Wound Healing/Keloids Flashcards
Use of negative pressure wound therapy with a sponge dressing is likely to result in an adverse outcome in which of the following clinical scenarios?
A) A hand wound with exposed tendons
B) A lower extremity wound with exposed femoral vessels
C) A Stage IV sacral pressure sore
D) As a bolster over a split thickness skin graft on the arm
E) Over a closed surgical incision after hernia repair
The correct response is Option B.
Negative pressure wound therapy (NPWT) has dramatically improved our ability to manage complicated and complex wounds. Advantages of NPWT include decreased healing time, simplified wound care with less frequent dressing changes, and promotion of healthy granulation tissue. However, there are several contraindications to the use of NPWT. The presence of exposed vessels is an absolute contraindication to its use; arterial rupture has been reported with multiple fatalities. In addition to placement over exposed vessels, significant bleeding has also been noted with use of NPWT in groin and sternal wounds, in patients on blood-thinning medications, and during removal of well-integrated foam pieces. Other complications include infections due to retained pieces of foam.
In addition to exposed vessels, NPWT should not be used in the setting of active, uncontrolled infection, malignant wounds, wounds with unexplored and/or nonenteric fistulas, and poorly debrided wounds.
Although NPWT may not be the definitive wound management in the other scenarios listed, there is no contraindication for its use.
2018
Which of the following technical factors has the greatest favorable impact on the final appearance of a surgical scar?
A) Closing the wound in a single layer
B) Use of an absorbable suture
C) Use of topical cyanoacrylate
D) Retention suture
E) Wound-edge eversion
The correct response is Option E.
The two technical factors that increase the likelihood of a “good” scar are placement of sutures that will not leave permanent suture marks and wound-edge eversion. In wounds where the skin is brought precisely together, there is a tendency for the scar to widen. In wounds where the edges are everted or hypereverted in an exaggerated fashion, this tendency is minimized possibly by reducing the tension on the closure. While the most common method of closing a wound is with sutures, there is nothing necessarily superior about sutures or a specific type of suture. Staples, skin tapes, or wound adhesives are also useful in certain situations. Regardless of the method of closure or type of suture used, precise approximation of skin edges without tension is essential to ensure healing with minimal scarring. Simple interrupted suture is the gold standard for suturing wounds closed and everting the skin edges. Retention sutures tend to leave the most obvious and unsightly cross-hatching if they are not removed early. Wounds deeper than the skin are closed in layers. The key is to eliminate the dead space and provide a strong closure to prevent dehiscence and reduce tension. However, not all layers necessarily require separate closure.
2018
A 23-year-old woman comes to the office because of a hypertrophic scar after undergoing abdominoplasty 3 months ago. A multimodal approach to improving the appearance of the scar is planned. Which of the following therapies is supported by the highest quality evidence in this patient?
A) Allium cepa extract
B) Fat injection
C) Microneedling
D) Silicone gel
E) Vitamin E
The correct response is Option D.
Silicone gel has demonstrated efficacy in improving hypertrophic scars in a number of studies and is supported by level I evidence. Vitamin E, fat injection, allium cepa extract and microneedling are supported by lesser quality studies in a recent comprehensive review of the literature.
2018
The use of routine systemic antibiotic prophylaxis is indicated in which of the following procedures?
A) Abdominoplasty
B) Carpal tunnel release
C) Excision of squamous cell carcinoma of the skin
D) Reduction mammaplasty
E) Rhytidectomy
The correct response is Option D.
Systemic antibiotic prophylaxis is recommended in clean breast surgery. Studies have shown that the use of antibiotic prophylaxis in patients undergoing breast surgery (with or without implant) significantly reduces the risk of surgical site infections. The benefit from routine antibiotic prophylaxis is greater in individuals receiving tissue expanders or breast implants for reconstruction, but patients undergoing breast augmentation or reduction mammaplasty also benefit from antibiotic prophylaxis. With the exception of cosmetic breast surgery, clean operations have not been shown to benefit from routine antibiotic prophylaxis. Therefore, the use of routine antibiotic prophylaxis is not indicated in clean surgical cases of the hand (carpal tunnel release), skin (squamous cell carcinoma of the skin), head and neck, or abdominoplasty. It is indicated in contaminated surgery of the hand or face.
2018
A 77-year-old man undergoes wide local excision of a melanoma on the posterior shoulder. Concomitant sentinel lymph node biopsy is positive for metastasis. Completion axillary lymph node dissection and adjuvant radiation therapy to the axilla are performed. Metastatic workup shows no abnormalities. Postoperatively, the patient develops chronically draining seroma and open wound to the axilla. He is referred for management of the radiation wound after it fails to improve with conservative local wound care. Physical examination shows a 2-cm open wound to the axilla, which tunnels 5 cm into the apex and is surrounded by extensive fibrosis and erythema. Which of the following interventions is most likely to result in a definitive closure?
A) Administration of 30 hyperbaric oxygen treatments at 2.4 ATA
B) Application of negative pressure wound therapy
C) Excision of the wound cavity and full-thickness skin graft reconstruction
D) Excision of the wound edges and application of acellular dermal matrix
E) Wide excision of the irradiated soft-tissues and repair with a thoracodorsal artery perforator flap
The correct response is Option E.
