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Expert Wound ClosureExpert Wound Closure
Presented by:
Dennis Tankersley P.A.-C., M.S.
Barbara Knudsen
©Ethicon, Inc. 2012.
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Course Objectives
Discuss the business of wound repair
Describe types of wound healing
Understand how to explore wounds
Demonstrate proper wound preparation
Differentiate needle and suture selection in various wound closure
Practice both complex wound closure techniques involving:‒ Mattress‒ Muti-layer‒ Subcuticular‒ Corner stitch‒ Partial amputations, nail bed injuries
‒ Ear, lip and nasal injuries
Discuss techniques to minimize scarring and infection
Recommend proper wound scar and suture removal
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Laceration Landscape
In the U.S. there are more than 12 million annual ED visits for traumaticwounds
Most wounds are located on the head and neck or upper extremities,‒ Upper extremity wounds usually involve the fingers
More than half of these wounds are caused by blunt force.
Wound care accounts for 5% to 20% of all ED malpractice claims
These claims result in 3% to 11% of all settlement dollars
Most common reason for litigation involves:
‒ Failure to diagnose foreign bodies
‒ Wound infections
‒ Failure to detect underlying injury to nerves, tendons or joint capsule
If a malpractice case is lost, mandatory reporting to regulatory agencies canbe a source of significant loss in professional standing.
Emerg Med 2007; 189-201; Pfaff, JA, et al.
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Wound Closure Documentation &Billing levels
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3 Procedure Codes ForLaceration Repair
Simple / Intermediate / Complex
Documentation of a wound should include:‒ The precise anatomical location‒ Length in centimeters‒ A description of the laceration type.
• curved, angular, stellate, jagged, etc.
‒ Distal Pulse, Motor, Sensory, & Capillary refill‒ Type of Closure and Material used
When multiple wounds are repaired of the same classification(simple, intermediate, complex) and the same anatomicregion, the lengths of the wounds are added together andcoded as one laceration.
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CPT Codes For Laceration Repair
Closure with adhesive strips used alone is not a simple repair, but isbundled with “first aid” care.
Simple ligation of blood vessels in an open wound is considered part ofthe repair code.
Simple “exploration” of nerves, blood vessels or tendons, exposed in anopen wound is also considered part of the essential treatment of thewound, and is not a separate procedure, unless appreciable dissection isrequired and documented.
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CPT Codes For Laceration Repair
SIMPLE LACERATION REPAIRS: CPT Codes 12001- 12018
Simple repair is used when the wound is superficial, e.g. involvingprimarily epidermis and dermis, or subcutaneous tissues withoutsignificant underlying damage
Requires simple, one layer closing
Topical Skin Adhesives (FDA Class II wound closure device, e.g.Dermabond) alone are considered as a simple closure.
This includes anesthesia
Chemical or Elctro-Cautery of wounds left open is also considereda simple closureICD-9 codes are found in the 870-894, Open Wound by site, category
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CPT Codes For Laceration Repair
INTERMEDIATE LACERATION REPAIR: CPT Codes 12031 – 12057
Used when the wound requires layered closure of one or moredeeper layers of subcutaneous tissue and superficial (non-muscle)fascia, in addition to the closure of the epidermal and dermal layers.
Single layer closure of heavily contaminated wounds that haverequired extensive cleaning or removal of particulate matter, alsoconstitute an intermediate repair.
Document type of contamination (e.g. dirt, infection, etc.)
These codes, like simple repairs, are subject to the multipleprocedure reduction rule
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CPT Codes For Laceration Repair
COMPLEX LACERATION REPAIR: CPT Codes 13100 – 13153
Includes the repair of wounds requiring more than layeredclosure, vizable scar revision, debridement (e.g. traumaticlacerations or avulsions), extensive undermining, stents orretention sutures.
Necessary preparation includes creation of a defect forrepairs (e.g. excision of a scar requiring complex repair) orthe debridement of complicated lacerations or avulsions.
Intermediate repairs requiring extensive debridement orapproximation can also be coded as complex lacerationrepair.
