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Surgery 1 (SAB) > Lecture 18: Principles of Reconstructive Surgery > Flashcards

Lecture 18: Principles of Reconstructive Surgery Flashcards

1
Q

When is reconstructive surgery performed

A
  • Close defects that occur secondary to trauma
  • Correct or improve congenital abnorms
  • After removal of neoplasms
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2
Q

What is important in reconstructive surgery

A

To select the appropriate technique or techniques to prevent complications & avoid unnecessary cost

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3
Q

How are large or irregular defects sometimes closed

A

Relaxing incision or “plasty” techniques

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4
Q

Define pedicle flaps

A

Tissues that are partly detached from the donor site & mobilized to cover a defect

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5
Q

Define a graft

A

The transfer of a segment of skin to a distant (recipient) site

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6
Q

Why is it important to have careful planning & meticulous atramautic surgical tech

A

To prevent excessive tension, kinking, & circulatory compromise

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7
Q

What reconstructive tech can survive on avascular bed

A

Properly developed & transferred local flaps

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8
Q

Which reconstructive tech requires vascular bed

A

Grafts & distant flap transfers

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9
Q

Describe Hirudiniasis

A
  • Attachment of leeches to the skin
  • Only for tissues impaired w/ venous circulation
  • The leech eats an avg of 5 ml of blood but blood oozes from the wound for 24 to 48 H after the leech detaches b/c of anticoagulants & vasodilator substances introed into the wound
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10
Q

What should be considered when planning reconstructive surgery

A
  • Location of the wound
  • Elasticity of surrounding tissue
  • Regional blood supply
  • Character of the wound be
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11
Q

What happens when apposing incision edges are under too much tension

A
  • Incisional discomfort
  • Pressure necrosis
  • Sutures “cutting out”
  • Partial or complete incisional dehiscence
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12
Q

What are methods of reducing tension

A
  • Undermining wound eges
  • Selecting appropriate suture patterns
  • Using relief incisions
  • Skin stretching
  • Tissue expansion
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13
Q

How is an animal positioned in surgery

A

Mobile skin is not pinned against the table or otherwise immobilized

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14
Q

If these methods do not allow primary appositon what can happen

A
  • The wounds may be allowed to heal by secondary intention
  • May be reconstructed w/ flaps or grafts
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15
Q

How do tension lines form

A

By the predominant pull of fibrous tissue w/in the skin

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16
Q

Where should incisions be made

A

Parallel to tension lines to be able to heal better & not gapes

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17
Q

What is good to know about tension lines

A
  • Traumatic wounds should be closed in the direction that prevents or min tension
  • Wound edges should be manipulated before closure to determine which direction the suture line should run to min tension
  • If tension is min a wound should be closed in the direction of its long axis
  • The direction of closure should prevent or min the creation of “dog ears” or puckers @ the ends of suture line
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18
Q

What incisions require more sutures

A

Perpendicular (A) & oblique (B) gape & req more sutures for closure than incisions that are parallel to skin tension lines

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19
Q

Why should wound edges be manipulated

A

To determine the direction of least tension & minimal “dog ear” formation

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20
Q

Describe undermining skin adjacent to the wound to relieve tension

A
  • Skin is undermined by using scissors to separate the skin or panniculus muscle (or both) from underlying tissue
  • Simplest tension-relieving proceudre
  • Releases skin from underlying attachments so that its full elastic potential can be used
  • Skin should be undermined deep to the panniculus muscle layer to preserve subdermal plexus & direct cutaneous vessels that run parrallel to the skin surface
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21
Q

How can bleeding be stopped during undermining of tissue

A
  • Electrocoagulation
  • Ligation
  • Skin tension & bandaging usually controls hemorrhage & prevents seromas
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22
Q

How is a subdermal plexus injury prevented

A
  • Cut skin w/ a sharp scalpel blade instead of scissors
  • Avoid crushing instruments
  • Manipulate skin w/ brown-adson thumb forceps, skin hooks, or stay sutures
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23
Q

What interfere w/ cutaneous circulation

A
  • Wound closure under excessive tension
  • Rough surgical tech
  • Division of direct cutaneous arteris
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24
Q

What can happen if cutaneous circulation is not preserved

A
  • Skin necrosis
  • Wound dehiscence
  • Infection
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25
Q

Describe skin stretching & expansion

A

Tech used in reconstructive surgery that takes advantage of the skin’s ability to stretch beyond its natural or inherent elasticity

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26
Q

When can skin be prestretched & why

A
  • Hours to days before surgery
  • Allow closure w/ less tension @ the time of the procedure
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27
Q

