Tumour removal and reconstructive sx Flashcards
how to approach tumour removal?
- dEcide margins
- Where is the mass
- Assess how much loose skin
- Have more than one option
- IF using flaps/grafts plan closure of donor site
- Use surgical markers for planning
- cLip ide if need to change plan
Tension lines?
*Pull of collagen and elastin in dermal and hypodermal tissues
*Close wounds along tension lines(parallel not perpendicular)
What is the best ay to close your tumour removal?
Ellipse is easy to close with best cosmetic appearance (benign)
* length to width ratio of 4:1 lessens dog ear formation
* Incise perpendicular through all layers to deep fascial plane (cookie cutter)
Describe circle closure?
- Circles require less skin compared to other patterns (potentially malignant)
- Some wounds convert to circles once cut due to tension lines
What are some tension relieving techniques for reconstructive surgery?
Approach to traumatic wound management ?
What are some methods of closure?
Describe the reconstructive ladder?
Describe how undermining works?
- Separating the skin from the underlying tissue
- Blunt and sharp dissection with Metzenbaum scissors
- Preserve the deep dermal plexus;
- Undermine deep to panniculus/platysma
describe the use of tension releiving sutures?
- Alleviate tension on the suture line
- Strong subcutaneous sutures are effective
- Stenting
- Far-near-near-far
- Far-far-near-near
- Mattress sutures
How are walking sutures done?
- Undermine
- simple interrupted sutures beteen dermis and fascia
- Start away from wound edge and walk the skin edges towards the wound
- Distributes tension
- Skin dimpling if placed correctly
Describe Mesh Expansion / Multiple Punctate Relaxing Incision
- Undermine adjacent to wound
- Full-thickness incisions in rows, 1cm apart & 1cm from wound
- Incisions heal by epithelialisation
- Too large or too close together → vascular compromise
- Do not use in skin flaps
What is a simple relaxing incision?
- Incision parallel to wound
- Undermine skin and move into the defect
- Relaxing incision can be closed or left to heal by second intention
- Useful for defects near an orifice or a joint
Describe a V or Y plasty?
- Provides an advancement flap to cover a wound
- Used to close chronic wounds under tension
What are the different closing ‘shapes’ we can use?
- Circular defects
- Crescents
- Triangles
- rectangles and squares -> cross
Skin stretching techniques?
Skin has inherent properties of stress relaxation and mechanical creep
Pre-tensioning or pre-suturing
➢ sutures placed to influence an existing wound or prior to an excision
➢ simple continuous or continuous intradermal suture, tightened daily
➢ velcro straps can be used
➢ plication of the skin with Lembert sutures
Dealing with dog ears?
- Minor cosmetic problem
- Resolves with time
- Various techniques to repair large dog ears
What are the different subdermal plexus flaps (random flaps)?
When to use local subdermal plexus flaps?
- Full thickness flaps adjacent to the defect
- Cover smaller areas than axial pattern flaps
Ho to do a local subdermal plexus flap?
- Blood supply subdermal plexus alone (no direct cutaneous artery)
- Just long enough to cover defect, wide base, tension free closure
- Incise sharply, undermine deep to subdermal plexus
- Careful handling – stay sutures or adson-brown thumb forceps
Should the base of your subdermal plexus flap be wide or narrow?
Wide -> aim for 2:1 length:base ratio
hat does a single pedicle advancement flap look like?
Describe H plasty?
- Blood supply subdermal plexus alone (no direct cutaneous artery)
- Just long enough to cover defect, wide base, tension free closure
- Incise sharply, undermine deep to subdermal plexus
- Careful handling – stay sutures or adson-brown thumb forceps
When are rotational flaps used?
- Useful to close triangular defects
- Semicircular incision from the base of the triangle until can achieve tension free
closure
When are transpositional flaps useful?
- Useful apart from distal extremities (difficulty closing donor site)
How are transposition flaps done?
- Rectangle of skin bordering the defect is transposed into the defect pivoting
on the point of the flap base furthest from the defect - Usually 45-90 degrees
What are interpolation flaps?
- Variation on transition flap
- No common border with wound
- Cut away remaining ‘bridge’ after 14 days
- Or create a ‘bridge’ incision
-> removes need for 2dn sx
Axillary & Inguinal folds flaps
Large defects on trunk, ventral thorax and abdomen, medial and lateral aspects of proximal limbs
Describe Axial Pattern flaps?
- Direct cutaneous artery
- Larger flaps with better survival
- Can rotate up to 180 degrees
- Peninsular flaps have intact skin
- Island flaps do not
- Peninsular flaps have intact skin
Axial Pattern flaps ?
- Direct cutaenous artery
- Larger flaps with better survival
- Can rotate up to 180 degrees
-> Pennincular flaps have intact skin
-> Island flaps do not
Survival with axial pattern flaps?
- Survival 87-100%; tip necrosis not uncommon
- Survival is 50% more than subdermal plexus flaps
How to secure & drain axial pattern flaps?
- Secure with SI sutures
- Drains often used to manage dead space/seroma (closed suction)
Visualise a caudal epigastric axial pattern flap?
Complications of skin flaps?
➢ Oedema
➢ Dehiscence
➢ Seroma
➢ Flap necrosis
➢ Infection
Skin grafts?
- Epidermis and dermis removed from the body and transferred to a new site
- Must re-establish a vascular supply (engraftment) for survival
- Mainly used for distal extremities in small animals
How to get successful skin grafts?
- Failure usually due to fluid accumulation, infection and movement separating
graft from the recipient bed- Meshing helps
- Bandages to immobilise – do not change for 48 hrs to allow fibrin seal
- Bandages used for 2-3 weeks after grafting
- Robert jones +/- splints
What factors are going to determine if the skin graft ‘takes’ well or not?
- Adherence
- Nutrition -> plasmatic inhibition, inoculation, revascularisation
- Oedema & colour changes
What different skin graft types /classification might we see?
- Extent of wound coverage
- Depth of skin harvested
