Principles of Plastic Surgery

Question 1

What is the definition of orthoplastics and microsurgery?

Answer 1

principles and practices of both specialists applied to a clinical problem either by a single provider or team of providers working in concert for the benefit of the patient

Question 2

what is the stepwise approach of wound coverage?

Answer 2

direct closure->grafts->local flaps->distant flaps->tissue transfer

Question 3

Where are the resting skin tension lines in the axis of muscles/tendons and joints

Answer 3

perpendicular to the long axis of muscles and tendons

parallel to the axis of joints at the level of the joints

Question 4

Where is the ideal incision placed in relation to the RSTL

Answer 4

parallel

Question 5

what does closing a surgical incision in layers do?

Answer 5

takes tension off the wound edges-dont make too many layers though to avoid tissue fibrosis etc

-leads to dec rate of deshicence and a prettier scar

Question 6

what is the 3:1 rule?

Answer 6

the length to width ratio for which skin is able to be mobilized is 3:1.

Question 7

what is apligraf made from?

Answer 7

human neonatal foreskin

• epidermal layer=human keratinocytes
• dermal layer: human fibroblasts in bovine type 1 collagen lattice

Question 8

what does apligraf contain?

Answer 8

matrix proteins, cytokines

Question 9

When do you use apligraf?

Answer 9

venous leg ulcers, diabetic ulcers,non-healed for 1 month for ulcers that havn’t responded to care

Question 10

contraindications of apligraf?

Answer 10

infected wounds, exposed tendon or bone, allergy to bovine collagen or sensitivity to apligraf

Question 11

how do you apply apligraph?

Answer 11

• debride wound
• saline
• fenestrate with 11 blade
• apply
• add dressing
• compression if needed

Question 12

what is dermagraft?

Answer 12

cryopreserved human fibroblast derived dermal substitute

• single layer
• 6months shelf life

Question 13

when do you use dermagraft

Answer 13

diabetic ulcers-full thickness, >6 weeks in duration

-venous leg ulcers

Question 14

contraindications of dermagraft?

Answer 14

-infected wounds, exposed tendon or bone, sinus tracts, allergy or sensitivity

Question 15

how to apply dermagraft?

Answer 15

• thawed from freezer
• debride
• apply
• apply non occlusive dressing (no petroleum)
• apply dressing
• offload pt

Question 16

what is oasis?

Answer 16

• porcine submucosa
• 3d lattice scaffold
• not living tissue

Question 17

indications of oasis?

Answer 17

chronic ulcerations
trauma
pvd
decubitus ulcerations

Question 18

contraindications of oasis

Answer 18

infected wound
exposed tendon or bone
sensitivity/allergy to porcine

Question 19

how to apply oasis

Answer 19

adequate wound debridement

• apply oasis
• saline
• dressing to keep moist

do not debride between applications

Question 20

What is integra?

Answer 20

• bilayer wound care product
• bovine collagen and silicone
• semi-permeable silicone membrane

Question 21

indications of integra?

Answer 21

• exposed tendon or bone

- diabetic, traumatic, vascular, venous, partial thickness, full thickness

Question 22

contraindications of integra?

Answer 22

exposed wound, known hypersensitivity to product

Question 23

what is the most commonly used free grafted tissue?

Answer 23

split thickness skin graft (STSG)

Question 24

what type of STSG is this?

• excellent host incorporation
• contracts the most
• greatest change for hypopigmentation
• most susceptible to trauma

Answer 24

Thin graft .008 - .012

Question 25

what type of STSG is this? - less contracture - more durable

Answer 25

Intermediate graft (0.012 - 0.016)

Question 26

what type of stsg is this? - less chance of incorporation-greater tissue demands - durability and contraction are much improved

Answer 26

thick graft (0.016-0.020)

Question 27

what type of stsg is this? - placed through mesher-fenestrates the tissue - expands to allow greater tissue coverage - prevents seroma and hematoma from collecting beneath the graft - interposed spaced heal by epithelial migration from the surrounding graft tissue

Answer 27

Meshed grafts

Question 28

what is the difference between stsg and full thickness skin grafts?

