Skin Surgery

Question 1

What are some skin surgery considerations?

Answer 1

• Suture techniques
• Suture placement
• Wound drainage
• Wound tension
• Blood supply
• Reconstruction techniques
• Pre-stretching
• Skin flaps
• Skin grafts
• Wound management

Question 2

What are the two main blood supplies to the skin?

Answer 2

1. Myocutaneous vessels

2. Direct cutaneous vessels

Question 3

Describe the myocutaneous blood supply?

Answer 3

These are the small vessels that come up from the skeletal muscle

Question 4

Describe the direct cutaneous blood supply…

Answer 4

Key vessels that come up between muscle bellies and feed directly into the panniculus etc. muscle

Question 5

Describe the deep subcutaneous plexus…

Answer 5

Terminal vessels that branch from the direct cutaneous vessels form this plexus
- Most of the blood comes from here to feed up to the skin

Question 6

Why do you have to be careful when stretching tissue to apposition?

Answer 6

If the tissue is over-stretched, there won’t be a blood supply
- the wound won’t heal

Question 7

At what angle/ direction do you want to make a skin incision to the lines of tension in the body?

Answer 7

A parallel incision

- this reduces the size of the wound

Question 8

What is dehiscence?

Answer 8

When the wound ruptures along the surgical suture

Question 9

What will push the limits of tissue viability?

Answer 9

• Trauma
• Bacterial contamination
• Surgery

Question 10

When do wound generally (if at all) start to break down?

Answer 10

After 3-5 days

• The blood supply terminates and the tissue begins debriding
• Sutures have “given up” and the wound is taking over

Question 11

What happens if you get premature failure of sutures?

Answer 11

The tissue loses its own strength and the wound will debride

Question 12

What are some problems with sutures?

Answer 12

• Too tight
• Too many
• Too big
• Use of irritant materials
  e. g catgut

Question 13

What is the effect of excessive skin tension?

Answer 13

• Pain (chew at sutures)
• Ugly scar
• Wound dehiscence

Question 14

What is important about fascia?

Answer 14

• It is where blood supply is (subdermal plexus)
• Sutures must engage underlying fascia to manage any wound tension
• Fascia is most tolerant to tension

Question 15

When suturing a wound, what should the skin be like once it comes together?

Answer 15

Skin edges should come into apposition without tension

- The tension is obtained within the deeper tissues where there is better blood supply!

Question 16

What are some options for good control of tension?

Answer 16

• Geometric closure
• Undermining
• Tension relieving sutures
• Tension relieving incisions
• Advancement flaps
• Pre-surgical techniques
• Advanced procedures

Question 17

What is geometric closure?

Answer 17

Large or irregular defects can be closed using V, Y or Z plasty instead of a straight line

Question 18

What is undermining?

Answer 18

One method of reducing skin tension

• Scissors are used to separate skin and/ or panniculus muscle from the underlying tissue
• Releases skin from underlying tissue so its full elastic potential can be used to stretch over the wound

Question 19

Describe tension relieving incisions…

Answer 19

An incision is made nearby the wound the same length as the original wound
- Undermine the new incision and move the elastic skin over to the original wound
“ borrowing” skin
- In most cases the new wound can be left open to heal by second intention

Question 20

What are the two rules of undermining?

Answer 20

1. Deep to fascia/ panniculus
2. Maintain elevation within established limits so as not to exceed local perfusion limits
   - Size of flap depends on location
   - Two small flaps better than one big one
   - Wider base to flap
   - Avoid subdermal plexus injury

Question 21

What are axial pattern flaps?

Answer 21

Advanced surgical procedures

• tongue-like flaps that include a direct cutaneous artery and vein at the base of the flap
• Elevated and transferred to tissue defects within their radius
• Usually rectangular or L-shaped
• Most commonly used after tumour removal or trauma