Plastic Surgery Flashcards
What are the 3 stages of wound healing and when do they BEGIN?
- Coagulation stage - 10-15 min after wound formation
- Inflammatory stage - first 24 hrs
- Initial proliferation - days 2-3
What happens during the coagulation stage?
- vasoconstriction, clotting cascade in first 10-15 min
- vasodilation 2/2 histamine, complement, kinins, PGs
What happens during the inflammatory stage? (early, late)
- Early - platelets release chemotactants, vasogenic amines, GFs. PMNs attracted to site.
- Late - blood monocytes/macrofages infiltrate at 48-72 hrs, replace PMNs
- Epithelialization begins by POD 2, Begins at wound edge, enlarges, flattens, migrates over wounds, dissolves clots and scabs
By 6 wks after wound formation ___% of strength is gained
60
What happens during the initial proliferation phase of wound healing? (2)
- collagen formation
- macrophages replaced by fibroblasts
When does the proliferative phase of wound healing occur and what 3 main things happen during this time?
- days 4-24
- Angiogenesis, fibroplasia, epithelialization continues
At what time do fibroblasts become the predominate cells during wound healing?
- Day 7
What is the role of the fibroblasts in wound healing (what do they produce) (3)?
- make fibronectins
- glycosaminoglycans
- Collagen (initially type III)
3 weeks after a wound the wound will be in the _____ stage
maturation/remodeling
What happens during the maturation/remodeling stage? (3)
- collagen III –> I (stronger)
- tensile strength increases due to collagen crosslinking (but never reaches full, max 80%)
- cells are myofibroblasts
How long does it take for scars to form?
up to 1 year
How do you treat abrasions?
scrub brush or dermabrasion to avoid traumatic tattoos
How do you treat contusions?
evacuate hematomas - cold early on, heat later
How do you treat lacerations?
debridement and suture
How do you treat punctures?
evaluate for underlying damage, debridement, and primary or secondary intention
What 3 things should occur during debridements?
- actual bleeding should be seen
- dress the wound in wet to drys - needs to be continuously moist
- tetanus shot, culture wound, abx
debridement must occur constantly for _______ wounds
chronically infected
____ will determine the extent of infection
x-ray
you must assess vascular supply of wounds with _____ (3)
- Doppler, angiogram, pulses
for wound healing you must have ____ control
glycemic
What is the role of hyperbaric O2 in wound healing?
- O2 gradient between the center of the wound and edge initiates wound healing
- helps neutrophils kill bacteria, aids in collagen synthesis and angiogenesis
What is healing w/2nd intention used for?
small wounds or if patient is too ill for the operation
What is a potential AE from healing w/2nd intention.
Marjolin’s ulcer (SCC)
What is primary intention closure and what is it used for?
- direct reapposition of wound skin edge
- used for low velocity
With primary intention closure look for signs of _____ that includes ______
- excessive skin tension
- pallor, loss of distal pulses, compartment pressures >30
What is secondary intention wound closure?
- wound left open to heal spontaneously via inflammatory phase
What happens during secondary intention wound healing?
- wound contracts and margins meet and re-epithelialize
What is tertiary intention closure?
Delayed wound closure and healing is intentionally interrupted
Primary contracture definition
contracture of the dermis due to elastin (the more dermis the more contracture). Full thickness skin grafts (FTSG) have the most primary contracture
Secondary contracture definition
contraction of the healed scar d/t myofibroblast activity. The thinner the graft the greater the contracture, as with split thickness skin graft (STSG) because the dermis layer inhibits contracture and STSG has less of the dermis
What is a split thickness graft (STSG)?
- epidermis + part of the dermis
What kind of split thickness graft has a better chance of taking?
thin grafts
Disadvantages to split-thickness grafts?
- shrinks in size as it heals since less dermis means its less affective at inhibiting secondary contraction
- less cosmetic d/t hyperpigmentation - DO NOT use on the hands or face
- more chance of trauma
What is a full thickness graft (FTSG)
- epidermis + dermis
Advantages to FTSG (2)
- inhibits contraction by inhibiting myofibroblast proliferation
- better cosmetic results
Disadvantages to FTSG (3)
- Less of a chance that it will take
- more primary contracture
- Less can be harvested
What are the complications of skin grafts (4) and which of these is the most common cause of skin graft failure?
- hematoma - MOST COMMON
- seroma
- infection
- shearing of the graft from the underlying bed causing rupture of tenuous attachments that allow revascularization of the graft
When is the plasmatic imbibition phase and what is it?
- 48 hrs
- its the diffusion of nutrients form recipient site to graft since the graft is ischemic and will take up the fluid from the underlying bed
STSG can tolerate plasmatic imbibition phase for __ days, and FTSG can tolerate it for __ days
- 5
- 3
Describe where capillary formation is at at 3 days
- Inosculation, “kissing” of pre-existing bvs
Describe where capillary formation is at at 5 days
- Angiogenesis - capillaries budding from the bed and circulation begins in the graft
What is the difference between skin grafts and flaps?
