Plastic And Reconstructive Surgery Flashcards by Denisse Tiangco

Time of injury until 3-4 days after injury

Hemostasis and inflammation-sterilization phase

Inflammation

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Platelet aggregation and release of vasoconstrictive factors (TXA, Factor V) 
Proinflammatory cytokine (PDGF, TGFB, IGF1, fibrinogen)

Leading to PMN recruitment

Hemostasis

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Cell recruitment

Neutrophil -> Mac -> Fibroblast -> Lymphocyte

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Matrix synthesis 1st to last

Fibronectin
Collagen III
Collagen I (stays)
Wound breaking strength

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PMNs induce vasodilation and recruitment of mac, lymphocyte, fibroblast

Superoxide and collagenase sterilize and degrade devitalized tissue

Inflammation-sterilization

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Major chemoattractant for fibroblast during proliferation phase

PDGF

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Wounds only reach this percentage of overall healed strength by 30 days

80%

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3-7 days after injury
Initial collagen matrix is laid down
Macrophage infiltrate and release cytokines
Inc vascular permeability and angiogenesis
Lymphocyte activation -> fibroblast response and epithelial cell migration

Proliferation

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Fibroblast activated by macrophage via EGF and IGF1

platelets via PDGF lay down disorganized collagen matrix (Type I, II, III)

Fibroplasia

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Collagen network provides scaffolding for vascular framework

Granulation

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Epidermal cells activated and migrate over the granulating field to close defect

Initial framework comprises developing membrane

Epithelialization

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Lasts 1 year after injury
Involves collagen remodelling and crosslinking -> inc wound strength dec vascularity

Maximum wound strength is achieved by

Remodelling and maturation

1 year

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Scars are dense collagen matrixes that lack

Dermal appendages such as hair follicle or sweat gland

Tensile strength 70-80% original tissue

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6th day, myofibroblast contract and persist for 4-6 weeks in wound

Final crosslinking contributes to final scar

Contracture

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Source: Mac, T cell

Target cell: fibroblast, mac

Activates mac, PMN, fibroblast
Induces collagenase activity

IFNy

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Source: Mac, fibroblast

Target: keratinocyte, endothelial cell, fibroblast

Triggers mitosis of fibroblast and keratinocyte
Induces collagen production, inc vascular permeability

IGF-1

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Source: PMNs, mac

Target cell: Fibroblasts, keratinocyte

Recruits fibroblast, keratinocyte
Induces collagen synthesis

IL1alpha

IL1beta

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Source: T cell

Target cell: Fibroblast

Recruits and triggers mitosis in fibroblast

IL2

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Source: Mac, Platelet, endothelial cell

Target: PMN, Mac, fibroblast, endothelial cell

Recruit PMN, mac, fibroblast
Stimulates angiogenesis
Inc vascular permeability

PDGF

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Source: mac, platelet, fibroblast

Target: fibroblast, keratinocyte, endothelial cell

Induces mitosis in fibroblast, keratinocyte
Promotes angiogenesis, matrix production

TGFB

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Source: PMNs

Target cell: Mac, fibroblast

Activates immune cells
Recruits mac
Induces cytotoxicity

TNFalpha

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Source: Mac, keratinocyte

Target: keratinocyte, endothelial cell

Stimulates angiogenesis
Induces inc vascular endothelial permeability

VEGF

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Most susceptible to radiation injury

fibroblast
keratinocyte
basal epithelial cell

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endothelial cell damage creates

hypoxic wound bed and severe inhibition of angiogenesis

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If patient presents with radiation-induced ulceration Confirm that ulceration is

not tumor recurrence Tx: complete excision of radiated bed with regional flap or flee flap reconstruction necessary for closure of complex wounds and revascularization of wound bed

If pedicle flap is used donor vessel from

nonirradiated tissue bed is preferred to minimize risk of flap necrosis

Wounds with this content of bacteria will not close and cannot support skin graft

>10 to the fifth bacteria/g

Oxygenases require minimum oxygen tension to function properly

20mmHg

Presence of this organism prevents wound healing

Beta hemolytic Streptococcus

Cytotoxic Inhibitor of angiogenesis Poorly vascularized fibrotic wound and inhibited fibroblast activity

