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Wound Closure Technique
–evolved from the earliest development of suturing materials to comprise resources that include synthetic sutures, absorbables, staples, tapes, and adhesive compounds
–The engineering of sutures in synthetic material along with standardization of traditional materials (eg, catgut, silk) has made for superior aesthetic results
Wound Closure Technique
– Similarly, the creation of natural glues, surgical staples, and tapes to substitute for sutures has supplemented the armamentarium of wound closure techniques
– Aesthetic closure is based on knowledge of healing mechanisms and skin anatomy as well as on an appreciation of suture material and closure technique
– Choosing the proper materials and wound closure technique ensures optimal healing
Phases of wound healing
– identified and studied based on
cellular
molecular level
–depend on an elaborate cascade of growth factors and cellular components interacting in a directed manner to achieve wound closure
Distinct Phases of wound healing
Inflammation
Tissue formation
Tissue remodeling
INFLAMMATORY PHASE
initial injury leads to the recruitment of inflammatory cells into the wound
– clot forms in response to disrupted blood vessels
scenario entails a complex interaction between local tissue mediators and cells that migrate into the wound
INFLAMMATORY PHASE
occurs first few days as inflammatory cells migrate into the wound
migration of epithelial cells occurs within the first 12-24 hours
further new tissue formation occurs over the next 10-14 days
TISSUE FORMATION
Epithelialization and neovascularization
– result from the increase in cellular activity
Stromal elements are secreted and organized
–extracellular matrix materials
TISSUE FORMATION
new tissue, called granulation tissue, depends on specific growth factors for further organization to occur in the completion of the healing process
physiologic process occurs over several weeks to months in a healthy individual
TISSUE REMODELING
Finally, tissue remodeling, in which wound contraction and tensile strength is achieved, occurs in the next 6-12 months
Systemic illness and local factors can affect wound healing
Types of Wound Healing
Traditionally
–primary intention
– secondary intention
PRIMARY INTENTION
surgical wound closure facilitates the biological event of healing by joining the wound edges
Surgical wound closure directly apposes the tissue layers, which serves to minimize new tissue formation within the wound
remodeling of the wound does occur and tensile strength is achieved between the newly apposed edges
closure can serve both functional and aesthetic purposes
PRIMARY INTENTION
purposes include elimination of dead space by approximating the subcutaneous tissues, minimization of scar formation by careful epidermal alignment, and avoidance of a depressed scar by precise eversion of skin edges
If dead space is limited with opposed wound edges new tissue has limited room for growth
atraumatic handling of tissues combined with avoidance of tight closures and undue tension contribute to a better result
SECONDARY INTENTION
method (spontaneous healing) is ancient and well established
It can be used in lieu of complicated reconstruction for certain surgical defects
depends on the 3 stages of wound healing to achieve the ultimate result
History
–begins more than 2,000 years ago with the first records of eyed needles
– Indian plastic surgeon, Susruta (AD c380-c450) described suture material made from flax, hemp, and hair
–At that time, the jaws of the black ant were used as surgical clips in bowel surgery
History
– In 30 AD, the Roman Celsus described the use of sutures and clips, and Galen further described the use of silk and catgut in 150 AD
– Before the end of the first millennium, Avicenna described monofilament with his use of pig bristles in infected wounds
– Surgical and suture technique evolved in the late 1800s with the development of sterilization procedures
– Finally modern methods created uniformly sized sutures
History
– Catgut and silk are natural materials that were the mainstay of suturing products and they remain in use today
– The first synthetics were developed in the 1950s, and further advancements have led to the creation of various forms
– different types of sutures offer different qualities in terms of handling, knot security, and strength for different purposes
– No single suture offers all of the ideal characteristics that one would wish for
– Often the trade-off is in tissue handling versus longevity versus healing properties
General Classification of Sutures
–natural and synthetic
–absorbable and nonabsorbable
–monofilament and multifilament
Sutures
–Natural materials are more traditional and still are used in suturing today
–Synthetic materials
less reaction
resultant inflammatory reaction around the suture material is minimized
Absorbable Sutures
–applicable to a wound that heals quickly and needs minimal temporary support
–purpose is to alleviate tension on wound edges
–newer synthetic absorbable sutures retain their strength until the absorption process starts
–Nonabsorbable sutures offer longer mechanical support
Monofilament Sutures
– less drag through the tissues
– susceptible to instrumentation damage
– Infection is avoided with the monofilament
braided multifilament potentially can sustain bacterial inocula
Natural Materials
gut, silk, cotton
–Gut is absorbable
– cotton & silk are not
–Gut is a monofilament
– silk & cotton are braided multifilaments
Synthetic Sutures
absorbable sutures