- grafts DON’T have their own blood supply
- flaps DO have their own blood supply
What is the difference between local vs. regional flaps?
- local flaps have random blood supply
- regional flaps have a known blood supply
What is the difference between pedicle vs. free flaps?
- own blood supply vs. supply not intact
TRAM flap
- transrectus abdominus musculocutaneous flap
- takes rectus muscle and moves it to the contralateral side with it’s blood supply
DIEP flap
Deep inferior epigastric perforators (free flap)
- removing skin and fat superior to the rectus muscles w/perforating arteries intact adn dissected out
- muscle sparing
____ and ___ slow healing dramatically
- smoking/nicotine
- glycemic
You worry about patients smoking and glycemic controls particularly after ____ surgeries because of ____
- flaps
- anastomoses
What affect do steroids have on healing?
- they inhibit macrophages and fibrogenesis
What do you want to give with steroids if the person has a wound that needs to heal? For how long do you give this?
- Vitamin A - counteracts their effect
- Give for 5 days if they’re healing from an incision, 10 days if it’s a chronic wound
Keloid scars - what are they? what is their pathophysiology?
- extend beyond the suture border
- 2/2 overabundance of collagen
- 75% relapse
How do you treat keloid scars?
- steroid injections
- radiation
- chemo (topical 5-FU)
- pressure therapy
- excision
Hypertrophic scars
- scars that stay within the suture line
- they tend to improve and have normal levels of collagen and fibrin
W/healing you expect to see _____ tissue and ___% healing per week
- red, bloody granulation tissue
- 10-15%
fat necrosis often looks like ____
pus
dry gangrene is 2/2 ___. Does it require immediate removal?
- ischemia
- no, it’s ok to leave on temporarily
wet gangrene is 2/2 ___. Does it require immediate removal? The next step when you find this is to ____.
- infection
- YES
- take an x-ray to look for air
____ causes gas in wet gangrene, but ___ causes a ______ infection that travels.
- clostridium
- strep
- necrotizing fasciitis
__ angiosomes in the foot/ankle (angiosomes = 3D space supplied by a given bv).
- __ come from the posterior tibial
- __ come from the anterior tibial
- __ come from the peroneal artery
- 6
- 3
- 1
- 2
How do autoimmune/vasculitis pts typically do if you operate on them?
worse! You don’t want to surgically debride
Buzzwords for pyoderma 2/2 AI/vasculitis origins?
pain out of proportion to the exam
what are the 3 types of burns?
- chemical
- electrical
- thermal
What is the % body surface area (BSA) of head, arms, back, chest, legs, perineum?
RULE OF 9S Head: 9% Each arm: 9% Back and chest each: 18% Each leg: 18% Perineum: 1%
How do you treat 2/3rd degree burns?
FLUIDS FLUIDS FLUIDS
- Silvadene
- IV narcotics
- tetanus/stress ulcer ppx
- early placement of biologic dressing/skin graft to PREVENT CONTRACTURES
Describe a first degree burn (4)
- only epidermis, dermis intact
- no blisters
- looks like a sunburn
- painful
How do you treat first degree burns specifically?
Silvadene (antimicrobial) + analgesics
Describe a second degree burn
- epidermis and part of the dermis
- blisters
- painful
Describe a third degree burn
- epidermis and full thickness of the dermis
- INSENSATE
- feels rubbery
- white (lacks capillary refill), charred
Describe fluid management in pts w/2nd/3rd degree burns
- want to maintain 1cc/kg/hr of urine
- first 24 hrs - 4x the pts weight in kgs x %BSA
- 50% of this should be given over the first 8 hrs and remaining over the following 16 hrs
What are 3 complications of burns?
- Shock
- Compartment syndrome
- Superinfection (pseudomonas or staph)
0.3 negative margins are needed when removing a ___
BCC
What type of BCC is most common? Most aggressive?
- nodular
- morpheaform
0.5 negative margins are needed when removing a ___ & ____
- SCC
- in situ melanoma
____ is a precursor to SCC. ____ is SCC in situ
- Actinic keratosis
- Bowmen’s
Melanoma prognosis and margins depend on _____ of the cancer
depth
_____ is the most common type of melanoma
superfical spreading
If a melanoma is < 1 mm in depth you want a ____ cm margin, if its >1 mm in depth you want a ____ cm margin
- 1 cm
- 2 cm
____ melanomas have vertical growth
nodular
____ melanomas are seen in AAs and Asians. On what part of the body?
- Acral letiginous
- nail beds and feet
_____ melanomas are seen in elderly. How aggressive are they?
- Lentigo maligna
- less aggressive
Which skin cancer has the lowest malignant potential?
- BCC
At what age do you repair cleft lips?
3 months
cleft lips result from failure of _____
primary palate
At what age do you repair cleft palates?
9 months
cleft palates result from failure of ____
secondary palate
1º and 2º palates are used primarily for ____
speech
With orbital and zygomatic fractures check _______
EOM and look for enophthalamos