Radiation

Congested wound with heavy drainage and poor immune cell/fibroblast wound localization Can lead to hypoxic tissue

Venous inssuficiency

Involved in crosslinking glycine residues from differing collagen bundles Involved in collagen synthesis

Vitamin C Deficiency results in scurvy

Involved in bone growth and vision Deficiency impairs monocyte activation cell localization and cell adhesion resulting in night blindness, xeropthalmia, keratomalacis

vitamin A | retinol

Promotes catabolic state and inhibits immune cell localization (PMN supressed)

Corticosteroid use

Impairment of wound healing by corticosteroid use is mitigated with

Topical Vitamin A administration

Antiangiogenesis therapy

bevacizumab

Associated with relative upregulation of MMP 2 and MMP 9 | Dec collagen synthesis

Aging

Skin bones tendon Ehlers Danlos Osteogenesis imperfecta Scurvy Primary form in healed wound

Type I

Cartilage Chondrodysplasia

Type II

Blood vessel skin granulation tissue Ehlers-Danlos syndrome Primary form in early phases of wound healing

Type III

Basement membrane lens of eye Alport syndrome

Type IV

Critical for wound healing | Requires Vit C for synthesis of repeating triplets of glycine-X-proline or glycine-X-lysine

Collagen

Suture removal face:

3-5 days

Suture removal neck/scalp:

5-7

Suture removal trunk:

10-14 days

Suture removal extremities:

10-14 days

Tissue re-approximation at time of injury

Primary closure

Tissues are not initially closed (initially too extensive to close) and close via tissue proliferation at edges

Secondary closure

Delayed primary closure Wound is purposely left open or had remained open for > 6-8 hours >12-24 h for highly vascular wounds such as neck, face, scalp Reapproximated at later time

Tertiary closure

Basic gold standard closure Enters perpendicular to skin and follow natural curve of needle creating trapezoid loop with skin edge eversion Staples are alternative

Simple interrupted

Used to increase skin eversion and direct skin tension away from wound edge and toward distal suture line

Vertical mattress

Improved tissue eversion and better hemostatic properties Most useful for thick skin (hands, feet)

Horizontal mattress

Superficial closure of dermal-epidermal junction minimizes external scars created by external sutures Not load bearing closure and should be combined with external strips, adhesive, deeper subdermal closure to reinforce

Subcuticular running

25, F African American Develops large keloid on left ear lobe after piercing Mx

Steroid injection INFy injection Topical retinoid improves appearance Surgical debulking and ear reconstruction followed by EBRT to minimize chance of recurrence

Percentage of keloids recurring following surgical excision alone

45-100%

Locally aggressive scar which original scar tissue extends beyond borders of original wound Collagen inappropriately deposited in adjacent tissue by dysregulation of collagen degradation and deposition ie fibroblast collagen synthesis is 20 fold normal Develops within 3 months of tissue injury

Keloid

How to prevent keloid formation

Minimize nonessential incision | Perform tension free repair

Dysregulated collagen deposition restricted to original wound border Dec genetic predisposition and related to chronic inflammation Occurs within 4 weeks Improved response to surgical resection

Hypertrophic scars

Most susceptible areas of pressue sore formation

Occiput Sacrum Heels supine

Stage I and II PU heal

wound care

Stage III-IV PU need

Vacuum assisted closure VAC | to stimulate granulation and dec wound size

Intact epidermis with nonblanching erythema | Heralds ulceration if pressure not relieved

Stage I

Partial thickness epidermal-to-superficial dermal ulceration or blistering

Stage II

Full thickness loss of epidermis and dermis with necrosis or ulceration extending to subcutaneous tissue No violation of underlying fascia Deep crater frequently superinfected

Stage III

Full thickness skin loss with fascial loss, extensive soft tissue necrosis, extension into underlying deep tissues Exposed muscle or bone evident on exam Superinfected

Stage IV

Basic premise of plastic and reconstructive surgery

Restoration of form and function

Reasons for failed skin graft

Poor skin hates infection: Poor vascular supply Shear mechanicsl force Hematoma Infection