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Debridement May Be Billed Separately, If:
Surgical debridement – document type of instrument used, i.e.scalpel, scissors, burr
Non-surgical debridement (sloughing) of an infected wound
Infection or signs of infections must be documented, i.e.cellulitis
Indicate debridement site on body parts form and describetype and method of debridement
Gross contamination requires prolonged cleansing
When appreciative amounts of devitalized or contaminatedtissue are removed
If debridement is carried out separately without immediateprimary closure
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Anesthesia Can Be Billed Separately, If:
Documented as used for pain control
Is remote in time to the wound repair
‒ i.e. a digital block preformed at triage for pain control while the patient awaits x-ray for foreign body or fracture
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Laceration Management
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Horizontal Mattress
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Defining Wound Healing
A “wound” is a break in the skin that may beaccompanied by disruption to the underlying tissues1
A “healed wound” is one where1
‒ Connective tissues have been repaired and
‒ Wound has been completely epithelialized by regeneration and
‒ Has returned to its normal anatomic structure and function without the need for continued drainage or dressing
Some wounds fail to heal properly, resulting in chronic,nonhealing wounds, requiring continued management2
Aberrations in certain phases of healing can result inexcessive healing (eg, hypertrophic scars, keloids)2
1.Enoch and Leaper. Surgery. 2008;26:31.2.Ethridge et al. Wound healing. In: Sabiston Textbook of Surgery. 18th ed. 2007.
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The Five Phases of Wound Healing
Enoch and Leaper. Surgery. 2008;26:31.
0.1 0.3 1 3 10 30 100 300
Days after wounding (log scale)
IV. Remodeling and scar formation
Ma
xim
um
res
po
ns
e
V.S
ca
rm
atu
rati
on
II. Inflammatory phase
I.H
em
osta
sis
III. Proliferative phase
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The Overarching Goals for Wound Closure
Cosmesis‒ Skin‒ Minimize tissue trauma‒ Achieve excellent wound
approximation
Closure strength‒ Skin and fascia‒ Appropriate strength during
critical healing period• Device wound holding strength• Absorption profile
Infection protection‒ Skin and fascia‒ Minimize conduits for infection‒ Actively reduce risk with
antimicrobial devices
SKIN:CosmesisStrength
Infection protection
FASCIA:Strength (rupture
reduction)Infection protection
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Why Should You Care About Cosmesis?
Preventing Abnormal Scarring‒ Occurs in: Skin
Key points for prevention:‒ Precise surgical technique
‒ Minimize tissue tension
• Lines of Langer
‒ Tissue perfusion and oxygenation
‒ Prevent infection
‒ Occlusive dressings
‒ Topical adhesives
Elevated Depressed
Hypertrophic Keloids
Téot. Wound Repair Regen. 2002;10:93.
Ethridge RT, Leong M and Phillips LG. Wound Healing. In: Townsend CM, Beauchamp RD, Evers BM and Mattox KL, eds.Sabiston Textbook of Surgery. 18th ed. Saunders, 2007:191-216.
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Why Should You Care About Strength?
Preventing Wound Dehiscence‒ Occurs in: Skin & Fascia
Influenced by patient and surgical factors
Key points for prevention:‒ Tailoring wound closure method
• Patient condition and comorbidities
‒ Wound preparation (Skin)‒ Undermining
‒ Circular Ellipsoid
‒ Minimize tension • Layered closure (Skin)
• Wound edge eversion (Skin)
Bennett et al. J Am Acad Dermatol 1988; 18: 619-37Carlson MA. Acute Wound Failure. In: Incisional Hernia. Springer-Verlag1999: 101-109Moreira et al. Crit Care Nurs Clin N Am 2012; 24: 215–237Riou et al. Am J Surgery 1992; 163: 324-330Leaper D. Basic surgical skills and anastomoses. In: Bailey and Love’s Short Practice of Surgery. 25th ed. Edward Arnold Ltd; 2008.
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Why Should You Care About InfectionProtection?
