Comprehensive Integument Assessment

Comprehensive Integument Assessment

• Eccrine sweat glands are exocrine glands that aid in thermoregulation by producing sweat, these are found in the skin
• Apocrine glands are located prominantly in the axilla and groin, activating after puberty to produce an odorous, viscous product

Embryology

• Trunk development involves the ectoderm/neural crest layer fusing with the somatic mesoderm during week 4

Burns

• Silver Nitrate is notable for leaching sodium, potassium, and calcium
• Mafenide Acetate inhibits carbonic anhydrase, leading to hyperchloremic metabolic acidosis and has great cartilage penetration
• Silver Sulfadiazine causes transient Leukopenia
• Parkland Formula calculates fluid resuscitation: 4 mL x Body weight (kg) x % TBSA

Z-Plasty

• Incisions run parallel to the long axis of the scar, different angles yield the following gains in length: 25% at 30 degrees, 50% at 45 degrees, 75% at 60 degrees, 100% at 75 degrees, 125% g at 90 degrees

Abdominal Wall Reconstruction

• TAP Blocks are performed between the internal oblique and transverse abdominis muscle
• Anterolateral abdominal wall innervation comes from thoracoabdominal nerves, ilioinguinal, and iliohypogastric nerves
• The transverse abdominis muscle is incised medial to the neurovascular bundles during Transverse Abdominis Release
• Component Separation involves a longitudinal incision in the external oblique aponeurosis, lateral to the linea semilunaris, with protection of the segmental intercostal nerves supplying the anterior abdominal wall by running between the internal oblique and transversalis muscle

Hidradenitis Suppurativa

• Hurley classification dictates the stage of HS includes:
  • I: with transient nonscarring inflammatory lesions
  • II: separate lesions consisting of recurrent abscesses with tunnel formation and scarring and single or multiple lesions separated by normal looking skin
  • III: coalescent lesions with tunnel formation, scarring, and inflammation
• Mild disease is treated with topical antibiotics and/or resorcinol, moderate disease is treated with oral antibiotics
• Refractory disease may benefit from antibody therapy, like Humira (adalimumab), a recombinant human igG1 anti-TNF monoclonal antibody
• It is caused by the occlusion of folliculopilosebaceous Units with hair follicles, sebaceous glands, apocrine glands being impacted

Pediatric Vascular Malformations

• Infantile Hemangiomas have a proliferative phase during early childhood (6-12 months) that grow into raised, rubbery, bright red tumors, resembling a strawberry
• Features distinguishing them from vascular malformations include positive GLUT-1 immunohistochemistry, increased endothelial proliferation, thick basement membrane, 5:1 female to male prevalence, rapid growth out of proportion to child's growth, and increased number of mastocytes

Pharmacology

• Papaverine's MoA → Phosphodiesterase Inhibitor and it is used for antispasmodic medication, antagonizing phosphodiesterase to inactivate cyclic guanosine monophosphate by inhibiting action of myosin light chain kinase, leading to relaxation and vasodilation of smooth muscle cells

Skin Grafts

• Plasmic imbibition is the earliest stage of wound healing
• The graft becomes edematous and may increase its volume by 30-40% due to plasma leak from recipient bed capillaries and venules, filling the space between the wound bed and the graft
• Fibrinogen within the plasma helps anchor the graft to wound and passively absorbs nutrients for 48 hours
• Revascularization and Inosculation are the second stage of skin grafting where it can take up to 4-5 days to become vascularized

Fat Grafting

• Volume retention and graft survival is between 50-80% with increased survivability if used soon after harvest
• The longer it is exposed to room temperature, the lower the adipocyte viability
• Breast Recon can cause benign lesions, cysts, and calcifications

Congenital Syndromes

• Poland Syndrome involves complete or partial pec major agenesis, breast and nipple aplasia or hypoplasia, chest wall and rib malformation & some will have to have ipsilateral arm/hand maldevelopments
• For Branchydactyly or possible syndactyly the best option is reconstruction with DIEP flap as submuscular expansion would not be possible and earlier surgical management is preferred
• Romberg Disease (Progressive Hemifacial Atrophy) for minimal-to-moderate soft tissue defects autologous fat grafting is recommended

