Skin Reconstruction Flashcards
what are the main vessels that supply/drain the subdermal plexus
direct cutaneous artery and vein
extends to the panniculus and branches out into the subdermal plexus –> middle plexus –> superficial plexus
where is the plane of dissection for skin flaps
underneath the panniculus muscle
do not want to cut above the panniculus because will cut into the subdermal plexus and cut off blood supply to flap
angiosomes
regions of skin that are supplied by the direct cutaneous arteries and veins
what is the goal of open wound management
transform the contaminated wound into a clean wound before closure
should you close contaminated wounds via primary closure
NO - must manage wound to clean before closure
surgical debridement
excising contaminated and necrotic tissue using a scalpel
freshen edges - ensure bleeding
lavage with sterile saline
clip, clean, flush
mechanical debridement
using a wide mesh gauze contact layer to wick away necrotic/foreign material away from the wound (debris gets removed with the bandage)
can be applied:
- wet to dry
- wet to wet
- dry to dry
can NOT use in place of surgical debridement
how often should wounds be assessed
minimum once daily to ID healthy granulation tissue, signs of infection, etc
1st intention healing
surgically bringing together the edges of the wound
- primary closure
- delayed primary closure
primary closure
suturing up a clean surgical wound
delayed primary closure
surgical closure BEFORE granulation tissue forms
used on mildly contaminated wounds
- debride and bandage for 1-3 days then surgically repair
2nd intention healing
natural healing via skin contraction and re-epithelialization
used on small wounds and long, thin wounds
- skin must be able to contract close enough to epithelialize
- does NOT work on circumferential wounds
3rd intention healing
surgical closure AFTER granulation bed forms
(“secondary closure”)
debride –> bandage –> form granulation tissue –> close with a graft
in what direction should you align the long axis of the wound to reduce tension
parallel to the natural lines of tension in that area
make elliptical cuts vertically from dorsal to ventral
what are adverse effects of wound tension
- dehiscence
- excess scar tissue
- increased post-op pain
- potential tourniquet effect
what is the main principle of tension reduction
using subcutaneous of tissues to remove tension at the skin margin
what are 5 methods of tension reduction
- patient positioning (place in most tense position before suturing)
- use interrupted tension relieving sutures
- undermine the skin
- walking sutures
- skin stretchers
what is undermining the skin
freeing up the skin that you are trying to maneuver from the underlying muscle
what are tension relieving sutures
interrupted cruciate sutures in the deep subcutaneous tissues
OR
mattress sutures
+/- incorporation of the panniculus
skin stretchers
applies a tensile force across the skin to stretch the dermal collagen fibers
can be used pre or post op
best for large abdominal or thoracic wounds
incisional plasty
making incisions adjacent to the wound to provide a small amount of tension relief
local flaps
elevating a flap of skin adjacent to the defect that can be moved around to cover the defect
what is the blood supply for local flaps
subdermal plexus
must dissect deep to the panniculus - do NOT want to incorporate the direct cutaneous vessels
appropriate base to length ratio for local flaps
1:2 base to length
ensures blood supply can make it all the way to the end of the flap
single pedicle advancement flap
flap created as wide as the widest point of the defect
extend the length of the defect from the widest part of the base –> elevate skin under panniculus muscle –> pull flap forward to cover entire defect –> place drain
bipedicle advancement flap
same as a releasing incision (incisional plasty)
often used on limbs to close a primary defect from oncological resection
transpositional flaps
skin is elevated adjacent to the flap and rotated up to 90 degrees to cover defect
used on caudal thigh
rotational flaps
incise in a semicircular fashion from the margin of the defect –> elevate skin and start rotating flap –> keep rotating until the defect is covered
used on lateral thigh (uses inguinal/axillary skin)
best for triangular/square defects
skin fold advancement flap
advancement flaps made from the axillary and inguinal folds
folds are attached in 4 places to the trunk and limbs: lateral, medial, distal, proximal
any 3 of the attachment sites can be cut to form a flap
axial pattern flaps
incising an entire angiosome to cover a larger defect
what is the blood supply for an axial pattern flap
direct cutaneous artery
must incorporate in the flap
free skin graft
removing skin from one area of the body and moving it to another
what is the blood supply for free skin grafts
NONE - must lay the skin graft over a healthy granulation bed to ensure regrowth of capillaries
what are the stages of free graft nutrition
- plasmatic imbibition
- first 2-3 days
- absorbing nutrients from wound - inosculation
- first week
- new capillary buds cross the wound bed to anastomose with vessels - revascularization
- 1-2 weeks
- growth of new capillaries that pass into grafted tissue
what are the 5 complications of wound reconstruction
- flap necrosis
- flap dehiscence
- seroma
- SSI
- contracture
what causes flap necrosis
vascular supply does not reach entire flap causing areas of necrosis
what is dehiscence
wound edges pull apart
can usually heal by second intention, may require closure
seroma treatment
warm pack and compression
can drain but may increase infection risk
signs of SSI
- purulent discharge
- swelling
- redness
- necrotic tissue
occurs within 14 days of surgery
treat with antibiotics
signs of SS reaction
- swelling
- redness
- centered around knots
NO discharge
