Reconstructive Surgery Flashcards
When is a wound ready to close?
- Tissue is healthy, no significant contamination, no infection, no ongoing necrosis
When should you be able to close a defect directly?
- If you can bring 2 points of skin together before cutting
What is often needed to close a defect directly, even if they should close?
- Undermining and walking sutures
- Close in multiple layers
What happens to a wound when you excise or undermine tissue?
- The resulting defect will be larger than the original measurement because skin is elastic, and you have freed it up from some of its attachments to other skin and/or SQ
Patient preparation for reconstruction
- Clip widely (put sterile lube to protect from hair clippings)
- Don’t limit skin movement
- Measure twice, cut once - use sterile skin marker and ruler
What are Halsted’s 7 principles?
A. Gentle tissue handling
B. Strict asepsis
C. Meticulous hemostasis
D. Accurate tissue apposition
E. Obliterate dead space (drains or suture)
F. Preservation of blood supply (most important)
G. Minimal tension
What aspects of pain control should you at least consider with reconstructive procedures?
- Multi-modal pain control!
- Diffusion catheter
- Prevent pain with prophylactic analgesics
Wound diffusion catheters
- can be used with reconstructive procedures
- Often use a topical analgesic such as bupivacaine
Is it easier to prevent pain or treat it after it is established?
- Much easier to PREVENT pain
What do you need to educate your client about BEFORE surgery?
A. Serious exercise restriction
B. Monitor surgery site
C. Keep bandages clean and dry
D. E-Collar
E. Keep appointments for follow-up visits
F. Risk of failure of part/all of flap/graft
G. May need >1 surgical procedure
H. Cosmetic changes
What is important to preserve with reconstructive procedures?
- Preservation of blood supply
Describe the blood supply to the skin
- Direct cutaneous arteries emerge from deeper tissue and turn to run parallel to the skin as the SUBDERMAL PLEXUS
- The subdermal plexus is at the level of the cutaneous muscle and sends branches to the skin
Where is the subdermal plexus?
- It’s at the level of the cutaneous muscle and sends branches out to the skin
Be able to draw the layers of the body wall and the blood supply to the skin without looking at the diagram. THis is important knowledge for reconstructive and oncologic surgery.
Just do it
Describe the coursing of the subdermal plexus
- Direct cutaneous arteries emerge from deep tissue and turn to run parallel to the skin as the subdermal plexus, which runs in the cutaneous muscle (when there is one) and sends branches to the skin.
Where is the subdermal plexus if there is not a cutaneous muscle?
- In the subcutaneous tissue (SQ) between the dermis and muscle fascia
How do you preserve blood supply to the skin as you free up an edge ot help close a wound or create a flap?
- Undermine deep to the subdermal plexus, or in other words, deep to the cutaneous muscle, which is the tissue layer containing the subdermal plexus
Why don’t you want to undermine deep to all of the SQ tissue if you don’t have to?
- It can be thick and makes it harder to move the undermined tissue
Where is the SDP in the limbs?
- Just in the subcutaneous layer
Which layer do you undermine deep to in the limbs?
- Undermine deep to the subcutaneous layer, immediately superficial to the muscle fascia
- Fortunately, there is not much SQ tissue on the limbs, so the added thickness is not as much of an issue
Where is the first bite of suture for tacking and walking sutures?
- First bite is on the underside of the undermined skin
- Second bite is in the wound bed
For tacking sutures, where is the bite in the wound bed relative to the bite in the skin?
- The bite in the wound bed is directly below the bite in the skin (see image)
- Straight down
For walking sutures, where is the bite in the wound bed relative to the bite in the skin?
- The bite in the wound bed is advanced in the direction you want the skin to move
- The skin is tretched as the walking sutures are tied
What do walking sutures take advantage of?
- Skin’s elasticity
Do tacking sutures and/or walking sutures decrease dead space?
- Yes for both
Do tacking sutures and/or walking sutures distribute tension?
I think walking sutures might do this better than tacking
Do tacking sutures and/or walking sutures advance skin over the wound?
I think only walking sutures advance the skin over the wound
Do tacking sutures and/or walking sutures have an increased risk of infection if too many are placed?
- Yes for both
Do tacking sutures and/or walking sutures have a risk of compromising blood supply?