–monofilamentous Monocryl (poliglecaprone)
–Maxon (polyglycolide-trimethylene carbonate)
–PDS (polydioxanone)
Synthetic Sutures
Braided absorbable sutures
–Vicryl (polyglactin)
–Dexon (polyglycolic acid)
Synthetic Sutures
Nonabsorbable sutures
–nylon
–Prolene (polypropylene)
–Novafil (polybutester)
–PTFE (polytetrafluoroethylene)
–Steel
–Polyester
Synthetic Sutures
Nylon and steel sutures can be monofilaments or multifilaments
Prolene, Novafil, and PTFE -monofilaments
Polyester suture - braided
Absorbable sutures
– lose their tensile strength before complete absorption
–Gut can last 4-5 days in terms of tensile strength
– chromic form gut (ie, treated in chromic acid salts) can last up to 3 weeks
Absorbable sutures
–Vicryl and Dexon
maintain tensile strength for 7-14 days
complete absorption takes several months
–Maxon and PDS
considered long-term absorbable sutures
last for several weeks
requiring several months for complete absorption
Nonabsorbable sutures
–have varying tensile strengths and may be subject to some degree of degradation
–Silk has the lowest strength
–Nylon has the highest
–Prolene is comparable
Nonabsorbable sutures
–Both Nylon and Prolene require extra throws to secure knots in place
–Polyester has a high degree of tensile strength
–Novafil is appreciated for its elastic properties
Adhesives
– simplify skin closure in that problems inherent to suture use can be avoided
Problems can occur with sutures and lead to an undesirable result both cosmetically and functionally
– reactivity
– premature reabsorption
–Several adhesives have been developed to alleviate this problem and to facilitate wound closure
Adhesives - cyanoacrylate
–used for 25 years and easily forms a strong flexible bond
– implanted subcutaneously
induce a substantial inflammatory reaction in some forms
– superficially on the epidermal surface
little problem with inflammation
Adhesives - cyanoacrylate
–Octyl-2-cyanoacrylate (Dermabond, Ethicon, Somerville, NJ.)
only cyanoacrylate tissue adhesive approved by the U.S. Food and Drug Administration (FDA) for superficial skin closure
–Octyl-2-cyanoacrylate
used only for superficial skin closure and should not be implanted subcutaneously
Subcutaneous Sutures
–used to take the tension off the skin edges prior to applying the octyl-2-cyanoacrylate
–aid in everting the skin edges
–minimize the chances of deposition of cyanoacrylate into the subcutaneous tissues
Demabond Adhesives
– surgical adhesive indication
– January 2001 US FDA granted approval
used as a barrier against common bacterial microbes
–Staphylococci
–Pseudomonas
–Escherichia coli
Fibrin-based tissue adhesives
– created from autologous sources or pooled blood
– typically used for hemostasis and can seal tissues
–do not have adequate tensile strength to close skin
– can be used to fixate skin grafts or seal cerebrospinal fluid leaks
Fibrin-based tissue adhesives
Commercial preparations -US FDA approved
–made from pooled blood sources
Tisseel (Baxter)
Hemaseel (Haemacure)
Fibrin-based tissue adhesives
– relatively strong and can be used to fixate tissues
Autologous forms made from patient's plasma
– concentration of fibrinogen in the autologous preparations is less than the pooled forms
have a lower tensile strength
Other materials
Staples
Adhesive tapes
Adhesive strips
Staples
–provide a fast method for wound closure
–associated with decreased wound infection rates
– composed of stainless steel
less reactive than traditional suturing material
– stapling requires minimal skin penetration
fewer microorganisms are carried into the lower skin layers
Staples
–more expensive than traditional sutures
– require great care in placement
especially in ensuring the eversion of wound edges
–with proper placement
resultant scar formation is cosmetically equivalent to that of other techniques
Adhesive tapes
–Closure using adhesive tapes or strips was first described in France in the 1500s, when Pare devised strips of sticking plaster that were sewn together for facial wounds
–method allowed the wound edges to be joined and splinted
Adhesive tapes
–porous paper tapes (Steri-Strips)
reminiscent of these earlier splints
used to ensure proper wound apposition
provide additional suture reinforcement
– can be used either with sutures or alone
– skin adhesives (eg, Mastisol, tincture of Benzoin) aid in tape adherence
Adhesive strips
–Newer products - ClozeX (Wellesley, Mass)
allows for rapid and effective wound closure that results in adequate cosmesis
– significantly cheaper than suturing or using a tissue adhesive
–not appropriate for many types of lacerations
Closure by secondary intention
–an adequate alternative to other wound closure techniques
especially on concave areas
– Head
– neck
– results achieved are aesthetic and functional
– spare the patient more complex procedures such as flap or skin graft reconstruction
Closure by secondary intention
–Concave surfaces
auricle
occiput
medial canthus
nasal alar crease
nasolabial fold
temple,
–heal well with minimal scarring
Closure by secondary intention
–Useful especially in defects (either superficial or deep) resulting from dermatological surgery
– final scar is less noticeable
older patients with skin laxity
lighter-skinned patients
–method is appropriate in conjunction with other reconstructive techniques
Basics of facial wound closure
–Good approximation of wound edges is paramount to proper wound closure technique
–entail the placement of deep sutures subcutaneously or in the deepest layer of disrupted tissue
– in some situations a single-layer closure is adequate
