Soft tissue surgery (reconstructive)

Question 1

what should be done after debridement/lavage of a wound?

Answer 1

reassess and recategorise the contamination (be cautious)

Question 2

what is primary wound closure?

Answer 2

immediate closure of the wound without any tension

Question 3

what contamination category would primary closure be used for?

Answer 3

clean
clean-contaminated

Question 4

what is delayed primary wound closure?

Answer 4

closure of a wound 1-5 days after the initial injury to allow granulation tissue to form

Question 5

what wounds would delayed primary closure be used for?

Answer 5

contaminated
if unsure about tissue viability around wound
if lots of oedema/tension around wound

Question 6

what is secondary wound closure?

Answer 6

closure of a wound more than 5 days after injury allowing granulation tissue bed to form

Question 7

what needs to be done when closing a wound via secondary closure?

Answer 7

incise a strip around the edge of the wound

Question 8

what wounds would secondary closure be used for?

Answer 8

contaminated
dirty

Question 9

what are the aims of skin reconstruction?

Answer 9

square skin edges
accurate apposition
no overlapping
slight eversion of wound edges
follow Halsteds principles

Question 10

how should incisions be made in relation to skin tension lines?

Answer 10

parallel

Question 11

when would you close a highly contaminated wound through primary closure?

Answer 11

if it is in an area that it can’t be managed as open (mouth, lip…)

Question 12

what ways can skin tension be reduced when closing wounds?

Answer 12

undermining and advancing
tension relieving sutures
relaxing incsions

Question 13

what wounds is undermining and advancing indicated for?

Answer 13

if they are too large for tension reliving sutures
too small for a flap

Question 14

how is undermining and advancing carried out?

Answer 14

free skin from subcutaneous attachments and use the skins elasticity to close the defect

Question 15

what are the two ways of undermining skin to use for closure?

Answer 15

blunt (scalpel handle, scissors…)
sharp (scalpel blade, scissors…)

Question 16

why does care need to be taken when undermining skin?

Answer 16

vascular supply needs to be maintained
undermine deep to the panniculus muscle layer

Question 17

what technique can help to move the skin that has been undermined towards the wound?

Answer 17

walking sutures

Question 18

what are the benefits of walking sutures?

Answer 18

help to spread tension evenly
obliterates dead space

Question 19

what are some tension relieving sutures?

Answer 19

simple interrupted - one large layer and one small layer
vertical/horizontal mattress sutures
far-near-near-far suture
far-far-near-near suture

Question 20

how are relaxing incisions used to relieve tension?

Answer 20

subcutaneous sutures placed to bring wound in
small stab incisions made down the skin to allow tightening of subcutaneous suture (made need multiple rows)

Question 21

how can wounds that are irregularly shaped be closed?

Answer 21

place sutures further apart on the longer side
dividing sutures - place suture half way along then half way along the two halves…

Question 22

how can rectangular/square wounds be sutured closed?

Answer 22

start suturing from the corners

Question 23

what is a cutaneous pedicle graft also known as?

Answer 23

skin flap

Question 24

what area of the body do cutaneous pedicle grafts tend to work best?

Answer 24

head, neck and trunk

Question 25

how big should a flap be in comparison to the site it is covering?

Answer 25

slightly larger (avoid tension)

Question 26

what features should a skin flap have?

Answer 26

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)

Question 27

why shouldn’t a unipedicle flap exceed a length-width ratio of more than 3:1?

Answer 27

it will compromise the blood supply to the end

Question 28

what is a unipedicle flap?

Answer 28

only attached at one end

Question 29

what is a bipedicle flap?

Answer 29

attached at two ends

Question 30

what is a transposition flap?

Answer 30

the defect shares a border with the flap and the skin is simply rotated

Question 31

what is a unipedicle advancement flap?

Answer 31

two slightly diverging incisions made and then the flap is pulled forward to cover the area that needs a graft

Question 32

what is a H-plasty?

Answer 32

two unipedicle advancement flaps on either side of the wound and then use each one to fill half of the wound

Question 33

what are the main reasons skin flaps fail?

Answer 33

arterial/venous occlusion - thrombi, torsion, stretching
tension - direct from skin or from haematoma
infection

Question 34

what subjective measures can be used to assess the health/viability of a flap?

Answer 34

colour
temperature
sensation
hair growth

Question 35

what is an objective way of determining the health/viability of a flap?

Answer 35

fluorescein (inject and see if it is carried in blood supply)

Question 36

what are some possible salvage techniques if there is partial necrosis of a flap?

Answer 36

ointments (keep it moist)
debridement followed by open wound management

Question 37

what are the main types of free skin grafts used?

Answer 37

full thickness mesh (main one)
split thickness pinch/punch

Question 38

what is the function of surgical drains?

Answer 38

remove excess fluid from wounds and close dead space

Question 39

what are the two basic types of surgical drains?

Answer 39

passive
active

Question 40

what is the main complication seen with surgical drains?

Answer 40

ascending infection going up the drain

Question 41

what should be used to cover the area where a surgical drain exits the body?

Answer 41

absorbent and non-adherent dressing

Question 42

what are the two ways passive drains drain fluid?

Answer 42

gravity
capillary action (pulls fluid along it)

Question 43

why should holes not be cut into passive surgical drains?

Answer 43

they drain partly by capillary action, cutting holes will prevent this process from working

Question 44

how do active surgical drains work?

Answer 44

have a structure that creates negative pressure on the wound, sucking out fluid and obliterating any dead space

Question 45

when should a surgical drain be removed?

Answer 45

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)