Post on 28-Oct-2014
MS SHAWALTUL AKHMA HARUN NOR RASHIDMS SHAWALTUL AKHMA HARUN NOR RASHID
PLASTIC SURGEON PLASTIC SURGEON
HOSPITAL RAJA PEREMPUAN ZAINAB II HOSPITAL RAJA PEREMPUAN ZAINAB II
KOTA BHARU KELANTANKOTA BHARU KELANTAN
Wound – breach of epithelium &/or deeper structure.
Type of wound healing – primary intention.
Secondary intention. Delayed
primary/tertiary intention.
Introduction
Skin edges directly apposed, normally heals
well with minimal scar formation.
Primary intention
Open wound which heals by contraction and
epithelialization.
Secondary intention/healing
Wound left open and closed as secondary
procedure.
Delayed primary healing
Demonstrate the
fundamental principle in planning closure of a defect from simple to more complex.
Reconstructive ladder
Methods of closing wounds – sutures, staples, skin tape and wound adhesives.
Principles of suturing skin – skin edges should be
Debrided everted. approximated without tension. deeper wound – closed in layers (to
eliminate dead space) Dermal suture provide strength so the
external sutures can be removed early.
Closure of skin wounds
Eversion of wound edge
Simple interrupted
sutures – gold standard and the commonest.
The suture is placed at the same depth and each side of the incision otherwise the edges overlap.
Suturing techniques
May be used when eversion of the skin edges
is desired and cannot be accomplished with simple suture alone.
Vertical and horizontal mattress sutures
Horizontal & vertical mattress
Obviate the need for external skin suture. Avoid suture marks on the skin and result in
the most favorable scar Absorbable/nonabsorbable sutures can be
used.
Subcuticular / intradermal continuous suture
Subcuticular/intradermal suture
Most often used for closure of scalp wounds
because it can be performed rapidly and hemostatic.
May be used in areas such as the face where the wound is uncomplicated and under no tension.
Locking - provided additional hemostasis. Is not nearly as precise as interrupted suture.
Continuous over and over / running suture
As a time saver for long incision/ to position a
skin closure or flap temporarily before suturing.
Grasping the wound edges to evert before placing the staples to prevent invertion.
Less inflammatory reaction than sutures. Must be removed early to prevent skin mark. Large wounds can be closed faster.
Skin staples
Skin staple
Used after skin sutures are removed to
provide added strength.
Skin tapes
Used in no tension
area or where strength of closure has been provided by a layer of buried dermal sutures.
Skin adhesives
Natural vs synthetic. Absorbable vs nonabsorbable. Braided vs monofilament. Further classification takes into consideration
the time until absorption occur, extent of tissue reaction and tensile strength.
Classification of suture materials
Catgut – derived from submocosal layer of sheep intestine
Evoke a moderate acute inflammation reaction Tensile strength is rapidly lose within 7 – 10 days. Chromization (chromic catgut) slightly prolonges. Indications – ligation of superficial vessels. - closure of tissue that heal rapidly. - to avoid suture removal as in small
children.
Absorbable sutures
Polyglactin (vicryl)/ Dexon – synthetis
material. Produce minimal tissue reaction. Completely absorbed within 90 days. Tensile strength 60-70% at 2/52, lost at 1/12. Indication – intradermal sutures - General soft tissue
approximationof skin and ligation
Absorbable sutures
Polydioxanone (PDS) – Synthetic monofilament. Minimally reactive. Complete absorption within 6/12. Less prone to bacterial seeding. Indication – all type of tissue approximation. Not to be used with prosthetic devises such as
heart valves or synthetic graft. Maxon/ monocryl – tensile strength 3 – 4 weeks General soft tissue approximation/ ligation
Absorbable sutures
The differences among the various non
absorbables are monofilament and braided. Monofilament (Nylon, prolene, dafilon,
dermalon) – minimal inflammatory reaction, slide well and easily removed.
Prolene – maintain its tensile strength longer than nylon which losses appr 15 – 20% per year.
Braided – Silk, polyester elicit an acute inflammatory reaction.
Indication – ligation.
Nonabsorbable sutures
Monofilament vs braided sutures
Def – skin that is removed from the body is
completely devascularized and is replaced in another location.
Standard option for closing defects that cannot be closed primarily.
Consist of epidermis and some or all of the dermis.
Skin graft
Split thickness skin graft and full thickness
skin graft. Split thickness skin graft (SSG)– contain
varying amounts of dermis. Full thickness skin graft (FTSG) – contains the
entire dermis.
Skin graft type
Skin graft
Skin graft can be taken from anywhere on the
body. Prefered area for ssg -- thighs, buttocks, and
abdomen, scalp. Slightly thicker grafts (0.012 to 0.014 inch) - ideal for face,
neck, hands and over joints because less scarring and more pliability would be anticipated for a thicker graft that contains more dermis.
FTSG – post auricle, upper eyelid, groin.
Skin graft donor site
FTSG
SSG
Mesh vs sheet graft
sheet graft
Meshed graft
Skin flap – has its
own blood supply.
Surgical flaps
Rotational/advancement flap
Pedicled flap
rotation flap
Free flap