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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_612_Библиотеки_им_академика_М_И_Перельмана
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Perform Adequate Debridement Before
Reconstruction
Foreign bodies, biofilm, and infected or devitalized tissues must be
removed prior to reconstructive surgery to promote healing. Dressing
changes, lavage, tangential excision, and/or sharp debridement may
be appropriate depending on the type of wound and chronicity.
Highly contaminated wounds often require multiple trips to the
operating room for sharp debridement before they are ready for
reconstructive surgery. Inadequate debridement significantly
increases the risk of reconstructive failure.
Preserve Vascularity
A detailed understanding of vascular anatomy facilitates definitive
closure of almost any wound. Tissue can be transferred from one
area to another if the blood supply is preserved. Blood supply is
critical for tissue viability and healing, and therefore, plastic surgeons
are obsessed with vascularity.
Plan incisions carefully, especially in the context of previous
unfavorable incisions. Create rotational flaps with a wide base.
Preserve the subdermal plexus when possible. Undermine minimally
to maintain blood flow from the deeper tissues. Identify and protect
perforating vessels.
Obliterate Dead Space
Seromas are a significant source of morbidity after surgery. Any
potential space left beneath the skin fills with fluid and acts as a
reservoir. Suture skin flaps to the underlying fascia to pexy the tissue
—this apposes the flaps, reduces friction, and promotes adherence
(Figure 1.2). Quilting (progressive tension) sutures reduce
complications in many procedures, including abdominoplasty,
4
rhytidectomy,5 and at flap donor sites.6 Use drains liberally to prevent
fluid accumulation in dissected tissue planes.
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FIGURE 1.2 Illustration of progressive tension suture
placement in an abdominoplasty. Sutures must include
Scarpa fascia and muscle fascia for secure fixation. (From
Pollock TA, Pollock H. Progressive tension sutures in
abdominoplasty: a review of 597 consecutive cases.
Aesthet Surg J. 2012;32(6):729-742. Figure 2 by
permission of Oxford University Press.)
Obtain Hemostasis and Irrigate Before Closure
Inspect the wound in a systematic manner and achieve hemostasis
at the end of each case. Start at the highest point on the wound and
work toward the most dependent part to avoid distraction by dripping
or pooling blood. Hemostasis must be achieved at the patient’s
baseline blood pressure—communicate with the anesthesiologist to
ensure the patient is normotensive. Irrigate to identify residual areas
of bleeding that require further attention. Meticulous hemostasis
reduces complications, optimizes wound healing, and improves
patient safety. Drains do not prevent hematomas.
https://t.me/med1917
There is always injured tissue after dissection and the use of
cautery. Necrotic fat globules can act as foreign bodies which
increase inflammation and predispose to infection. Irrigation helps to
remove debris.
Optimize Scarring
The final appearance of a scar is dependent on many factors,
including a patient’s age, skin quality, medical comorbidities, the
location and direction of the incision, tension on the closure, and
surgical technique. We cannot control a patient’s innate healing
capability but can perfect our technique to optimize scarring. Afterall,
the skin closure is the only part of the surgery that the patient directly
sees.
When possible, plan incisions so that the final scar will be parallel
to the relaxed skin tension lines (Figure 1.3). Hide incisions by
placing them at the junction of esthetic subunits where the eye
expects a change in contour (ie, at the junction of the cheek and the
nose or along the nasolabial fold, Figure 1.4).
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FIGURE 1.3 Relaxed skin tension lines. (Reproduced
with permission from Ruberg RL. In: Smith DJ, ed. Plastic
Surgery: A Core Curriculum. St. Louis: Mosby; 1994.)
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FIGURE 1.4. Hide incisions along the junction of esthetic
subunits.
Mobilize the surrounding tissue for tension-free skin closure. Close
wounds in layers by placing sutures in the fascia or dermis. Avoid
suturing fat as this strangulates the tissue and does not add
strength. Approximate skin edges meticulously with uniformity and
slight eversion. In most cases, simple interrupted sutures provide an
appropriate amount of eversion (Figure 1.5). Eversion always
flattens over time.
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FIGURE 1.5 Types of skin closure. A, Simple interrupted.
B, Vertical mattress. C, Horizontal mattress. D, Running
subcuticular. E, Half-buried horizontal mattress. F, Simple
running. G, Staples. H, Skin tape.
Avoid creating visible ledges, dog ears, or irregularities. Do not
leave the operating room until you are pleased with the way things
look. If it does not look good on the table, it will not look any better
later. Revision procedures are exponentially more difficult.
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Remove permanent sutures as soon as possible to prevent track
marks (Figure 1.6). Sutures on the face can usually be removed in 3
to 5 days and sutures on the body in 7 to 10 days.
FIGURE 1.6. Track marks can be avoided by removing
sutures early or using subcuticular sutures.
Apply Dressings Meticulously
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The dressing is the first thing a patient sees on awakening from
surgery. Take care to clean dried blood and skin prep from the
patient and apply the dressing neatly. Think about the goal of the
dressing: is it simply to cover the incision or can it be used to prevent
infection, support the surgical site, reduce swelling, or improve pain?
Splints are often used in extremity surgery, but the concept can also
be applied to other procedures. Foam, compression garments, and
surgical bras are used to support tissue after liposuction, breast, or
body contouring surgery. Incisions can be immobilized with tape. For
wounds that are open or expected to drain (ie, a skin graft donor
site), apply a dressing that is absorptive and occlusive.
Control Pain
Use local anesthesia liberally. Add bicarbonate to act as a buffer and
reduce injection site pain.7 Inject at 90° to the skin, subcutaneously
first, and then intradermally along the incision lines (Figure 1.7).
Create a wheal of local anesthesia out in front of the needle before
advancing it (Figure 1.8). Add a vasoconstrictor (epinephrine) to
lengthen the duration of effect and reduce blood loss. Blocks reduce
the need for intra- and postoperative narcotics.
8,9
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FIGURE 1.7 Insert the needle at 90° to the skin and inject
local anesthetic subdermally. Fewer nerve fibers are
irritated when the needle is perpendicular. Injecting in the
subcutaneous tissue is less painful and blocks the nerves
at their trunk. (From Strazar AR, Leynes PG, Lalonde DH.
Minimizing the pain of local anesthesia injection. Plast
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Reconstr Surg. 2013;132(3):675-684. Figures 1.2 and
1.4.)
FIGURE 1.8. Inject 0.5 mL of local anesthetic into the
subcutaneous tissues and wait 30 seconds for effect.
Then, create a wheal of local anesthesia out in front of the
needle before advancing it. (From Strazar AR, Leynes PG,
Lalonde DH. Minimizing the pain of local anesthesia
injection. Plast Reconstr Surg. 2013;132(3):675-684.
Figure 1.6.)
Start postoperative analgesia before the local anesthetic wears off.
Appropriate analgesia decreases heart rate and blood pressure,
which reduces the risk of hematoma formation. Similarly, nausea
should also be treated aggressively—venous and arterial pressures
are increased in a vomiting patient, which can predispose to wound
dehiscence or a bleed.
https://t.me/med1917
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