Basics of facial wound closure
–placing deep sutures
absorbables typically are used
– gut
– Dexon
– Vicryl
– Monocryl
–knot is buried
Basics of facial wound closure
– clear permanent suture can be buried deeply in areas of tension
Prolene or nylon
–deep sutures
serve to eliminate the dead space
relieve tension from the wound surface
ensure proper alignment of the wound edges
contribute to their final eversion
Basics of facial wound closure
–Before placement of the sutures wound closure may require sharp undermining of the tissues to minimize tension on the wound
scalpel or scissors in the subdermal plane
–achieve hemostasis prior to wound closure
to avoid future complications such as hematoma
Basics of facial wound closure
–Employ atraumatic skin-handling technique with instruments
skin hooks
small forceps
– cutting needle - needle of choice
Various curvatures are available depending on tissue depth
Basics of facial wound closure
–wound closure in the head and neck region
small 5-0 or 6-0 sutures of nonabsorbable
– Prolene
– Nylon
absorbable catgut are appropriate
– take great care to avoid tension during closure
–avoid strangulation with the suture at the superficial skin level
Basics of facial wound closure
– take the greatest care to ensure that wound edges not only are aligned but also are everted
– Eversion of all skin edges avoids unnecessary depression of the resultant scar
– With simple sutures
place knots away from the opposed edges of the wound
– Normally remove nonabsorbable suture after 4-5 days
– In certain situations nonabsorbables can be removed at 10-12 days
Suturing techniques
Simple suture or everting interrupted suture
Simple running suture
Simple running suture – Lock variant
Mattress sutureVertical Mattress
Horizontal Mattress
Subcuticular suture
Simple suture or everting interrupted suture
– Insert the needle at a 90° angle to the skin within 1-2 mm of the wound edge and in the superficial layer
–needle should exit through the opposite side equidistant to the wound edge and directly opposite the initial insertion
–Oppose equal amounts of tissue on each side
Simple interrupted suture
Simple suture or everting interrupted suture
– surgeon's knot helps place the nonabsorbable suture
– Strive to evert the edges and avoid tension on the skin
– Place all knots on the same side
Surgeons Knot
Step1 - Lay two pieces of string or line together
Step2 - Make a loop.
Step3 - Draw one end of the strings through the loop. Pass the same end through the loop a second time.
Step4 - Pull on either end of the string until it's tight.
Step5 - Form a figure-eight knot.
Step6 - Wet the knot to help keep it secure.
Step7 - Create a loop at one end of the knot by folding over one end of the rope
Step8 - Pass the folded end through a loop. Pass the folded end through the loop a second time
Step9 - Gently pull the loop and the other end of the knot until the knot is tight
Step10 - Trim off the excess rope when you are done tying the knot
Simple running suture
–method entails similar technique to the simple suture without a knotted completion after each throw
–precision penetration and tissue opposition is required
– speed of this technique is its hallmark
associated with excess tension and strangulation at the suture line if too tight
– leads to compromised blood flow to the skin edges
Simple running suture
Simple running suture –Lock variant
– simple locked running suture
has the same advantages and similar risks
– locked variant allows for greater accuracy in skin alignment
–Both styles are easy to remove
– running sutures are more watertight
Mattress suture
Vertical Mattress Horizontal Mattress
Vertical Mattress sutures
aid in everting the skin edges
Employ this technique
–attachments to a fascial layer
needle penetrates at 90° to the skin surface near the wound edge and can be placed in deeper layers either through the dermal or subdermal layers
Vertical Mattress sutures
exit the needle through the opposite wound edge at the same level and then turn it to repenetrate that same edge but at a greater distance from the wound edge
final exit is through the opposing skin edge again at a greater distance from the wound edge than the original needle entrance site
place knot at the surface
knot placed under tension risks a stitch mark
Horizontal Mattress
used to oppose skin of different thickness
entrance and exit sites for the needle are at the same distance from the wound edge
Half-buried mattress sutures are useful at corners
Horizontal Mattress
On one side an intradermal component exists in which the surface is not penetrated
knot is placed at the skin surface on the opposing edge of the wound
Subcuticular suture
–placed intradermally in either a simple or running fashion
–Place the needle horizontally in the dermis 1-2 mm from the wound edge
–Do not pass the needle through the skin surface
Subcuticular suture
–knot is buried in the simple suture
technique allows for minimization of tension on the wound edge
– continuous subcuticular stitch
suture ends taped to the skin surface without knotting
Running Subcuticular Suture
Complications
– immediate and delayed complications may occur with wound closure
–other complications
stitch marks
wound necrosis
Immediate complications
hematoma formation
– improper hemostasis technique
development of a wound infection
–Prophylactic antibiotics
against wound infection
Late complications
scar formation
improper suturing with excess tension
lack of eversion of the edges
hypertrophic scarring
keloid formation
–unfortunate later complications of wound closure
Late complications