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Surgery > Plastic And Reconstructive Surgery > Flashcards

Plastic And Reconstructive Surgery Flashcards

1
Q

Time of injury until 3-4 days after injury

Hemostasis and inflammation-sterilization phase

A

Inflammation

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2
Q 
Platelet aggregation and release of vasoconstrictive factors (TXA, Factor V) 
Proinflammatory cytokine (PDGF, TGFB, IGF1, fibrinogen)

Leading to PMN recruitment

A

Hemostasis

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3
Q

Cell recruitment

A

Neutrophil -> Mac -> Fibroblast -> Lymphocyte

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4
Q

Matrix synthesis 1st to last

A

Fibronectin
Collagen III
Collagen I (stays)
Wound breaking strength

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5
Q

PMNs induce vasodilation and recruitment of mac, lymphocyte, fibroblast

Superoxide and collagenase sterilize and degrade devitalized tissue

A

Inflammation-sterilization

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6
Q

Major chemoattractant for fibroblast during proliferation phase

A

PDGF

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7
Q

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

A

80%

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8
Q

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

A

Proliferation

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9
Q

Fibroblast activated by macrophage via EGF and IGF1

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

A

Fibroplasia

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10
Q

Collagen network provides scaffolding for vascular framework

A

Granulation

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11
Q

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

Initial framework comprises developing membrane

A

Epithelialization

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12
Q

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

Maximum wound strength is achieved by

A

Remodelling and maturation

1 year

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13
Q

Scars are dense collagen matrixes that lack

A

Dermal appendages such as hair follicle or sweat gland

Tensile strength 70-80% original tissue

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14
Q

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

Final crosslinking contributes to final scar

A

Contracture

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15
Q

Source: Mac, T cell

Target cell: fibroblast, mac

Activates mac, PMN, fibroblast
Induces collagenase activity

A

IFNy

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16
Q

Source: Mac, fibroblast

Target: keratinocyte, endothelial cell, fibroblast

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

A

IGF-1

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17
Q

Source: PMNs, mac

Target cell: Fibroblasts, keratinocyte

Recruits fibroblast, keratinocyte
Induces collagen synthesis

A

IL1alpha

IL1beta

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18
Q

Source: T cell

Target cell: Fibroblast

Recruits and triggers mitosis in fibroblast

A

IL2

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19
Q

Source: Mac, Platelet, endothelial cell

Target: PMN, Mac, fibroblast, endothelial cell

Recruit PMN, mac, fibroblast
Stimulates angiogenesis
Inc vascular permeability

A

PDGF

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20
Q

Source: mac, platelet, fibroblast

Target: fibroblast, keratinocyte, endothelial cell

Induces mitosis in fibroblast, keratinocyte
Promotes angiogenesis, matrix production

A

TGFB

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21
Q

Source: PMNs

Target cell: Mac, fibroblast

Activates immune cells
Recruits mac
Induces cytotoxicity

A

TNFalpha

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22
Q

Source: Mac, keratinocyte

Target: keratinocyte, endothelial cell

Stimulates angiogenesis
Induces inc vascular endothelial permeability

A

VEGF

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23
Q

Most susceptible to radiation injury

A

fibroblast
keratinocyte
basal epithelial cell

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24
Q

endothelial cell damage creates

A

hypoxic wound bed and severe inhibition of angiogenesis

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25
Q

If patient presents with radiation-induced ulceration

Confirm that ulceration is

A

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

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26
Q

If pedicle flap is used donor vessel from

A

nonirradiated tissue bed is preferred to minimize risk of flap necrosis

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27
Q

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

A

> 10 to the fifth bacteria/g

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28
Q

Oxygenases require minimum oxygen tension to function properly

A

20mmHg

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29
Q

Presence of this organism prevents wound healing

A

Beta hemolytic Streptococcus

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30
Q

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

A

Radiation

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31
Q

Congested wound with heavy drainage and poor immune cell/fibroblast wound localization

Can lead to hypoxic tissue

A

Venous inssuficiency

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32
Q

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

A

Vitamin C

Deficiency results in scurvy

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33
Q

Involved in bone growth and vision

Deficiency impairs monocyte activation
cell localization and cell adhesion resulting in night blindness, xeropthalmia, keratomalacis

A

vitamin A

retinol

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34
Q

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

A

Corticosteroid use

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35
Q

Impairment of wound healing by corticosteroid use is mitigated with

A

Topical Vitamin A administration

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36
Q

Antiangiogenesis therapy

A

bevacizumab

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37
Q

Associated with relative upregulation of MMP 2 and MMP 9

Dec collagen synthesis

A

Aging

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38
Q

Skin bones tendon

Ehlers Danlos
Osteogenesis imperfecta
Scurvy

Primary form in healed wound

A

Type I

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39
Q

Cartilage

Chondrodysplasia

A

Type II

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40
Q

Blood vessel skin granulation tissue

Ehlers-Danlos syndrome

Primary form in early phases of wound healing

A

Type III

41
Q

Basement membrane lens of eye

Alport syndrome

A

Type IV

42
Q

Critical for wound healing

Requires Vit C for synthesis of repeating triplets of glycine-X-proline or glycine-X-lysine

