V-Y Flap Closure

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • The V-Y flap closure is used to close high-tension wounds in areas where undermining the skin alone will not close the wound. It should be reserved for less cosmetically sensitive areas.
  • The V-Y flap closure is satisfactory for areas with excellent subcutaneous blood supply.
CONTRAINDICATIONS
  • Diabetes (relative)
  • Impaired wound healing
  • Vascular compromise to region
  • Keloid or hypertrophic scar formation
  • Previous radiation to region
  • Coagulopathy (intrinsic or induced through anticoagulants such as warfarin)
  • Wound location on lower extremity, especially the feet (due to slow healing) (relative)
EQUIPMENT
  • Topical antiseptic wash: Povidone-iodine or chlorhexidine gluconate
  • 5-mL syringe with needles (16- to 20-gauge to draw up anesthetic, and 27- to 30-gauge for tissue injection)
  • Injectable local anesthetic: 1% to 2% lidocaine with epinephrine for most areas. If flap viability is going to be a concern, it is best to limit or eliminate the use of epinephrine.
  • Sterile drape
  • Sterile gloves
  • Sterile gauze pads
  • Telfa pad (Covidien Ltd., Mansfield, MA) and Tegaderm (3M, St. Paul, MN)
  • Skin marking pen
  • Nylon suture (4-0, 5-0, or 6-0, depending on location)
  • 4-0, 5-0, or 6-0 absorbable suture such as Vicryl or Dexon, if deep sutures are indicated
  • Adson forceps
  • Needle holder (smooth)
  • No. 15 scalpel
  • Suture scissors
  • Two skin hooks
  • Scissors, Metzenbaum, curved, 5 to 5½ inches
  • Hemostats, curved, mosquito, 2 inches
  • Hemostats, straight, small, 2 inches
  • Good lighting
ANATOMY

Skin

  • The skin is composed of three layers—epidermis, dermis, and subcutaneous tissue.
  • The epidermis, the outermost layer of skin, is composed of epithelial tissue.
  • The dermis is the layer below the epidermis; it not only supports the skin, but it contains sweat glands, erector muscles, hair follicles, nerves, and blood vessels.
  • The subcutaneous tissue is below the dermis and consists of adipose tissue and larger blood vessels and nerves.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • For the first 24 hours after surgery, the patient must rest and avoid exertion.
  • Keep the wound clean and covered with a thin coat of antibiotic ointment.
  • Refrain from alcohol and aspirin-containing medicines for at least the first 24 hours.
  • The wound should be dressed with a small piece of Telfa, covered by Tegaderm or Roll Dressing. If subcuticular sutures are used above, place Steri-Strips (3M, St. Paul, MN), followed by the Telfa and Tegaderm dressing. Then place a thick outer dressing of 4 × 4 gauze or another bandage.
  • Placing ice on the area for 2 to 4 hours helps to relieve pain, swelling, and bleeding.
  • After 24 hours, the thick outer bandage may be removed.
  • Each day, the wound should be checked carefully to ensure that no crust or blood has accumulated. If blood or crust accumulation is noted, gently cleanse the wound.
  • For patients likely to get the wounds dirty, continue to have a wound covering at least during the daytime after the first 24 hours.
  • At any time that the wound dressing gets wet or contaminated, it should be replaced.
  • After 24 hours, it is acceptable to shower and wash (not scrub) the wound.
  • If the wound bleeds at any time, the patient should apply firm pressure for 15 minutes and should place a new dressing over the wound.
  • Instruct the patient to call the office or go to the emergency room for persistent bleeding, signs of infection, or wound/suture breakdown.
  • Advise the patient on when to follow up for suture removal and wound check.
COMPLICATIONS
  • Acute complications (within 2 weeks)
    • Bleeding
    • Bruising
    • Swelling
    • Hematoma
    • Pain
    • Infection
    • Wound dehiscence
  • Chronic or permanent complications
    • Scarring/contractures
    • "Railroad tracks" from delayed suture removal
    • Hypertrophic scars
    • Keloid
    • Hyperpigmentation
    • Hypopigmentation
    • Nerve damage
    • Skin atrophy
    • Hair loss
    • Recurrence of excised lesion
  • In the excision of potentially malignant lesions, tumor-free margins must be obtained before a commitment is made to any flap closure.
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