Radiation damage produces a hypoxic, hypovascular, and hypocellular environment that can lead to delayed healing and even ulcer formation. Principles of management once a chronic radiation wound has developed include aggressive surgical removal of the entire zone of injury, which is sometimes larger than initially anticipated, and repair with well-vascularized tissue. A thoracodorsal artery perforator flap will provide sufficient healthy and supple soft tissue to cover the entire axilla. The thoracodorsal pedicle should be intact as it is not regularly divided during axillary lymph node dissection.
Negative pressure wound therapy would be contraindicated in this wound because of the potential for exposure of blood vessels in the axilla as well as for sponge retention in the tunneled wound and is, therefore, incorrect.
Excision of the wound edges only may be inadequate treatment of the zone of injury, and it is not the best choice. Furthermore, acellular dermal allograft plays no role, aside from possibly a temporizing measure, in the treatment of radiation ulcers.
Hyperbaric oxygen therapy is indicated for soft tissue radionecrosis. This delivers increased levels of oxygen to the hypoxic, irradiated wound and establishes a steeper oxygen gradient between the wound and surrounding tissues. The cellular response to this gradient stimulates neovascularization and can improve or even heal some wounds. However, with this large, cavitary wound, hyperbaric oxygen therapy, as a single-line treatment, would be unlikely to heal the wound completely.
Excision of the wound cavity and full-thickness skin graft reconstruction is not the best option for two reasons. First, the excision may lead to exposure of neurovascular structures that should not be covered with a skin graft. Second, risk of partial or total loss of a full-thickness skin graft may be unacceptably high in an irradiated wound bed.
2018
During which of the following phases of wound healing is collagen deposition the greatest?
A) Collagen deposition occurs equally during all phases of wound healing
B) Collagen deposition does not occur during wound healing
C) Inflammatory
D) Proliferative
E) Remodeling
The correct response is Option D.
The proliferative phase of wound healing occurs in two phases. Fibrin and fibronectin are formed during the initial proliferative period. Around day 3 of wound healing, fibroblasts appear and begin production of collagen. The proliferative phase ends between 2 to 4 weeks of wound healing when collagen accumulation reaches a maximum and collagen remodeling begins, marking the beginning of the remodeling phase of wound healing.
Inflammatory phase is dominated by white blood cells. There is an influx of polymorphonuclear leukocytes (PMNs), macrophages, and lymphocytes. PMNs are not essential to wound healing, but macrophages are essential. Sterile incisions normally heal without PMNs.
Type III collagen is converted to type I in the remodeling phase. In this phase there are increased collagen cross-linking and increased tensile strength.
Collagen deposition does not occur during wound healing is incorrect. It occurs during all phases of wound healing.
Collagen deposition occurs equally during all phases of wounding healing is incorrect because collagen deposition is heaviest during the proliferative phase. Fibroblasts differentiate from resting mesenchymal cells in connective tissue. They are chemoattracted to the site, divide and produce components of ECM and their primary function is to synthesize collagen during that phase.
2018
A 40-year-old man with a history of seizure disorder presents with jaw pain and malocclusion 12 hours after he was punched in the face during a brawl. X-ray studies show a displaced left angle fracture and right parasymphyseal fracture. He smokes one pack of cigarettes daily. Open reduction and internal fixation of the fractures is planned. Which of the following factors in this patient’s clinical presentation places him at greatest risk for postoperative wound infection?
A) History of seizures
B) History of tobacco use
C) Patient age
D) Patient gender
E) Surgery delayed until 5 days after injury
The correct response is Option B.
Although early treatment of mandible fractures would help relieve pain, delay of treatment in multiple series has not been directly correlated with an increased wound infection rate. In a recent review, tobacco use has been associated with a sixfold increase in wound infection compared with nonsmokers. Although the incidence of complications after mandible fractures is lower in children, in the adult population, patient age and gender do correlate with an increased complication rate. Factors that have correlated with a higher complication rate include the number of mandible fractures present and incision location, intraoral and combined intraoral, and combined intraoral and extraoral incisions were associated with higher infection rates than only extraoral incisions.
2018
A 45-year-old woman undergoes breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. During donor site closure, a size-0 absorbable suture that maintains the greatest strength over time is desired for closure of Scarpa fascia. Which of the following sutures is most appropriate?
A) Chromic gut
B) Poliglecaprone (Monocryl)
C) Polydioxanone (PDS)
D) Polyglactin (Vicryl)
E) Polypropylene (Prolene)
The correct response is Option C.
Chromic gut is an absorbable natural monofilament suture whose strength decreases to 50% in approximately 14 days, with near complete loss of strength at approximately 3 weeks.
Polyglactin (Vicryl) is an absorbable synthetic polyfilament suture whose strength decreases to 50% in approximately 2 to 3 weeks, with near complete loss of strength at approximately 1 month.
Poliglecaprone (Monocryl) is an absorbable synthetic monofilament suture whose strength decreases to 50% in approximately 7 to 10 days, with near complete loss of strength at approximately 3 weeks.
