Suturing Flashcards
Inflammation immediately starts the healing process after injury
HIGH VELOCITY OF FLOW IN NORMAL ARTERIOLES KEEPS
PLATELETS IN MIDSTREAM
BLEEDING SLOWS VELOCITY AND ALLOWS PLATELETS TO DRIFT TO THE EXIT POINT.
The fresher the wound the more successful the closure
In the intact blood vessel the flow dynamics keeps the platelets with their pro inflammatory cytokines in the center of the stream. Much as a stick stays in the center of a fast moving stream. When a the vessel wall is breached the flow slows significantly and the platelets drift to the walls or are carried to the leak to plug t hole. Cytokines cause WBC and fibrin to migrate to the walls of the wound and seals it so the body can begin to pull the sides together.
The sooner the walls of the wound can be approximated the better and faster it will heal or resist infection.
Every wound will try to heal itself
Wounds the size of a dime will heal themselves easily. Larger wounds need closure or skin grafts to bridge the gap. See how the edges of a large self healing wound push up on the edges in a futile attempt to push the skin edges toward the middle.
THREE basic PRINICIPLES OF WOUND REPAIR
minimize trauma to tissue
minimize tension on wound edges (approximate, don’t strangulate)
accurately approximate wound edges and landmarks
The three cardinal rules of skin closure. Know them well and your wounds will be pristine. Plastic Surgery is built on meticulous adherence to these rules. BE KIND TO THE TISSUE AND IT WILL BE KIND TO THE PATIENT AND YOUR REPAIR!
Three phases of wound healing
INFLAMMATORY PHASE
Begins immediately and
lasts 5 days.
PROLIFORATIVE PHASE
Starts within 24 hours
seals wound from water.
continues for 6 months.
REMODELING PHASE
Continues up to two years.
delay in closing
The important point is that healing begins immediately upon creation of the wound. The body has no idea you are going to intervene and help it heal, so it first starts the process of attempting to stop hemorrhage and begin to seal the wound. The longer you leave the wound open the more the healing processes will progress to seal the wound. Delaying closure will allow the healing process to seal the wound edges in preparation for self healing which will extend the healing process and strength of the closure. Delayed closures are necessary however for contaminated wounds. Wounds are usually sealed at 24 hours so they can handle flooding of water such as with wound irrigation or showering.
To close or not to close?
CLOSE
Fresh wounds hours old
Large clean wounds
Over cartilage or bone
To reduce scarring
To reduce bleeding
Surgically debrided and irrigated wounds
DON’T CLOSE
Old (days),or contaminated wounds ..unless in a cosmetic area .
Abscess that are drained
Wounds that have opened after previous repair
? foreign bodies in the wound
wounds heal best from…
the bottom up. They tend to push foreign matter to the surface of the healing wound. To close a contaminate wound over this foreign matter is to invite abscess formation. Small deep puncture wounds such as cat bites, snake bites, and nail and splinter wounds are prone to abscess formation because the top of the wound closes before the bottom.
why do anesthetics not work well in abscesses?
Abscess fluid is generally acidic in nature, Local anesthetics have polarity so they can attach at the synapses and depolarize the nerves thus temporally blocking the pain impulses to the brain. Placing local anesthetics in an acid environment destroys their polarity and negates their effect. Shooting lidocaine into an abscess will increase the pressure in the abscess and markedly increase the pain without blocking the nerve impulses. Regional blocks above the abscess or refrigerants such as Ethyl Chloride applied to the skin will allow for drainage of the abscess.
ethyl chloride
Ethyl ‘Chloride is a quick acting refrigerant that can be directed with pin-point accuracy to an injection site or to the skin over an abscess to super=cool nerve endings and slow transmission of pain impulses to allow incision and drainage or injections.
tissue tension
leads to scarring.
There are many forces at play on the skin edges of a wound. Natural tension of the skin over joints pull edges apart. Underlying muscles pull edges apart. The sides of the wound can move in both horizontal and vertical directions when they become detached from one another. Movement of wound edges in any direction slows or impedes healing.
Forces that cause movement of wound edges or distraction of those edges contribute to widening of the healing surface and scarring. Preventing movement and forces of distraction of the wound edges is key to the formation of very narrow and cosmetically pleasing scars.
The major task of the physician is to recognize and arrest the possibility of movement with strategically placed sutures in each layer of the underlying tissue. Muscle and fat do not hold stitches well so suture much be placed in facial layers or lower dermal layers. Closing the skin on top without attention to the lower layers will result in a scar that approximates the with of the original wound.
ABCDs of wound closure
refers to where to put the stitches.
The more suture in the wound, the greater the chance of infection
sutures in muscle always pull out!
Sutures relieve tension on the wound edges and bring deep tissue together.
Deep sutures of the absorbable variety fix the wound for greater periods of time and result in better cosmetic results. Care must be taken to not place too many deep sutures.
langer’s lines
Close wounds parallel to langers lines for best cosmetic results
The body has natural tension lines like creases in a pair of trousers or a dress. Closing wounds parallel to these lines result in less tension to the wound edges and better results. Closing perpendicular to these lines increase tension and result in widening of the scar.
undermining or undercutting
Wound edges can be freed up and mobilized using the technique of under-cutting or under-mining. This usually involves mobilizing extending out under the wound edges a minimum of 2/3 the width of the wound to adequately reduce the tension on the wound edges.
Undermine out to 2/3 width of the defect
simple interrupted sutures
The basic stitch that will close virtually all wounds is the simple interrupted stitch. Symmetry is the key to a good a result
Place the needle straight down when over an equal distance on the apposite skin edge then straight up to the skin surface. The more equal and identical you can place the suture to the opposite side the better the result. Angling the needle slightly outward at the base of the wound so the bottom suture is wider than the top will evert the skin edges presenting a greater surface for the epidermis to heal making the scar stronger and narrower.
evert =
pucker
