Principles of wound closure/reconstruction

Question 1

How should an elective incisional wound be closed?

Answer 1

in the same direction in which it was made

closure in a different orientation is sometimes used in reconstruction e.g. z-plasty

Question 2

How are elective excisional wounds closed?

Answer 2

closed immediately

surgeon must have an idea before excising and prep

Question 3

What are the 2 most important things to consider when repairing traumatic wounds?

Answer 3

contamination

skin deficits

Question 4

What are the 4 options for wound closure?

Answer 4

primary
delayed primary
secondary
second intention healing

Question 5

What influences the method of closure that is chosen? 5

Answer 5

physical status
contamination
soft tissue damage
vascularity
amount of adjacent tissue available

Question 6

What is the aim of wound reconstruction? 5

Answer 6

complete and durable closure
shortest time
minimise discomfort
minimise morbidity
cosmetic appearance

Question 7

What should be evaluated when planning wound reconstruction?

Answer 7

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

Question 8

How can wound edges be closed? 2

Answer 8

primary

delayed primary

Question 9

How can local skin be mobilised? 2

Answer 9

suture techniques

skin-stretching

Question 10

How can adjacent skin be mobilised? 2

Answer 10

subdermal plexus flaps

axial pattern flaps

Question 11

How can distant skin be mobilised? 2

Answer 11

distant direct flaps

distant indirect flaps

Question 12

How can skin grafts be used? 2

Answer 12

partial thickness

full thickness

Question 13

How does second intention healing work?

Answer 13

contraction and epithelialisation

Question 14

List some different tension-relieving techniques - 8

Answer 14

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

Question 15

What affects skin thickness, pliability and tension?

Answer 15

species
breed
individual
body region
BCS
certain diseases

Question 16

What does the theory regarding dominant lines of skin tension suggest?

Answer 16

wounds should ideally be created and closed parallel to the lines of the greatest tension

Question 17

If wounds are made at an oblique angle to tension lines, what shape is the wound?

Answer 17

rhomboid

Question 18

T/F: wound dehiscence is much more likely when 2 suture lines intersect.

Answer 18

True

e.g. T, Y or X

Question 19

What type of excision is commonly used for small skin lesions?

Answer 19

fusiform or eliptical

length:width ration of 4:1 recommended to avoid creating dog-ears at the apices of the incision

Question 20

What are ‘dog ears’?

Answer 20

triangular, raised areas of skin which may be seen following closure of a skin wound under a number of circumstances.

Question 21

In what shape can wounds be closed?

Answer 21

TRIANGLE: 3 point closure (Y shaped)
SQUARE: centripetal closure (X shaped)
RECTANGLE: centripetal (double Y shaped)

begin at corners and progress to centre

Question 22

How can ‘dog ears’ be dealt with?

Answer 22

number of techniques to remove and improve them
OR
leave in situ (natural elasticity of skin results in them flattening over 6-8 weeks)

Question 23

How can local tension be relieved? 2

Answer 23

V-Y plasty or Z-plasty

Question 24

What is the simplest technique to relieve skin tension?

Answer 24

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

Question 25

What are the correct planes for undermining skin?

Answer 25

cutaneous muscle present - undermine below mm cutaneous mm not present - undermine in loose fascia below skin associated with mm - undermine below mm fascia

Question 26

What are vertical mattress tension sutures used for?

Answer 26

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

Question 27

Where can skin stretchers stretch skin? 2

Answer 27

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.

Question 28

What does a tissue expander consist of?

Answer 28

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.

Question 29

Why are walking sutures good?

Answer 29

s tatis effect distributes tension over a wide area and a dynamic effect move skin towards the wound edges

Question 30

What are tension sutures?

Answer 30

they are placed to overcome tension within the wound. they may be placed a the sole suture pattern or as a secondary retention suture.

Question 31

How long are skin stretchers left in place?

Answer 31

5-7 days (as with tension sutures)

Question 32

What is a relaxing or a release incision?

Answer 32

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.

Question 33

When are relaxing incisions indicated?

Answer 33

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).

Question 34

What are multiple punctate relaxing incision?

Answer 34

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.

Question 35

What are the different types of skin flap?

Answer 35

advancement transposition rotation flank fold

Question 36

When are advancement flaps used?

Answer 36

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.

Question 37

What is a transposition flap? | Features?

Answer 37

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

Question 38

What is a rotation flap?

Answer 38

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

Question 39

What are flank folds used for?

Answer 39

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.

Question 40

What is the deep paniculus mm closely associated with?

Answer 40

deep or subdermal plexus

Question 41

What is an angiosome?

Answer 41

a region of her tissue that is supplied by a specific group of veins and arteries

Question 42

Name 1 disease that can cause fragile skin

Answer 42

Hyperadrenocorticism

Question 43

Name 3 ways to control wound dead space

Answer 43

suture it closed apply external dressing use a drain (first two often together)

Question 44

What is local undermining?

Answer 44

go deep to the cutaneous trunci mm

Question 45

What is a SDPF?

Answer 45

subdermal plexus flap

Question 46

What are axial pattern flaps planned around?

Answer 46

planned around the direct cutaneous vessels

Question 47

What are the thoracodorsal landmarks?

Answer 47

scapula spine depression between triceps and deltoids dorsal midline

Question 48

Where is a reverse saphenous conduit used?

Answer 48

useful in distal HL (distal metatarsal region)

Question 49

What is a compound or composite flap used for?

Answer 49

to create skin and muscle coverage

Question 50

When should distant direct subdermal plexus flaps be used?

Answer 50

``` distal limb injuries fresh wound, healthy GT or omentalised wound single or bipedicle requires at least 2 anaesthetic episodes needs tolerant patient ```

Question 51

When are free skin grafts indicated?

Answer 51

``` distal limb injuries fresh wound, healthy GT or omentalised wound not over exposed bone/tendon/ligaments not if infection/movement not if chronic GT ```

Question 52

What terminology describes free skin grafts? 4

Answer 52

split vs full thickness full sheet or meshed (expanded or not) pinch or punch line grafting

Question 53

What dictates homograft survival? 4

Answer 53

adhesion plasmatic imbibition vascular ingrowth (inoscultation) maturation

Question 54

What is plasmatic imbibition?

Answer 54

the initial way a homograft is nourished, it describes how the graft 'drinks' plasma

Question 55

How is a homograft nourished after plasmatic imbibition?

Answer 55

by capillary inosculation (this should happen within 36 hours of the transplant)

Question 56

Outline the basic technique for performing a homograft transplant

Answer 56

``` 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 ```

Question 57

Outline the use of silicon mesh as a non adherent and low/non-absorbent passive dressing. Example?

Answer 57

``` expensive soft easy to apply stick to dry skin need secondary absorptive layer re use ``` EXAMPLE = Mepitel

Question 58

What is omentalisation?

Answer 58

the placement of omentum around organs or within cavities to improve vascularisation or drainage. Also used to help reconstruct infected skin wounds.

Question 59

List some examples of omentalisaiton

Answer 59

``` repair of diaphragmatic defects augment thoracic wall reconstruction augment suture lines (GIT, bladder) prostatic abscessation wound reconstruction chylothorax ```

Question 60

What should you do if a wound that you repair falls apart?

Answer 60

don't panick! | manage the wounds open until they are healthy enough to undergo another reconstruction.