Polydioxanone (PDS) is an absorbable synthetic monofilament suture whose strength decreases to 50% in approximately 4 weeks, with near complete loss of strength at approximately 6 weeks.
Polypropylene is a a nonabsorbable synthetic monofilament suture.
2017
A patient presents with an 8-cm linear laceration to the forearm from a bicycle accident. Compared with typical suturing techniques, which of the following outcomes is more likely with a cyanoacrylate glue–only closure?
A) Dehiscence
B) Hyperpigmentation
C) Infection
D) Keloid scarring
E) Pain
The correct response is Option A.
While cyanoacrylate glue closures such as Dermabond and Indermil offer the advantages of speed, ease-of-use, and comfort in the closure process, some studies show that the outcomes are unpredictable, especially for longer lacerations. One pediatric groin hernia incision closure showed a 24% dehiscence rate, while a porcine study of 10-cm lacerations showed a 15% dehiscence rate. Glue closures do have a role in smaller, tension-free lacerations, particularly in children or others who may not easily tolerate traditional closure. This simplicity of closure does come with the cost of a higher dehiscence rate, so glue closures may be inappropriate for longer, more complex wounds. When used as an adjunct to a comprehensive subdermal interrupted closure, it appears that the dehiscence rate normalizes. Data are less convincing on long-term scar results, but it does not appear likely that glue closures improve or worsen scarring to any appreciable extent for wounds that achieve primary healing without disruption.
2017
Negative pressure wound therapy with a sponge dressing is CONTRAINDICATED in which of the following clinical scenarios?
A) An abdominal wound with an enteric fistula
B) A dorsal hand wound with an exposed tendon
C) A lower extremity wound with acute osteomyelitis
D) Over a closed surgical incision
E) A radiated scalp wound with exposed bone
The correct response is Option C.
The use of negative pressure therapy (NPT) is contraindicated in wounds with active infection including osteomyelitis. Negative pressure dressings in these wounds convert an open, draining wound into a closed wound, which could potentially lead to abscess formation and/or sepsis. NPT has become an integral part of wound management over the past decade and a half. It is a commonly used wound dressing and/or chronic wound management tool. It is instrumental in acute wounds as well (e.g., lower extremity trauma, abdominal wall trauma), and as a skin graft bolster dressing. The major contraindications for its use include wounds with active infection such as untreated osteomyelitis, malignant wounds, wounds with exposed major vessels and/or organs, and wounds with unexplored and/or nonenteric fistulas.
Apart from the infected wound, all the wounds mentioned in the option set may benefit from the use of NPT. It may not be the definitive management for those wounds, but it could be used as a temporary measure prior to the definitive treatment. Recently, studies have shown that the use of NPT over closed incisions may reduce the risk for dehiscence and infections.
2016
A 63-year-old man underwent resection of a chest wall sarcoma that was covered with an anterolateral thigh flap. He now undergoes external beam radiation therapy, and there is erythema, edema, and dry desquamation of the surgical sites. Which of the following is the most appropriate treatment?
A) Diphenhydramine
B) Hyaluronic acid
C) Hydrocortisone
D) Salicylate
E) Vitamin E
The correct response is Option C.
Radiation dermatitis is one of the most common side effects of radiotherapy for cancer and can occur any time, from hours to weeks after radiation exposure.
Acute radiation-induced skin changes depend on the radiation dose and include erythema, edema, pigment changes, epilation, and dry or moist desquamation. They can also be accompanied by pain and pruritis.
For the lower grade changes described for this patient, topical corticosteroids with low to medium potency, such as hydrocortisone 1% cream, are recommended. This is in addition to a skin-washing protocol to keep skin clean and dry before treatments.
All of the other topical agents listed – antihistamines, salicylate analgesics, vitamin E, and hyaluronic acid – have all been previously studied and shown to have no added benefit.
More severe skin changes such as moist desquamation, skin necrosis, or intractable pain may require radiation to be stopped, resulting in inadequate disease treatment.
2016
A 38-year-old unconscious and intoxicated woman is brought to the emergency department after being struck by a motor vehicle. She sustained multiple injuries, including a wound on the right thigh, which measures 12 × 18 cm with areas of exposed fat and muscle. There is dirt and gravel in the wound. Which of the following is the most appropriate next step in management?
A) Broad-spectrum antibiotic therapy
B) Injection of tetanus toxoid
C) Negative pressure wound therapy
D) Split-thickness skin grafting
E) Wound irrigation and debridement
The correct response is Option B.
In a patient with a grossly dirty wound, it is appropriate to administer a tetanus shot. Tetanus (also known as lockjaw) is characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by Clostridium tetani, a gram-positive, rod-shaped, obligate anaerobe. Infection generally occurs through wound contamination and often involves a cut or deep puncture wound.
In the acute period before definitive wound closure can be achieved, it is critical to debride all devitalized tissue such that there is a healthy, viable wound bed. The administration of broad-spectrum intravenous antibiotics has not been shown to decrease the risk of wound infection, and may, in fact, lead to the development of selecting out for resistant pathogens. The mainstay of treatment is performing repeat surgical debridement as often as necessary until the wound is clean. Debridement and cleansing of the wound are ideally performed in the operating room under controlled conditions; however, depending upon the condition of the patient, concomitant injuries, and the ability of the patient to tolerate the procedure, it may be necessary to perform a limited, conservative wound washout at the bedside or in the emergency department. Over the course of the initial hospital stay, debridement should continue until healthy tissue is encountered, which can be identified by visual inspection and the presence of punctate bleeding.