A

Collagen

43
Q

Suture removal face:

A

3-5 days

44
Q

Suture removal neck/scalp:

A

5-7

45
Q

Suture removal trunk:

A

10-14 days

46
Q

Suture removal extremities:

A

10-14 days

47
Q

Tissue re-approximation at time of injury

A

Primary closure

48
Q

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

A

Secondary closure

49
Q

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

A

Tertiary closure

50
Q

Basic gold standard closure

Enters perpendicular to skin and follow natural curve of needle creating trapezoid loop with skin edge eversion

Staples are alternative

A

Simple interrupted

51
Q

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

A

Vertical mattress

52
Q

Improved tissue eversion and better hemostatic properties

Most useful for thick skin (hands, feet)

A

Horizontal mattress

53
Q

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

A

Subcuticular running

54
Q

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

Mx

A

Steroid injection
INFy injection
Topical retinoid improves appearance

Surgical debulking and ear reconstruction followed by EBRT to minimize chance of recurrence

55
Q

Percentage of keloids recurring following surgical excision alone

A

45-100%

56
Q

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

A

Keloid

57
Q

How to prevent keloid formation

A

Minimize nonessential incision

Perform tension free repair

58
Q

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

A

Hypertrophic scars

59
Q

Most susceptible areas of pressue sore formation

A

Occiput
Sacrum
Heels

supine

60
Q

Stage I and II PU heal

A

wound care

61
Q

Stage III-IV PU need

A

Vacuum assisted closure VAC

to stimulate granulation and dec wound size

62
Q

Intact epidermis with nonblanching erythema

Heralds ulceration if pressure not relieved

A

Stage I

63
Q

Partial thickness epidermal-to-superficial dermal ulceration or blistering

A

Stage II

64
Q

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

A

Stage III

65
Q

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

A

Stage IV

66
Q

Basic premise of plastic and reconstructive surgery

A

Restoration of form and function

67
Q

Reasons for failed skin graft

A

Poor skin hates infection:

Poor vascular supply
Shear mechanicsl force
Hematoma
Infection

68
Q

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

A

Split thickness skin graft

69
Q

Epidermis and complete dermis

Used for mobility, sensation and cosmesis (over joint, digit, face)

Dec risk of contracture
Improved movement
Greater sensation

A

Full thickness skin graft

70
Q

Skin grafts adhere to wound on fragile fibrin scaffold within

A

3 days of placement

71
Q

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

A

Imbibition

72
Q

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

A

Inosculation

73
Q

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

Wound closure?

A

Gracilis free flap with STSG of muscular flap

74
Q

Indication for skin flap wound closure

A

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

75
Q

Have own blood supply

Do not depend on wound bed for initial survival

A

Reconstructive flaps

76
Q

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

A

Local flap

77
Q

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

A

Pedicle flap

78
Q

Most common cause of free flap failure

A

Venous congestion

79
Q

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)

A

Free flap

80
Q

If ischemia is suspected, perform emergent

A

reexploration of flap

81
Q

Most common breast reconstruction technique

A

Implant reconstruction

82
Q

Implant reconstruction indication

A

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

83
Q

tissue expander followed by silicone or saline prosthesis submuscularly with skin flaps closed primarily over site

Single stage reconstruction may be performed

A

Implant reconstruction

84
Q

Most common autogenous reconstruction

Myocutaneous tissue transfered based on epigastric artery and includes abdominal adipose and skin

A

TRAM flap

TRAM variant

85
Q

TRAM pedicled on

A

Superior epigastric artery

86
Q

TRAM harvested as free flap

A

Inferior epigastric artery

87
Q

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

A

TRAM

88
Q

CI to TRAM

A

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

89
Q

Complications of TRAM

A

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

90
Q

Pedicled flap transposing lats dorsi and blood supply (thoracodorsal)

A

Latissimus dorsi flap

91
Q

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

A

Latissimus dorsi flap

92
Q

Irradiated cadaveric skin used in burn closure or abdominal wall reconstruction

Useful in contaminated wound such as open abdomen closure after trauma

A

Allograft

93
Q

Dermal sub made from silicone and nylon

Breathable closure where clot can form to facilitate deep tissue granulation

A

Biosynthetic dermal substitute

94
Q

Crossedlinked sheets with silicon outer layer

Promotes dermal healing and breathable barrier function

A

Bovine collagen

95
Q

Made from patient’s own cell

Cultured with mouse epidermal cell that supply proliferation signals

A

Keratinocyte sheet

96
Q

Wounds amenable to tertiary closure

Except?

A

Wounds that have been open for more than 6-8 hours

Except facial injuries which can remain open for 12-24h (highly vascular)

97
Q

Tx of acute ischemic flap from venous congestion

A

Emergent exploration

Leech use to temporize congested flap until they develop own collaterals

98
Q

Advantage of free flap compared to pedicle flap

Disadvantage

A

Large number of donor
Immediate defect closure
Independent microcirculation

Anastomoses
Lack collateral circulation

99
Q

Potentially contaminated wound

preferred closure?

A

Interrupted suture compared to subcuticular running closure

Dec association with risk of infection

Surgery (17 decks)

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