Plastic/reconstructive surgeries Flashcards
What are candidates for primary closure of wounds (aka immediate closure of wounds)?
“clean traumatic” with 3-6 golden hour window, tissue is healthy and not heavily contaminated, can also do En Bloc if dirty
Delayed primary closure wound is left open for __-__ days before granulation tissue formation
2-5 days
Delayed primary closure wounds permit what?
Repeated lavage and debridement to convert wound to clean contaminated status that is appropriate for closure
What wounds are candidates for second intention closure?
- Dirty/Infected
- Insufficient skin to close
- Financial constraints
Incision lines or wound closure lines should be ___ to _____ ____
parallel to tension lines
What are the tension relieving techniques we talked about?
Undermining, walking sutures, strong subq sutures, tension relieving sutures, skin stretching techniques and relaxing the incision
Undermining means to do what?
Blunt dissect under the panniculus muscle, preserves direct cutaneous vessels
What are some skin stretching techniques?
Mechanical creep, stress relaxation, biological creep
What are examples of relaxing incision methods?
Single or multiple releasing incision, Z-plasty, M-Plasty, V to Y Plasty
Guidelines for flap development-
o Large enough to cover defect (1-1.5 x the size/length of defect)
o Avoid incisions converging towards base (base slightly wider than tip)
o Undermine to preserve subdermal plexus (under panniculus if possible)
Rotating flaps are semicircular flaps that cover the defect ____ to the ____
adjacent to the flap
what are examples of rotating flaps??
Elbow fold flap or flank fold flap
What flap types are rectangular pedicle flaps developed within 90 degrees of the long axis of the defect, with one border adjacent to the wound bed??
Transposition flap
What is it called when there are two incisions made roughly perpendicular to wound (single pedicle)
Advancement flap
“pouch flap” aka
direct distant flap
___ pattern flaps are based on direct cutaneous arteries
Axial pattern flaps
What is the most common skin grafting technique?
Sheet, full thickness
Cessation of wound contraction involves tension in surrounding skin exceeding ?
the pull of myofibroblasts
***As myofibroblasts lay down ____ they increase tension and cause_____
collagen; contraction
What does too much tension cause?
Dehiscence, compromise of bf, distal wounds with biologic tourniquet
Skin stretching via presuturing are when sutures are placed ___-___ days before sx
1-3 days
what releasing incisions must be bandaged?
Multiple releasing incisions parallel to the incision that are staggered to preserve bf and heal by second intention
What is the easiest angle for a Z-Plasty?
60 degrees
What are 3 common challenges with primary wound closure?
Dog ears, step defects, irregular wounds
How can we close irregular wounds with one end longer as the goal?
Bites closer together on short end, bites further apart on long end, closes in straight line, “bisecting” technique
When you should close delayed primary closure?
2-5 days after injury
secondary closure via ______ ______ is allowed to form in wound prior to closure in ___-___ days
Granulation tissue; 5-7 days
Rectangular pedicle flap developed within ___ angle of long axis of the defect
90 degrees
*What is an interpolation flap (local)
subdermal plexis flap, does not share a common border, crosses intake skin
Axial flaps are based on what? what do they contain?
Direct cutaneous arteries; contain direct arterial supply
Complications involved with caudal superficial epigastric flap?
Flap necrosis (inadequate perfusion (too long, tension, excessive manipulation, kinking of vessels with more than 180 angle rotation)
Never rotate a flap more than _____ degrees***
180 degrees
Recipient bed requirements where grafts will take–>
Requires rich vascular supply, fresh wound with healthy blood supply, healthy muscle, NOT bone or tendon, avascular fat, chronic granulation, etc.
Free of infection
Mesh graft allows for what?
Allows for drainage of blood and serum from under graft
The process of “graft take” (Avascular engraftment) -
Adherence (fibrin strands in Phase 1, Fibroblasts in Phase 2), plasmatic inhibition, inosculation, neovascularization
What are the 3 ways grafts get nutrients?
Plasmatic imbibtion, inosculation, neovascularization
What are the stages of graft healing?
Fluid from graft bed (serum), peaks at 48 hrs, tissues become edematous, cyanotic = normal
Inosculation is defined as…
anastomosis of cut ends of capillaries which can start at 22 hrs and is more prominent at 48-72 hrs SO DONT BANDAGE BEFORE 48 HRS!!
Neovascularization is ingrowth of new ____ and peaks at ___-__ days post sx
Vessels; peaks at 5-7 days post sx
What are some causes of graft failure???
Movement, hematomas, seromas, infection, poor blood supply to graft bed
**Tension in surrounding skin exceeding pull of myofibroblasts =
Cessation of wound contraction***
Define mechanical creep:
Skin is “viscoelastic”
Defined as elongation under constant load
Unraveling of collagen/elastin bundles
Parallel to tension
Define biological creep:
creation of new dermal and epidermal components after a prolonged, constant load (i.e. new skin)
Loose skin after weight loss
Large tumors, etc…
you must bandage releasing incision, t/f
true!!!
**Rotating flaps are semicircular flaps covering the defect ____ to ___ and includes which two types???
Adjacent to the flap; elbow fold flap and flank fold flap
**Transposition flaps:
rectangular pedicle flap developed within 90° of the long axis of the defect, with one border adjacent to wound bed
What flaps have direct cutaneous arteries involved??
Axial pattern flaps
What allows for drainage of blood and serum from under a skin graft?
Mesh graft (sheet graft with staggered slits parallel)
** The Process of “Graft Take” (Avascular Engraftment)
Adherence, plasmatic imbibition, inosculation, neovascularization
**What is the “golden window” for closing a clean traumatic wound?
3-6 hrs
Closing in 5-7 days is what type of closure?
Secondary closure
Closing in 2-5 days is what type of closure?
delayed primary closure
what is the safest timing for a distant flap?
3 weeks