The surgeon must consider several things when deciding between closure with a flap or a graft. The defect in this patient is too large to achieve primary closure. The use of negative pressure wound therapy for such a large wound may be helpful as a temporary measure, but, as a method of definitive wound closure, would result in healing by secondary intention, scarring, and prolonged wound care. If there were exposed bone, tendon, nerves, blood vessels, or significant dead space, this would make a stronger argument for a flap-over-skin graft. Although not provided as an option in this question, the use of biosynthetic materials or dermal matrix tissues has been reported in the literature as an intermediate step to skin grafting, but it is important to consider the necessity of these materials in effecting outcomes in light of the significant cost of using them.
Split-thickness skin grafts can provide wound coverage over a large area. A mechanical dermatome is often used. Typical thicknesses may range from 8/1000th of an inch to 14/1000th of an inch. The graft can be meshed in various ratios such as 1:1.5, 1:2, and 1:3 to allow for a larger area of coverage per unit of harvested skin. It is important that the underlying wound bed be viable and free of necrotic tissue or infection to allow for healing of the skin graft (“skin graft take”). Adequate immobilization of a skin graft is important for “take” of the graft, and can be achieved with negative pressure wound therapy, or tie-over bolster dressing. The thigh has an abundant amount of soft tissue and muscle, which is why skin grafts are often sufficient for wound coverage rather than flaps.
2016
An 82-year-old man is referred for reconstruction of the scalp after Mohs micrographic surgery for an aggressive squamous cell carcinoma. He is scheduled to undergo radiation therapy as soon as possible after reconstruction. The patient has pulmonary fibrosis and is receiving oxygen via nasal cannula. Physical examination shows a vertex scalp defect of 4 × 4 cm with calvarium exposed throughout. Which of the following is the most appropriate management?
A) Bilaminate neodermis
B) Delayed reconstruction
C) Local tissue rearrangement
D) Radial forearm free flap
E) Split-thickness skin graft
The correct response is Option C.
In any reconstruction, many factors (local, regional, and systemic) have to be considered before deciding on a proper treatment option. Indeed, there may very well be multiple options. The patient described is an elderly man who is an extremely poor candidate for anesthesia (example of systemic consideration). Additionally, he will need radiation therapy to the scalp as soon as possible. Therefore, the reconstruction option needs to have excellent blood supply to heal in the first place, heal quickly, and withstand the effects of radiation. Additionally, coverage of the exposed calvarium is necessary, as periosteum has been removed by the Mohs surgeon. Out of the options given, local scalp flap coverage best accomplishes this goal.
Delay of treatment is not recommended because it only creates a greater problem after radiation therapy, because all local options as well as the calvarium will be irradiated, which severely hampers the surgeon’s ability to provide a low-morbidity procedure and avoid a substantial operation.
Dermal matrices (any form) are not appropriate options here for many reasons. They are not the definitive treatment option in a patient who is about to undergo radiation. Once the matrices become incorporated, they will usually need a skin graft to complete reconstruction or they will need a prolonged period of dressing changes, neither of which is optimal in this patient (a second surgery or a prolonged healing phase). Also, they need to be placed on a well-vascularized bed in order for them to “take” and heal more effectively. An exposed calvarium (without additional burring of bone) is not an optimal bed for a dermal matrix.
Skin grafts (of any variety) lack blood supply after harvest. They also need to be placed on a well-vascularized bed in order for them to “take” and heal more effectively. An exposed calvarium (without additional burring of bone) is not an optimal bed for a skin graft. Also, a thin skin graft may not be the best form of reconstruction in a patient who is about to undergo radiation therapy, if other options exist.
Radial forearm free flap is too complex an operation for this patient with many comorbidities and a relatively small defect.
2016
An otherwise healthy 25-year-old woman is scheduled to undergo resection of a 3 × 5-cm atypical nevus of the right thigh. Medical history includes systemic lupus erythematosus. She has been receiving oral corticosteroid therapy for more than 5 years. She is well nourished. Perioperatively, administration of which of the following vitamins is most likely to improve this patient’s wound healing?
A) A
B) B complex
C) C
D) D
E) E
The correct response is Option A.
Perioperative administration of vitamin A is most likely to improve wound healing in this well-nourished patient receiving chronic corticosteroid therapy.
Corticosteroids have been shown to negatively affect all major steps of the wound healing process. Several mechanisms have been proposed, including a stabilizing effect in the lysosomal membrane of cells. Vitamin A was known to cause the opposite (destabilizing) effect in lysosomal membranes in vivo, which led to the first studies on the interaction between these two classes of drugs in wound healing in the 1960s. Since then, supplementation of vitamin A in patients receiving corticosteroids has been shown to counteract most of the deleterious effects of corticosteroids in wound healing, with the exception of wound contraction and infection.