Preventing Incisional Hernia‒ Occurs in: Fascia
Risk is multi-factorial: Patient & surgical factors‒ Dehiscence and/or infection Incisional hernia
Key points for prevention:‒ Prophylaxis (for infection)
‒ Choice of wound closure method• Based on patient condition & comorbidities
• Continuous > Interrupted suturing
• Absorbable > non-absorbable sutures
‒ Minimize tension• Prosthetic mesh
Israelsson et al. Eur J Surg 1996; 162: 125-129; Vant’ Riet et al. Am Surg 2004; 70: 281-286Edminston et al. Surgical site infection control in the critical care environment. In: Infectious Disease in Critical Care 2007.Ceydeli et al. Current Surgery 2005; 62: 220-225; Luijendijk et al. N Engl J Med 2000;343:392-8.Carlson MA. Acute Wound Failure. In: Incisional Hernia. Springer-Verlag1999: 101-109Riou et al. Am J Surgery 1992; 163: 324-330
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Why Should You Care About InfectionProtection? Surgical Site Infections (SSIs)
Occurs in Skin and Fascia
SSIs: infections in the wound created by an invasivesurgical procedure1,2
‒ US: ≈780,000 / Europe: ≈1.4 million SSIs per year
Increased risks associated with SSIs1,2
‒ 2× as likely to die‒ 2× as likely to spend time in an ICU‒ 5× more likely to be readmitted after discharge
Infection increases hospital costs1,2
‒ Increases length of stay up to 21 days worldwide‒ US: $1.6-$3 billion/Europe: €1.5- €19.1 billion per year
Hospital-acquired infections (HAIs), particularly SSIs, areunder surveillance in many countries3,4
SSI = surgical site infection; ICU = intensive care unit; HAI = healthcare-associated infection.
1. National Collaborating Centre for Women’s and Children’s Health. Surgical site infection: prevention and treatment of surgicalsite infection. Clinical Guideline. October 2008; 2. World Health Organization. WHO Guidelines for Safe Surgery 2009;3. APIC. http://www.apic.org/downloads/legislation/HAI_map.gif; 4. HELICS. SSI Statistical Report. 2004.
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Presence of an Implant Can Increase theRisk of Infection
Like all implants, sutures can be colonized by bacteria,which can lead to biofilm formation1
1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:250.
Colonization of a suture knotColonization of a braided suture
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Preventing SSIs
Many precautions are currently in place to control the riskof bacterial contamination1
‒ Preoperative skin preparation
‒ Preoperative trimming
‒ Preoperative hand and forearm antisepsis by surgical team
‒ Sterile operative environment
‒ Avoiding hypothermia
However, additional controllable risk factors can beaddressed with innovative devices2
‒ Tissue trauma by closure devices such as staples
‒ Bacterial colonization of the suture
‒ Entry of bacteria at incision closure during postoperative healing
1. National Collaborating Centre for Women’s and Children’s Health. Surgical site infection: prevention and treatment of surgicalsite infection. Clinical Guideline. October 2008.
2. World Health Organization. WHO Guidelines for Safe Surgery 2009.
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Wound Healing Summary
Healing of acute wounds involves a complex, dynamicseries of events
Many factors may delay or impede wound healing,resulting in long-term complications, but steps can betaken to ensure the best outcomes for your patients
Cosmesis, strength, and infection protection are theoverarching goals of wound closure
SSI prevention is a critical factor in achieving optimalacute and long-term wound healing
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The Golden Period of the Wound
Time interval from injuryto closure with low risk ofinfection
Dependent on patient andwound factors─ Location
─ Etiology
─ Timing
─ Underlying Comorbidities
Berk et al. Ann Emerg Med 1988;17:496
Healing Rates
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Tissue-Specific Healing Time Guides theChoice of Tissue Repair Material
0 1 2 3 4 5 6 7 8 9
Bone
Fascia
Peritoneum
Subcutaneous
Mucosa
Skin
Critical Wound Healing Period*
14-28 days
7-14 days
7-14 days
5-7 days
5-7 days
8-12 weeks
Weeks
*Minimum healing times shown here are for healthy individuals without medical complications.
