Tobias 77: Tension Relieving Techniques

Front 1

what is a biological tourniquet?

Back 1

when tension is exerted in limb wounds

Front 2

what are halsteads principles? (7)

Back 2

strict aseptic technique
gentle tissue healing
meticulous hemostasis
preservation of blood supply
obliteration of dead space
accurate apposition of tissue planes
minimization of tension on tissues

Front 3

what happens to skin as dogs age?

Back 3

becomes thinner and less well perfused as it ages, making geriatric skin more susceptible to ischemia and stress

Front 4

do you close wounds parallel or perpendicular to the lines of tension?

Back 4

parallel

Front 5

what techniques are recommended for wounds of various sizes?

Back 5

<5cm: direct closure or tension relieving technique

5-10cm: tension relieving technique, skin flap

<10cm:tension relieving technique, skin flaps, staged procedures, partial closure, second intention healing.

Front 6

where are shear forces very important to consider?

Back 6

axilla
inguinal
jaw/lips
joints
tail base
foot pads

Front 7

name techniques for relieving tension

Back 7

undermine
tension relieving sutures
skin stretching techniques
pretensioning sutures and presuturing
relaxing incisions
walking sutures chronic skin expansion

Front 8

in what layer should undermining be performed?

Back 8

in areas with panniculus, undermine deep to that layer

in areas without panniculus undermine down to fascia of musculature, or even take some fascia.

Front 9

what are the most common tension relieving sutures?

Back 9

strong subcutaneous sutures
stent sutures
far near, near far
far far, near near
mattress

Front 10

stent sutures

Back 10

approximately 2 cm away from wound edge
tied after closure of primary line
left in for 3-4 days

use of buttons is not recommended because they don't distribute the tension as well

Front 11

far near, near far
far far, near near

Back 11

fnnf: about 1cm from wound edge

ffnn: about 5mm from wound edge

good for minor tension or cyclic tension

equally effective, surgeon's preference

keep fairly loose

often interspersed with simple interrupted

Front 12

where should knots be placed for tension releiving sutures?

Back 12

NOT over the incision but off to the side

Front 13

horizontal mattress.

Back 13

genrally not recommended for SA reconstruction because horizontal part can compromis blood supply

Front 14

vertical mattress.

Back 14

causes eversion of wound edges

fnnf more functional?

Front 15

what are some skin stretching techniques?

Back 15

pretensioning sutures

Front 16

pretensioning sutures

Back 16

take advantage of mechanical creep and stress relaxation (viscoelasticity)

Front 17

Back 17

stent suture

Front 18

Back 18

stent

Front 19

define pretensioning and presuturing

Back 19

pretensioning:sutures placed to influence an existing wound

presuturing:sutures placed to influence an area planned for excision

work well in hock/carpus/trunk, proximal limb

Front 20

4 ways of doing presuturing/pretensioning

Back 20

1.insertion of simple continuous line through skin of wound edges
2.continuous horizontal intradermal running pattern secured through a button at either end
3.externally applied stretching device with velcro (cn also be used postop
4.lemberts (24 hours before sx)
4.

Front 21

pre

Back 21

simple continuous pretensioning

Front 22

Back 22

pretensioning velcro

Front 23

Back 23

pretensioning vertical mattress

Front 24

Back 24

pretensioning sutures in wound on cat dorsum
gradually tightened over several days, then closed

Front 25

axute intraop skin stretching

Back 25

skin hooks, towel clamps, etc.
must tension for 30-45minutes
may not provide much benefit over simply undermining

Front 26

walking sutures

Back 26

staggered rows of interrupted sutured through dermis to underlying fascia

skin appears dimpled

must not penetrate epidermis (risk of deep infection)

Front 27

what are some cautions for walking sutures?

Back 27

need fairly think skin

can damage blood supply--not recommended in skin flaps

careful of pocketing--not good in infected/contaminated wounds

Front 28

what is chronic skin expansion and when is it indicated
what is biologic creep?

Back 28

in treatment of large sefects

in chronic wounds (not for acutely traumatized wounds)

utilizes biologic creep: biologic creep is the creation of new dermal and epidermal components after prolonged and constant loading

an inflatable silicone device is placed surgically in sq.
after initial healing period of few day, it is expanded 10-15% every 48 hours until final volume is reached.

decreases sq and fat while expanding epidermis

skin perfusion is enhances. best to give it a few days at final volume to improve skin quality

Front 29

name 5 types of relaxing incisions

Back 29

mesh expansion
simple relaxing incision
v-y plasty
z-plasty
m-plasty

Front 30

mesh expansion technique

Back 30

intially wound edges are undermined.
then 1cm stab incisions 1 cm from wound edge and 1 cm apart. rows should be staggered.

can mesh circumferentially in a limb

oclussive bandage placed until epithelialization

skin can look bad for a few days but outcome is usually excellent.

not recommended for flaps

Front 31

what is a simple relaxing incision?

what are the measurements?

what should you not exceed

Back 31

also called a bipedicle flap

great near orifices or important structures

incision parallel to wound with length the same as wound and width of healthy skin bridge the same as width of wound

length to width issue should not exceed 4:1 because vascular supply to wound bridge can be compromised

Front 32

v-y plasty

Back 32

indicated for closing defects that are chronic and surrounded by inelastic skin and closing wounds in areas that could be easily distorted if under tension (near eye)

Front 33

z plasty
when is it best

Back 33

1.along a cicatrix (most commonly used technique for contracture bands in humans)

2.facilitate closure of nearby wounds

only perform when sufficient laxity parallel to the wound

create central arm perpendicular to the long axis of the wound, at least 3 cm away from wound edge.
central limb is directed along lines of tension
3 limbs should be the same length
the arms are angled back about 60 degrees (30-90)

Front 34

m-plasty

Back 34

can be used at 1 or both ends of a fusiform incision
useful at sternal end of mastectomy closure

Front 35

m-plasty

Back 35

Front 36

closing crescent shaped defects if disparity between edges less than 20%

Back 36

1. edges can be fudged

2.closing the wound from both ends and then cutting the central ear

3.closing the wound from the center and excising both dog ears on the ends

Front 37

fudging the edges to deal with length disparity

Back 37

Front 38

what techniques can you use when there are larger length discrepancies

Back 38

half bow tie technique

equilateral triangle is dissected from the skin of the longer wound edge

Front 39

triangular defects

Back 39

Front 40

rectangular defects

Back 40

Front 41

name 4 ways to close circular defects

Back 41

1. close in a linear fashion with excision of dog ears
2.convert to fusiform
3. divide circle into 3 equal arcs. perform 3 point closure
4.combined v-plasty/O to S plasty

Front 42

closure of circular defect with 3 arcs

Back 42

Front 43

closure of circular defect with Vplasty/ O to S

Back 43