There is no consensus in dose and duration of treatment. Most proposed regimens include oral administration of 10,000 to 25,000 international units (IU) per day for 5 to 14 days. Various topical regimens have also been proposed, with doses around 200,000 IU every 8 hours.
Administration of vitamins B, C, D, or E has not been shown to significantly improve wound healing in well-nourished patients. Vitamin C deficiency impairs collagen synthesis, which may lead to poor wound healing and scurvy.
2016
A 30-year-old man is evaluated one year after undergoing vascularized allograft transplantation at the midforearm level. Surveillance angiogram and duplex ultrasound show 60% closure of the ulnar artery and complete occlusion of the radial artery. The patient is adherent to the prescribed immunosuppressive therapy. Clinical evidence of chronic ischemia is suspected. Which of the following underlying processes is most likely in this patient?
A) Deposition of preformed immune complex and complement activation
B) IgA-mediated response
C) IgM and IgG antigen–mediated response
D) T-cell–modulated immune response
The correct response is Option D.
Hypersensitivity reactions are divided into four different responses.
Type 1 (allergy) refers to immediate release of IgE, mediated release of histamine, and other vasoactive mediators resulting in manifestation within minutes. Examples include asthma or anaphylaxis.
Type 2 (cytotoxic-antibody dependent) refers to binding of IgM or IgG to the target cell, which in this case is a host cell. This results in the membrane attack complex (MAC) destruction of the targeted cell. Examples include thrombocytopenia, Goodpasture, and membranous nephropathy.
Type 3 (immune complex–mediated reaction) refers to IgG binding to circulating antigen resulting in formation of an immune complex. These complexes can end up collecting in the vasculature, joints, and kidneys resulting in local destruction. Examples include rheumatoid arthritis, systemic lupus erythematosus, and serum sickness.
Type 4 (delayed type hypersensitivity) refers to the activation of TH1 helper T cells by an antigen-presenting cell. This establishes an immune response memory and when activated again, the TH1 cells activate a macrophage-mediated response resulting in cellular damage. Examples include chronic transplant rejection, contact dermatitis, and multiple sclerosis.
Transplant patients require immunosuppression to avoid a type 4 hypersensitivity. Although an overwhelming majority of the recent upper extremity transplants have done well, there have been several cases of vascular compromise attributed to chronic rejection. Close monitoring of vascular status is part of the vascularized composite transplant protocol.
2016
A 32-year-old man with a history of self-inflicted gunshot wound is evaluated because of significant facial deformity despite multiple complex reconstructive procedures. Composite tissue allotransplantation is performed. One episode of rejection is successfully treated 4 weeks postoperatively. Three months postoperatively, the patient develops recurrent swelling and hyperemia of the facial skin. Which of the following is the most likely cause of this condition?
A) ABO incompatibility
B) Acute rejection
C) Antibody incompatibility
D) Chronic rejection
E) Hyperacute rejection
The correct response is Option B.
The most likely diagnosis is acute rejection, because this patient is still in the early postoperative period when acute rejection is most likely to occur (0 to 3 months). ABO incompatibility and antibody incompatibility would result in hyperacute rejection, which is mediated by the humoral immune system and occurs within minutes of transplantation. Chronic rejection occurs after years and is characterized by vasculopathy and fibrosis.
2015
A 36-year-old man with traumatic injuries, who is intubated and sedated in the intensive care unit, is noted to have extravasation of concentrated calcium solution from a peripheral access intravenous line. The consult is made immediately after extravasation. Which of the following is the most appropriate management of this injury?
A) Intravenous administration of dexrazoxane
B) Local injection of hyaluronidase
C) Phentolamine infiltration
D) Topical application of dimethyl sulfoxide
E) Topical application of heat
The correct response is Option B.
Hyaluronidase is an enzyme that breaks down hyaluronic acid, a mucopolysaccharide that is a normal component of the interstitial fluid barrier. It has been shown to increase the rate of absorption of an injected substance by facilitating diffusion of the substance over a large area. When injected locally within 1 hour of extravasation, it breaks down hyaluronic acid and decreases the viscosity of the extracellular matrix, and facilitates absorption and dispersal of the extravasated chemical.
The ischemic effects of extravasated vasoconstrictive agents such as norepinephrine and dopamine may be reversed with local infiltration of phentolamine, which is an alpha-blocking agent. Topical heat application has been recommended in vinca alkaloid extravasation to promote local circulation and speed up clearance of the extravasated agent. Topical cooling in animal models has been demonstrated to increase ulcer formation.
Dexrazoxane has been shown to antagonize the effects of several topoisomerase II poisons such as anthracycline agents, including doxorubicin. Recent clinical trials in Europe have demonstrated its efficacy in minimizing tissue damage from anthracycline extravasation if administered intravenously within 6 hours of extravasation. It is now the recommended initial treatment of anthracycline extravasation, especially in light of its FDA approval in 2007.
Dimethyl sulfoxide (DMSO) is a free radical scavenger and an effective solvent. It may also have antibacterial, anti-inflammatory, and vasodilatory properties. Its topical application is effective in preventing ulcerations caused by doxorubicin extravasation.
