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Surgery Subspecialties > Plastic Surgery > Flashcards

Plastic Surgery Flashcards

1
Q

What are the 3 stages of wound healing and when do they BEGIN?

A
  • Coagulation stage - 10-15 min after wound formation
  • Inflammatory stage - first 24 hrs
  • Initial proliferation - days 2-3
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2
Q

What happens during the coagulation stage?

A
  • vasoconstriction, clotting cascade in first 10-15 min

- vasodilation 2/2 histamine, complement, kinins, PGs

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3
Q

What happens during the inflammatory stage? (early, late)

A
  • 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
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4
Q

By 6 wks after wound formation ___% of strength is gained

A

60

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5
Q

What happens during the initial proliferation phase of wound healing? (2)

A
  • collagen formation

- macrophages replaced by fibroblasts

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6
Q

When does the proliferative phase of wound healing occur and what 3 main things happen during this time?

A
  • days 4-24

- Angiogenesis, fibroplasia, epithelialization continues

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7
Q

At what time do fibroblasts become the predominate cells during wound healing?

A
  • Day 7
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8
Q

What is the role of the fibroblasts in wound healing (what do they produce) (3)?

A
  • make fibronectins
  • glycosaminoglycans
  • Collagen (initially type III)
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9
Q

3 weeks after a wound the wound will be in the _____ stage

A

maturation/remodeling

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10
Q

What happens during the maturation/remodeling stage? (3)

A
  • collagen III –> I (stronger)
  • tensile strength increases due to collagen crosslinking (but never reaches full, max 80%)
  • cells are myofibroblasts
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11
Q

How long does it take for scars to form?

A

up to 1 year

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12
Q

How do you treat abrasions?

A

scrub brush or dermabrasion to avoid traumatic tattoos

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13
Q

How do you treat contusions?

A

evacuate hematomas - cold early on, heat later

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14
Q

How do you treat lacerations?

A

debridement and suture

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15
Q

How do you treat punctures?

A

evaluate for underlying damage, debridement, and primary or secondary intention

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16
Q

What 3 things should occur during debridements?

A
  • actual bleeding should be seen
  • dress the wound in wet to drys - needs to be continuously moist
  • tetanus shot, culture wound, abx
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17
Q

debridement must occur constantly for _______ wounds

A

chronically infected

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18
Q

____ will determine the extent of infection

A

x-ray

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19
Q

you must assess vascular supply of wounds with _____ (3)

A
  • Doppler, angiogram, pulses
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20
Q

for wound healing you must have ____ control

A

glycemic

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21
Q

What is the role of hyperbaric O2 in wound healing?

A
  • O2 gradient between the center of the wound and edge initiates wound healing
  • helps neutrophils kill bacteria, aids in collagen synthesis and angiogenesis
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22
Q

What is healing w/2nd intention used for?

A

small wounds or if patient is too ill for the operation

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23
Q

What is a potential AE from healing w/2nd intention.

A

Marjolin’s ulcer (SCC)

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24
Q

What is primary intention closure and what is it used for?

A
  • direct reapposition of wound skin edge

- used for low velocity

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25
Q

With primary intention closure look for signs of _____ that includes ______

A
  • excessive skin tension

- pallor, loss of distal pulses, compartment pressures >30

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26
Q

What is secondary intention wound closure?

A
  • wound left open to heal spontaneously via inflammatory phase
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27
Q

What happens during secondary intention wound healing?

A
  • wound contracts and margins meet and re-epithelialize
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28
Q

What is tertiary intention closure?

A

Delayed wound closure and healing is intentionally interrupted

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29
Q

Primary contracture definition

A

contracture of the dermis due to elastin (the more dermis the more contracture). Full thickness skin grafts (FTSG) have the most primary contracture

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30
Q

Secondary contracture definition

A

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

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31
Q

What is a split thickness graft (STSG)?

A
  • epidermis + part of the dermis
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32
Q

What kind of split thickness graft has a better chance of taking?

A

thin grafts

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33
Q

Disadvantages to split-thickness grafts?

A
  • 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
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34
Q

What is a full thickness graft (FTSG)

A
  • epidermis + dermis
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35
Q

Advantages to FTSG (2)

A
  • inhibits contraction by inhibiting myofibroblast proliferation
  • better cosmetic results
36
Q

Disadvantages to FTSG (3)

A
  • Less of a chance that it will take
  • more primary contracture
  • Less can be harvested
37
Q

What are the complications of skin grafts (4) and which of these is the most common cause of skin graft failure?

A
  • hematoma - MOST COMMON
  • seroma
  • infection
  • shearing of the graft from the underlying bed causing rupture of tenuous attachments that allow revascularization of the graft
38
Q

When is the plasmatic imbibition phase and what is it?

A
  • 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
39
Q

STSG can tolerate plasmatic imbibition phase for __ days, and FTSG can tolerate it for __ days

A
  • 5

- 3

40
Q

Describe where capillary formation is at at 3 days

A
  • Inosculation, “kissing” of pre-existing bvs
41
Q

Describe where capillary formation is at at 5 days

A
  • Angiogenesis - capillaries budding from the bed and circulation begins in the graft
42
Q

What is the difference between skin grafts and flaps?

A
  • grafts DON’T have their own blood supply

- flaps DO have their own blood supply

43
Q

What is the difference between local vs. regional flaps?

