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ULCERS .......17
Pressure Ulcers {Sores)
Leg Ulcers
.at6months,tissuestrengthpIateausat$!o$.9finormaltissuestrength
A$NORMAL T{EAX,TNG
D hypertrophic scars (these generally improve with time if left to heal)
. hypertrophic tissue does not cross the boundaries ofthe scar
. common sites include back, shoulder. stemum
. red, raised, frequently pruritic
, ,, : I r, treatment is conservative . ,,
I amenable to sureical revision
O keloid scars (these do;ot resolve spontaneouslv)
. tissue extends beyond the s&r boundari6S iunlike hVp'ertrophic scars)
.
Table I. SutureTgrpes
Type Description Indications
Surgical gut organic, absorbable monofi lament Subcutaneous closure and ligation
(plain or chromic)
'notygty.Slif i"iai synthetlc. absorbable monofilament le.g- ilionocryl I Transcutaneous and subcuticular closure
and braided (e.g. Vicryl, Dexonl
Nylon Synthetic, nonabsorbable monofi lament (e.g. Ethilon) Soft tissue approximation and microsurgery procedures
and braided {e.g. Nurolonl
Polypropylene Synthetic nonabsorbable monofi lament Genenl soft tissue approximation, used in
(e.g. Prolene) contaminatediinlected wounds
SKIN GRAFTS
E definition: a segment of skin detached from its blood supply and dependent on
revascularization from the recipient site
I donor site selection
n must consider size, color, hair pattem, texture and thickness of skin required
.usuallytaken from inconspicuous areas {e.g. buttocks, lateral thighs, etc.)
.for facial grafts, preferable to take graft from above clavicle {e.9. post-auricular area}
E slcin graft "take" occurs in 3 phases
.plasmatic imbibition - nourishment via diffusion (first 48 hours)
.inosculation - vessels in gnft connect with those in recipient bed
.neovascular ingrowth - gmft revascularized by ingrowth of new vessels into bed
E reouirements for survival
" bed: well vascularized (bone and tendon are unsuitable beds]
. contact between graft and recipient bed : fully immobile
. staples, sutures, splinting, and appropriate dressings (pressure).,,,,,,,,,
are used to prevent hematoma, seroma, and movement of graft
. recipient site: clean {to prevent infection)
'rliI lypg5i,,ll ; j ':'.i rii .:i ]:; I
Split Thickness Skin Graft (SISG) Full Thickness Skin Graft (F"[sG)
Definition Epidermis and part of dermis Epidermis and all of dermis
Donor Site More sites Limited donor sites
llealing Re-epithelialization via dermal appendages Primary closure or split thickness skin gnft
Re,haruesting -10 days (fasteron scalpl
Graft take Good; shoner nutrient diffusion distance Lower rate of survival
Contraction More Less
r;'
Sensation POOr Good
Aesthetic Poor Good
Comments Can be meshed for greater area Use on hce, fingers tips and over ioins
Advantage - Take wellin less hvorable conditions Resist contraction, potential for growth,
textu re/prgment more norrnal
Disadvantage ppnnact signifi q4ntly, abnormal pigmentation, Require well vascularized bed
nrgn suscepuollrry ro uauma
rhin
.l
f Epidermis
spllr I nlcKness ---l Medium
sKrn uran I
t-,
L_ Thick
Dermis
fuil I nrcKness
Skin Graft
Subcutaneous Tissue
OTETER GRAFTS
F'[.APS
I definition: tissue transferred from one site to another with vascular supply intact
{not dependent on neovascularization} unlike a graft
fl classifidd according to blood supply to skin: random and axial
fl indications for flaoi
I soft tissue coveraee i,e. oaddine bonv prominences
. reconstruction i.e:after facial, bieast,bi lower leg tissue loss
c' to lmprove Dlooo supply to Deo l.e. oone
provide vascular recipient bed for skin graft
Rotation Flap
Limberg Flap
r.FI,AP
tsTIRNS
D etiolosv: Children - most commonlv scald bums
Adults - most commonly flame bums
Anterior
4t /2"rc
Zone of hyperemia
i:3
W Zoneofstasis
f] zone ofcoagulation
DUTGNOSTIC NOTES
D estimate body surface area =TBSA) - rule of 9's includes second and third degree burns only
nate bum size (total bod
dren underase
ildren
{children under age l0 use a Lund-Browder chart)
-patient's
O patch
for patchy_b
'atchv bums, ntb pEpalm represents approximatelv l% of the TBSA
. u n1s-.