Epidermis and portion of dermis For large surface area wounds (burn) in which coverage is more important than function Meshed to inc surface area Increased contracture rate Donor site closes secondarily via reepithelialization from upregulated dermal appendage Donor site can be reharvested for additional graft

Split thickness skin graft

Epidermis and complete dermis Used for mobility, sensation and cosmesis (over joint, digit, face) Dec risk of contracture Improved movement Greater sensation

Full thickness skin graft

Skin grafts adhere to wound on fragile fibrin scaffold within

3 days of placement

Allows for direct nutrient supply to new graft in first 24 h

Imbibition

Graft vessels align and anastomose with recipient bed and provides blood supply until angiogenesis in 5-7d

Inosculation

19, tibial fracture with extensive degloving 30cm exposed tibia Neovascularly intact Wound closure?

Gracilis free flap with STSG of muscular flap

Indication for skin flap wound closure

Poorly vascularized bed Full thickness facial injury (eyelid, lip, ear, nose) Deep soft tissues Exposed tendon or bone

Have own blood supply | Do not depend on wound bed for initial survival

Reconstructive flaps

Cutaneous flap in areas where wounds cannot be closed primarily or where skin graft would fail or result in unacceptable function or cosmesis locally elevated and rotated or advanced into wounds with primary closure of secondary defect

Local flap

Fasciocutaneous or mycocutaneous flap used in wounds where defect is too large for local advancement or requires additional soft tissue bulk Blood supply from named vessel or known cutaneous angiosome Use is limited by length of donor vessel

Pedicle flap

Most common cause of free flap failure

Venous congestion

Tissue transfer to distant location For wounds requiring specialized tissue (bone, nerve, enteral conduit) Requires microvascular anastomoses of arterial and venous system For head and neck reconstruction (free transverse rectus abdominis muscle TRAM and limb salvage rectus, gracilis)

Free flap

If ischemia is suspected, perform emergent

reexploration of flap

Most common breast reconstruction technique

Implant reconstruction

Implant reconstruction indication

Need for bilateral reconstruction (though free tissue recon is feasible) Patient inability to tolerate extended operative time Lack of adequate donor site CI: adjuvant radiation

tissue expander followed by silicone or saline prosthesis submuscularly with skin flaps closed primarily over site Single stage reconstruction may be performed

Implant reconstruction

Most common autogenous reconstruction Myocutaneous tissue transfered based on epigastric artery and includes abdominal adipose and skin

TRAM flap | TRAM variant

TRAM pedicled on

Superior epigastric artery

TRAM harvested as free flap

Inferior epigastric artery

More robust blood supply than pedicled TRAM but do require microvascular anastomosis to IMA

TRAM

CI to TRAM

prior abdominoplasty patient inability to tolerate extended operative time significant blood loss

Complications of TRAM

postoperative abdominal wall laxity 20 partial flap failure 20 complete flap failure 4

Pedicled flap transposing lats dorsi and blood supply (thoracodorsal)

Latissimus dorsi flap

Primary alternative to TRAM with anatomic TRAM CI Single stage procedure but implant necessary for additional bulk CI: nodal or axillary radiation, prior thoracotomy, adjuvant radiotherapy

Latissimus dorsi flap

Irradiated cadaveric skin used in burn closure or abdominal wall reconstruction Useful in contaminated wound such as open abdomen closure after trauma

Allograft

Dermal sub made from silicone and nylon Breathable closure where clot can form to facilitate deep tissue granulation

Biosynthetic dermal substitute

Crossedlinked sheets with silicon outer layer Promotes dermal healing and breathable barrier function

Bovine collagen

Made from patient’s own cell | Cultured with mouse epidermal cell that supply proliferation signals

Keratinocyte sheet

Wounds amenable to tertiary closure Except?

Wounds that have been open for more than 6-8 hours Except facial injuries which can remain open for 12-24h (highly vascular)

Tx of acute ischemic flap from venous congestion

Emergent exploration | Leech use to temporize congested flap until they develop own collaterals

Advantage of free flap compared to pedicle flap Disadvantage

Large number of donor Immediate defect closure Independent microcirculation Anastomoses Lack collateral circulation

Potentially contaminated wound preferred closure?

Interrupted suture compared to subcuticular running closure Dec association with risk of infection