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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

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Page 1: Wound Closure Technique

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

Page 2: Wound Closure Technique

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

Page 3: Wound Closure Technique

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

Page 4: Wound Closure Technique

Distinct Phases of wound healing

Inflammation

Tissue formation

Tissue remodeling

Page 5: Wound Closure Technique

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

Page 6: Wound Closure Technique

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

Page 7: Wound Closure Technique

TISSUE FORMATION

Epithelialization and neovascularization

– result from the increase in cellular activity

Stromal elements are secreted and organized

–extracellular matrix materials

Page 8: Wound Closure Technique

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

Page 9: Wound Closure Technique

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

Page 10: Wound Closure Technique

Types of Wound Healing

Traditionally

–primary intention

– secondary intention

Page 11: Wound Closure Technique

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

Page 12: Wound Closure Technique

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

Page 13: Wound Closure Technique

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

Page 14: Wound Closure Technique

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

Page 15: Wound Closure Technique

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

Page 16: Wound Closure Technique

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

Page 17: Wound Closure Technique

General Classification of Sutures

–natural and synthetic

–absorbable and nonabsorbable

–monofilament and multifilament

Page 18: Wound Closure Technique

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

Page 19: Wound Closure Technique

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

Page 20: Wound Closure Technique

Monofilament Sutures

– less drag through the tissues

– susceptible to instrumentation damage

– Infection is avoided with the monofilament

braided multifilament potentially can sustain bacterial inocula

Page 21: Wound Closure Technique

Natural Materials

gut, silk, cotton

–Gut is absorbable

– cotton & silk are not

–Gut is a monofilament

– silk & cotton are braided multifilaments

Page 22: Wound Closure Technique

Synthetic Sutures

absorbable sutures

–monofilamentous Monocryl (poliglecaprone)

–Maxon (polyglycolide-trimethylene carbonate)

–PDS (polydioxanone)

Page 23: Wound Closure Technique

Synthetic Sutures

Braided absorbable sutures

–Vicryl (polyglactin)

–Dexon (polyglycolic acid)

Page 24: Wound Closure Technique

Synthetic Sutures

Nonabsorbable sutures

–nylon

–Prolene (polypropylene)

–Novafil (polybutester)

–PTFE (polytetrafluoroethylene)

–Steel

–Polyester

Page 25: Wound Closure Technique

Synthetic Sutures

Nylon and steel sutures can be monofilaments or multifilaments

Prolene, Novafil, and PTFE -monofilaments

Polyester suture - braided

Page 26: Wound Closure Technique

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

Page 27: Wound Closure Technique

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

Page 28: Wound Closure Technique

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

Page 29: Wound Closure Technique

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

Page 30: Wound Closure Technique

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

Page 31: Wound Closure Technique

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

Page 32: Wound Closure Technique

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

Page 33: Wound Closure Technique

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

Page 34: Wound Closure Technique

Demabond Adhesives

– surgical adhesive indication

– January 2001 US FDA granted approval

used as a barrier against common bacterial microbes

–Staphylococci

–Pseudomonas

–Escherichia coli

Page 35: Wound Closure Technique

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

Page 36: Wound Closure Technique

Fibrin-based tissue adhesives

Commercial preparations -US FDA approved

–made from pooled blood sources

Tisseel (Baxter)

Hemaseel (Haemacure)

Page 37: Wound Closure Technique

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

Page 38: Wound Closure Technique

Other materials

Staples

Adhesive tapes

Adhesive strips

Page 39: Wound Closure Technique

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

Page 40: Wound Closure Technique

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

Page 41: Wound Closure Technique

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

Page 42: Wound Closure Technique

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

Page 43: Wound Closure Technique

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

Page 44: Wound Closure Technique

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

Page 45: Wound Closure Technique

Closure by secondary intention

–Concave surfaces

auricle

occiput

medial canthus

nasal alar crease

nasolabial fold

temple,

–heal well with minimal scarring

Page 46: Wound Closure Technique

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

Page 47: Wound Closure Technique

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

Page 48: Wound Closure Technique

Basics of facial wound closure

–placing deep sutures

absorbables typically are used

– gut

– Dexon

– Vicryl

– Monocryl

–knot is buried

Page 49: Wound Closure Technique

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

Page 50: Wound Closure Technique

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

Page 51: Wound Closure Technique

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

Page 52: Wound Closure Technique

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

Page 53: Wound Closure Technique

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

Page 54: Wound Closure Technique

Suturing techniques

Simple suture or everting interrupted suture

Simple running suture

Simple running suture – Lock variant

Mattress sutureVertical Mattress

Horizontal Mattress

Subcuticular suture

Page 55: Wound Closure Technique

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

Page 56: Wound Closure Technique

Simple interrupted suture

Page 57: Wound Closure Technique

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

Page 58: Wound Closure Technique

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

Page 59: Wound Closure Technique

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

Page 60: Wound Closure Technique

Simple running suture

Page 61: Wound Closure Technique

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

Page 62: Wound Closure Technique

Mattress suture

Vertical Mattress Horizontal Mattress

Page 63: Wound Closure Technique

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

Page 64: Wound Closure Technique

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

Page 65: Wound Closure Technique

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

Page 66: Wound Closure Technique

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

Page 67: Wound Closure Technique

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

Page 68: Wound Closure Technique

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

Page 69: Wound Closure Technique

Running Subcuticular Suture

Page 70: Wound Closure Technique

Complications

– immediate and delayed complications may occur with wound closure

–other complications

stitch marks

wound necrosis

Page 71: Wound Closure Technique

Immediate complications

hematoma formation

– improper hemostasis technique

development of a wound infection

–Prophylactic antibiotics

against wound infection

Page 72: Wound Closure Technique

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

Page 73: Wound Closure Technique

Late complications