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What is primary wound closure?
direct apposition of wound edges with suture before the presence of granulation tissue
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What are the advantages of primary wound closure? (5)
- simple wound care
- less need for bandages
- faster healing
- reduced pain
- less scarring
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What is second intention healing?
a wound that heals without suturing; full thickness wound undergoes epithelialization and contraction; partial thickness wound undergoes adnexal re-epithelialization
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What is third intention healing?
primarily closing a wound after the presence of granulation tissue; start with open wound management until you have enough skin, pre-stretch skin, use flap or graft
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What is the blood supply to the skin?
direct cutaneous vessels that come from the subdermal plexus [don't dissection the subQ b/c subdermal plexus comes deep to this]
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What wounds are able to be closed primarily?
- clean, clean-contaminated, or VERY RARELY contaminated
- traumatic wounds less than 6 hours old (non-crushing wounds, non-degloving) in healthy patients
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What direction are the lines of tension in the lateral, ventral, and dorsal aspects?
- Lateral trunk: vertical (dorsal to ventral)
- Lateral limbs: horizontal
- Ventral trunk: horizontal (midline to lateral trunk)
- Dorsum: horizontal
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What sutures do you use for primary closure of fascia?
PDS, Maxon (0, 2-0, 3-0)- needs to be there for a while because fascia grows slowly
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How od you make an incision with respect to lines of tension?
make incision ALONG LINES OF TENSION, never perpendicular to tension lines
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What type of sutures do you use for primary closure of subQ tissue?
monocry, biosyn (3-0, 4-0- small to bury)- subQ heals faster
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What type of suture do you use to close skin for primary wound closure?
Nylon, staples (3-0, 4-0)
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What are challenges to closing large defects in the skin?
- dog ears occurs when closing circular defects
- cosmetic issue (make incision elliptical for fusiform to begin with) (resect dog ears)
- possibility for seroma
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How do you handle step defects?
place sutures at equal levels for epidermis
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What are methods of managing tension or large defects? (4)
- local tension relieving techniques
- local or subdermal plexus flaps
- axial pattern flaps
- grafts
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What is a safe method of undermining for local tension relieving?
undermine by blunt dissection DEEP TO PANNICULUS (preserve blood supply)
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What are local tension relieving techniques? (6)
- undermining
- walking sutures
- tension relieve suture patterns
- skin stretching
- relaxing incisions (mesh, bipedicle flap, V-Y plasty, Z plasty)
- change shape (close triangular defects as Y, close rectangular defects as X or double Y, close circle and trim dog ears or by S plasty)
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What is "walking sutures"?
- staggered rows of interrupted sutures in dermis to fascia
- advance undermined skin, "walking" it towards the center of the wound
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What are methods of skin stretching? (3)
- mechanical creep and stress relaxation
- velcro
- pretensioning
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What is mesh expansion?
making multiple small incisions, creating multiple wounds that heal by second intention
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What is a simple relaxing incision?
(aka bipedicle flap) single parallel incision, creating new wound; used near orifices
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Why is Z plasty useful?
- changes direction of skin tension
- useful for areas of contracture
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Describe Z plasty incision.
central arm of Z is perpendicular to the long axis of the wound
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Describe a V-Y plasty incision.
point of V away from defect, then close it as a Y shape
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What are subdermal plexus flaps?
- vascularized skin in local vicinity used to close defect
- used for acute or chronic wounds
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What are the principals of subdermal plexus flaps? (4)
- elevate UNDER panniculus to keep blood supply intact
- wide base
- length sufficient to close defect
- must be able to close donor site
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What are axial pattern flaps? What are the advantages?
- incorporate a direct cutaneous artery and vein
- can make larger flaps that have better survival, can rotate 180 degrees
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What is a disadvantage of axial pattern flaps?
limited to area of elbows and stifles because skin from trunk can't reach distally
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What are types of skin grafts? (6)
- pinch and punch grafts- small pieces of skin places into granulation tissue
- paw pad grafts- small pieces of paw pad placed into wound
- full thickness grafts
- partial thickness grafts
- meshing grafts
- microvascular free grafts
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How do partial thickness wounds heal?
- adnexal re-epithelialization
- [contrast to full thickness wounds- granulation tissue, epithelialization, and contracture]
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