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Time Frame for Closing the Wound
American College of Emergency Physicians policy is no morethan 8 to 12 hours from the time of injury
Wounds that are at low risk for infection, safely approximated upto 12 hours after the time of injury
Likewise, wounds that are at moderate risk or infection within a 6-to 10-hour period
Clinical judgment may allow the time period for primary repair incertain situations to be extended up to 20 hours
DeBoard R. Principles of Basic Wound Evaluation and Management in the Emergency Department. Emerg Med Clin N Am 25(2007) 23–39
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Physical Examination
Hemostasis
Adequate lighting
Neurovascular exam
Foreign bodies
Tendon, vascular & joint injuries
Patient history
Time and mechanism of injury
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Wound Preparation
Anesthesia─ Lido w/ Epi vs. Lido w/o Epi
─ L.E.T. / T.A.C. / E.M.L.A.
Wound cleansing methods─ Irrigation
─ Scrubbing
• Soaps
Cleansing solution─ NS vs. tap water
─ Wet functioning antiseptic
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Period ofcontamination
106
102-3
Time of injury
2-6hours
3-5days
Infection
Q
Kinetics of Wound Bacterial Growth
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Absorbable vs. Non-Absorbable
“Nonabsorbable sutures, such as nylon, long have been thestandard material for use in closure of skin wounds, withabsorbable suture reserved for use in closure of deep tissuelayers. Recent literature calls this practice into question andprovides evidence that absorbable suture may beappropriate for skin closure.” Lloyd J. Closure Techniques. Emerg Med Clin N Am 25 (2007) 73–81)
Other Studies Parrell GJ, Becker GD. Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. Arch
Facial Plast Surg 2003;5(6):488–90.
Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbableand nonabsorbable sutures.
AmJ Emerg Med 2004;22(4):254–7. Rosenzweig LB, Abdelmalak M, Ho J, Hruza GJ. Equal cosmetic outcomes with 5-0poliglecaprone-25 versus 6-0 polypropylene for superficial closures.
Dermatol Surg. 2010 Jul;:36 (7):1126-9
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Traditional Closure Options
Sutures Staples Strips
Closure strength Varies with suture Strongest Weak
Infection protection Yes for Plus Sutures No No
CosmesisGood/Excellent
Dependent on suture patternMay leave marks Varies
Handlingand
ease of use
Good, precise woundapproximation, multipletechniques for variety of
wounds/incisions
Less precise woundapproximation, limited
techniques
Less precise woundapproximation, limited
techniques
Patientsatisfaction
Varies, may require removal byphysician
Poor, showering notrecommended for period of time
Requires removal by physician
Poor, showering notrecommended for period of time
May require removalby physician
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Suture Types and Properties
Various suture types with different properties givechoices for a range of procedures
What are the traits of the “ideal” suture?
Leaper D. Basic surgical skills and anastomoses. Bailey and Love’s Short Practice of Surgery. 25th ed. 2008.
Synthetic Natural
Polymers
Less reactive
More predicable
Silk/cotton/stainless steel/gut
Easy handling
May be reactive and unpredictable
Absorbable Nonabsorbable
Absorb over time for quick-healing woundsProvide long-term support
Remain in the body or require removal
Monofilament Braided
Smooth passage
No wicking; reduced contamination risk
Easy handling and knot tying
Higher risk for bacterial colonization
Antibacterial Non-antibacterial
Actively inhibit bacterial colonization of the suture No protection against bacterial colonization
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Plus Antibacterial Sutures Are the Only CommerciallyAvailable Sutures With Antimicrobial Protection
Plus Sutures have been shown in vitro to kill bacteria andinhibit bacterial colonization of the suture for 7 days or more1
Plus Sutures are effective against pathogens commonlyassociated with SSIs1-3
‒ Staphylococcus aureus
‒ Staphylococcus epidermidis
‒ MRSA
‒ MRSE
‒ Escherichia coli*
‒ Klebsiella pneumoniae*
Plus Sutures retain the handling/tying characteristics andabsorption profiles of the untreated suture materials4-6
*MONOCRYL Plus and PDS Plus only.