Flaps

• For severe cases use free flaps
• Administration of tPA during revision of a microanastamosis decreases the rate of fat necrosis
• SCIP flap over Radial forearm because improved donor site outcome, SCIP can be closed, RFAF requires skin graft
• Pudendal Fasciocutaneous flaps permits vaginal reconstruction with sensate flaps, based on terminal branches of the internal pudendal vessels including the superficial perineal nerves, posterior labial nerve of the pudendal nerve & blood supply being the terminal branches of the superficial perineal artery
• Use of vasopressors has been shown to be safe with no adverse effects on flap outcomes
• Superficial Circumflex Iliac Vessels are the most likely vascular pedicle that will perfuse the groin flap territory, emerging from the femoral system and coursing laterally across the groin and superficial to the sartorius muscle
• Pedicled ALT is used for perineal reconstruction, must be tunneled under the rectus femoris and Sartorius, deriving blood supply from the lateral femoral circumflex artery, descending branch, sending perforating branches through the vastus lateralis and rectus femoris

Bone Flaps

• Mandibular Defects present the need for adjuvant radiation which is a contraindication & 4cm is the maximum advisable length for a bone graft
• Osteogenesis is the formation of new bone by cells in a flap/graft survive the transfer
• Fibula Free Flap donor site morbidity includes Loss of flexor hallucis longus, leading to claw toe and weakened dorsiflexion
• Superficial Inferior Epigastric Artery (SIEA) Flap has the advantage of highest risk for vascular thrombosis but does not violate the rectus sheath
• SIEA flap disadvantage is Smaller vessel caliber, shorter pedicle length, higher propensity to spasm, vessel in the subcutaneous plane of the edge of the flap & Least amount of abdominal wall morbidity given no violation of abdominal wall fascia
• Keystone flaps require minimal undermining
• Scapular Flaps can be used to reconstruct the shoulder, back of the neck, or the axilla
• As a free flap, they can be harvested as a fasciocutaneous flap or with scapular bone with a blood supply of Circumflex Scapular Artery (branch of the subscapular artery) anastomoses with the transverse scapular artery and dorsal scapular artery
• Profunda Artery Perforator flap is an alternative to abdominally based autologous breast reconstruction
• In harvesting this flap Gracilis is reflected anteriorly, adductor magnus fascia is entered & the perforator courses through the adductor magnus

Gender Affirmation Surgery

• The World Professional Association for Transgender Health (WPATH) Criteria includes well documented persistent gender dysphoria
• With female to male top surgery, it requires the patient has the capacity to make to be fully informed consent for treatment, to ensure what is being agreed to, and to be of the age of majority in a given country whilst the patient's medical and mental health concerns are well controlled
• Phalloplasty Urethra creation involves prelamination of flap with skin graft which presents the highest risk of urethral stricture by using a single flap, tube in tube construct or use of second flap
• Adams Apple Surgery involves Chondroplasty of the tracheal cartilage where Endoscopy assists verifying location of the anterior commissure to avoid injury to vocal cords. Anterior commissure tendon injury leads to a deepened voice

Reproductive Pathology

• Vaginal Agenesis (Mayer-rokitansky-Kuster-Hauser Syndrome) is a congenital absence of the vagina with or without a functioning uterus
• Those affected have a female chromosome patten (46,XX) arising from mullerian duct aplasia and failure of uterus and vagina to develop properly
• There is have normal ovarian function and normal external genitalia.
• There is association with abnormalities of the skeletal, urinary or digestive system
• If recon presents with sensation desire, can use Singapore (pudendal fasciocutaneous flaps)
• Serial dilation treatment has the highest rate of re stenosis due to inadequate patient compliance Survival with penile reimplantation depends on arterial flow from the dorsal artery & preputial skin and glans supplied by terminal branches of the dorsal artery

Tissue Expanders

• Highest rate of complications in tissue expanders are seen placed in the scalp or extremities and in the scalp they should be placed under the galea/superficial muscular aponeurotic system: Galea and Temporalis muscle

Congenital Nevi

• Giant Nevus are 20cm in greatest dimension in an adult or a nevus that will become 20cm in greatest dimension once child is fully grown depending on location in childhood
• The 9cm nevus presents on head or neck & a 6cm nevus on body & excision can have malignant potential
• Nevus Sebaceous can be treated with serial monitoring and selective excision such lesion sources that are a source of irritation, difficult to monitor clinically, or aesthetically displeasing

Skin Malignancies

• Actinic Keratosis has a rate of malignant transformation of 10 % requiring recommended treatment
• If there are few or solitary lesions Cryotherapy is indicated and for multiple lesions topical fluorouracil, topical Imiquimod, or photodynamic therapy with photosensitizers are potential treatments

Malignant Melanoma

• Malignant Melanoma can be managed with wide local excision with margins
• Melanoma location of Mis: 0.5 - 1cm, M </= 1.0 mm thickness: 1cm, M 1-2mm: 1-2cm, M 2-4mm: 2cm & M > 4mm: 2cm