2015
A 30-year-old woman who underwent uneventful abdominoplasty is evaluated 2 weeks postoperatively because of midline wound dehiscence with tissue necrosis. She reports that she did not stop smoking before surgery as instructed. A photograph is shown. Which of the following mechanisms is the most likely cause of the delayed wound healing?
A) Decreased catecholamine production
B) Decreased hemoglobin concentration
C) Decreased leukocyte function
D) Increased fibrinogen production
E) Increased microvascular vasoconstriction
The correct response is Option E.
Cigarette smoking is a leading cause of preventable death and disability in the United States. Over the past 20 years, several studies have demonstrated an increased risk of postoperative complications following plastic surgical procedures, including rhytidectomy, breast reconstruction, digital replantation, muscle flaps, and body-contouring procedures. Tobacco smoke is a complex mix of particulate matter, volatile acids, and gases. There are over 4000 different compounds in cigarette smoke, many of which are toxic, mutagenic, and carcinogenic. Tobacco-induced vasoconstriction is mediated directly and indirectly by nicotine, a colorless, odorless, and poisonous alkaloid.
Increased cellular levels of nicotine cause direct microvascular vasoconstriction. Indirect pathways of vasoconstriction include the enhancement of thromboxane A2 and stimulation of catecholamine release. Random skin flaps such as abdominoplasty, rhytidectomy, and mastectomy flaps are predominantly supplied by the subdermal plexus, which is very sensitive to sympathomimetic agonists such as catecholamines.
Smoking also increases carboxyhemoglobin levels, which shifts the oxygen-hemoglobin saturation curve to the left. The net result is decreased oxygen-carrying capacity by direct competitive inhibition from carbon monoxide. Other effects caused by smoking include decreased prostaglandin I2 (prostacyclin) production, increased platelet aggregation and blood viscosity, decreased collagen production, decreased red blood cell deformability, increased fibrinogen production, and decreased leukocyte function (mediated by hydrogen cyanide). The net effect is a prothrombogenic state with impaired inflammation that also contributes to slow wound healing. Although fibrinogen production is increased and leukocyte function is decreased, the primary mechanism by which wound healing is impaired is related to the nicotine-induced vasoconstriction of the subdermal plexus.
Rhytidectomy patients who smoke are 12.5 times more likely to develop skin necrosis compared with patients who do not smoke. One study showed a 47.9% rate of wound-healing problems in abdominoplasty patients who smoked compared with 14.8% in those who did not smoke. Another large study of patients undergoing breast reconstruction using a free transverse rectus abdominis musculocutaneous (TRAM) flap showed no difference in free flap survival in those patients who smoked, but the smoking population had a significantly higher rate of mastectomy skin flap loss, abdominal donor-site complications, and hernias. Current recommendations for smokers who desire elective cosmetic surgery are to avoid smoking and all nicotine products for 4 weeks before and after surgery.
2015
A 45-year-old man sustains a facial laceration and develops a keloid scar. Compared with a hypertrophic scar, this patient’s scar is most likely to have which of the following characteristics?
A) Decreased fibroblast density
B) Increased fibroblast proliferation rates
C) Increased ratio of type III to type I collagen
D) Regression of the scar over time
E) Smaller and thinner collagen fibers
The correct response is Option B.
Hypertrophic scars generally arise during the first few weeks following the initial scar, grow rapidly, and then regress. On the other hand, keloid scars appear later following the initial scar, and then gradually proliferate, often indefinitely.
Both keloid and hypertrophic scars demonstrate increased fibroblast density.
Keloid scars demonstrate increased fibroblast proliferation rates compared with hypertrophic scars.
Keloid scars demonstrate a decreased ratio of type III to type I collagen. This is not observed in hypertrophic scars.
Keloid scars demonstrate thicker, larger, and more randomly oriented collagen fibers compared with hypertrophic scars.
2015
A 10-year-old boy underwent removal of a pigmented nevus from his scalp 2 weeks ago with suture closure. The tensile strength of the incision line today is most likely which of the following percentages of its final strength?
A) 10%
B) 20%
C) 40%
D) 60%
E) 80%
The correct response is Option A.
The tensile strength of a skin incision 2 weeks following repair is approximately 10%. Classic studies by Madden and Peacock showed that a cutaneous wound achieves 5% of its ultimate strength after 1 week, 10% after 2 weeks, 20% after 3 weeks, 40% after 4 weeks, and 80% after 6 weeks. The scar has its full strength 12 weeks after repair.
2015
An 87-year-old woman with a history of squamous cell carcinoma on the left lower extremity comes for evaluation because of the ulcer shown in the photograph. When the tumor did not resolve 9 months ago, she underwent radiation therapy for 4 weeks followed by excision. All margins were negative. Coverage of the wound with a split-thickness skin graft 6 months ago was not successful. Physical examination shows an ulcerated area over the anterior compartment. There is moderate fibrinous debris within the ulcer. Which of the following is the most likely underlying cause of the impeded wound healing?
A) Decreased vascularity
B) Elevated oxygen tension
C) Enhanced angiogenesis
D) Fibroblast hyperplasia
E) Peripheral margin hypokeratosis
The correct response is Option A.
