Debridement techniques
Surgical Mechanical Chemical Autolytic Biological
Debridement techniques: Surgical
Surgical debridement-quick, dependent on surgeon’s judgement of non-viable tissue. Risk of damaging underlying or surrounding viable tissue
Debridement techniques: Mechanical
Cleaning of tissue or dressing removal
Debridement techniques: Chemical
Enzymes to lyse necrotic tissue
More selective
Debridement techniques: Autolytic
Allow body to remove tissue
Most selective but takes longest to work
Debridement techniques: Biological
Maggots and other agesnts to clear wound leaving a healthy base e.g. ischamic ulcers in PVD
Reconstructive Ladder
Secondary intention Primary Intention Delayed prmary intention Skin grafting (Split skin and full thickness) Tissue expansion Local Flap Free flap
Split skin graft advantages
Epidermis and small layer of dermis
Cell islands at donor site regenerate-so multiple uses and multiple sites
Donor graft is thin so large surface area of graft site can be covered
Thin layer contours to underlying surface
May ‘take’ in graft sites with marginal blood supply
Split skin graft disadvantages
Often poor cosmetic result: Colour mismatch graft contracts as it heals-also contractures may form Meshing visible in final scar Donor site scarring
Full thickness graft (Epidermis and dermal components)
Usually reserved for the face
Less contracture
Grow alongside the local tissue
Better colour matching
epidermal appendages transplanted
Caveats:
Limited and once only harvestation
Require good graft site blood supply to take
Take
Adherence
Inosculation
Skin lesion classification
Benign, premalignant and malignant
Skin lesions: Benign (6)
Cysts Fibroma Papilloma Haemangioma Moles and naevi Hidradenitis suppurativa
Skin lesions: Premalignant
Keratocanthoma
Intraepidermal neoplasia
Skin lesions: Malignant
BCC
SCC
Malignant melanoma
Cysts
Epidermal cyst
Trichilemmal cyst
Pilar cyst
Dermoid cyst
Epidermal cyst
Keratinous infected material often foul smelling and cheesy in appearance lying in a keratinised squamous cell lined cavity with a granular layer. Occurs from the infundibular portion of hair follicle.
Occur where sebacious glands are present in hair lying areas-not on soles of feet or palms
Trichilemmal cyst
As for epidermal cyst but genetic element-autosomal dominant
No granular layer
Hair follicle epithelium derivation
May calcify
Pilar Cyst
Proliferation of epithelium lining cyst
Ulcerates and proliferates and may resemble a SCC (Pott’s peculiar tumour)
Dermoid cyst
Cysts deep to the skin lined by stratified squamous epithelium with epidermal appendages e.g. hair follicles, sweat glands etc (unlike in epidermal cysts)
Dermoid cysts sites
Sites of fusion: Lateral and medial ends of eyebrow (external and internal angular dermoid) Mid line of nose (nasal dermoid) Sublingual Mid line of neck Mid line of trunk
Fibromata: Dermatofibroma
Benign lesions of fibroblasts
May be pigmented red or brown
Require excision
Fibromata: Neurofibroma
Overgrowth of neural (ectodermal) and fibrous (mesodermal) elements
Affected nerve e..g. VIII may be affected but most are symptomless
Regrowth common and can be difficult to excise
Von Recklinghausen’s disease
AD multiple neurofibromatosis associated with:
- Cafe au lait spots (>6 1.5cm) but may be absent
- Acoustic neuromas
- malignant change 5-13%
- Phaeo’
- Scoliosis
Mental retardation
Plexiform neurofibroma
Very rare
Excessive overgrowth of neural tissue (ectoderm)
May be confused with lymphatic oedema
Papilloma: Benign papilloma
Overgrowth of all skin layers-not a neoplasm just skin tag
Papilloma: Seborrhoeic keratosis
Overgrowth of basal epidermis
Papilloma: Warts
Papilloma virus causes hyperkeratotic skin overgrowth
Haemangiomas
Strawberry naevus Pyogenic granuloma Port wine stain Vin rose patch Spider naevus Telangiectasis Osler Weber Rendu Syndrome Campbell de Morgan spot
Keratocanthoma
Overgrowth of hair follicles, central lump often collapses leaving a scar and mistaken for SCC
Bowen’s disease
Thickened brown or pink plaques and may progress to SCC
Solar keratosis
skin damage causing hyperkeratosis