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Fundamentals of Plastic Surgery Flashcards

1
Q

Two main layers of the skin

A

Epidermis

Dermis

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2
Q

What is responsible for 95% of skins thickness?

A

Dermis

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3
Q

What type of epithelium is the epidermis?

A

Stratified squamous epithelium

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4
Q

What do melanocytes produce?

A

Melanin

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5
Q

Function of melanin

A

Skin colour

Protection against UV radiation

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6
Q

Function of dermis

A

Strength and elasticity of skin

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7
Q

What type of tissue is the dermis?

A

Connective tissue

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8
Q

What is a key feature that the dermis contains?

A

Rich dermal vascular plexus

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9
Q

Assosiated appendages of the skin

A

Hair follicles
Glands
Nails

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10
Q

Function of layers beneath the skin

A

Nutrition of skin

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11
Q

Where do blood vessels run in the skin?

A

Through the muscular layers
Sending perforating vessels through the investing fascial layer
To contribute to the rich dermal plexus

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12
Q

Main function of the skin

A

Barrier

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13
Q

Skin provides protection to underlying structures from…..

A

Direct physical trauma
Chemicals
Biological agents e.g. bacteria, fungi
Radiation e.g. sunlight

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14
Q

Functions of the skin

A 
Barrier
Synthesis of vit D
Regulation of body temp 
Fluid balance
Sensory 
Social 
Aesthetic
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15
Q

People with facial disfigurement are likely to be stereotyped with what characteristic?

A 
Dishonest
Unintellegent
Untrustworth 
Ineffective
Unpopular
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16
Q

What is a wound?

A

The end result of damage to the skin or other secondary structures secondary to some form of trauma, whether accidental e.g. following an assault, or intentional e.g. during an operation

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17
Q

What is a bruise?

A

An area of injury (not unique to skin) assosiated with the escape of blood from ruptured underlying vessels, as a result of some form of trauma

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18
Q

Colour of bruises

A

Initial black/red

Gradually changes colour with time

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19
Q

Why do bruises gradually change colour over time?

A

Due to the breakdown of haemoglobin

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20
Q

What is an abrasion?

A

A graze or minor wound caused by rubbing or scraping of the skin

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21
Q

What is a laceration?

A

A tear of a tissue or organ, acquired secondary to trauma

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22
Q

Pathology of a laceration

A

The tissue is forcibly stretched and fails, resulting in a wound with irregular edges that have a compromised blood supply

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23
Q

What is an incised wound usually caused by?