1. Rothenburger et al. Surg Infect (Larchmt). 2002;3(suppl1):s79;2. Ming et al. Surg Infect (Larchmt). 2007;8:209; 3. Ming et al.Surg Infect (Larchmt). 2008;9:451; 4. MONOCRYL Plus IFU; 5. VICRYL Plus IFU; 6. PDS Plus IFU;
Plus Sutures createa zone of inhibitionaround the suture
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Characteristics of an Ideal Surgical Suture
Appropriate Strength‒ High wound holding strength & strength retention
‒ Predictably absorbed by the body after critical healing period
‒ High knot security
Minimal Tissue Trauma‒ Excellent handling, with smooth passage through tissue
‒ Low tissue reactivity
Infection Protection‒ Smooth surface area
• Less susceptible to bacterial colonization
‒ Actively reduces infection risk with antimicrobial coatings
Ethicon, Inc. Wound Closure Manual. 2005:1-119.
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Needle Types and Associated Application
Type Use
Taperpoint Needle(eg, CT-1, SH, BV-1)
For soft, easily penetrated tissues
TAPERCUT™ SurgicalNeedle (eg, V-5, CC-1)
Cutting tip, taper body. For tough tissue,like 2 needles in one
Conventional CuttingNeedle (eg, CR-1, CPS-3)
Two opposing cutting edges, witha third on inside curve. Change incross-section from a triangle cutting tipto a flattened body
Reverse Cutting Needle(eg, OS-6, X-1)
Cutting edge on outer curve. For tough,difficult-to-penetrate tissues
Ethicon, Inc. Wound Closure Manual. 2005.
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Needle Types and Associated Application(cont’d)
Type Use
Precision Point Needle(eg, P-3, PS-2)
For delicate plastic or cosmeticsurgery. Cutting tip electropolished foradded sharpness
Precision Cosmetic-Conventional Cutting PCPRIME™ Needle (eg, PC-5,PC-12)
For delicate plastic or cosmeticsurgery. Conventional cutting tip andPRIME geometry for increasedsharpness
ETHIGUARD™ Safety Needles(eg, SHB, CTB-1)
Taper body. For reducing needlestickinjuries while suturing muscle andfascia
Ethicon, Inc. Wound Closure Manual. 2005.
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Characteristics of an Ideal Surgical Needle
Appropriate Strength & Stability‒ As slim as possible but strong‒ Rigid to resist bending but without breaking‒ Stable in the grasp of a needle holder
Minimal Tissue Trauma‒ Able to carry suture material through tissue with minimal
trauma‒ Sharp enough to penetrate tissue with minimal resistance
Infection Protection‒ Sterile and corrosion-resistant: prevents microorganisms
or foreign materials from entering into the wound
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Association for Professionalsin Infection Control and Epidemiology (US)
The Benefits of Antibacterial Sutures
“Although the use of antimicrobial sutures is not a routinepractice, the benefits are becoming increasingly apparent.Recent evidence-based clinical studies have demonstratedboth the clinical and economic benefit of this technology.”
APIC. Guide to the Elimination of Orthopedic Surgical Site Infections. 2010.
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In vivo Absorbable Suture InflammatoryResponse
*Data on File
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Out of Package Absorbable Suture TensileStrength
*Data on File
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Relaxed Skin Tension Lines
6-0
5-0
0
4-0
3-02-0
0
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Common Types of Suture Closures
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Vertical Mattress Suture
Key points to remember‒ Used to evert the edges
‒ Collecting the deep tissue is as important as the superficial edges
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Vertical Mattress Suture Video
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Rule of Halves
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Needle Entry Angle @ 90°
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Corner Subcuticular
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Multilayer Closure
Deep sutures are indicated when;‒ Wound extends to the muscle layer
‒ Superficial closure will leave dead space
‒ Wound surface tension is high
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Superficial Closure not Sufficient
DeadSpace
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Simple Interrupted Suture Video
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Simple Interrupted Suture:Percutaneous and Deep
Key points to remember‒ For a buried knot, the route is inside-out, then outside-in
‒ Where you start is where you end and where the knot will be
‒ Test the strength of the tissue you are suturing
• Poor tissue strength can lead to weak closure
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Deep Suture Placement
1 2 3
4 5 6
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Deep Suture Placement
Knot @ Bottom
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• Deep suturing may include
subcutaneous and deep dermal
closure
• Or a single deep suture may be a
combination subcutaneous/deep
dermal closure.
deep dermal stitch
subcuticular
subcutaneous
Deep Suture Placement
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Finishing Multilayer Closure
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Wound Edge Resection
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Undermining Extrinsic tension on a wound is the “pulling” tension of a wound outward.