Radiation therapy produces many changes in the skin, whether it is directed at the skin, such as for skin cancer, or directed at deeper structures. Direct damage to blood vessels in the wound bed (obliterative endarteritis) produces decreased oxygen tension. Unlike nonirradiated wounds, radiated wounds do not respond with increased angiogenesis. Decreased breaking strength of radiated wounds is caused by both edema of collagen bundles and direct injury to the fibroblasts that would otherwise repair them. Radiated wounds have hyperkeratotic edges, which impair both contraction and keratinocyte migration.
2015
A 60-year-old woman is seen in the hospital for a pressure ulcer in the lumbar region. A photograph is shown. A sponge for negative pressure wound therapy is about to be applied directly to the wound. Which of the following is the most likely complication of this therapy in this patient?
A) Enterocutaneous fistula
B) Excessive bleeding
C) Excessive wound drainage
D) Infection
E) Retained sponge in wound
The correct response is Option D.
Infection due to retained necrotic tissue would be the most likely complication in this patient. The vacuum-assisted negative pressure wound closure device should not be used in place of good wound care principles such as debridement.
Use of negative pressure wound therapy has been used for pressure ulcers, open abdomen, traumatic extremity wounds, chest wounds, burns, and skin grafts. Negative pressure wound therapy works through mechanisms that include fluid removal, drawing the wound together, microdeformation, and moist wound healing. Several randomized clinical trials support the use of negative pressure wound therapy in certain wound types. Serious complications include bleeding and infection.
Negative pressure wound therapy devices should be used with caution in infected wounds. They should not be used until the wounds are adequately debrided. This wound has not been adequately debrided and negative pressure wound therapy should not be used until necrotic tissue has been removed.
Bleeding is the next most common complication, but is usually seen in anticoagulated patients and after debridement. Use of a conventional gauze dressing for several hours after a debridement before placing a sponge-based negative-pressure wound therapy device may decrease the risk of excessive bleeding. Most significant bleeding has occurred secondary to disruption of major vessel grafts, cardiac bypass grafts, or the ventricle itself when sponges are placed directly on the structures. This wound is not near any major blood vessels.
Use of a single sponge or a long roll of gauze within any deep wounds is recommended to avoid retained foreign bodies.
Negative pressure wound therapy has been used to control wound drainage. Increased drainage would be caused by the lack of debridement and infection.
Even in clean wounds, a recent report on abdominal wound closure found the most likely complication to be infection rather than recurrent hernia or enterocutaneous fistula. This wound is on the back and would not be likely to have an enterocutaneous fistula. Although initially contraindicated for use with enterocutaneous fistula, recent reports have shown its use to be safe and effective in selected cases.
2014
A 56-year-old woman who has been undergoing treatment for breast cancer has pain around the port site 6 hours after the extravasation of paclitaxel from a subcutaneous tunneled subclavian vein catheter. The patient is hemodynamically stable and breathing comfortably. Moderate swelling and tenderness are observed between the port and clavicle. Which of the following is the most effective management?
A) Application of calcium gluconate gel
B) Application of topical collagenase
C) Line change over a wire
D) Line removal and observation
E) Operative debridement
The correct response is Option D.
This patient has paclitaxel extravasation due to a malpositioned or leaking catheter with minimal symptoms; therefore, removal of the line and observation is warranted. Calcium gluconate gel is indicated after generously washing areas exposed to hydrofluoric acid as it neutralizes the fluoride ion. Topical collagenase is indicated in wounds with limited tissue necrosis and thus has no role in this patient. Changing this patient’s line over a wire is contraindicated as the catheter is either malpositioned or broken. Although operative debridement is sometimes indicated in extravasation injuries, it is unusual, and expectant management is the norm. As this patient has no acute signs of compartment syndrome or tissue necrosis, line removal and observation are indicated.
The incidence of extravasation is 0.01 to 6%. Chemotherapeutic agents that cause reactions are classified as irritants or vesicants. Irritants cause immediate and typically limited local reactions such as erythema, warmth, and tenderness. Common irritants are: bleomycin, carboplatin, carmustine, cisplatin, dacarbazine, etoposide, ifosfamide, and thiotepa. Vesicants can cause erythema, blistering, and skin necrosis. Itching in the absence of pain is common. In addition, vesicants can cause delayed ulceration that is self-perpetuated when the vesicant is rereleased upon lysis of affected cells. Common vesicants are: dactinomycin, daunorubicin, epirubicin, idarubicin, mechlorethamine, mitomycin, mitoxantrone, paclitaxel, vinblastine, vincristine. Paclitaxel is derived from the bark of the Pacific yew tree and induces microtubular assembly and stabilization, which leads to cell death. It is a vesicant, and if extravasation occurs, symptoms can range from localized pain, swelling, and erythema to severe skin necrosis and ulceration requiring surgical debridement. The vast majority of extravasations are managed non-operatively.
2014
A 55-year-old woman who is wheelchair-bound has a stage IV ischial pressure ulcer. She has a history of systemic lupus erythematosus and multiple sclerosis. Medications include prednisone and gabapentin. BMI is 21 kg/m2 and has been stable for the past year. White blood cell count is 10.5 × 109/L, hematocrit is 30%, and serum albumin concentration is 3.6 mg/dL. After debridement of nonviable tissue, wound care is instituted. Supplementation with which of the following is most likely to promote wound healing?