What are some methods for recruiting skin to close wounds under tension

A
  • Presuturing
  • Adjustable sutures
  • Skin stretchers
  • Skin expanders
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28
Q

Describe skin stretchers

A
  • Noninvasive device capable of stretching the skin both adjacent to & distant from the surgical site
  • More skin can be stretched or recruited in this tech
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29
Q

Describe inflatable tissue expanders

A
  • Inflated in SubQ tissue to stretch overlying skin
  • Expanders have an inflatable bag & reservoir
  • Gradual expansion involves injecting to a given pressure or volume @ intervals spanning days to weeks (every 2 to 7 days)
  • When the tissue is sufficiently stretched to allow reconstruction the device is removed & a skin flap is created to close the defect
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30
Q

What is this

A

Adjustable sutures

31
Q

What flaps are preferable to tissue expanders for large wound reconstruction

A

Axial pattern flaps

32
Q

Describe subdermal sutures

A
  • Sutures place in subdermal or subcuticular tissue to reduce tension on the skin sutures & brine skin edges into apposition
  • Reduce scarring
33
Q

What fascia is strong & tolerates tension better than SubQ tissue or skin

A

Subdermal fascia

34
Q

What suture is used for subdermal & subcuticular sutures

A
  • 3-0 or 4-0 polydioxanone
  • Poliglecaprone 25
  • polyglyconate suture w/ a buried know
35
Q

Describe walking sutures

A
  • Move skin across a defect
  • Obliterate dead space
  • Distribute tension over the wound surface
  • Skin is advanced toward the center of the wound by interrupted subdermal sutures @ the depths of the wound
  • Sutures placed through fascia of the body wall closer to the center of the wound than the bite through the subdermal fascia or or deep dermis
36
Q

What are the steps of placing walking sutures & advancing the skin toward the center of the wound

A
  • Place the suture through the fascia of the body wall @ a distance closer to the center of the wound than the bite through the subdermal fascia or deep dermis
  • The distance from A to B increases b/c of the skin stretching when the suture is tied
37
Q

Describe external tension relieving sutures

A
  • Helps prevent sutures from cutting it which occurs when pressure on the skin w/in the suture loop exceeds the pressure that allows blood flow
  • Pressure is reduced by spreading it over a larger area of skin
  • Placing sutures farther from the skin edge or using mattress or cruciate sutures helps disperse pressure
38
Q

Describe a standard tension relieving suture for the skin

A
  • The vertical mattress suture
  • Placed 1 to cm away from the primary row of sutures apposing the skin edges
  • Are placed while the skin is approx w/ towel clamps/ skin hooks
  • Can be removed by the third day after surgery
39
Q

Describe stents

A

Placing padded material beneath the suture loops

40
Q

What are some other suture patterns that relieve tension

A
  • Alternating wide & narrow bites using simple interrupted sutures
  • Placing pulley sutures
  • Horizontal mattress sutures w/ or w/out rubber tubing stents
41
Q

How is “dog ears” prevented

A
  • Placing sutures close together on the convex side of the defect & farther apart on the concave side
  • Outlining w/ an elliptic incision removing redundant skin & apposing the skin edges in a linear or curvilinear fashion
42
Q

How can “dog ears” be corrected

A
  • May be incised in the center to form two triangles; one triangle should be excised & the other used to fill the resultant defect
  • Both triangles may be excised & the edges apposed creating a linear suture line
43
Q

T/F: Many dog ears flatten w/out excision

A

True

44
Q

What skin is less prone to the formations of dog ears

A

Thin elastic skin is less prone than thick skin

45
Q

What do relaxing incisions allow for

A

Skin closure around fibrotic wounds or impt structures before radiation therapy or after extensive tumor excision

46
Q

Where are relaxing incisions indicated

A
  • On distal extremities
  • Around the eyes & anus
  • To cover tendons, ligaments, nerves, vessels, or implants
47
Q

When do relief incisions heal

A
  • By contraction & epithelialization in 25 to 30 days
  • Some that are surrounded by loose elastic tissue can be closed primarily after the wound is approximated
48
Q

Describe using multiple punctate relaxing incisions

A
  • Small, parallel, staggered incisions made in skin adjacent to a wound to allow closure w/ reduced tension
  • Are more cosmetic than single relaxing incisions but provide less relaxation & have a higher risk of causing significant circulatory compromise
49
Q

Describe a Z-plasty

A
  • Made adjacent to a wound to reduce tension on the wound & facilitate wound closure
  • Parallel to the greatest lines of tension (perpendicular to the incision you are closing)
  • 1/3 to 1/2 the length of the incision you are closing
  • Cut a 60 degree on “limbs of the Z”
50
Q

