Plastic/reconstructive surgeries

Question 1

What are candidates for primary closure of wounds (aka immediate closure of wounds)?

Answer 1

“clean traumatic” with 3-6 golden hour window, tissue is healthy and not heavily contaminated, can also do En Bloc if dirty

Question 2

Delayed primary closure wound is left open for __-__ days before granulation tissue formation

Answer 2

2-5 days

Question 3

Delayed primary closure wounds permit what?

Answer 3

Repeated lavage and debridement to convert wound to clean contaminated status that is appropriate for closure

Question 4

What wounds are candidates for second intention closure?

Answer 4

• Dirty/Infected
• Insufficient skin to close
• Financial constraints

Question 5

Incision lines or wound closure lines should be ___ to _____ ____

Answer 5

parallel to tension lines

Question 6

What are the tension relieving techniques we talked about?

Answer 6

Undermining, walking sutures, strong subq sutures, tension relieving sutures, skin stretching techniques and relaxing the incision

Question 7

Undermining means to do what?

Answer 7

Blunt dissect under the panniculus muscle, preserves direct cutaneous vessels

Question 8

What are some skin stretching techniques?

Answer 8

Mechanical creep, stress relaxation, biological creep

Question 9

What are examples of relaxing incision methods?

Answer 9

Single or multiple releasing incision, Z-plasty, M-Plasty, V to Y Plasty

Question 10

Guidelines for flap development-

Answer 10

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)

Question 11

Rotating flaps are semicircular flaps that cover the defect ____ to the ____

Answer 11

adjacent to the flap

Question 12

what are examples of rotating flaps??

Answer 12

Elbow fold flap or flank fold flap

Question 13

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??

Answer 13

Transposition flap

Question 14

What is it called when there are two incisions made roughly perpendicular to wound (single pedicle)

Answer 14

Advancement flap

Question 15

“pouch flap” aka

Answer 15

direct distant flap

Question 16

___ pattern flaps are based on direct cutaneous arteries

Answer 16

Axial pattern flaps

Question 17

What is the most common skin grafting technique?

Answer 17

Sheet, full thickness

Question 18

Cessation of wound contraction involves tension in surrounding skin exceeding ?

Answer 18

the pull of myofibroblasts

Question 19

***As myofibroblasts lay down ____ they increase tension and cause_____

Answer 19

collagen; contraction

Question 20

What does too much tension cause?

Answer 20

Dehiscence, compromise of bf, distal wounds with biologic tourniquet

Question 21

Skin stretching via presuturing are when sutures are placed ___-___ days before sx

Answer 21

1-3 days

Question 22

what releasing incisions must be bandaged?

Answer 22

Multiple releasing incisions parallel to the incision that are staggered to preserve bf and heal by second intention

Question 23

What is the easiest angle for a Z-Plasty?

Answer 23

60 degrees

Question 24

What are 3 common challenges with primary wound closure?

Answer 24

Dog ears, step defects, irregular wounds

Question 25

How can we close irregular wounds with one end longer as the goal?

Answer 25

Bites closer together on short end, bites further apart on long end, closes in straight line, “bisecting” technique

Question 26

When you should close delayed primary closure?

Answer 26

2-5 days after injury

Question 27

secondary closure via ______ ______ is allowed to form in wound prior to closure in ___-___ days

Answer 27

Granulation tissue; 5-7 days

Question 28

Rectangular pedicle flap developed within ___ angle of long axis of the defect

Answer 28

90 degrees

Question 29

*What is an interpolation flap (local)

Answer 29

subdermal plexis flap, does not share a common border, crosses intake skin

Question 30

Axial flaps are based on what? what do they contain?

Answer 30

Direct cutaneous arteries; contain direct arterial supply

Question 31

Complications involved with caudal superficial epigastric flap?

Answer 31

Flap necrosis (inadequate perfusion (too long, tension, excessive manipulation, kinking of vessels with more than 180 angle rotation)

Question 32

Never rotate a flap more than _____ degrees***

Answer 32

180 degrees

Question 33

Recipient bed requirements where grafts will take–>

Answer 33

Requires rich vascular supply, fresh wound with healthy blood supply, healthy muscle, NOT bone or tendon, avascular fat, chronic granulation, etc.
Free of infection

Question 34

Mesh graft allows for what?

Answer 34

Allows for drainage of blood and serum from under graft

Question 35

The process of “graft take” (Avascular engraftment) -

Answer 35

Adherence (fibrin strands in Phase 1, Fibroblasts in Phase 2), plasmatic inhibition, inosculation, neovascularization

Question 36

What are the 3 ways grafts get nutrients?

Answer 36

Plasmatic imbibtion, inosculation, neovascularization

Question 37

What are the stages of graft healing?

Answer 37

Fluid from graft bed (serum), peaks at 48 hrs, tissues become edematous, cyanotic = normal

Question 38

Inosculation is defined as…

Answer 38

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!!

Question 39

Neovascularization is ingrowth of new ____ and peaks at ___-__ days post sx

Answer 39

Vessels; peaks at 5-7 days post sx

Question 40

What are some causes of graft failure???

Answer 40

Movement, hematomas, seromas, infection, poor blood supply to graft bed

Question 41

**Tension in surrounding skin exceeding pull of myofibroblasts =

Answer 41

Cessation of wound contraction***

Question 42

Define mechanical creep:

Answer 42

Skin is “viscoelastic”
Defined as elongation under constant load
Unraveling of collagen/elastin bundles
Parallel to tension

Question 43

Define biological creep:

Answer 43

creation of new dermal and epidermal components after a prolonged, constant load (i.e. new skin)
Loose skin after weight loss
Large tumors, etc…

Question 44

you must bandage releasing incision, t/f

Answer 44

true!!!

Question 45

**Rotating flaps are semicircular flaps covering the defect ____ to ___ and includes which two types???

Answer 45

Adjacent to the flap; elbow fold flap and flank fold flap

Question 46

**Transposition flaps:

Answer 46

rectangular pedicle flap developed within 90° of the long axis of the defect, with one border adjacent to wound bed

Question 47

What flaps have direct cutaneous arteries involved??

Answer 47

Axial pattern flaps

Question 48

What allows for drainage of blood and serum from under a skin graft?

Answer 48

Mesh graft (sheet graft with staggered slits parallel)

Question 49

** The Process of “Graft Take” (Avascular Engraftment)

Answer 49

Adherence, plasmatic imbibition, inosculation, neovascularization

Question 50

**What is the “golden window” for closing a clean traumatic wound?

Answer 50

3-6 hrs

Question 51

Closing in 5-7 days is what type of closure?

Answer 51

Secondary closure

Question 52

Closing in 2-5 days is what type of closure?

Answer 52

delayed primary closure

Question 53

what is the safest timing for a distant flap?

Answer 53

3 weeks