Pediatric Skin Lesions

• Pilomatrixomas are calcifying epitheliomas, benign adnexal tumors from hair follicle matric cells

Pressure Injuries

• Trochanteric pressure injury is adressed with the Tensor fascia lata musculocutaneous flap which can be advanced in either a V-Y fashion or as a retro positioned flap if the defect is on the posterior aspect of the trochanter supplied by the ascending branch of the lateral femoral circumflex artery
• For patients with Stage III and Stage IV wounds, the risk of osteomyelitis is high, requiring a bone biopsy is needed for diagnosis

Scarring

• Keloids have a response that excision following radiation having the lowest recurrence rate
• Minimally Invasive Percutaneous Collagen Induction (Microneedling) uses Increased neocollagen and elastin where small zones of injury and created in the papillary dermis which then undergo wound healing process and cascade and to start treatment at 7 weeks

Breast Infections

• Staph. Aureus; Staph. Epi; and Pseudomonas are the most common sources of breast infections

Nerves

• Ulnar Nerve distal to elbow has Motor Innervation of Flexor carpi ulnaris, Flexor digitorum Profundus to ring and small finger & Intrinsic hand muscles
• Sensory to the dorsal hand

Nerve Injury

• If the gap is </= 3cm gap repairs with primarily anastomose & If it is >3cm then peripheral nerve autografts are the most reliable choice with Donar sites including Sural Nerve, Medial antebrachial cutaneous nerve, Lateral antebrachial cutaneous nerve, Dorsal cutaneous branch of the ulnar nerve, Superficial peroneal nerve & Posterior and lateral cutaneous nerves of the thigh

Lymphedema

• An initial treatment → Complete Decongestive Therapy requires Therapist driven modality & Manual lymphatic drainage, daily bandaging, exercise and skin care

Nail Deformities

• Hook Nail develops when an amputation to the fingertip occurs and the nail bed is not supported by bone. Part of the distal phalanx is removed proximal the distal end of the sterile matrix
• This leads to nail growing volarly over the tip requiring Treatment of trimming the distal aspect of the sterile matrix to match the length of the distal phalanx stops the growth of the nail in the volar direction

CMC Joint Dislocations

• 4th and 5th CMC joint dislocations and fracture dislocations are uncommon and Joints are more mobile compared with the 2nd and 3rd

SLAC Wrist

• Scapholunate advanced collapse is Characterized by the Watson Classification
• Stage I is Arthritis between scaphoid and radial styloid while Stage II is Artritis between scaphoid and entire scaphoid facet of the radius
• Stage III is Arthritis between the capitate and lunate

Lower Extremity Fractures

• Masquelet Technique aka Induction membrane technique is a two stage technique for managing large bone gaps (>20cm) featuring a 1st Stage: meticulos debridement and placement of antibiotic cement spacer promoting creation of an organized psudosynovial membrane rich in inductive molecules & a 2nd Stage of Membrane is incised and cancellous bone graft is placed & optimal time between the stages is 4 weeks, if delay is needed 2nd stage can be performed at 6-8 weeks

• Key steps include throughout debridement and stable external fixation with Placement of a spacer into the bine defect

• Allow this to allow healing around spacer for 4-6 weeks to generate a membrane around the spacer until ready for incision and removing the spacer while filling the defect with cancellous autograft, most often obtained from the femur or iliac crest

Upper Extremity Reimplantation

• Upper limb amputations proximal to the wrist tolerate max warm ischemia time of 4-6 hours requiring to Restore arterial inflow with shunt ASAP
• This is followed second by Bone Shortening, third , Rigid bone fixation, fourth, Repair tendons and muscles, fifth repair Vascular followed with Nerve repairs

Digital Reimplantation

• In order for the Most efficient the process is sequenced by Structure: Bone, Tendons, arteries, nerves, veins

Finger Dislocations

• Dorsal MCP joint Dislocation are more comples and usually unable to be reduced nonoperatively but require Surgical intervention;
• Surgical intervention can be preforemed using the Volar Approach which presents the risk of Radial digital nerve and requires precaution during initial exposure or with the Dorsal approach avoids this risk

Volar PIP Dislocation

• Can result in a central slip injury causing Results from volarly directed force in a semirigid digit that causes injury of the central slip, volar plate, and collateral ligaments & Extensor lag is not uncommon after reduction
• requires Treatment of PIP splinting in extension for 4-6 weeks with free DIP joint