-Fatie
TBSA > 50% have ba'sal metabolic rate'(BMR) 1.5-21. predicted
tr age --.more
more complications
cgmplications if.< or > 60 years old
if < 3 o
tr pepth classificaiion (see Table 7)
tr tocauon
.
face. hands. feet, perineum are critical areas reouirins soecial care of a bum unit
.
circLimfereritial bdms arg manqged with eschardtomf(ah incision down to and including fat)
to Drevent toumiouet effect of Sschar
! watch forlnhalation iniury, associated iniuries (fractures), co-morbid factors
(concunent d isability, aliohol ism, renal ili sease )
Red Flag
r-l Susp6ct inhalation iniurv if bnrn sustained in closed space, singed nasal hairs,/eyebrows,
sooi around nares,/oril calitv, hoarseness, and coniunitisitis. REquires immediate
intubation due to impendinjairway edema.
Deep partial thickness Second degree lnto deep dermis Difficult to distinguish from full thickness
Full thickness Third deeree Throueh dermis Hard, leather-like texture of skin
Fourth dEgree involves, underlying tissue, eschar formation, purple fluid, insensate
muscle. Done
I
lJ chemical bums posinq
posing thre'at of functional or'cosmetic impa
threat bf inipairment
E bums associateil with majortrauma . , ..i,,...,i,iir:1,^i;;,,;ili;
AcurE cARE oF' EURFr pAqreryFg.tni;;oi;11;l:a'
: ':rr';r)tt
RespiratoryDistress
tr if inhalation iniury suspected (bum sustained in closed space, sinsed nose hairVevebrows, soot around
nares and oral'caviry, hoarseness, conjunctivitis, history of explosiSns or flash bum6), intubate immediately
beiore edema occurs
E acute causes
" carbon monoxide (CO) poisoning {treat with 100% Oz, decreases half-life of carboxryhemoglobin
from 210 minutes to minutes)
. eschar encircling chest59 (perform escharotomy)
u late onset
. due to smoke inhalation and pulmonary injury
. risk of pulmonary insufficiency (up to 48 hours) and pulmonary edema [48-72 hours)
. causes'chemical'injury to alveioiai basement membiane and fulmonary edema
. if humidified Oz not duccessful, mav need to intubate and ventilate
n watch for secondary lung infections'(after I week) Ieading to progressive pulmonary insufficiency
. watch for bronchopneumonia (up to 25 days)
Burn Shock
D definition: hvpovolemia due to movement of HzO and Na+ in zone of stasis and eeneralized increased
capillarv permeabiliw in all oreans {occurs if > 30% TBSA}
D reiuscitaiion with Paikland forinula' to restore plasma volume and cardiac output (see Table 8l
. 4 cc Rinser's/ke/% TBSA over first 24 hou'n
. TBSA noiinclude lst deeree areas
. 12 of ddes
this in I st 8 hours post 6um. rest in next I 6 hours
E
" in followins 6 hours eive'0.35-0.5 cc plasma/kePATBSA, then D5W at rate to maintain normal serum Na*
extra fluid administration. rEquired in bum's greaterihan 80% TBSA, associated traumatic injury, electrical bum,
_ inhalation iniury, delayed st€irt of resuscitati6n, pediatric bums, and 4o burns
U mOnlIOf feSUSClIatlOn :,....,r, r,, t,,.,.,,..
