Skin reconstructive surgery

Question 1

Halsteads Principles (6 principles)

Answer 1

1. Strict adherence to aseptic technique.
2. Gentle tissue handling.
3. Sharp anatomic dissection of tissues.
4. Meticulous haemostasis.
5. Obliteration of dead space.
6. Avoidance of tension.

Question 2

Suggest ways to accomplish1. Strict adherence to aseptic technique.

Answer 2

Proper PPE
Appropriate (often wide) clipping and draping
Perioperative antibiotic use
Cover wounds post op until patient leaves the hospital

Question 3

Suggest ways to accomplish 2. Gentle tissue handling.

Answer 3

Use most appropriate instruments
Keep tissues moist to avoid desiccation during surgery
Use stay sutures to manipulate skin edges

Question 4

Name of forceps for skin

Answer 4

Adson Brown forceps for skin

Question 5

Name of forceps for fat

Answer 5

Debakey forceps for fat

Question 6

Suggest ways to accomplish 3. Sharp anatomic dissection of tissues.

Answer 6

Use a scalpel and not scissors to cut skin
Limit blunt dissection
Use Metzenbaum scissors for fine sharp dissection

Question 7

Name of scissors used for fine sharp dissection

Answer 7

Metzenbaum scissors

Question 8

Suggest ways to accomplish 4. Meticulous haemostasis.

Answer 8

Use haemostats to control bleeding
Use diathermy if available
Haematomas increase wound dehiscence and infections
Dab tissues with swabs, don’t wipe, to reduce trauma

Question 9

Suggest ways to accomplish 5. Obliteration of dead space.

Answer 9

Careful tissue dissection
Using sutures to close dead space (i.e. walking sutures)
Using wound drains

Question 10

Why should we avoid using drains in oncological surgeries

Answer 10

Can increase the risk of infection
Avoid in oncological surgery as can spread tumour cells

Question 11

Types of drain

Answer 11

Open passive drain (penrose)
Active closed drains (Jackson pratt)

Question 12

How do passive/penrose drains work

Answer 12

Act via capillary action, overflow and gravity
No collecting device
Drains into dressing (ideally)

Question 13

Should the exit of a drain be at the wound

Answer 13

Must exit through a separate incision NOT the wound
Must be placed in gravity dependant position to allow drainage

Question 14

Management of open drains

Answer 14

Should be covered with a dressing which is changed regularly (often left open at home)
Monitor the fluid volume soaking into the dressing.
Remove when volume reduces (usually 2-5 days)
Drain will not stop producing fluid
Dog should wear an e collar (they will eat the drain)

Question 15

How do active/Jackson pratt drains work

Answer 15

Rely on a vacuum
Fluid is drain through a tube which exits the skin into a collection chamber
Do not need to be placed in a dependant location
Can place anywhere

Question 16

Suggest ways to accomplish 6. Avoidance of Tension

Answer 16

No layers are under excessive tension
Skin edges are opposed without tension

Question 17

Close parallel or perpendicular to tension lines?

Answer 17

Close PARALLEL to tension lines

Question 18

What does walking sutures do

Answer 18

Used after undermining
Helps to obliterate deadspace and distribute tension over the wound
Moves wound edges closer together

Question 19

How to avoid dog years

Answer 19

Make elliptical incisions
Parallel to tension lines
Length should be 3x the width

Question 20

Advancement flap

Answer 20

Can be created anywhere
Size limited by vascular supply
Blood supply through subdermal plexus
Dependant on the amount of loose skin available
Maximise the width of the base as much as possible
2:1 flap length:base width ratio