding by suture ligation or electrosurgery, full-layer re-closure, insert drain if indicated
Fluctuant: aspirate daily, pressure bandaging
Does prophylaxis with antibiotics for routine or elective MS generally lower the risk of infection?
No
What are the current guidelines for withholding antiplatelet drugs and other anticoagulants?
Continue warfarin or plavix to avoid thrombotic events
Prophylactic antibiotics are indicated in patients with traumatic wounds in what three situations?
- Wounds that are obviously infected
- Contaminated wounds that are closed primarily
- Lymphadematous patients
What are the arguments against using antibiotics in traumatic wounds?
If cleaned and properly maintained, pt is healthy, then they don’t need any prophylactic antibiotics
T/F: Wounds can not dehisce as long as sutures are in place.
False
Name the four things that can typically cause a wound to dehisce.
- Too much tension
- Too little tension
- Inappropriate suture material
- Poor tissue quality
Name six causes of hypertrophic scars and keloids.
- Genetics
- Body site
- Quality of the surgery
- Skin tension
- Skin types
- The patient’s health status at the time
Contrast the definitions of hypertrophic scarring and a keloid.
Hypertrophic - as enlargement of the scar within the boundary of the original scar
Keloid - enlargement of the scar beyond the original scar boundary
Name two reasons for/advantages of using a 4-point corner stitch.
Used for lacerations and specialty procedures
