• septo-cutaneous arteries (most important)
• musculocutaneos arteries (thin)
• direct cutaneous arteries (seldom)

→ Subepidermal, dermal, subdermal plexus

1. Morphilaxy aka Regeneration → replacement with identical tissue (i.e. liver)
2. Epimorphosis aka Real Scarring → fibrous tissue

→ but only relative difference, any wound = scar

dermis

1. when removed → good looking
2. next 4-8weeks → hard +elevated, red + itchy = hyperplasic stage
3. after → discolored, flatten, soften, stop itching

sun exposure

1. Hyperthrophic = spontaneously reduce in 2-3y

2. Cheloid = no tendency to reduction, might even worse → Presotherapy, Steroid injection into cheloid scar (Øcreams❗), Radiotherapy

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• Superficial vs. deep
• simple vs complex
• minimal vs large
• with vs without skin defection
• shape regular vs odd
• clean vs poluted
• mechanism cut, contusion..

1. Asepsy + repeated chemical wound cleansing
2. Wound excision as rigurous as possible, conserving as much important anatomic elements as possible
3. Decompression incision, fasciothomy, fasciethomy, evacuation hematomas, foreign bodies, bone fragments, hemostasis
4. repair of injured anatomical elements + defect covering (immediate of active delayed emergency: 24-72h)

• without tension
• treads maintain borders in contact
• not to many treads

autograft -self

heterograft - others

grafts: only few cutaneous elements + no vascularization (thats why they are planted into vascular bed)

flaps: contain a vascular network (to ensure survival)

full thickness

(functionality is superior + no real donor site (bc. can just be sutured up, also better cosmetic outcome)

free split skin graft (→ donor site cant really be sutured up when that large thats why Øfull thickness)

if possible → full thickness

if too large → split

Granular surface → always with split

→ esp thigh, buttocks

• small grafts → scalpel

• Dermatome 📷

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1. Simple
• Cutaneos (skin+ superf. fascia)
• Fasciocutaneous (+deep fascia)
• Muscle flaps (only muscle)
• Fascial flap (only fascia, no skin)
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2. Complex
• Musculocutaneous (muscle+skin)
• Osteomusculocutaneous (bone, muscle,skin)
• Osteomuscular (without skin)
• Joint flaps 📷
• Finger flaps 📷
3. Complex

Pedicle vs Island flap

Pedicle Flap → a flap which is left attached to the original site by a narrow base of tissue to provide a blood supply during grafting

Island flap → incised on all borders → no cutaneous attachments between the skin of the flap + adjacent skin of the donor site. The Donor and receiver site share the vascular pedicle of the flap

Free flap → tissue and its blood supply (artery and vein) are surgically removed from one part of the body and transferred to another area of the body (no connection donor + receiver site)

1. Local → immediate proximity
2. Regional → same region but Ø very close
3. Locoregional → donor site at one region, receptor at another anatomical level

1. Direct skin system - random + axial
2. Musculocutaneous -perforates
3. Fasciocutaneous - perforates

• Rotation transposition 📷
• Elimination of fat tissue
• Bandage

• vascular insufficiency
• necrosis
• infection
• hematoma
• seroma

• Øidentifiable vascular source
• supplied by random vessels
• cant survive unless length/width ratio 2:1

to release tension caused by contractile scars (i.e. finger contraction)

decrease tension with Burow traingle at the sites

direct artereies are running axial to flap → can be extended (in with+lenght) 📷

• pedicle
• island
• microsurgerical free transfer

Type 1: one vascular pedicle

Type 2: one dominant and at least one minor pedicle

Type 3: 2 dominant vascular pedicles

Type 4: multiple similar sized pedicles (segmental)

Type 5: one dominant and multiple secondary segmental pedicles→ complete harvesting with significant skin part

free fasciocutaneous flap from forearm

radial artery can be the only blood supply for the hand!