A

Sharp object such as knife or scalpel

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24
Q

Pathology of an incision

A

Usually has clean, well defined edges with viable vascularity to the wound edges

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25
What is degloving?
A type of laceration, in which the skin is sheared from the underlying fascia by rotational and/or crushing forces
26
What may degloving result in?
Skin ischaemia as the feeding blood vessels are torn
27
Most common cause of degloving injury
Limb is caught beneath a vehicle wheel
28
What is an avulsion?
Involves tearing or forcible separation of a structure from its origin e.g. the traumatic avulsion of a digit in machinery
29
What is a puncture wound?
Penetrating injuries usually caused by sharp objects
30
Pathology of puncture wounds
Extents into subcutaneous tissue or beyond
31
Significance of puncture wounds
Potential for damage to deep structures | Infection or foreign material may be carried deep into the wound
32
What is a haematoma?
An accumulation of blood within a tissue, organ or space, which clots and forms a solid swelling.
33
Why do haematomas increase the risk of a wound becoming infected?
They provide an ideal culture medium for various organisms
34
Natural history of a haematoma
Cycle of clotting and liquefaction | Gradual re-absorption
35
Potential issues caused by a haematoma
Discomfort Compress underlying or overlaying structures Infection risk
36
Example of a chronic wound
Ulcers
37
What is an ulcer?
A discontinuity of an epithelial surface (not unique to skin) which fails to heal spontaneously
38
What are ulcers usually associated with?
Infection | Inflammation
39
What is a sinus?
A blind track, lined by granulation tissue, leading from an epithelial surface into the surrounding tissues.
40
What is a fistula?
An abnormal connection between two epithelially lined surfaces e.g. gut and skin
41
Reasons for persistence of an acquired sinus/fistula
Presence of foreign body e.g. suture material Infection Malignancy
42
Two main groups of traumatic wounds
Clean | Contaminated
43
What are clean traumatic wounds?
Usually surgical or incised wounds, which contain no devitalised tissue
44
What are contaminated wounds usually as a result of?
Lacerating/crushing/avulsion/de-gloving injuries
45
Is it safe to close contaminated wounds primarily?
no
46
What may contaminated wounds contain?
Large amounts of devitalised tissue | Foreign material
47
What steps are necessary for the management of any wound?
Wound inspection + / - wound exploration Wound lavage (washout with copious amounts of fluids) Wound excision (excision of unhealthy or devitalised tissue Wound closure
48
Which wounds should not be closed during first wound management procedure?
High degree of wound contamination | Large amounts of devitalised tissue
49
What is the basic used for planning a procedure for a removal of a lesion or management of a traumatic wound?
Reconstructive ladder
50
What are the steps of the reconstructive ladder?
``` Primary suture or delayed primary suture Split thickness skin grafts Full thickness skin grafts Local flaps Distant / free flaps ```
51
What does a primary suture involve?
Bringing skin edges together with sutures at the time of initial wound assessment
52
What is delayed primary suture?
Suturing of the wound at a later date, following steps 1-3 of wound management
53
What is healing by secondary intention?
Wound edges are not brought together by suturing, however the wound would still heal, would just be prolonged and an unsightly scar may result
54
When would healing by secondary intention be used?
Grossly contaminated wound when closure would inevitably result in infection and wound breakdown Areas of extensive abrasions No definite wound edges to close
55
What is a skin graft?
A piece of skin, either part, or the full thickness of skin, that is completely detached from its original site (the donor site) and moved to a distant site (the recipient site)
56
What do split thickness skin grafts consist of?
Epidermis and variable amounts of dermis
57
What will the donor site of a split thickness skin graft heal by?
Granulation
58
Size of donor area available in a split thickness skin graft
Large
59
What is used in split thickness skin grafts which means large areas can be covered?
Meshing
60
Colour of split thickness skin grafts
Poorer colour match to surrounding skin
61
What do full thickness skin grafts consist of?
Entire dermis and epidermis
62
What does the donor site of a full thickness skin graft require?
Closure
63
Size of graft of a full thickness skin graft
Limited
64
Colour match of full thickness skin graft
Better colour match to surrounding skin
65
Examples of donor sites for full thickness skin grafts
Posterior auricular skin | Skin of the supraclavicular fossa
66
What is a 'take'?
A skin graft gaining attachment to its recipient site and gaining a blood supply
67
What is initial adherence of a graft due to?
Fibrin deposition
68
What is fibrin deposition of a graft gradually replaced by?
Collagen
69
What sites can skin grafts not be used?
``` Bone stripped of periosteum Tendon stripped of paratenon Cartilage stripped of perichondrium Exposed metalwork Open joints Fat ```
70
What can lead to graft failures and why?
Excessive mobility of the area - secondary to shear forces between graft and secondary site Haematoma beneath graft can lift graft of its bed Gross bacterial contamination
71
What is a flap?
A transferable block of tissue that may or may not include skin, which has its own blood supply
72
What are flaps used to do?