A
  • local flaps have random blood supply

- regional flaps have a known blood supply

44
Q

What is the difference between pedicle vs. free flaps?

A
  • own blood supply vs. supply not intact
45
Q

TRAM flap

A
  • transrectus abdominus musculocutaneous flap

- takes rectus muscle and moves it to the contralateral side with it’s blood supply

46
Q

DIEP flap

A

Deep inferior epigastric perforators (free flap)

  • removing skin and fat superior to the rectus muscles w/perforating arteries intact adn dissected out
  • muscle sparing
47
Q

____ and ___ slow healing dramatically

A
  • smoking/nicotine

- glycemic

48
Q

You worry about patients smoking and glycemic controls particularly after ____ surgeries because of ____

A
  • flaps

- anastomoses

49
Q

What affect do steroids have on healing?

A
  • they inhibit macrophages and fibrogenesis
50
Q

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?

A
  • Vitamin A - counteracts their effect

- Give for 5 days if they’re healing from an incision, 10 days if it’s a chronic wound

51
Q

Keloid scars - what are they? what is their pathophysiology?

A
  • extend beyond the suture border
  • 2/2 overabundance of collagen
  • 75% relapse
52
Q

How do you treat keloid scars?

A
  • steroid injections
  • radiation
  • chemo (topical 5-FU)
  • pressure therapy
  • excision
53
Q

Hypertrophic scars

A
  • scars that stay within the suture line

- they tend to improve and have normal levels of collagen and fibrin

54
Q

W/healing you expect to see _____ tissue and ___% healing per week

A
  • red, bloody granulation tissue

- 10-15%

55
Q

fat necrosis often looks like ____

A

pus

56
Q

dry gangrene is 2/2 ___. Does it require immediate removal?

A
  • ischemia

- no, it’s ok to leave on temporarily

57
Q

wet gangrene is 2/2 ___. Does it require immediate removal? The next step when you find this is to ____.

A
  • infection
  • YES
  • take an x-ray to look for air
58
Q

____ causes gas in wet gangrene, but ___ causes a ______ infection that travels.

A
  • clostridium
  • strep
  • necrotizing fasciitis
59
Q

__ 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
A
  • 6
  • 3
  • 1
  • 2
60
Q

How do autoimmune/vasculitis pts typically do if you operate on them?

A

worse! You don’t want to surgically debride

61
Q

Buzzwords for pyoderma 2/2 AI/vasculitis origins?

A

pain out of proportion to the exam

62
Q

what are the 3 types of burns?

A
  • chemical
  • electrical
  • thermal
63
Q

What is the % body surface area (BSA) of head, arms, back, chest, legs, perineum?

A 
RULE OF 9S
Head: 9%
Each arm: 9%
Back and chest each: 18%
Each leg: 18%
Perineum: 1%
64
Q

How do you treat 2/3rd degree burns?

A

FLUIDS FLUIDS FLUIDS

  • Silvadene
  • IV narcotics
  • tetanus/stress ulcer ppx
  • early placement of biologic dressing/skin graft to PREVENT CONTRACTURES
65
Q

Describe a first degree burn (4)

A
  • only epidermis, dermis intact
  • no blisters
  • looks like a sunburn
  • painful
66
Q

How do you treat first degree burns specifically?

A

Silvadene (antimicrobial) + analgesics

67
Q

Describe a second degree burn

A
  • epidermis and part of the dermis
  • blisters
  • painful
68
Q

Describe a third degree burn

A
  • epidermis and full thickness of the dermis
  • INSENSATE
  • feels rubbery
  • white (lacks capillary refill), charred
69
Q

Describe fluid management in pts w/2nd/3rd degree burns

A
  • 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
70
Q

What are 3 complications of burns?

A
  • Shock
  • Compartment syndrome
  • Superinfection (pseudomonas or staph)
71
Q

0.3 negative margins are needed when removing a ___

A

BCC

72
Q

What type of BCC is most common? Most aggressive?

A
  • nodular

- morpheaform

73
Q

0.5 negative margins are needed when removing a ___ & ____

A
  • SCC

- in situ melanoma

74
Q

____ is a precursor to SCC. ____ is SCC in situ

A
  • Actinic keratosis

- Bowmen’s

75
Q

Melanoma prognosis and margins depend on _____ of the cancer

A

depth

76
Q

_____ is the most common type of melanoma

A

superfical spreading

77
Q

If a melanoma is < 1 mm in depth you want a ____ cm margin, if its >1 mm in depth you want a ____ cm margin

A
  • 1 cm

- 2 cm

78
Q

____ melanomas have vertical growth

A

nodular

79
Q

____ melanomas are seen in AAs and Asians. On what part of the body?

A
  • Acral letiginous

- nail beds and feet

80
Q

_____ melanomas are seen in elderly. How aggressive are they?

A
  • Lentigo maligna

- less aggressive

81
Q

Which skin cancer has the lowest malignant potential?

A
  • BCC
82
Q

At what age do you repair cleft lips?

A

3 months

83
Q

cleft lips result from failure of _____

A

primary palate

84
Q

At what age do you repair cleft palates?

A

9 months

85
Q

cleft palates result from failure of ____

A

secondary palate

86
Q

1º and 2º palates are used primarily for ____

A

speech

87
Q

With orbital and zygomatic fractures check _______

A

EOM and look for enophthalamos

Surgery Subspecialties (6 decks)

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