Week 6

Question 1

understand the concept of Langer’s lines. What are “two” advantages of using this knowledge when doing minor surgery?

Answer 1

• Correspond to the natural orientation of collagen fibers in the dermis and parallel to the orientation of the underlying muscle fibers
• Advantages: Minimize wound tension, Heal faster, Produce less scarring than those cut across.

Question 2

what are the “problem areas” of the body for increased risk of scarring/keloids?

Answer 2

Keloids are more common when incisions are made across Langer’s lines.
Surgery/wounds in these “problem areas” tend to cause more scarring/keloids
-The upper chest and back
-The shoulders

Question 3

how do Kraissl’s line compare to Langer’s lines?

Answer 3

Kraissl’s lines differ in that where Langer’s lines were defined in cadavers, Kraissl’s lines were based on observations in living people.

Question 4

when a wound occurs, what essentially, is the body’s only interest?

Answer 4

The body’s first and only interest is survival

Question 5

be able to list and describe the three phases of healing (slide #11)

Answer 5

phase 1: inflammation (1st few hours)- local edema, pain, fever, and redness, debridement (clean up)- leukocytes and macrophages are on clean up crew, maturation (scab formation)- seal in healing fluids, prevent microbial invasion
phase 2: proliferation (day 5-3 weeks)- fibroblasts begin to form collagen and ground substance, myofibroblasts (in fibroblasts) cause wound contraction, angiogenesis, granulation tissue adheres the wound edges together
phase 3: maturation (3 weeks-2 yrs)- healing continues, but at a slower pace in phase 3, tensile strength incr. due to increased cross-linking of fibers (for up to two years), wound contracture occurs and because of this closing wounds with slight eversion allowing for a better appearing “flat” scar.

Question 6

what is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?

Answer 6

tissue strength is typically only about 5-6%

Question 7

understand the difference between clean, clean-contaminated, dirty/contaminated and infected wounds

Answer 7

clean: free from microorganisms, ex. heart surgery
clean contaminated: non significant contamination and less than 6h elapsing until medical care, ex. biliary and gastric surgeries
contaminated: w/o local infxn and more than 6h elapsing until medical care, ex. colon surgeries
infected: intense inflammatory rxn, and frank infectious process, ex: appendicitis, and colecistis

Question 8

is there a “golden period” of the time for closing lacerations?

Answer 8

We now know that these “Golden Periods” are no longer applicable for good wound care!

Question 9

what are the four “goals of surgery”?

Answer 9

1. Close the wound efficiently
2. No infection occurring during the healing process. End up with a small scar that is as inconspicuous as possible
3. No loss of function.
4. Only a portion of these goals are within our ability as a surgeon to control; a portion is dependent upon the patient.

Question 10

what factors involving the patient and surgeon affect wound repair?

Answer 10

surgeon factors:
Length/direction of the incision/wound
dissection technique
careful tissue handling
removal of necrotic tissue/foreign materials
good hemostasis
choice of closure materials
elimination of dead space in the wound
closing with sufficient and proper tension
anticipation of post-op wound stressors
immobilization of the wound if needed

patient factors:
patient’s age
patient’s weight
nutritional status
degree of hydration
inadequate blood supply to the wound site (e.g. DM)
patient’s immune response
presence of chronic disease
malignancies
debilitating injuries
localized/systemic infection
patient corticosteroids use
immunosuppressive or antineoplastic drugs
hormone use
radiation therapy

Question 11

understand the concept of “healing by first (primary) intention. what are the goals and outcomes of this method?

Answer 11

start with a clean wound
close promptly
produce minimal edema
have no local infection
have no serious discharge
heal in a minimum of time
heal with good skin edge approximation and eversion
heal with minimal scar formation

Question 12

what are the two possibilities that lead to a wound “healing by secondary intention”? can it be a reasonable choice made by the patient or surgeon? what are its advantages and disadvantages?

Answer 12

1. Wound fails to heal via primary (first) intention or
2. Wound is left open on purpose (wound allowed to heal without closure, heals from the inner layers toward the surface (“granulation from below”)
   Advantages:
   its simplicity
   relatively low risk of infection
   Disadvantages:
   may take forever to heal
   tends to cause larger scars

Question 13

describe the steps in “delayed primary closure (DPC)”. when should it be used? what are its advantages?

Answer 13

1. Debride the wound of non-vital tissues
2. Leave the wound open
3. Pack the wound with a sterile dressing
4. Cover with a supporting bandage – REPEAT DAILY.
   - recommend for heavily contaminated wounds (combat wounds/major trauma) where there is extensive tissue loss and high risk of infection even with proper cleansing and primary closure
   - uncomplicated closure with low risk of infection, and a “reasonable” scar

Question 14

what are the advantages of using a “running stitch”? where on the body is this a good stitch to use?

Answer 14

Running stitches are a convenient, rapid means of suturing well-approximated tissue with equal wound edges on which little tension is placed.
They tend to be much faster to perform than simple interrupted stitches.
Running stitches are valuable on eyelids, neck, and scrotum, or wherever loose skin is found.