Wound Closure

Question 1

Ways of wound closure

Answer 1

1. Secondary intention/ closure
2. Primary intention/closure
3. Delayed primary closure

Techniques
1. Skin grafting and skin substitutes
2. Flap closure

Question 2

Primary closure

Answer 2

■Wound edges are apposed
■Minimal new tissue need to be formed by the body
■Healing without complications:
=>little contraction
=>no excess fibroblasts activity
■Optimal results

Question 3

Delayed primary closure

Answer 3

■When there is a suspicion of contamination, which could lead to infection
Possible reasons?
=>Lacerations by a dirty object e.g, a lawn mower blade
=> Kitchen knife 🔪 cuts when the pt takes time to present to the hospital (More than 6-12 hours)
■Wound left open initially: Put dressings, change daily, and reevaluate: look for signs of inflammation, including pus formation.
■Edges approximated 4 - 6 days later if the is no infection.

If there is infection, do not close: Secondary closure!

Question 4

Secondary closure

Answer 4

●Surfaces not approximated
●Defect filled by granulation
●Covered with epithelium
¤Less functional outcome!

Question 5

What is a graft?

Answer 5

Transfer of tissue from one area to another without its blood supply or nerve supply.

Question 6

Tissue transferred from one location to another on the same patient.

Answer 6

Autograft

Question 7

Tissue transfer between two genetically identical individuals, i.e. between two identical twins.

Answer 7

lsograft

Question 8

Tissue transfer between two genetically different members, e.g. kidney transplantation (Human to human) (Homograft).

Answer 8

Allograft

Question 9

Tissue transfer from a donor of one species to a recipient of another species (Heterograft).

Answer 9

Xenograft

Question 10

What is a Skin Grafting

Answer 10

●It is transfer of skin from one area (donor area) to the required defective area (recipient area).
●It is an autograft.

Question 11

How are skin grafts classified?

Answer 11

Based on thickness
1. PARTIAL THICKNESS GRAFT (Split-thickness skin graft-SSG)
2. FULL THICKNESS GRAFT (Wolfe Graft)

Question 12

Split-thickness skin graft-SSG

Answer 12

Also called Thiersch graft, it is removal of full epidermis + part of the dermis from the donor area.
●Depending on the amount of thickness of the dermis taken, SSG may be:
(1) Thin SSG;
(2) Intermediate SSG;
(3) Thick SSG

Question 13

What are the indications of SSG

Answer 13

1. Well-granulated ulcer
2. Clean wound or defect which cannot be apposed.
3. After surgery to cover and close the defect created
   For example:
   - After wide excision in malignancy
   - After mastectomy
   - After wide excision in squamous cell carcinoma
   Graft can survive over periosteum or paratenon or perichondrium.

Question 14

Prerequisite for SSG

Answer 14

■Healthy granulation area ■Beta-haemolytic streptococci load less than 10⁵ per gram of tissue. Otherwise, graft failure will occur

Question 15

Contraindications to SSG

Answer 15

■SSG cannot be done over bone, tendon, cartilage, Joint

■Cannot be done if the pus swab confirms the presence of GBS

Question 16

The Donor Area

Answer 16

Commonly thigh, occasionally arm, leg, forearm;
Knife used is Humby’s knife; ●Blade is Eschmann blade, Down’s blade;
●Using Humby’s knife graft is taken, punctate bleeding is observed which says that proper graft has been obtained.

Donor area is dressed and dressing is opened after 10 days - 14 days, not earlier!!!

Question 17

The Recipient area

Answer 17

●The recipient area is scraped well, and the graft is placed after making window cuts in the graft to prevent the development of seroma.
●Graft is fixed, and tie-over dressing is placed.
●If graft is placed near the joint, then the part is immobilised to prevent friction, which may separate the graft.
■On the 3rd - 5th day, dressing is opened and observed for graft take up.

Mercuro chrome is applied over the recipient margin to promote epithelialisation.

Question 18

The key signs that indicate a successful take and integration of a skin graft

Answer 18

1. Color:
   
   • The graft should have a pinkish-red color, indicating good blood flow and oxygenation.
   • The color should be similar to the surrounding normal skin.
2. Texture:
   
   • The graft should have a smooth, supple texture, without any areas of hardness or induration.
   • It should feel soft and pliable to the touch.
3. Adherence:
   
   • The graft should be firmly adhered to the wound bed, with no areas of separation or lifting.
   • There should be no visible gaps or spaces between the graft and the underlying tissue.
4. Absence of drainage:
   
   • There should be no visible oozing, weeping, or discharge from the graft site.
   • Any fluid accumulation, such as a seroma, should have been properly drained.
5. Absence of infection:
   
   • There should be no signs of infection, such as redness, swelling, increased warmth, or purulent discharge.
6. Hair growth:
   
   • In areas where hair-bearing skin was grafted, the appearance of new hair growth can indicate a successful graft take.
7. Sensation:
   
   • The graft should regain sensation over time, as the nerve endings regenerate.