A) Echinacea
B) Ferrous gluconate
C) Glutamine
D) Lipid emulsion
E) Vitamin A
The correct response is Option E.
Vitamin A is essential because it promotes epithelialization in collagen synthesis for wound healing, and supplementation is advocated in patients on chronic corticosteroid immunosuppressive medications such as prednisone. A 20,000-IU daily dosage can be useful for wound healing in immunosuppressed or irradiated patients and appears to reverse the wound healing–suppressive effects of the medication.
Patients with chronic wounds frequently have some form of malnutrition that can impede the wound-healing process. In this case, the patient has a serum albumin concentration within the reference ranges, and a stable BMI, signifying adequate protein. In protein-deprived patients, supplementing amino acids that serve as the building blocks of protein synthesis is vital. L-arginine, in particular, has been shown to augment wound healing and collagen production. One study in elderly human subjects found that daily supplementation of 30 g of arginine aspartate for 14 days resulted in markedly enhanced collagen production and total protein.
Ferrous gluconate is a useful supplement in iron deficiency anemia. This patient has borderline anemia, though not of a severity likely to be the central impediment to wound healing. Echinacea is a common herbal supplement used as an immunostimulant but has also been shown to have immunosuppressive effects. Lipid emulsion would be useful in a severely malnourished patient, though in this case, the patient’s BMI is stable in the normal range. Of note, omega-3 fatty acids appear to inhibit the quality of collagen strength, and avoiding this common supplement during healing may be advisable.
2014
A 73-year-old man is evaluated for a non-healing wound on the medial aspect of the calf. The wound has been present for 8 months, and he has undergone several months of serial debridements and moist wound care without improvement. A photograph is shown. Ten years ago, he was diagnosed with squamous cell carcinoma of the medial calf skin, and the condition was managed solely with radiation therapy. Which of the following is the most appropriate next step in management?
A) Hyperbaric oxygen therapy
B) Negative pressure wound therapy
C) Wound biopsy and culture
D) Wound debridement and skin graft
E) Continued observation and wound care
The correct response is Option C.
Based on the clinical scenario described, wound biopsy and culture is the most appropriate management option. Despite wound debridement and moist wound care, the wound has not improved and is in the region of a previous malignancy. Wound biopsy would allow the diagnosis of recurrent malignancy and aid in the determination of further surgical intervention. Wound culture would allow the diagnosis of soft-tissue infection contributing to the wound’s persistence.
Although wound debridement would be beneficial in this case, application of a skin graft in the face of possible recurrent malignancy and probable marked radiation injury would be associated with increased risk of delayed wound healing and may delay management of recurrent malignancy. If the wound was attributed only to radiation therapy, a better strategy would be to excise the irradiated soft tissues and cover the whole defect with a well-vascularized flap.
Hyperbaric oxygen therapy has been shown to be beneficial for the management of radiation soft-tissue injury. This therapeutic modality should only be instituted after a complete evaluation of the patient’s wound, which would include soft-tissue biopsy because the patient previously had a malignancy in the region.
Complete evaluation of the wound would include pertinent history and physical examination, evaluation of the patient’s nutritional status, examination of extremity vascular inflow and outflow, diagnosis and treatment of wound infection, and optimization of wound characteristics.
The patient has already undergone debridement and wound care for several months; therefore, continued observation and wound care would be an inadequate management option.
It is inappropriate to perform negative pressure wound therapy in an irradiated wound without diagnosis by tissue biopsy.
2014
A male newborn is evaluated because of the scalp anomaly shown in the photograph. Which of the following is the most appropriate initial management of the affected area?
A) Application of a skin substitute
B) Local wound care with antibiotic ointment
C) Primary closure
D) Skin grafting
E) Tissue expansion
The correct response is Option B.
This child has aplasia cutis congenita, or cutis aplasia, of the scalp. First described in 1767 by Cordon, cutis aplasia is the congenital absence of all skin layers including the epidermis, dermis, and subcutaneous fat. This process most commonly affects only focal areas of tissue but involvement can be extensive. The majority of cases involve the scalp, but this process can occur in any cutaneous area of the body. Cutis aplasia can occur in isolation or as part of a syndrome, the most common being Adams-Oliver syndrome. Cutis aplasia of the scalp can range from small areas of involvement that often heal in utero and appear at birth as a “congenital scar” to massive defects that are devoid of scalp and cranium. Most small- or intermediate-sized full-thickness defects heal quickly (as in the patient described) if kept moist and the resultant scar can be excised secondarily. Bone healing is often complete in small lesions, and residual defects can be reconstructed when the child is older if needed. Large areas are more problematic and extensive scalp defects that threaten dural integrity may require early operative intervention. Cutis aplasia involving large areas of the scalp has a reported mortality ranging from 20 to 55%, typically as a result of sagittal sinus hemorrhage or associated congenital defects. In such cases, coverage of the dura can be life-saving. Described methods of soft-tissue coverage include skin graft, cultured allograft, acellular dermis, and immediate or delayed reconstruction with a flap. Tissue expansion of the scalp in a newborn presents many challenges and is not recommended.
2014