This tension varies with the direction of the laceration in relation to theskin tension lines.
Undermining relieves this extrinsic tension, allowing advancement andeversion of the skin edges.
Undermining involves the separation of the skin and attached superficialsubcutaneous tissue from deeper subcutaneous tissue and fascia.
The palm of the hand, sole of the foot, or fingertips should not beundermined.
Undermining may lead to additional scar formation; perform only whenrelease of tension allows closure of the wound.
Amount of undermining necessary is approximatelydouble the width of the gap of the laceration at its widest point.
Emergency Procedures and Techniques, Third Edition.; pg 313-15. Robert R. Simon, MD and BarryE. Brenner, MD
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Undermining
For example: A 1 cm wide laceration may be undermined 1 cm on both sides ofthe wound.
Undermining is most commonly done within the fatty layer that liesimmediately beneath the dermis. It is best if a thin layer of fat can be left onthe underside of the dermis, which minimizes disruption to subdermal vascularstructures.
Dissection may be sharp or a “spreading” type and should occur in a normalfascial plane when possible.
Emergency Procedures and Techniques, Third Edition.; pg 313-15. Robert R. Simon, MD and Barry E. Brenner, MD
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Clinical Recommendation EvidenceRating
Saline or tap water may be used for wound irrigation.Whereas povidone-iodine, detergents, and hydrogen peroxide shouldbe avoided.
B
The sting from a local anesthetic injection can be decreased by slowadministration and buffering the solution.
B
Suturing is the preferred technique for skin laceration repair. C
Tissue adhesives are comparable with sutures in cosmetic results,dehiscence rates, and infection risk.
A
Applying white petrolatum to a sterile wound to promote woundhealing is as effective as applying an antibiotic ointment.
B
A = consistent, good-quality patient-oriented evidenceB = inconsistent or limited-quality patient-oriented evidenceC = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.
Am Fam Physician. 2008 Oct 15;78(8):945-951.
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Ear Wound Repair
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Ear Anatomy
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Ear Innervation
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Ear Wound Repair
The primary goals of wound management are theexpedient coverage of exposed cartilage and theminimization of wound hematoma
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Ear Anesthesia
For small wounds to the ear without cartilaginousinvolvement, local infiltration may be used.
Regional nerve blocks or field blocks are the preferredmethod of anesthesia in significant ear lacerations.
Some experts suggest avoiding the use of epinephrinewhen anesthetizing the ear for fear of ischemic necrosis‒ No good evidence exists to support this view
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Wound Closure
Sutures placed 3 – 5 mm apart
Suturing through cartilage not recommended
Up to 3mm of cartilage can be removed withoutsignificant cosmetic defect‒ Skin coverage without cartilage resection is always preferred
‒ Do not undermining over cartilage
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Hematoma prevention
Compression dressing‒ Apply digital pressure for 5-10 minutes, and then apply compression dressing.
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Compression dressing can be applied noninvasively or surgically.‒ Noninvasive methods include a simple compression dressing or, if available,
application of silicone splints or plaster mold to the medial and lateral aspects of theauricle
‒ Surgical dressing involves securing cotton bolsters, buttons, or thermoplastic splints[6] with through and through sutures to the medial and lateral aspects of theauricle.
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Compression Dressing
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Hematoma Treatment
Needle aspiration‒ Use an 18- or 20-ga needle to aspirate blood from the most fluctuant or full area.‒ Although still widely used, this method is no longer recommended by many sources because of
hematoma reaccumulation.‒ The aspiration is often inadequate and the hematoma requires additional management.‒ Some sources recommend primary needle aspiration followed by the incision method, if
reaccumulation occurs.
Incision and drainage‒ Incise the edge of hematoma along the natural skin folds using a No. 15 scalpel.
• A small (5 mm) incision is often all that is necessary.
‒ Gently separate the skin and perichondrium from the hematoma and cartilage and completely express or suction out the hematoma, as shown below. Be careful not to damage theperichondrium. Auricular hematoma incision and drainage.
‒ Use normal saline to Irrigate the pocket with an 18-ga angiocatheter.‒ Reapproximate the perichondrium to the cartilage.
