Principles of wound reconstruction

Question 1

elective incisional wound

Answer 1

shouldn’t present problem in closure is wound is closed the same direction it was made
closure in different orientation sometimes used in reconstruction e.g z-plasty

Question 2

elective excisional wound

Answer 2

can cause large skin deficit, can be a challenge to close
usually closed immediately following the excicion + plans for reconstruction needed prior to surgery for preparations to be made

Question 3

traumatic wounds

Answer 3

potential for contamination must be addressed

need plans for reconstruction before surgery

Question 4

options for wound closure

Answer 4

primary closure
delayed primary closure
secondary closure
second intention healin

Question 5

choice of technique for wound closure - factors

Answer 5

patients physical statues
wound contamination
soft tissue damage
vascularity of tissues
amount of adjacent tissue available for closure

Question 6

aim of wound reconstruction

Answer 6

complete + durable wound closure
wound healing in shortest possible time
minimal discomfort
minimal morbidity e.g adequate limb function
cosmetic appearance

Question 7

planning wound reconstruction

Answer 7

evaluate inherent elasticity of local skin
identify skin tension lines + their likely effect
position + importance of local structures
location of adjacent direct cutaneous arteries
previous surgical or traumatic wounds in the region
evaluation of viability + vascularity of local skin

Question 8

closure of edges

Answer 8

delayed/primary closure

Question 9

mobilisation of local skin

Answer 9

suture techniques

skin-streching

Question 10

mobilisation of adjacent skin

Answer 10

subdermal plexus flaps

axial pattern flaps

Question 11

mobilisation of distant skin

Answer 11

distant in/direct flaps

Question 12

use of free skin grafts

Answer 12

partial/full thickness graft

Question 13

second intention healing

Answer 13

contraction + epithelialisation

Question 14

tension relieving techniques

Answer 14

maximise available skin - patient 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 + stents

Question 15

excessive tension

Answer 15

compromised circulation
slow wound healing
dehiscence
distortion of anatomic areas

Question 16

effect of tension on closure of skin wounds

Answer 16

wounds made parallel to tension lines close + have minimal tension
wounds perpendicular to tension lines gape + have greater tension
wounds made at oblique angle to tension lines form rhomboid wound

Question 17

patient positioning

Answer 17

patient should be suitably positioned depending on the site of surgery
ease of access to loose, available skin

Question 18

management of dog-ears

Answer 18

raised areas of skin after wound closure

can be removed to improve cosmetics of the wound but flatten over 6-8 weeks naturally

Question 19

triangle wound

Answer 19

3-point closure - Y shaped

Question 20

square wound

Answer 20

centripetal closure - X shaped

Question 21

rectangular wound

Answer 21

centipetal closure - double Y shaped wound

Question 22

undermining skin edges

Answer 22

simplest technique to release tension
skin is relieved from underlying attachments - allow inherit elastic properties to be used
care taken to avoid trauma to subdermal plexus + direct cutaneous arteries

Question 23

planes for undermining skin - cutaneous muscle present

Answer 23

undermine below muscle

Question 24

planes for undermining skin - cutaneous muscle not present

Answer 24

undermine in loose fascia below

Question 25

planes for undermining skin - skin associated with muscle

Answer 25

undermine below muscle fascia`

Question 26

skin stretching - pre-suturing

Answer 26

vertical mattress tension sutures used to imbricate normal skin either side of a lesion
sutures removed after time+ lesion excised using extra skin to achieve wound closure
simple + cheap but needs 2 operations

Question 27

skin stretching - skin stretchers

Answer 27

externally applied, non-invasive, adjustable devices that can stretch skin adjacent to + distant from the wound
stretching not immediately next to the wound allows for more gains than pre-suturing
cables crossing the wound can also hold dressing in contact with the wound

Question 28

skin stretching - skin expanders

Answer 28

silicone elastomer bag connected by tube to self-sealing implantable injection port
put under skin and slowly expanded with sterile saline

Question 29

walking sutures

Answer 29

simple + effective adjunctive method
static effect distributes tension over wide area
dynamic effect moves skin towards wound edges

Question 30

tension sutures

Answer 30

overcome tension in a wound
can be sole suture pattern or secondary retention sutures
retention, stay or echelon sutures consist of second suture line at distance from primary incision to reduce tension

Question 31

tension-relieving incisions - relaxing or release incisions

Answer 31

incision created parallel to long axis of a wound to ease closure
incisions may be singe, 1 either side of wound, double, or multiple
if skin mobility allows, secondary defect may be closed primarily

Question 32

relaxing incision for primary closure

Answer 32

incision placed adjacent + parallel to primary wound to allow intervening skin to close the defect
indicated when allows primary closure of main wound
in some cases skin elasticity will allow closure of secondary wound also

Question 33

multiple puncate relaxing incisions

Answer 33

multiple stab incisions in staggered rows parallel to primary wound
release tension + allow primary wound closure
left to heal by 2nd intention
indicated primarily for closure of wounds on the extremities

Question 34

relaxing incision for skin flaps

Answer 34

tension may prevent skin flap from being used
incisions in flap or adjacent tissue may be used to relieve this tension
incisions in adjacent skin are preferred as vascularity of flap not compromised
careful to avoid regional direct cutaneous artery
other procedures(V-Y + Z-plasty) should also be considered

Question 35

advancement flaps

Answer 35

limited to areas where there’s lose skin
additional skin made available for wound closure by making use of skin elasticity - no new skin moved into the wound
these flaps developed so that they advance parallel to lines of skin tension
skin tension may cause dehiscence or distort recipient wound

Question 36

transposition flaps

Answer 36

rectangle flap made within 90 degrees of long axis of defect
1 long edge of the flap shared by defect to be closed
loss of length of flap + incr likelihood of dog-ear development with incr are of rotation
90 degree transposition most useful + 180 dgree is max possible
measurements critical for closure of both sites
90 degree flap aligned parallel to lines of greatest tension which aids development of larger flap + helps transverse closure of donor site

Question 37

rotating flaps

Answer 37

arc of skin which shares common border with triangle defect
if planned properly, no secondary donor site defect created
skin from stretching (advancement) + moving adjacent skin (transposition)
no advantage over transposition flap but good for triangle defects
length of incision needed approx 4x length required to rotate the flap to cover the defect
incision progressively developed with undermining until flap cover defect

Question 38

flank folds

Answer 38

loose skin of axilla + flank fold used for reconstruction in these regions
fold of skin can be left attached to the limb + used for reconstruction of the limb, or can be left on the flank + used on the flank