Principles of wound reconstruction Flashcards
elective incisional wound
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
elective excisional wound
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
traumatic wounds
potential for contamination must be addressed
need plans for reconstruction before surgery
options for wound closure
primary closure
delayed primary closure
secondary closure
second intention healin
choice of technique for wound closure - factors
patients physical statues wound contamination soft tissue damage vascularity of tissues amount of adjacent tissue available for closure
aim of wound reconstruction
complete + durable wound closure wound healing in shortest possible time minimal discomfort minimal morbidity e.g adequate limb function cosmetic appearance
planning wound reconstruction
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
closure of edges
delayed/primary closure
mobilisation of local skin
suture techniques
skin-streching
mobilisation of adjacent skin
subdermal plexus flaps
axial pattern flaps
mobilisation of distant skin
distant in/direct flaps
use of free skin grafts
partial/full thickness graft
second intention healing
contraction + epithelialisation
tension relieving techniques
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
excessive tension
compromised circulation
slow wound healing
dehiscence
distortion of anatomic areas
effect of tension on closure of skin wounds
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
patient positioning
patient should be suitably positioned depending on the site of surgery
ease of access to loose, available skin
management of dog-ears
raised areas of skin after wound closure
can be removed to improve cosmetics of the wound but flatten over 6-8 weeks naturally
triangle wound
3-point closure - Y shaped
square wound
centripetal closure - X shaped
rectangular wound
centipetal closure - double Y shaped wound
undermining skin edges
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
planes for undermining skin - cutaneous muscle present
undermine below muscle
planes for undermining skin - cutaneous muscle not present
undermine in loose fascia below
planes for undermining skin - skin associated with muscle
undermine below muscle fascia`
skin stretching - pre-suturing
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
skin stretching - skin stretchers
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
skin stretching - skin expanders
silicone elastomer bag connected by tube to self-sealing implantable injection port
put under skin and slowly expanded with sterile saline
walking sutures
simple + effective adjunctive method
static effect distributes tension over wide area
dynamic effect moves skin towards wound edges
tension sutures
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
tension-relieving incisions - relaxing or release incisions
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
relaxing incision for primary closure
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
multiple puncate relaxing incisions
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
relaxing incision for skin flaps
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
advancement flaps
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
transposition flaps
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
rotating flaps
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
flank folds
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
