Skin Reconstruction Flashcards
1
Q
What are the factors that influence wound management?
A
- Wound Factors
- Patient Factors
- Client Factors
2
Q
What Wound Factors influence wound management? Examples?
A
- Size and Location
- Examples:
- Large wounds or those in hard to close areas may require reconstructive techniques or may need to be left open
- trying to force close a distal limb wound may cause a tourniquet effect ⇢ cut off venous and lymphatic return ⇢ limb edema
- Wounds over joint or near an orifice may cause pathology if allowed to heal on their own
- Joint - contracture can lead to decreased range of motion
- Orifice - may distort the normal margins of the orifice
- Large wounds or those in hard to close areas may require reconstructive techniques or may need to be left open
- Examples:
- Tension
- high tension wounds are best left to heal by second intention or managed with reconstructive techniques
- Motion
- Heal incompletely if left to heal by second intention
- best managed with wound closure at some point during healing
- Pressure
- Heal incompletely if left to heal by second intention
- best managed with wound closure at some point during healing
3
Q
What are the Patient Factors that effect wound management?
A
- Species
- Temperament
- Comorbidities
- Diabetes mellitus, Cushing’s, malnutrition, uremia, and immunosuppression
- Nursing animals w/ wounds neonates may interact with
- Ability to be anesthetized
- Cardiac or chronic respiratory disease
4
Q
What are the Client Factors that effect wound management?
A
5
Q
What are some reconstructive techniques?
A
- Second Intention healing
- Tension lines
- Undermining
- Strong Subcutaneous sutures
- Stent and Bolster sutures
- Pre-tensioning/Pre-suturing/Tie-over bandage
- FNNF/FFNN sutures
- Mesh expansion
- Simple relaxing incisions
- Walking sutures
- V to Y plasty
- Z plasty
- Subdermal Plexus Flaps
- Axial Pattern Flaps
6
Q
What is Second Intention healing? When is it used?
A
- The animal’s natural healing processes will be utilized to gradually heal the wound
- Will contract (decrease surface area of the wound)
- can take several weeks to months
- Wounds in high motion/pressure areas and in animals with delayed healing may not heal at all
- Wounds near orifices or over high motion joints may suffer contracture
- Wounds that are dirty/infected or have tissue that is of questionable viability should at least initially be managed as an open wound
- Large wounds or wounds that have too much tension to close may be left open while skin tensioning techniques are used
Wounds initially managed as open and then closed later is called “delayed primary closure” or “secondary closure” depending on whether closure is before or after the appearance of granulation tissue
7
Q
What are Tension lines?
A
- Naturally occurring
- “Langer lines”
- incisions made along these lines will not have as much tension as incision made perpendicular
- Traumatic wounds should still have an effort made to close wounds along the axis of least tension
- Exception: distal limb where the long axis of any excision should be made proximodistally and the wound should be closed from medial to lateral
8
Q
What is Undermining? When should it be used/avoided
A
- Skin surrounding a wound is freed form its deep attachments via a combo of blunt and sharp dissection underneath the panniculus carnosus muscle
- leave subdermal plexus (blood vessels) intact
- should only be done for as much is needed for tension free closure (no wider than the width of the wound)
- Result: skin no longer tethered and able to stretch to its full elastic potential
- Necessary to perform other tension relieving techniques:
- mesh expansion, relaxing incisions, walking sutures, and any type of skin flap
- Should NOT be performed in infected/highly contaminated wound, or in wounds with questionable viability of the skin
9
Q
What are Strong subcutaneous sutures? When should they be used/avoided?
A
- Placing sutures across a wound in the hypodermis (+/- deeper layers) allows for tension free closure of the skin in mild to moderate tension wounds
- Can combine with undermining
- Should use rapidly absorbable suture in traumatic wounds where suture may serve as a nidus for infection
- Interrupted patterns are better (failure of one does not equal failure of all)
10
Q
What are Stent and Bolster sutures? When should they be used/avoided?
A
- For wounds in which other closure methods are not adequate
- Can be helpful in high motion areas
- Bolster:
- Widely spaced bites (1-2cm from wound edge) are preplaced along the entire length of an incision
- incision is then closed primarily
- one closed it is covered with a bandage and a role of padding
- Pre-placed sutures are then tied tightly around the padding
- Stent:
- Preplaced sutures are in a vertical mattress pattern with the far bites ~2cm away from the wound edges and near bits ~1cm away
- loops of suture on one end of the wound are placed across one stent and the free suture ends on the other side of the wound are tied across a second stent
- penrose drains are commonly used as stents
- Benefits:
- tension is distributed across the stent/bolster and not the main suture line
- Bolsters provide padding for the underlying incision and may be good in areas of increased pressure
- Stents are “low profile” - better for areas where Bolster may be problematic
- Should be removed in 3-4 days (primary incision sutures 10-14days)
11
Q
What is Pretensioning/Presuturing/Tie-over bandage? When should it be used/avoided?
A
- All ways of stretching the skin out prior to closing a defect
- Make use of skin “creep”
- collagen fibers will reorient in the line of tension, elongated the skin in that plane
- Pretensioning:
- slowly increasing the amount of tension across a wound
- Wound and peri-wound must be relatively healthy
- Large gauge suture is used to create a simple continuous pattern across the wound
- pulled as tight as possible (still a sizeable defect)
- 24hrs later remove slack from suture until it is taut
- repeated every 24 hours for 72+hrs until the edges are close enough to allow primary closure
- Presuturing:
- exact same as pretensioning, except done across intact skin, in an area where a proposed surgical excision will be challenging to close without providing some mechanical creep.
- sutures usually placed in a continuous Lembert pattern with bites 1-2cm on either side of the planned surgical incision
- exact same as pretensioning, except done across intact skin, in an area where a proposed surgical excision will be challenging to close without providing some mechanical creep.
- Tie-Over Bandage:
- make suture loop circumferentially around a wound ~1-2cm from the edges
- Large gauge suture is used and wide bites are taken.
- Suture then tied so there is a loop
- wound is then bandaged primarily and umbilical tape is laced back and forth through the suture loops across the bandage
- Tape is tied tightly to hold the bandages in place and provide some mechanical creep
- Advantage of allowing wound management for a contaminated or dirty wound
12
Q
What are FNNF/FFNN sutures? When should they be used/avoided?
A
- Taking 4 bites in row perpendicular to the incision/wound
- allows the tension to be distributed over those points while still providing appositional closure
- Should NOT be used alone in areas of moderate to high tension
13
Q
What is Mesh expansion? when should it be used/avoided?
A
14
Q
What are simple relaxing incisions when should they be used/avoided?
A
15
Q
What are walking sutures? When should they be used/avoided
A
