Principles of wound closure/reconstruction Flashcards
How should an elective incisional wound be closed?
in the same direction in which it was made
closure in a different orientation is sometimes used in reconstruction e.g. z-plasty
How are elective excisional wounds closed?
closed immediately
surgeon must have an idea before excising and prep
What are the 2 most important things to consider when repairing traumatic wounds?
contamination
skin deficits
What are the 4 options for wound closure?
primary
delayed primary
secondary
second intention healing
What influences the method of closure that is chosen? 5
physical status contamination soft tissue damage vascularity amount of adjacent tissue available
What is the aim of wound reconstruction? 5
complete and durable closure shortest time minimise discomfort minimise morbidity cosmetic appearance
What should be evaluated when planning wound reconstruction?
inherent elasiticity (local skin) skin tension lines and likely effects local structures direct cutaneous arteries previous surgical or traumatic wounds viability and vascularity of local skin
How can wound edges be closed? 2
primary
delayed primary
How can local skin be mobilised? 2
suture techniques
skin-stretching
How can adjacent skin be mobilised? 2
subdermal plexus flaps
axial pattern flaps
How can distant skin be mobilised? 2
distant direct flaps
distant indirect flaps
How can skin grafts be used? 2
partial thickness
full thickness
How does second intention healing work?
contraction and epithelialisation
List some different tension-relieving techniques - 8
maximise available skin - positioning
change local skin tension - geometric closure patterns
change regional skin tension - skin directing
mobilise local skin - undermine skin
increase local skin - skin stretching
distribute tension - walking sutures
overcome tension - tension sutures and stents
remove tension - relaxing incisions
What affects skin thickness, pliability and tension?
species breed individual body region BCS certain diseases
What does the theory regarding dominant lines of skin tension suggest?
wounds should ideally be created and closed parallel to the lines of the greatest tension
If wounds are made at an oblique angle to tension lines, what shape is the wound?
rhomboid
T/F: wound dehiscence is much more likely when 2 suture lines intersect.
True
e.g. T, Y or X
What type of excision is commonly used for small skin lesions?
fusiform or eliptical
length:width ration of 4:1 recommended to avoid creating dog-ears at the apices of the incision
What are ‘dog ears’?
triangular, raised areas of skin which may be seen following closure of a skin wound under a number of circumstances.
In what shape can wounds be closed?
TRIANGLE: 3 point closure (Y shaped)
SQUARE: centripetal closure (X shaped)
RECTANGLE: centripetal (double Y shaped)
begin at corners and progress to centre
How can ‘dog ears’ be dealt with?
number of techniques to remove and improve them
OR
leave in situ (natural elasticity of skin results in them flattening over 6-8 weeks)
How can local tension be relieved? 2
V-Y plasty or Z-plasty
What is the simplest technique to relieve skin tension?
undermining - the skin is relieved from its underlying attachments, thus allowing its inherent elastic properties to be used. Care is taken to avoid trauma to subdermal plexus and the direct cutaneous arteries. Undermineing proceeds undtil the wound edges approcimate without excessive tension
What are the correct planes for undermining skin?
cutaneous muscle present - undermine below mm
cutaneous mm not present - undermine in loose fascia below
skin associated with mm - undermine below mm fascia
What are vertical mattress tension sutures used for?
to imbricate normal skin either side of a cutaneous lesion e.g. skin tumour. removed after a period of time and lesion excised. simple and cheap, but requires 2 surgical procedures
Where can skin stretchers stretch skin? 2
adjacent too and distant from
(the ability to stretch large areas of skin not immediately adjacent to the wound allows more significant gains than pre-suturing.
What does a tissue expander consist of?
a silicone elastomer bag connected by a tube to a self-sealing, implantable injection port. variety of shapes/sizes. it is buried in a pocket below the skin to be stretched and the injection port is buried in adjacent tissue. periodic inflation of the expander by injecting sterile saline into the injection port is performed.
Why are walking sutures good?
s tatis effect distributes tension over a wide area and a dynamic effect move skin towards the wound edges
What are tension sutures?
they are placed to overcome tension within the wound. they may be placed a the sole suture pattern or as a secondary retention suture.
How long are skin stretchers left in place?