. urine output is the best measure
o maintain urine output > 0.5 cdkghr ladults) and I.0 cdkg/hour (children
r also maintain a cle'ar sensorium,-HR < 12O/minute, mean *BP > 70 mmHe < l2
years)
:i iif i-lil
Other Considerationo in Burn Management
D nutrition: calories. viiamin C, vitamin AICuz*, 7p2+, fs2+
lJ tmmunosuDDressron ano Sepsls
n eastrointedtinal {Gl} bleed mav occur with bums > 40% TBSA
. treatment': tube feedind or NPO, antacids, Hz blockers
fl renal failure sgcondary to hypbvo.lgmia . rq,re
. beware oI neDirotoxlc antlDlotlcs ln Durn care
I tetanus toxoid shou'ld be administered to all patients sustaining bums deeper than superficial
partial thickness
CIIEMICAL BURNS
D coaeulate tissue oroteins causinq necrosis
D sevEriw depends on: wpe of ch6mical {alkali worse than acid},
concenirati6n, ouantiw-,'and contact time, deqree of tissue penetration
E bums are deeB6r than initially appear and m-ay progress with time
LJ rnsoec eves
I corirmon bgents: cement, hydrofluoric acid, phenol, tar
U treatment
. dilution with wdterisinitial treatment " ' l
. wash eyes out with saline and refer to ophthalmoiogy
e repeatecl aDDllcatlon oI Polvsponn tor removal oI taf
. loial care ak'er l2 hours, debridement, topical antibiotics
. wound closure same forthermal bum
E beware: underestimated fluid resuscitation, renal, liver, and pulmonary damage
ELECTRICAL BURNS
tr depth ofbum depends on voltage and resistance ofthe tissue
n in decreasine ord'erof conductioi, nerve, blood, muscle, skin, tendon, fut and bone debridement
n oftenimitl p'unctate burns on skin with massive deep tissue damage which requires
! iniurv more severe in tissue with hieh resistance (i.e.'bone)
U elbarical bums require ongoing mo-nitoring as latent iniuries become manifest
I watch. for
opul monary nl uries €.g..ventricular fi brill ation
. cardi
i
mvoglobrnuna/nemogtoDlnufl&., -;
. frdctlres and dislocations, especially. shoulder and spine
. tissue necrosis secondary to vessel thrombosls
n decrease in RBC (beward of hemonhages)
increased creatinine/potassium and addity indicating tissue destruction
". seizures
. intraperitoneal damaee ;
E treatment
. toDical aeent with sood penetratine abiliw (silver sulfadiazine)
. ion-viablEtissde early and repeat prn {every 48 hrs} to prevent sepsis
. ddbride
maior amputations ffequently requlred
FROSTBITE
D intracellular ice crvstals leadine to cell lvsis
D microvascular occfusions and deriphenl vasoconstriction leading to ischemia
D suoerficial frostbite: onlv skin and subcutaneous tissues frozen
D de'ep frostbite: underlyihg tissues frozen as well
fl man'aeement
o rewarm raoidlv in waterbath (40-42"C)
. after rewaiming, tissue becomes purple, edematous, painful blisters may appear,
resolving after several weeks
'.leave i4iured region oPen to air
leave blisters intact
.debride skin eentlv with dailv whirlpool immersion
{ scrubbi ng, m'assa{e and topi cal oi ntmenls lrot
req u i re.d }
.sursery mlv be ne-eded to ielease constrictive, circumferential eschar
. waii until complete demarcation before proceeding with amputations
CET,[,E LTTIS
I non-suppurative infection ofskin and subcutaneous tissues
I signs airii symptoms '
. pain, tendemess, edema, erythema with poorly defined margins
"o iever, chills, malaise (systemjc symptoms'diffeientiate it fronisimple initation)
can lead to lymphangitis (visible red streaking in areas proximal to infection)
, I skin:flora most common org-anisms: S. auTeus, p-hemolytic Strepiocotcus .,
I treatment is antibiotics: firit line Pen G 2 miliion uniti q6-8h'lV + cloxacillin I g gg"8h lV
I outline area of erythema to monitor success of treatmeni i .
Red Flag
I Soft frssue Infections: Sus;rect necrotizing fasciitis with rapidly spreading erythema and
ederna. Must dernarcate ergthernatous area on adrnission,in,order,to determine amount
of spread.
MANAGEMENT
Non.Malignant Lesions
! incl udes- hvperkeratoti c, fi brous, cvstic. vascu lar and oism ented lesions
D treat with dbrmatological method.d or surgical excisioh iT necessary - to halt further growth,
IOr COSmeSTS Or lI Cltntcallv susptclous
Malienant Lesions
I balal cell carcinoma (BBCI (see Colour Atlas D2I)
. primarilv taneentiai drowth
. Lurettag-e and electr6dessication: for smaller lesions; include a 2'3 mm marein of normal skin
. surgicafexcision: deep infiltrative lesions; 3-5 mm margins beyond visible a-nd palpable tumour border;
mav reoulre sKtn grafi or ilao
. I-ray therapV: less*traumatii and useful in difficult areas to reconstruct, requires a skilled physician
because of manv complications
. cure rate is the dame iapproximately 9)%|,forthe above procedures in competent hands
ii squamous cell carcinoma (SCp)-(see Colour Atlas Dl7)
. pnmantv ventcat growln
. same ontions for ireatment as for basal cell carcinoma
. more aggressive tieatment because more malignant than BCC
PLl6 - Plastic Surgery MCCQE 2002 Review Notes
I melanoma (see Colour Atlas A23)
. excision is prirnarv management
o forlesions < 0.75 inm thiikness: a I cm margin is recommended
. for lesions > 0.75 mm thickness: a 5 cm mariin is recommended
n node dissection for lesions > 0.75 mm
. beware of lesions that regress - tumour is usually deeper than one anticipates
c assess sentinel nodes