These signs typically appear within the first 7-10 days after the skin grafting procedure, as the graft begins to revascularize and integrate with the wound bed. Careful monitoring and assessment by the healthcare team is essential to ensure proper graft take and healing.

Question 19

What are the Stages of Graft Intake

Answer 19

1. Stage of plasmatic imbibition: ☆Thin, uniform, layer of plasma forms between recipient bed and graft.
2. Stage of inosculation:
   ☆Linking of host and graft, which is temporary.
3. Stage of neovascularisation: ☆New capillaries proliferate into graft from the recipient bed, which attains circulation later.

Question 20

What are the advantages of split-thickness skin grafts (SSG)

Answer 20

●Technically easier.
●The wide area of the recipient can be covered.
=>To cover large areas like burns wound, graft size is increased by passing the graft through a Mesher, which gives multiple openings to the graft, which can be stretched on the wider area like a net.
=> It can cause expansion up to 6 times.
●Graft take up is better; the donor area heals on its own.

Question 21

What are the disadvantages of split-thickness skin grafts (SSG)

Answer 21

1. Contracture of graft.
   - Can be primary or secondary
   ■Primary contracture:
   •SSG contracts significantly once graft is taken from donor area (20-30%).
   •The thicker the graft, the more likelihood of the primary contractures.
   ■Secondary contracture:
   •Occurs after graft has taken up to recipient bed during healing period, due to fibrosis.
   •Thinner graft has more likelihood of underging secondary contracture.
2. Seroma and haematoma formation will prevent graft take up.
3. Infection; Graft failure.
4. Loss of hair growth, blunting of sensation.
5. Dry, scaling of skin due to nonfunctioning of sebaceous glands. So after healing, oil (coconut oil) should be applied aver the area.

Question 22

What is a FULL THICKNESS GRAFT (Wolfe Graft)

Answer 22

■Both epidermis+ full dermis.
■It is used over the face, eyelid, hands, fingers, and over the joints.
Technique:
=>It is removed using scalpel blade.
=>Underlying fat should be cleared off properly.
=>The deeper raw donor area is closed by primary suturing. =>If a large area of graft is taken, then that donor area has to be covered with SSG.

Donor areas:
●Groin crease
●Post-auricular
●Supraclavicular

Question 23

Advantages of a full thickness skin graft?

Answer 23

1. Colour match is good. =>Especially for face.
   =>No contracture (unlike in SSG).
2. Sensation, functions of sebaceous glands, hair follicles are retained better compared to SSG.
3. Functional and cosmetic results are better.

Question 24

What are the disadvantages of a full thickness skin graft?

Answer 24

●It can be used only for small areas.
●The wider donor area has to be covered with SSG to close the defec

Question 25

What are flaps?

Answer 25

It is the transfer of donor tissue with its blood supply to the recipient area.

Question 26

Parts of Flaps

Answer 26

1. Base,
2. Pedicle: where vasculature goes through
3. Tip of flap: where often flap goes for necrosis.

Question 27

What are the indications for flaps?

Answer 27

1. To cover the wider, deeper areas.
2. To cover over the bone, tendon, and cartilage.
3. If skin graft repeatedly fails.

Areas where flaps are used:
●Oral cavity, neck, breast, limbs (leg), buttock, bedsores.

Question 28

What are the different types of flaps

Answer 28

1. Random pattern flaps:
   =>Here, vascular basis is subdermal plexus of blood vessels.
   =>No known blood vessel is supplying it
   => Rectangular flap with length to width ratios 1 :1 or less than 1.5:1.
2. Axial pattern flaps:
   =>Here, superficial vascular pedicles pass along their long axes, e.g., forehead flap, deltopectoral flap, groin flap. =>Anatomically, a known blood vessel is supplying it.
   It is a long, lengthy flap.

Question 29

Anatomical types depending on the types of tissue in the flap

Answer 29

1. Cutaneous flap: Forehead flap, deltopectoral flap.
2. Fasciocutaneous flap: Radial forearm flap, scapular flap, lateral arm flap, groin flap.
3. Muscle flap: Gluteus maximus muscle flap, gracilis flap, tensor fascia lata muscle flap.
4. Myocutaneous flap: Pectoralis major myocutaneous flap, latissimus dorsi flap-composite flap.
5. Osteomyocutaneous flaps: Radius with brachioradialis and skin, rib with intercostal muscles and skin-composite flaps
6. Local rotation flaps, transposition flaps: When the flap moves laterally, it is called transposition flap
7. ‘Z’ plasty
8. . Free flaps: Vascular pedicle of the flap, both artery and vein, are anastomosed to recipient vessels using operating binocular microscopes.
9. Omental flaps.
10. Island flap: Localised flap is swung around a stalk from the donor area to the recipient area, often with the pedicle buried underneath the skin bridge in between. Pedicled flap is also an island flap

Question 30

What are the disadvantages of flaps

Answer 30

1. Long-term hospitalisation
2. Infection
3. Kinking, rotation, and flap necrosis
4. Staged procedure