Primary Wound Closure Techniques

Question 1

Skin tension

Answer 1

Determined by the pull of collagen and elastin fibers in dermal and hypodermal tissues

Question 2

Attempt to close the wound ____ to the tension lines.

Answer 2

Parallel

Question 3

Tension Relief - Undermining

Answer 3

• Use of scissors or scalpel to separate the skin from underlying tissue, usually through distinct plane of dissection
  
  • Include the panniculus muscle with the skin when present (cutaneous trunci, platysma, sphincter colli superficialis)
    
    • Deep to panniculus muscle
• Blunt and sharp dissection in combination often most appropriate
• Draws upon full elastic potential of the skin
• First line closure technique
• Preserve direct cutaneous vessels and subdermal plexus

Question 4

Undermining in the presence of granulation tissue

Answer 4

• Separate epithelialized skin from granulation bed
• Use blade @ junction of normal and new epithelium
• Seaprate skin from granulation tissue deep to the subdermal plexus - leaves subQ tissue with our skin!

Question 5

Tension relieving sutures - subdermal sutures

Answer 5

Sutures placed in the fibrous layer of the hypodermal, or subdermal, tissue rather than the fatty subcutaneous layer

Question 6

tension relieving sutures - walking sutures

Answer 6

• Move skin across a defect
• Obliterate dead space
• Distribute tension across a wound surface

Question 7

External tension relieving sutures

Answer 7

• Far-near-near-far or far-far-near-near patterns
• Mattress sutures
• Placed 1-2 cm form skin edge

Question 8

Tension relieving sutures - stent sutures

Answer 8

Sutures cushioned with a bolster

Question 9

stent suture

Answer 9

Question 10

Answer 10

Stent suture

Question 11

Releasing/Relaxing Incisions

Answer 11

• Incisions in healthy areas that allow skin to stretch and cover wounds
• Distal limbs, perineal area, eyelids
• Heal by second intention or secondary wound closure

Question 12

Simple relaxing incision

Answer 12

• Starts @ point of maximal tension
• Extend as necessary to relieve tension
• UNDERMINE
• typically heals in ~4 weeks
• Usually requires bandaging until sufficient healing

Question 13

Multiple Punctate Incisions

Answer 13

• Small (~1 cm or less)
• Parallel
• Made in staggered rows
• More cosmetic than simple incisions
• Higher risk of circulatory compromise and may not provide as much relaxation as a simple incision
  
  • More likely to hit vessels that go to the wound

Question 14

V-toY Plasty

Answer 14

• Used in areas that would cause distortion if closed under tension (eyelids)
• V shaped incision ~3 cm from wound
• UNDERMINE
• Close original wound
• Close V incision in shape of a Y
• Dehiscence risk at meeting of 3 points

Question 15

Z-Plasty

Answer 15

• Gives length
• Z can be incorporated into wound or adjacent
• Central arm is made in direction for lengthening
• 2 arms made at 30-90 degrees, same length as central limb
  
  • 60 degrees is optimal
  • Larger angles give more length

Question 16

“Dog Ears”

Answer 16

• Formed by unequal suture spacing
  
  • Sometimes unavoidable
• More of a cosmetic nuisance
• Minimize by using ellipitical incisions
• Can correct/remove
• Often flatten out with time

Question 17

Skin Stretching/Expanding

Answer 17

• Takes advantage of skin’s ability to stretch beyond inherent elasticity
  
  • Mechanical creep
  • Stress relaxation
• Can be done hours or days before surgery

Question 18

Skin stretching - pre-suturing

Answer 18

• Done 24 hours prior to definitive surgery
• Effective only where elastic skin is limited (like distal extremities)
• Use tension relieving pattern
• Place sutures way from wound 3-5 cm
• Use large, non-absorbable suture

Question 19

External Skin Stretching

Answer 19

• Commercial products or homemade
• Velcro
• Attach externally with adhesive
• Adjust tension over the course of several days to stretch skin

Question 20

Skin stretching - tissue expanders

Answer 20

• Commercial products
• Implant in SQ tissue adjacent to wound
• Inflate a silicone bag with saline - stretches overlying skin
• Can be done acutely in surgery or gradually over time
• Expensive
• Potential complications
  
  • Pain, skin necoriss, seroma, infection, dehiscence, scar widening

Question 21

Skin biopsy

Answer 21

• Important diagnostic for acute or chronic skin disease
• Eliminate secondary pyoderma before biopsy
• Need multiple samples, especially in chronic cases
• Special skin preparation
  
  • Clip and prepare skin with saline only
  • No harsh scrupping of the skin
• Consider taking normal skin for comparison
• Perform at junction of normal and abnormal for incisional biopsy
• Use good, atraumatic technique to reduce artifacts
• Laser and electrosurgery will induce artifacts and make interpretations more difficult

Question 22

Skin tumor excision

Answer 22

• Good planning
• Consider location, tension lines, elasticity of neighboring skin
• Plan shape to maximize eas of closure
• Always have a plan for getting closure - may not always be priamry closure
• Prep large areas - to make sur enot along hair margin as you are closing

Question 23

How much tumor to incise - benign vs malignant

Answer 23

• 1 cm for benign
• 2-3 cm for malignant