2. Reconstructive Surgery of Wounds.pptx

Veterinary Surgery

1. Reconstructive Surgery of Wounds

2. Plastic Surgery?  comes from the Greek word plastike ( teckhne ) or the art of modeling or sculpting

3. Plastic Surgery???

4. Types of plastic surgery: Cosmetic or aesthetic plastic surgery Reconstructive plastic surgery performed to change body shape or appearance, usually when no medical condition is present generally involves treatment of conditions that have caused an abnormal change in body shape or appearance.

5. What if the wounds cannot be closed by simply suturing them together? Reconstructive surgery of WOUNDS full thickness sliding flaps

6. This techniques involves local undermining of adjacent tissue along a subcutaneous plane in such a way that the dermal blood supply is maintained. How? In some instances, removal of excessive scar tissue beneath the surface may facilitate primary closure of the wound.

7. How many simple reconstructive procedures to allow primary closures? Four of which are utilizing various methods of sliding flap One involves in the removal of excessive scar tissue Objective: ALLOW PRIMARY CLOSURES

8. 1. Elliptical excision undermining for repair of an elongated defect Using scissors or scalpel , the surgeons undermines the adjacent skin in an elliptical fashion . The mobilized skin flaps can then be moved toward each other , to allow a primary closure .

9. The use of tension sutures in addition to the row of simple interrupted sutures may be indicated.

10. Lumpectomy vs Mammectomy

11. Closure of Elliptical Incisions: Indications of Elliptical incisions: 1.) removal of skin tumors 2.) debridement of traumatic wounds The " Rule of Halves " Since loss of a section of skin occurs, the closure of the defect can result in so called “ dog-ears ” at each end of the incision (small flaps of skin that protrude from the ends of the incision). 

12. An easy method to prevent dog-ears: “ rule of halves ” technique also called bisectional closure

13. This technique is used for the deep fascia and subcutaneous layers of the wound . The sutures below the skin relieve the tension across the incision and align the skin edges making the final suturing of the skin much easier. Subcuticular??

14. Technique for the Rule of Halves Closure Take the first suture bite of the deep fascia and/or subcutaneous tissue in the middle of the incision Now take suture bites in the middle of each of the 2 defects, then in the middle of the 4 defects, and so on until the subcutaneous layer is completely closed

15. Then suture the skin routinely

16. How about for Fusiform elliptical incision?

17. Proposed lines for excision of a mast cell tumor in a dog:   X = tumor, circle indicates 3 cm margins elliptical lines proposed incision

18. 2. Wound Closure Using Tension-relieving Incisions How?  small tension-relieving skin incisions are made adjacent to the wound, to facilitate wound closure or, at least, to decrease the healing time for the primary defect. It has been described as the “ mesh-expansion technique ”.

19. The skin adjacent to the defect is undermined. S eries of stab incisions is made parallel to and approximately 1 cm from the skin edge. Three rows stab incisions are made on each side of the wound in a staggered fashion, with adjacent rows approximately 1 cm apart.

20. The size of the stab incisions varies. In the initial descriptions of the technique, the use of 10-mm stab incisions allowed sufficient expansion in fresh wounds and resulted in more rapid healing than the 7-mm tension-relieving incisions were used. In older wounds , however, with fibrosis and thickening of the surrounding skin, longer incision (approx. 15mm) are recommended. When the stab incisions have been made, the original wound edges are drawn into apposition and are sutured.

21. Wounds are managed postoperatively with bandaging or casting , depending on the individual case. The release of blood and exudate through the stab incisions FACILITATE the success of the technique by aiding revascularization and preventing hematoma and seroma formation

22. 3. Sliding H-flap Indication: Repair of rectangular or square defects. Two flaps are generally created ; however, if skin is not available on both sides, half of the H- plasty may be used. The actual defect serves as the crossbridge of the letter H, and two arms are created.

23. Triangles are cut at either end of each arms to prevent puckering of the skin when the flaps within the “H” are undermined and are slid together. Vertical mattress sutures are replaced in the undermined flaps to act as tension sutures.

24. The two flaps are then brought together and are sutured in a simple interrupted pattern . When performed correctly, sliding of the flaps together closes the triangular defects. This incision lines are also sutured in a simple interrupted pattern.

25. 4. Z- plasty (Z to S incision lines) It has two major indications: It may be used as relaxation procedure for elliptical defects It can be used for scar revision of the palpebral when scar formation has produced acquired ectropion . Z to S incision lines

26. A z-incision is made adjacent to the elliptical defect. The central incision of the “Z” (AB) should be perpendicular to the elliptical defect and centered over the area of greatest tension. The two triangles created by the incision should be equilateral; that is, having angles 60 degrees.

27. The triangles are undermined to create two skin flaps. These skin flaps are then interchange , and they are sutured in place. The principle behind this technique is that the interchange of the two flaps lengthens the original line (AB) by 50%.

28. 5. Removal of Excessive Scar Tissue ( Debulking ) A cross section of a typical situation in which exuberant granulation tissue or scar tissue coexists with incomplete skin closure. A dotted line indicates the incision for removal of excess tissue, which is removed with sharp dissection, this allows the primary closure of the skin over the dead space. Placement of a subcutaneous drain is appropriate in this situation.

29. 6. Pinch-Skin Grafting Several methods of free-skin grafting are available, including full thickness and split-thickness and mesh grafts .

30. If these grafts “ take ”, the results are usually cosmetically superior to those of pinch-skin grafts or punch-skin grafts . The typical indication for free skin graft in large animals is for the large, slowly healing region of granulation resulting from a laceration to the distal equine limb, however. In these situations, results with full thickness grafts have been better, but it is a complex and costly procedure.

31. The grafting techniques described may be successful in the presence of a hostile grafting bed and when prevention of limb motion is not as critical. Even if the graft does not take, its presence seems stimulate epithelialization from the periphery. This grafting technique may be performed in the standing patient, and it is a useful, simple technique for the veterinarian in the field.

32. Ano ginawa sakin , cosmetic surgery o reconstruction?