- yes for both
Do tacking sutures and/or walking sutures compartmentalize dead space (which makes it hard for drain to work if used)?
- Yes for both
What is the easiest shape to close?
- Symmetrical ellipse
For a horizontal incision, what is the most efficient way to suture? Why?
- From the side of your dominant hand towards the side of your non-dominant hand
- This direction puts your thumb forceps (held in your non-dominant hand) on the side of the incision that has not been closed yet, where they can be the most useful
What is the most efficient way to suture a vertical incision regardless if you are right or left-handed?
- Top to bottom
How do you avoid dog ears with an asymmetrical ellipse?
- Space sutures so that they are further apart on the longer side than on the shorter side
Describe the split the difference technique (which is another way to avoid dog ears)?
- 1st suture goes halfway between the two corners of the wound
- 2nd suture goes halfway between the 1st suture and A on each side
- 3rd suture goes halfway between the 1st suture and B on each side
- Continue until all of the gaps are filled in. Result will be described later
What type of suture for walking sutures?
- Absorbable, monofilament
- Essentially horizontal mattress
- Monocryl or PDS could work
- Monocryl has a shorter half life
Where is the first walking suture?
- At the level of where the skin and the wound beds meet
- Pre-place them, tag them, and then place the next ones
- Tighten all at the end
How do you close triangle shaped wounds?
- Suturing inward from the corners
- It will look like a little three-lined thing
How do you close a square shaped wound?
- You go in from the corners
- Will look like an envelope
How can you close a circle shaped wound?
- Convert to an ellipse for easier closure
What are relaxing or releasing incisions?
- They are placed to “mesh” skin adjacent to the wound, relieving tension that is preventing closure
- This is often used on limbs, where there is not much extra skin and fewer options for skin flaps
Technique for relaxing or releasing incisions
- Suture can be preplaced or placed after releasing incisions
- Make staggered rows of releasing incision full thickness through the skin (tailor # and size to what is needed to relieve tension)
- Undermine skin between the wound and incisions (remember it’s deep to the SC layer on the limbs)
How can you close relaxing incisions?
- May be sutured if it can be closed without tension; otherwise leave to heal on their own (second intention)
What’s the difference between a subdermal plexus flap and an axial pattern flap?
- Subdermal plexus flaps don’t attempt to have direct cutaneous arteries entering the base of the flap
- Axial pattern flaps are deliberately placed to include direct cutaneous artery in the flap’s attachment; thus the flap has a robust blood supply
Pros of subdermal plexus flap
- Can create anywhere
- variable shapes
Cons of subdermal plexus flap
- Much shorter length than APF
- Requires healthy wound
Pros of axial pattern flap
- can create much longer flap than SDF
- May use on a somewhat unhealthy wound because it brings its own blood supply
Cons of axial pattern flap
- Limited locations
- Limited shapes
How do you do a sliding advancement flap?
- What determines the width of the flap?
- What should the length to width ratio not exceed?
- Basic subdermal plexus flap
- Make little Burrow’s triangles on the edges
- Incise and undermine flap
- Advance the flap over the wound
- Width of flap = width of the wound
- Length to width ratio should not exceed 2:1 or 3:2
What happens if you exceed the length to width ratio of the sliding advancement flap?
- Necrosis
Undermine the flap deep to what layer on the trunk?
- Cutaneous muscle
Undermine the flap deep to what layer on a limb?
- Subcutaneous layer
What is a skin graft?
- Healthy piece of skin removed from one site on the body and placed on a healthy wound
- A healthy wound is essential for a skin graft to survive
Which layers of the skin are on a skin graft?
- Epidermis and dermis
What can grafts be?
- Sheets of skin that are meshed or small plugs of skin taken with a dermal biopsy punch
What determines survival of a skin graft?
- New blood vessels growing from healthy wound bed into the graft
- These vessels are microscopic and fragile
What could happen if there is any movement between the new graft and the wound?
- Shearing of new vessels and compromise of the blood supply
Bandage changes with skin grafts
- Every 2-3 days
- Even a very careful bandage change can cause movement of the graft
Aftercare with skin grafts
- VERY careful bandage change
- Cage confinement
- Negative pressure wound therapy is now routinely applied post-grafting to ensure good contact between the graft and wound and stimulate healing
How long does it take to know if a graft is going to survive?
- 7-10 days
