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Transcript of Principle of Wound coverage Flap Surgery - · PDF filePrinciple of Wound coverage and Flap...
![Page 1: Principle of Wound coverage Flap Surgery - · PDF filePrinciple of Wound coverage and Flap Surgery Tse WL AADO. HKSSH Nursing symposium](https://reader037.fdocuments.us/reader037/viewer/2022103107/5a7945607f8b9af91c8c392b/html5/thumbnails/1.jpg)
Principle of Wound coverage and
Flap Surgery
Tse WLAADO. HKSSH
Nursing symposium
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Why Wounds need to be covered ?
To avoid :
• Infection : Acute or Chronic• Exposure of important tissues : nerve,
vessels, tendon, bone, joint• Electrolyte loss• Protein loss
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Consequence of poor wound coverage
• Uncontrolled sepsis – life threatening• Extensive scarring – cosmetic and
functional deficit
• Ideally, wound coverage should be achieved within 1 week after injury
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Management of Severe limb injury
Primary Goal (initial healing and
infection control)
• Skeletal stability• Adequate blood
supply• Soft tissue coverage
Secondary goal(functional
reconstruction)
• Nerve repair/graft• Muscle & tendon
repair/transfer• Bone & Joint
reconstruction
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Adverse Factors for wound healing
• Infection • Retained foreign bodies• Retained devitalized tissue• Poor circulation• Radiation or chemotherapy• Systemic factors : malnutrition,
immunosuppression, medical diseases e.g DM, PVD, smoking, obesity
• Wrong choice of treatment
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Patient preparation• Local :
– adequate debridement– Dressing care : keep wound clean and tissue viability,
barrier to infection
• Systemic :– Nutritional support– Antibiotics– Pain control– Stress relief
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Dresssing
• Debridement ( of non viable tissue) – e.g. Iroxol
• Decontamination ( of infective agents)– Seasorb silver (contain alginate
to trap water)– Anticoat (silver only)– Aquacel (hydrofiber)
• Promotion of healing– Solcoseryl– Actovergin– Collagen
• External stimulation : – Hyphecan
• Optimal Environment
• Local tissue circulation
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Bacteriology
• All wounds are colonized by bacteria• Presence of bacteria ≠ infection• Established infection does not preclude wound
coverage surgery– Except certain bacteria– Streptococcus
• Streptolysin• Clear thin exudate
– Pseudomonas• Green colour exudate
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Bacteriology
• Rational use of antibiotics• Nature of wounds• Intelligent guess• Avoid prolonged topical antibiotics• Surgical debridement of dead and infected
tissues
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Anatomy
• What structures are missing– Loss of major peripheral nerves
• What needs to be replaced– Cavity filling
• What tissues available nearby– Vascular anatomy
• What tissues available distant– Free tissue transfer
• Overall vascular status of the limb
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WOUND PREPARATION
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Topical Negative Pressure (VAC)
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Vacuum Assisted Closure
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VAC regime
• Negative pressure– Most wound : 125mmHg– 50-125mmHg for skin grafts
• Cycle :– Constant for 48 hr then intermittent (5minon/2min off)
• Dressing changes– Most wound : 48 hr then every 4-5 days– Infected : less than 48 hr– Clean wound : 4-5 days
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Reconstruction ladder• Primary closure• Secondary intention “wound contraction”• Skin graft• Flap
– Local– Distant– Free
• Select the simplest method that fulfill wound requirement
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Skin graft
• Full thickness (including dermis) or splitted(~0.015 inches)
• Survive on vascularized bed by “imbibrition”
• May achieve sensation by ingrowth of sensory nerve into the graft
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SSG preparation
Tie over
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Donar site
• Keep dressing intact x 2-3 weeks unless infection is suspected
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• Failed by poorly vascularized bed, infection, shearing
• Bulky dressing, “Tie over dressing”, VAC, plaster immobilization
• For SSG : inspect after D5, FTSG : D7• Skin contracture, hyperpigmentation
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SSG
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SSG vs FTSG
• SSG– Depends on the vascularity of recipient bed– Scars usually bad– Good for large areas – Donor sites can be used repeatedly
• FTSG– Limited supply– Good skin like quality– Different mechanism of recipient site incorporation– Can be used on bare tendon or bone
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FLAP
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FLAPs
• Skin flap– Subcutaneous tissues– Random pattern 1:1 length to width ratio– Pedicle
• Major artery• Perforator • Could be of high length to width ratio• Venous drainage of flap
– Free• microsurgery
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Choices
• Muscle flap– Cavity to fill– Bring in vascularity
• Myocutaneous flap– Donor site morbidity
• Composite tissue transfer– Skin, Muscles, Fascia, Tendons, Nerves,
Blood vessels, Periosteum, Bone, Whole digits
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Decision Making
• Tissues required• Scarring and flap appearance• Donor site morbidity• Patient acceptance• Surgeon factor
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How to choose the correct flap ?Recipient site:
• Where• Size • Shape • Presence of contracture• Nature
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Nature of recipient site
• Clean / contaminated / infected ?• Fresh / Granulation bed ?• Tissue lost : muscle, tendon, nerve, bone
– Thickness– Support– Sensation– motion
• Tissue status surrounding the wound : circulation, adjacent joint
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Choice of Donar
• Healthy with no previous surgery, injury , irradiation
• Minimal disturbance in appearance and function after flap harvest
• Stable arterial supply, few variation • Diameter of artery, length of pedicle• Cutaneous nerve
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Different categories of FLAPs
• Blood supply– Random or Axial
• Method of transfer– Pedicle or Free
• Location – Local, regional, distant
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VY Advancement
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Local lateral arm flap
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Muscle flaps
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Gastronemius Muscle flap
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Flap for NF
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Latissimus dorsi myocutaneousflap
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Pedicle flap
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PIA (posterior interosseous flap)
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Radial Forearm Flap
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Radial Forearm Flap
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Foucher (1st DMA flap)
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Saphenous flap
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Lateral supramalleolar flap
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Free flaps
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Dorsalis pedes flap
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LD + SA flap
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Vascularized fibula bone graft
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Free gracilis flap
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Flaps may fail !• No pressure
/compression on pedicle
• Elevation• Hydration • Anticoagulation • Close monitoring of
circulation• Haematoma• Infection
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Thank you