Answer 28

-FTSG involves dermis AND portion of superficial fascia

Question 29

when is FTSG indicated?

Answer 29

-coverage in WB area of flexion points

Question 30

what are the donor sites of ftsg?

Answer 30

- popiteal fossa, inguinal fossa | - pedal donor sites: medial arch; sinus tarsi

Question 31

advantages of ftsg?

Answer 31

permanent coverage, simple, low risk, can be applied to almost any area of the body

Question 32

disadvantages of ftsg?

Answer 32

inc failure rate over tendon and bone, graft contracture, inc failure rate, infection, non healing donor site

Question 33

What are the stages of skin graft healing?

Answer 33

- Plasmotic stage - Inosculation stage - Re-organization stage - Re-innervation stage

Question 34

What stage of skin graft healing is this? - occurs 24-48 hrs following graft application - a fibrin layer is formed between the graft and host bed which serves to anchor and allow diffusion of nutrients to the graft

Answer 34

plasmotic

Question 35

What stage of skin graft healing is this? - begins at 48 hrs - revascularization of the graft occurs - graft will demonstrate a pink hue during this stage - lymphatic drainage will be established by the 4th to 5th day

Answer 35

inoscultation stage

Question 36

What stage of skin graft healing is this? - continues for months after grafting - CT reorganizes and regulates vascular and lymphatic flow

Answer 36

re-organization stage

Question 37

What stage of skin graft healing is this? - occurs simultaneously with re-organization - can take 1-2 yrs to complete

Answer 37

re-innervation stage

Question 38

What are some reasons for graft failure?

Answer 38

lack of compression of the graft to the recipient site -movement/shearing -infection seroma/hematoma

Question 39

-Tissue harvested and applied whithin same individual

Answer 39

autograft

Question 40

-tissue transferred between individuals of the same species

Answer 40

allograft/homograft

Question 41

tissue harvested and applied within a set of identical twins

Answer 41

isografts

Question 42

tissue transferred between different species | -function as biologic dressing and never incorporates into the host's tissues

Answer 42

xenografts

Question 43

what is a threedimensional anatomic unit of tissue fed by a source artery

Answer 43

angiosome

Question 44

these link angiosomes to each other - demarcate each angiosome - provide indirect collateral flow

Answer 44

Choke vessels

Question 45

what arteries make up the posterior tibial artery angiosomes

Answer 45

medial calcaneal | lateral and medial plantar

Question 46

are incisions placed perpendicular to the joint to avoid scar contracture impeding mobility?

Answer 46

yes

Question 47

DO skin flaps maintain vascular supply?

Answer 47

yes

Question 48

what are the indications of skin flap use?

Answer 48

coverage for areas of poor vascularity - reconstruction of full thickness deficits - padding over boney prominences - coverage of areas requiring operation at later date - restoration of sensation to the area

Question 49

What is the flap of a skin flap

Answer 49

-tongue of the tissue

Question 50

what is the pedicle of a skin flap

Answer 50

-base or stem of the tissue

Question 51

- derive blood supply from cutaneous dermal-subdermal plexus - no axial arteries - limited based on dimensions - pedical must be wide enough to support the flap - base should be at lease as wide as the flap is long

Answer 51

-random pattern cutaneous flap

Question 52

- derive blood supply from cutaneous artery - survival of these flaps are dependent on the dimensions of the artery and the length of the territory of the artery not on the width of the pedicle - island flaps-no skin bridge - free flaps; transferred from distant site

Answer 52

axial pattern-arterial flaps

Question 53

- adjacent to the deficit - either rotate on a pivot point or are advanced forward form their base to cover a defect - include epidermis, dermis and subq tissue - donor site is either closed primarily or skin grafted

Answer 53

local flaps

Question 54

- flaps that rotate on a pivot point - pivot about pedicle - includes skin and subq tissue

Answer 54

rotational flaps

Question 55

- rotate on pivot point - usually rectangular or square with rounded edges - movement is in an arc and can be rotated as much as 90 degrees

Answer 55

transposition flap

Question 56

-rotate on a pivot point when defect has a rhomboid shape

Answer 56

limberg flap