Reconstruct defects when either the recipient area has an insufficient blood supply of its own to allow healing by a technique such as skin grafting, or when some characteristic of the tissue transferred is desireable e.g. skin colour for face
73
Where does the skin receive its blood supply via?
Dermal plexus
74
What are the large named vessels that supply muscles and fascia known as?
Vascular pedicle
75
Names of different flaps
``` Skin (cutaneous) flap Muscle flap Myocutaneous (muscle and skin) Fascial flap Fasciocutaneous (fascia and skin) ```
76
Where are local flaps transferred?
A site adjacent to the donor site
77
When are local flaps commonly used?
Reconstruction of small facial defects
78
Where are distant flaps transferred?
Transferred from a remote location or the area to be covered is taken to the flap donor site
79
What is a free flap?
Completely detacted from its original site and blood supply transferred to a distant defect
80
3 main requirements for wound healing
Vascular response Inflammatory response Cellular response
81
What does the vascular response required for wound healing involve?
``` Vasoconstriction Activation of clotting cascades Platelet activation Aims to stop bleeding by production of fibrin clot Platelet degranulation ```
82
What does the inflammatory response involve in respect to wound healing?
Release of inflammatory mediators Local capillaries become permeable Cells can move from the bloodstream into the injured tissue Scavenger cells migrate to the area to remove any foreign or devitalised material
83
What does the cellular response required for wound healing involve?
Epithelialise and close defect with scar tissue Fibroblasts produce collagen - which becomes organised into scar tissue Width of wound is reduced over time by contraction of myofibroblasts
84
What is a scar?
Normal end result of wound healing
85
How long do normal scars take to mature?
6 months - 2 years
86
3 major phases of wound healing
healing - 1-6 weeks = exudate scab fine line Remodelling - 2 weeks - 2 years = red raised itchy tender contraction Maturation - 6 months - 2+ years = pale flat, quiet contracture
87
Reasons for poor final scar result
Poor wound preparation Poor surgical planning and/or technique Wound infection
88
Characteristics of hypertrophic scars
Scar tissue raised above normal level of scar Scar tissue stays within original scar boundaries Scar often red in appearance Often resolve with time
89
First line management of hypertrophic scars
Reassurance
90
What else can help hypertrophic scars?
Massaging scar | Sustained pressure
91
Characteristics of a keloid scar
Scar tissue extends out with the boundaries of the original scar Surrounding normal tissue involved Excision usually leads to recurrence
92
Notorious sites for keloid scar formation
Pre sternal region Deltoid region Earlobes
93
Highest risk groups for developing keloid scars
African Afro carribean African American
94
Management of keloid scars
Injection of steroid (triamicinolone) into the scar Silicon massage of scar Sustained pressure Exision and radiotherapy - last resort
95
What is the most common pigmented lesion in young people?
Naevi
96
What are naevi?
A concentration of melanocytes in the epidermis
97
Does the number of naevi increase or decrease from early life?
Increase
98
How many naevi does the average adolescent have?
20-40
99
Where are seborrheic ketatoses commonly found?
Trunk of older people
100
Do seborrheic ketatoses have malignant potential?
No
101
What do many patients with seborrheoic ketatoses report?
Lesion falling off
102
Who does actinic keratoses affect?
Elderly
103
What does actinic keratoses appear like?
Scaly skin areas seen on sun exposed areas e.g. scalp
104
Does actinic keratoses have malignant potential?
Yes if not treated - turn into SCC
105
Treatment of actinic keratoses
Cryotherapy Topical chemotherapeutic agents Excision
106
Presentation of bowens disease
Often asymptomatic Persistent reddish patch of skin Crust or scaling 3/4 of lesions on leg
107
Major aetiological factor for bowens disease
Sun exposure
108
Who gets bowens disease?
> 60 y/o | F > M
109
Pathology of bowens disease
SCC in situ (in epidermis)
110
If bowens disease is left untreated, what may result?
invasive SCC
111
Treatment of bowens disease
``` Cryotherapy Topical chemotherapeutic agents Curettage Excision Lasers Photodynamic therapy Radiotherapy ```
112
What old scars in particular can SCC arise in?
Burns scars
113
What are SCC arising in old scars called?
Marjolins ulcers
114
Why do marjolins ulcers grow slowly?
As the scars contain no blood vessels
115
Treatment of marjolins ulcers
Excision of affected area | Followed by reconstruction using technique from the reconstruction ladder
116
What is the commonest skin cancer?
Basal cell carcinoma (BCC)
117
Relationship between incidence of BCC and age
Increases with age
118
Major aetiological factor of BCC
UV exposure from sunlight
119
Risk factors for BCC
UV exposure from sunlight Sunburn in childhood +ve FH of BCC/other skin malignancy
120
Where are the majority of BCC found?
Head and neck
121
Classical appearance of BCC
Raised, rolled edge Pearly appearance Telangectasiae Ulcerated centre
122
Treatment of BCC
Surgical excision Reconstruction from reconstruction ladder Cryotherapy Topical chemotherapeutic agents
123
What is a SCC?
A malignant skin tumour arising from the epidermis or its appendages
124
Who is SCC common in?
Transplant patients taking long term immunosuppressants
125
Presentation of SCC
Crusted lesion | With or without ulceration
126
Treatment of SCC
Surgical excision Reconstruction Lymph node dissection may be required Radiotherapy may be required post op

Plastics (4 decks)

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