Tendon Transfers

• Extensor indicis proprius tendon transfer is Frequently performed for restoration of extensor pollicis longus function when delayed presentation prevents direct repair of the extensor pollicis longus due to musculotendinous retraction
• The advantage this approach requires the EIP is expendable due to the presence if extensor digitorum communis tendon to the index finger, resulting in a straight-line similar vector of pull to the extensor pollicis longus, adequate excursion, and is reliably present greater than 95% with a 12-15cm length
• Plantaris Tendon is the Longest tendon in the human body averaging 30-45 cm in length

Hypoplastic Thumb Deformity

• Blauth Classification dictates management for Type I with Minor generalized hypoplasia receiving No treatment while Type II with Intrinsic thenar muscle hypoplasia, first web space narrowing, and ulnar collateral ligament (UCL) insufficiency this Usually requires opponensplasty with web deepening and UCL stabilization

Blauth Classification Cont.

• Blauth Classification TYPE III for Similar to type II, plus extrinsic muscle and tendon abnormalities with bone deficiency and stable trapeziometacarpal (TMC) Joint is treated needs Extrinsic tendon transfer in addition to the procedures for type II while a IIIb patient is the same except that TMC joint is unstable or missing requiring to be Best threated with pollicization of the index finger adding ablation of the residual thumb if present
• Final clasifications state, IV is “pouce flottant” or floating thumb and Type V is Absent thumb
• All the classifications, type II is charachterized by Narrow first web space, Thenar muscle insufficiency and MCP joint instability
• This can also classify as a clasped thumb deformity which can be accessed witn an extensor indicis proprius tendon transfer from the surgerical manegenent to address all 3 deficiencies at the same time and to do this Flexor digitorum superficialis tendon can be used

Treatment

• The flexor digitorum superficialis tendon of the ring finger can be used to perform an opponensplasty and ulnar collateral ligament reconstruction
• If the FDS tendon is long enough to perform both is recommended and for cases of Narrow first web a Four flap is perfomed

Thumb and UCL Issues

• If Blauth Type IIIB -V is present then Index finger pollicization is reasonable option for CMC joint instability for ulnar colleteral of ligament requires Pollicization of the transfer of proximal phalanx to the thumb metacarpal as well as taking into account any Ulnar Collateral Ligament Injury
• These issues with Ulnar Collatteral damage is likely to have a Stener Lesion which is a Unique type of UCL injury as to where Dorsal adductor aponeurosis becomes interposed between theruptured distal end of the ligament and its insertion at the proximal phalanx

Stener Lesion Diagnosis

• Prevents healing of ligament thus cannot be treated closed and Ultrasound for identification
• This makes it easier for a diagnosis of an uninjured UCL will appear as a hypoechoic arc & with it being Stener lesion the arc disrupted

Hand Masses

• Lung cancer is most common source of metastasis to hand (34%) & 2nd: GI (25%), 3rd: Renal , 4th: Breast (5%) and 5th or Thyroid (2%)
• Epithelioid Sarcoma requires Biopsy with anaplastic cells with an epithelioid, mixed, spindled appearance & wide radical excision to Improve disease-free survival
• Liposarcoma is Malignant requiring Wide surgical excision with clear margins
• Giant Cell Tumor: The most common site metastasis to lungs causes Locally aggressive tumors

Nerofibromatosis

• Nerofibromatosis is also called von Recklinghausen Disease displaying Cutaneous Plexiform Neurofibroma with possible presentation to MRI and showing Skin thickening and hypertrophy & Muscle split fat where mass mass displaced fat

Nerve Syndromes

• Split fat or benign more often seen in benign lesions or low malignancy grade tumors
• Compression Neuropathies with progressive nerve compression & Nerve edema, increased cross or Demyelination can occur with severe nerve compression
• Carpal Tunnel Syndrome indicates a Change in sensort nerve are detected earlier than motor with Early NCS displaying Prolonged Sensory signals
• Volkman Ischemic Contracture is the result of untreated deep pressure from increased power and FDP and FPL

Central and rhematoid issues

• Central Slip Avulsion and Boutinere issue may Lead to a test by activating flexors
• Rehamatoid can cause extensor damage and distortion

Artherty Issues

• Hypophamic hammer syndrome related to ulnar treatment and finger

Nose and Breast Procedures

• Nose empty sundrome occurs when nasal opening is damaged and breast lift should be used
• Facial and cranial procedures all aim to follow the same procedures and techniques

Breast and Lasers

• Breast and laser technology
• Laser should be used to target color for best effect