Reconstructive Sx Flashcards
When it comes to wound closure you should use
the simplest techniques possible
What are the different methods of wound closure
1) Primary closure (1st intention healing)
2) Delayed primary closure
3) Secondary closure (3rd intention healing)
4) Second intention healing
5) Tension relieving
6) Local flaps
7) Axial pattern flaps
8) Skin grafts
What are methods of tension relieving
-Undermining
-Walking Sutures
-Tension relieving suture pattenrs
-Stents
-Skin stretchers
-Releasing incisions
-Skin reconstruction: flaps and grafts
where the segment of skin and SQ tissue with its vascular attachment is moved from one area of the body to another (local or distant)
Skin Flaps (pedicle grafts)
What is another word for a skin flap
Pedicle graft
Free skin and SQ tissue moved from one area of the body to another
no vascular attachment
survive the first 48 hours by absorbing tissue fluid from the recipient bed, ultimately reestablish a blood supply
Skin grafts
How does pedicle grafts differ from skin grafts
Pedicle grafts maintain vascular attachment
How do skin grafts survive the first 48 hours
by absorbing tissue fluid from the recipient bed, ultimately to reestablish a blood supply
What are the different type of skin grafts
Meshed graft
Punch grafts
What are the two methods of skin flaps
1) Subdermal Plexus Flaps: anywhere
2) Axial Pattern Flap: known artery and vein that perfuses the body
Can subdermal plexus or axial pattern flaps be larger
Axial pattern flaps
Can you use subdermal plexus flaps or axial pattern flaps anywhere
subdermal plexus flaps
they rely on the subdermal plexus which is everywhere in the body
What does subdermal plexus flap rely on
random blood supply
the terminal branches of direct cutaneous arteries
associated with the panniculus muscle layer
Is surviving area higher with subdermal plexus flaps or axial pattern flaps
Axial pattern flaps surviving area 50% greater than subdermal flaps of comparable dimension
arterial pedicle flap
Axial pattern flap
you should limit flap length to
size required to cover the recipient bed without creating tension
if too short = tension (less healing)
if too long = might not perfuse and will become necrotic
What is really important when handling flaps
atraumatic tissue handling is essential
when making a skin flap you need to undermine
deep to the cutaneous muscle
The recipient bed of skin flap needs to be
1) Infection free
2) No necrotic tissue
3) Freshen edges of chronic wounds (if chronic debride and freshen the edges)
pedicle grafts developed adjacent to recipient bed
where loose, elastic skin predominates
Local subdermal plexus flap
pedicle grafts constructed at a distance from the recipient bed extremities
distance subdermal plexus flap
What is the outome of subdermal plexus skin flap
51% complication rate (37% minor, 14% major)
mean time 1 week
good to excellent outcome in 84% of cases
What are the common subdermal skin flaps
Advancement
Rotational
Transposition
Skin Fold Flaps
When doing subdermal skin flaps, the base of the flap should never be
narrower than the body of the flap
ie the base hshould be widest part of the flap
When doing subdermal skin flaps the flap length should be
1-3x the width of the base
most of the time aim for about 1-3x the width of the base
Rotational flaps work well for what shape of wound
triangular
ensure the distance of semi-circle is 4x the height of the wound
How do you do a rotational flap
cut a semi-circle that is 4x the wound triangle height to the edge of the flap base.
then rotate the healthy tissue over the wound and suture
How do you do a transposition flap
Ensure the width of the flap for 90 degree transposition
(Width of wound)
Ensure length of flap for 90 degree transpostion
Pivot point to furthest point of wound
In an advancement flap, why does the base have to be the widest part
because that is where your blood supply is coming from
How do you do an advancement flap
from wound, draw lines (as wide as the wound fanning out so that the base it te longest
cut and pull together to cuture
How does a skin fold flap work
Flank and elbow skin folds: medial and lateral layers of skin separated by loose connective tissue
Four attachements: medial and lateral attachements to limb
Dorsal and ventral attachments to trunk
Division of any 3 attachments
Separation of medial and lateral skin layers
In skin fold flap, it utilizes the four attachments which are
Medial and lateral attachments to the limb
Dorsal and ventral attachments to the trunk
What is required of distant subdermal plexus flaps
For extensive distal wounds
Circumferential wounds
Staged surgical procedures (2-3 weeks)
Long-term bandaging
-may not be tolerated in some dogs
-Obese
-Significant orthopedic or neurologic disease
Axial Pattern flaps can be for
large defects
single staged procedures
can place over bone, tendons, and ligaments (more robust blood supply)
What is the survivability of Axial Pattern flaps
87-100% overall survival
50% greater survival than subderman plexus (random) flaps
What are the cons of Axial Pattern flaps
-Limited use on distal limbs
-Variabilty in vascular anatomy (doppler, angiogram studies, ICG) : each animal is different
-Questionable cosmetic results
-Dirty cut? Tumor resection
What are the different Axial Pattern flaps
1) Caudal superficial epigastric
2) Thoracodorsal
3) Omocervical
4) Superficial brachial
5) Deep circumflex iliac
6) Genicular
7) Caudal auricular
8) Lateral caudal
9) Superficial temporal
10) Reverse saphenous conduit
What are general considerations for Axial Pattern flaps
-Meticulous planning
-Delicate tissue handling (skin hooks, stay sutures)
-Tension free closure for the flap
-Healthy free closure for the flap
-Healthy recipient bed (granulation tissue not required)
-Two layer closure
-Active suction drains
What are the indications for thoracodorsal flap
-Thorax
-Axillary
-Shoulder
-Elbow
-Carpus (cat)
What are the indications for caudal superficial epigastric flap
-Inner thigh defects
-Flank
-Stifle
-Perineum
-Preputial area
-Tarsus (cat)
very versatile
What are the landmarks for caudal superficial epigastric flap
essentially a mastectomy
uses a caudal superficial epigastric
distance is twice the distance from midline to nipple
take glands 5,4,3
What are complications of flap
-Seroma
-Brusing
-Flap edema
-Incisional dehiscence
-Flap necrosis
90% of dogs with axial pattern flaps had complications