5-7 days (as with tension sutures)
What is a relaxing or a release incision?
a skin incision created parallel to the long axis of a wound to facilitate its closure.
single/double/multiple
generally heal by second intention
if local skin mbility following undermining of the skin allows it, the secondary defect may also be closed primarily. In this respect, the single relaxing incision is a bipedicle advancement flap.
When are relaxing incisions indicated?
when it will allow primary closure of the main wound (in some cases, the inherent elasticity of the skin will also allow the closure of the secondary wound).
What are multiple punctate relaxing incision?
multiple small stab incisions made in staggered rows parallel to the primary wound. they release the tension in the skin adjacent to the wound and allow the primary wound to be closed. The stab incisions are left to heal by second intention and, being small the cosmetic appearance is generally acceptable. They are indicated primarily for closure of wounds on the extremities.
What are the different types of skin flap?
advancement
transposition
rotation
flank fold
When are advancement flaps used?
where there is loose skin
They are developed so they will advance parallel to the lines of skin tension.
Unless created carefully, theis skin tension may promote wound dehiscenc eor may distort the recipient wound, which is important if this wound is to close a natural orifice or other mucocutaneous junction.
What is a transposition flap?
Features?
a rectangular lap within 90 degrees of the long axis of a defect. one long edge is to be shared by the defect to be closed.
most versatile of local flaps and additonal skin is moved into the wound
What is a rotation flap?
an arc of skin which shares a common border with a triangular defect. if planned with care, no secondary donor site defect is created.
skin for closure is provided by a combination of stretching (advancement) and moving adjacent skin (transposition)
no real advantage over a transposition flap, but is useful for the local closure of triangular defects
What are flank folds used for?
the loose skin of the axilla and flank fold may be used for reconstruction in these regions. The fold may be left attached to the limb and used for reconstruction of the limb or may be left attached to the flank and be used for reconstructions of the flank.
What is the deep paniculus mm closely associated with?
deep or subdermal plexus
What is an angiosome?
a region of her tissue that is supplied by a specific group of veins and arteries
Name 1 disease that can cause fragile skin
Hyperadrenocorticism
Name 3 ways to control wound dead space
suture it closed
apply external dressing
use a drain
(first two often together)
What is local undermining?
go deep to the cutaneous trunci mm
What is a SDPF?
subdermal plexus flap
What are axial pattern flaps planned around?
planned around the direct cutaneous vessels
What are the thoracodorsal landmarks?
scapula spine
depression between triceps and deltoids
dorsal midline
Where is a reverse saphenous conduit used?
useful in distal HL (distal metatarsal region)
What is a compound or composite flap used for?
to create skin and muscle coverage
When should distant direct subdermal plexus flaps be used?
distal limb injuries fresh wound, healthy GT or omentalised wound single or bipedicle requires at least 2 anaesthetic episodes needs tolerant patient
When are free skin grafts indicated?
distal limb injuries fresh wound, healthy GT or omentalised wound not over exposed bone/tendon/ligaments not if infection/movement not if chronic GT
What terminology describes free skin grafts? 4
split vs full thickness
full sheet or meshed (expanded or not)
pinch or punch
line grafting
What dictates homograft survival? 4
adhesion
plasmatic imbibition
vascular ingrowth (inoscultation)
maturation
What is plasmatic imbibition?
the initial way a homograft is nourished, it describes how the graft ‘drinks’ plasma
How is a homograft nourished after plasmatic imbibition?
by capillary inosculation (this should happen within 36 hours of the transplant)
Outline the basic technique for performing a homograft transplant
Prepare recipient wound (no haemorrhage) make template of recipient wound wrap recipient wound make outline of graft at donor site excise graft, clean and place directly into recipient suture periphery (direct or overlap) protect with bandage - non adherent change dressing (under GA) in 48 hours
Outline the use of silicon mesh as a non adherent and low/non-absorbent passive dressing.
Example?
expensive soft easy to apply stick to dry skin need secondary absorptive layer re use
EXAMPLE = Mepitel
What is omentalisation?
the placement of omentum around organs or within cavities to improve vascularisation or drainage. Also used to help reconstruct infected skin wounds.
List some examples of omentalisaiton
repair of diaphragmatic defects augment thoracic wall reconstruction augment suture lines (GIT, bladder) prostatic abscessation wound reconstruction chylothorax
What should you do if a wound that you repair falls apart?
don’t panick!
manage the wounds open until they are healthy enough to undergo another reconstruction.
