Skin Reconstructive Surgery Flashcards
what are Halstad’s principles 6
- strict adherence to aseptic technique
- gentle tissue handling
- sharp anatomic dissection of tissues
- meticulous hemostasis
- obliteration of dead space
- avoidance of tension
how should aspetic technique be maintained
Surgeon, instrument and patient prep
Clip widely and drape widely
Appropriate use of perioperative antibiotics:
Cefuroxime 20mg/kg q90min intraoperative if surgery will exceed 90 mins. Stop at end unless other factors
Keep surgical incisions covered postoperatively until patient leaves
how can gentle tissue handling be done
trauma = inflammation = infection + dehiscence
Keep tissues moist: dessiccation = inflammation
Thumb forceps:
Skin: Adson brown
Fat: plain; debakey
Stay sutures to manipulate skin edges
how is sharp anatomic dissection performed
Scalpel not scissors to cut skin
Fine sharp dissection: Metzenbaum scissors
Limit blunt dissection
how is meticulous hemostasis maintained
Hematoma increases dehiscence + infection
- Hematomas
- Electrocautery
Dab do not wipe with swabs reduces trauma
what does dead space cause
Dissection cavity in tissue planes collects fluids
Seroma forms
how is dead space prevented 2
- suture closed dead space
- use of wound drains
how do you suture closed dead space
Tension relieving walking sutures do this too
when would you use wound drains and when would you not
Careful case selection: increase risk of infection
Avoid in oncosurgery: spread tumour cells
what is an open passive drain
penrose drain
how does a penrose drain work
No collection device
Drains into dressing
Cheap and work consistently
Must be placed dependently (gravity flow)
Big increases in risk of infection
Must be covered at all times
how do you place an open drain
Always exit drain through separate stab incision
Secure drain with sutures as exits skin
Place in dependent position for gravity assisted drainage
how do you manage an open drain
Cover with sterile dressing
Monitor fluid volume soaking into the dressing
Remove when volume reduces
what is a closed, active drain
spiral drain
how does a spiral drain work
Collection device to contain fluid
Collection device generates suction
Expensive and prone to leakage
Least risk of infection
Versatile positioning not dependent on gravity
how do you place an active, closed drain
Can be placed anywhere
Do not need positioning dependently
Cover drain/skin interface as this is a potential point of ascending infection
how do you remove an active, closed drain
Drainage will never reach zero
Removed when volume decreases significantly (~48 to 72hr after placement)
Leave stoma open to heal by second intention
why do you avoid tension in the wound
Tension always leads to wound dehiscence
how should you close wounds to avoid tension
No layers are under tension
Skin edges apposed without tension
how do achieve no tension
Planning incision:
- Utilize tension lines
- Appreciate this may change with limb movement
Closing parallel to tension lines
Close in layers
Tension distribution: walking sutures
Tension removal: skin flaps
what are tension lines
Pull of tissues creates tension lines
how should you close wounds using tension lines
parallel to tension lines
how do you avoid tension by planning
how should you position limbs to minimize tension
drape limbs in
position so tensile forces are apparent
how can layered wound closure reduce tension
what are undermining + walking sutures
Mobilizes skin
Preserves blood supply
Combine with walking sutures to relieve tension
what is the undermining dissection plane
Panniculus present:
Dissect below
Panniculus absent:
Dissect off underlying fascia
what are walking sutures
Following undermining
Distributes tension through wound
Moves edges closer together for closure
Place multiple sutures
when would a temporary mattress suture be used
Stented mattress:
- Drip tubing to spread load
Skin stretches over first 72 hours
Remove and replace with other closure
how would you close small wounds on dog ears
Convert to elliptical incisions
Parallel to tension lines
Length 3x width
what is a simple advancement flap
no separate donor site wound
elastic recoil may distort wound ednge
what is an H plasty advancement flap