What should be done before a tumor is removed

A

The skin tension & elasticity should be assessed but excessive tumor manipulation should be avoided

51
Q

What should be planned before skin tumor surgery

A
  • Direction of skin tension lines
  • Shape of the excision
  • Method of closure
52
Q

What should be done for large areas in a skin tumor removal

A

Clipped & aseptically prepared especially if there is a chance that skin flaps may be needed for closure

53
Q

What does the excision of skin tumors include

A
  • the tumor
  • Previous biopsy sites
  • Wide margins of norm tissue in 3D
54
Q

What should be removed w/ benign tumors

A
  • the tumor
  • 1 cm of norm tissue
55
Q

What should be removed in malignant tumors

A
  • Tumor
  • Margin of more than 2 to 3 cm may be necessary for complete local excision ( margins in all dimensions including the deep margin if feasible)
56
Q

What tumors call for a greater margin distance

A
  • Mast cell tumors
  • Melanomas
  • Squamous cell carcinomas
  • Feline mammary adenocarcinomas
  • Hemangiopericytomas
  • Infiltrating lipomas
57
Q

What tissues are resistant to neoplastic invasion & therefore often spared during resection

A
  • Cartilage
  • Tendon
  • Ligaments
  • Fascia
  • Other collagen-dense & vascular poor tissue
58
Q

How many fascial layers below the tumor margins should excision of infiltrative or aggressive tumors extend

A

At least on fascial layer below

59
Q

Describe radical tumor excision

A
  • Removal of an entire compartment or structure, amputation, or lobectomy
  • Indicated for poorly localized tumors or those w/ high grade malignancy
60
Q

What should be included in excision of infiltrative or aggressive tumors

A
  • Greater than 2 to 3 cm of norm tissue around the lesion
  • Extend the dissection @ least one fascial layer below the tumor margins
61
Q

Why do local tumors often recur

A

B/c the surgical margins for the original tumor were inadequate

62
Q

Describe advancement glaps

A
  • Local subdermal plexus flaps
  • Flaps formed in adjacent loose elastic skin that can slid over the defect
  • Developed parallel to the lines of least tension
  • Single pedicle, bipedicle, H-plasty, V-Y flaps
63
Q

Describe rotational flaps

A
  • Local flaps that are pivoted over a defect w/ which they share a common border
  • Semicircular & may be paired or single
  • Used to close triangular defects w/out creating a secondary defect
  • The skin is undermined in a stepwise fashion until it covers the defect w/out tension
64
Q

Describe the steps of rotational flaps

A
65
Q

Describe transposition flaps

A
  • Rectangular local flaps that bring additional skin when rotated into defect
  • 90 degree transposition flaps are aligned parallel to the lines of greatest tension to get the bulk of the flap to cover the defect
  • Width of the flap equals the width of the defect
  • Length is determined by measuring from the pivot point of the flap to the most distant point of the defect
66
Q

Describe interpolation flaps

A
  • Lacks a common border w/ the wound
  • Leaves an area of interposed skin btw/ the donor bed & the recipient wound
  • Created in the same way as a transposition flap except that the length must include the length of the intervening skin segment
  • Sub Q tissue is left exposed
67
Q

Describe tubed pedical flaps

A
  • Uses a multi staged procedure to “walk” an indirect distant flap to a recipient site
  • Advanced procedure performed by a specialist
68
Q

List the steps of creating tubed pedical flaps

A
69
Q

Describe axial pattern flaps

A
  • Include a direct cutaneous artery & vein @ the base of the flap
  • Terminal branches supply the subdermal plexus T
  • Have better perfusion than pedicle flaps w/ circulation from the subdermal plexus alone
  • Flaps are elevated & transferred to cutaneous defects w/in their radius
70
Q

What direct cutaneous vessels are used in axial pattern flaps

A
  • Caudal auricular
  • Omocervical
  • Thoracodorsal
  • Caudal superficial epigastric
  • Medial genicular
  • Deep circumflex iliac
  • Superficial lateral caudal inset
  • Superficial brachial inset
  • superficial temporal
71
Q

Why is a concurrent ovariohysterectomy recommended

A

B/c transposed glands remain functional

72
Q

How can skin grafts be meshed

A

By making small full thickness incisions through the graft

73
Q

List some skin grafts

A
  • Full thickness grafts
  • Sheet grafts
  • Plug, punch or seed grafts
  • Strip grafts
  • Mesh Grafts
  • Split thickness skin grafts

Surgery 1 (SAB) (16 decks)

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