Soft tissue surgery (reconstructive) Flashcards
what should be done after debridement/lavage of a wound?
reassess and recategorise the contamination (be cautious)
what is primary wound closure?
immediate closure of the wound without any tension
what contamination category would primary closure be used for?
clean
clean-contaminated
what is delayed primary wound closure?
closure of a wound 1-5 days after the initial injury to allow granulation tissue to form
what wounds would delayed primary closure be used for?
contaminated
if unsure about tissue viability around wound
if lots of oedema/tension around wound
what is secondary wound closure?
closure of a wound more than 5 days after injury allowing granulation tissue bed to form
what needs to be done when closing a wound via secondary closure?
incise a strip around the edge of the wound
what wounds would secondary closure be used for?
contaminated
dirty
what are the aims of skin reconstruction?
square skin edges
accurate apposition
no overlapping
slight eversion of wound edges
follow Halsteds principles
how should incisions be made in relation to skin tension lines?
parallel
when would you close a highly contaminated wound through primary closure?
if it is in an area that it can’t be managed as open (mouth, lip…)
what ways can skin tension be reduced when closing wounds?
undermining and advancing
tension relieving sutures
relaxing incsions
what wounds is undermining and advancing indicated for?
if they are too large for tension reliving sutures
too small for a flap
how is undermining and advancing carried out?
free skin from subcutaneous attachments and use the skins elasticity to close the defect
what are the two ways of undermining skin to use for closure?
blunt (scalpel handle, scissors…)
sharp (scalpel blade, scissors…)
why does care need to be taken when undermining skin?
vascular supply needs to be maintained
undermine deep to the panniculus muscle layer
what technique can help to move the skin that has been undermined towards the wound?
walking sutures
what are the benefits of walking sutures?
help to spread tension evenly
obliterates dead space
what are some tension relieving sutures?
simple interrupted - one large layer and one small layer
vertical/horizontal mattress sutures
far-near-near-far suture
far-far-near-near suture
how are relaxing incisions used to relieve tension?
subcutaneous sutures placed to bring wound in
small stab incisions made down the skin to allow tightening of subcutaneous suture (made need multiple rows)
how can wounds that are irregularly shaped be closed?
place sutures further apart on the longer side
dividing sutures - place suture half way along then half way along the two halves…
how can rectangular/square wounds be sutured closed?
start suturing from the corners
what is a cutaneous pedicle graft also known as?
skin flap
what area of the body do cutaneous pedicle grafts tend to work best?
head, neck and trunk
how big should a flap be in comparison to the site it is covering?
slightly larger (avoid tension)
what features should a skin flap have?
slightly larger than donor site
panniculus undermines if present
infection free - no contamination or necrotic tissue
should not exceed a length width ratio of 3:1 (compromises blood supply)
why shouldn’t a unipedicle flap exceed a length-width ratio of more than 3:1?
it will compromise the blood supply to the end
what is a unipedicle flap?
only attached at one end
what is a bipedicle flap?
attached at two ends
what is a transposition flap?
the defect shares a border with the flap and the skin is simply rotated
what is a unipedicle advancement flap?
two slightly diverging incisions made and then the flap is pulled forward to cover the area that needs a graft
what is a H-plasty?
two unipedicle advancement flaps on either side of the wound and then use each one to fill half of the wound
what are the main reasons skin flaps fail?
arterial/venous occlusion - thrombi, torsion, stretching
tension - direct from skin or from haematoma
infection
what subjective measures can be used to assess the health/viability of a flap?
colour
temperature
sensation
hair growth
what is an objective way of determining the health/viability of a flap?
fluorescein (inject and see if it is carried in blood supply)
what are some possible salvage techniques if there is partial necrosis of a flap?
ointments (keep it moist)
debridement followed by open wound management
what are the main types of free skin grafts used?
full thickness mesh (main one)
split thickness pinch/punch
what is the function of surgical drains?
remove excess fluid from wounds and close dead space
what are the two basic types of surgical drains?
passive
active
what is the main complication seen with surgical drains?
ascending infection going up the drain
what should be used to cover the area where a surgical drain exits the body?
absorbent and non-adherent dressing
what are the two ways passive drains drain fluid?
gravity
capillary action (pulls fluid along it)
why should holes not be cut into passive surgical drains?
they drain partly by capillary action, cutting holes will prevent this process from working
how do active surgical drains work?
have a structure that creates negative pressure on the wound, sucking out fluid and obliterating any dead space
when should a surgical drain be removed?
when consistent small volume of serosanguineous fluid is being produced (drain incites a foreign body reaction so will always be a small volume of fluid)