easy harvest nice caliber, thin, fine, can include bone, tendon, nerves

free flap (small skin island) from back of the foot with central cutaneous vein

venous + included superf. nerve = neurocutaneous flap

• heat burns→ liquids, hot solids, flame→ closed space burns
• chemical burns→ corrosive substances
• electrical burns

• ACTH → ↑Mineralcorticoids
• ADH
• beta-endorphins
• catecholamins
• TSH
• cortisone
• glucagon

catabolic hypermetabolism:

• ↑endogenous glucose synthesis
• proteic hypercatabolism

• serotonine
• kinins
• prostaglandins
• necrolides
• leukocyte release

suppression→makesbody prone to endogenous or exogenous infection

rule of nine 📷; rule of palm (1%) 📷

1. extinguish fire
2. drop cloths, rings etc
3. cool out the tissues but avoid hypothermia!
4. chemicalburns→ maybe washing out with saline

• tetanus prophylaxis
• surface and depth evaluation
• resuscitation, cervical immobilisation

1. lesions of airway→inspiration trauma (hoarseness of voice, burn in mouth)
2. thorax lesions
3. unconscious patient (CO intox?)

• re-evaluation of patient (surface+depth + prognosis index)
• neurologic test Lab, blood gases, radiologic evaluation
• iv fluids
• monitoring

just remember some of them

1. III degree
2. inhalation
3. burn >20% body surface (>10% if <10y or >50y)
4. at specific locations
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5. Electrical + Chemical burn
6. comorbidities
7. homeless

1. cool out (not hypothermia❗)
2. wound cleaning
3. topical desinfectants (in III degree)
4. special dressings (tegaderm 📷, opsite) (not on face→just topics)

1. early excision and grafting → deep + large (>30% Surface Area)
2. tangential excision 📷→ use dermatome
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Tangential excision: The term refers to the removal of the necrotic surface of a burn by taking repeated parallel slices using a skin graft knife, as opposed to using a scalpel to excise burned skin and subcutaneous tissue together.

3. excision to fascia 📷 → only in full thickness burns and wound infections, or failed first skin graft
4. seriate excision → well delimitate burns, repeat every week until all the whole region is grafted

• regarding healing-process:
• late healing
• hypertrophic, retractable scar
• itching
• multiorgan failure
• ulcerations + Marjolin ulcer
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Marjolin's ulcer:
• Aggressive ulcerating squamous cell carcinoma that occurs in previously traumatized, chronically inflamed, or scarred skin.
• Commonly associated with chronic wounds: including burn injuries, varicose veins, venous ulcers, ulcers from osteomyelitis, and post-radiotherapy scars.

functional rehabilitation

re-attachment of a completely severed limb

reattachment of a partially amputated limb segment

complete amputation→ two teams needed

incomplete amputation with partially preserved venous-lymphatic drainage→ saves time

warm ischemia >32° C.

cold ischemia <5-10° C.

→ optimal preservation conditions: 5-10°C

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1. introduction in wet gauze dressing 📷
2. into a tight sealed bag
3. into a container with ice ~10°
4. Labelling

two teams→ one for amputated segment, one for the stump

• abundant washing
• fasciotomy + excision
• identification and isolation of important anatomical elements

1. osteosynthesis
2. extensor and flexor tendon suture
3. artery suture
4. venorrhaphy
5. skin suture

also neurorrhaphy

• Osteosynthesis
• Artery suture
• Extensor tendons suture
• Flexor tendons suture
• A second artery suture
• Venorrhaphy (sodium bicarbonate washing)
• Skin

• ↑vascular suture tension
• vascular suture in injured vessel wall
• sutured vessel compression

• bandage
• immobilisation- plaster cast
• position- postural drainage
• vasodilators
• anti-coagulants

→ Heparin dependent on patient and trauma

• venous congestion
• ischemia
• infection
• hematoma
• seroma
• partial necrosis

→ pseudoarthrosis, stiff joints

• Osteitis +vicious bone consolidation
• cold intolerance

• early start
• long standing
• complete

another finger for the thumb or toe to finger transfer