After either technique a pressure dressing should be placed
24 hour follow-up for wound check is required
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When to get Help
Specific injuries of the ear require urgent referral to aplastic surgeon. Such injuries include the following:‒ Large overlying skin avulsion (approximately 5 mm or greater)
‒ Severe crush injuries
‒ Complete or near-complete avulsions[3] or amputations[5, 6]
‒ Large cartilage defects (approximately 5 mm or greater)
‒ Wounds that require the removal of more than approximately 5 mm of tissue
‒ Significant involvement of the auditory canal
‒ Obvious devitalization
‒ Total ear avulsion
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Lip Wound Repair
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Importance of careful Repair
Lip lacerations may result in significant cosmetic defectsif not properly repaired.
Vermilion boarder defects of greater even 1mm arenoticeable
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Key Stich
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Lip Anatomy
The lip has two significant anatomic landmarks:
The mucosal border, which divides intraoral and externalportions of the lip,
The vermilion border, which separates the lip mucosafrom the skin of the face.‒ Meticulous alignment of the vermilion border and its associated
"white line" is the cornerstone of cosmetic repair.
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Lip Anesthesia
Local infiltration for small perioral wounds is acceptable
Regional Nerve blocks are preferred‒ Less distortion of landmarks
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Lip Innervation
Lower Lip‒ Mental Nerve
Upper Lip‒ Infraocular Nerve
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Wound Preparation
Given the high bacterial content of the oral cavity, liplacerations will not remain clean during repair.
The goal of irrigation is to remove clotted blood and grosscontaminants such as tooth fragments or dirt.
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Wound Closure
If full thickness repair the mucosa first‒ 4-0 absorbable
‒ A gauze pad or roll inside the mouth may be helpful
Irrigate well after mucosal repair
For vermillion border involvement place key stich
Repair muscle with 3-0 or 4-0 absorbable suture usingfigure of 8 sutures
Repair the skin 6-0
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When to get Help
Greater than 1/5th of the lip is lost
Inability to repair orbicularis oris muscle
Unstable dental fractures
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Wounds of the Digits
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Fingertip / Nail Anatomy
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Digital Anesthesia
Ring Digital Block‒ Base of digit always both sides
‒ Each finger is innervated by 4 digital nerves:
• Two palmar digital nerves and two dorsal digital nerves.
‒ The dorsal nerves run in the 10 and 2 o’clock positions
‒ The palmar branches run in the 4 and 8 o’clock
‒ Great toe needs dorsal coverage
Transthecal Digital Block‒ 1-2cc placed in flexor tendon sheath
‒ Insertion point is just proximal to the MCP joint
Local Anesthesia
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Wound Preparation
Note distal PMSC
Anesthetize the area
X-ray for fx or fb
Obtain Hemostasis
Explore wound‒ If wound over tendon range fully to observe for possible tendon
laceration
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Sterile Glove Tourniquet
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Nail Bed Wound Repair
With a simple laceration through the nail, remove the nail surrounding thelaceration to allow for suturing the laceration closed
When a crush injury results in open hemorrhage from under the fingernail, thenail must be completely elevated to allow proper inspection of the damage to thenailbed.‒ Use a straight hemostat to separate the nail from the nailbed.
Use fine scissors to cut away the surrounding nail or remove the entire nail intactfor re-insertion after the nailbed is repaired.
Close approximation of the nailbed is necessary to prevent nail deformity. Alsopreserve the skin folds around nail margins.
If the nail is intact, it can be cleaned and reinserted for protection as described in"Fingernail or toenail avulsion". If the nail is ruined, place a stent under theeponychium to prevent adhesion to the nail bed.
Apply a nonadherent dressing and plan a dressing change within 24 hours toprevent painful adherence to the nailbed.
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What not to do
Do not use non-absorbable sutures to repair the nailbed.
Do not attempt to suture a nailbed laceration through thenail.‒ It can be done, but precludes the meticulous approximation
necessary for smooth nail regrowth.
Do not do any more than minimal debridement of thenailbed and its surrounding structures.‒ Only clearly devitalized and contaminated tissue should be
removed to prevent future nail deformity.
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Nail bed Repair
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Finger Tip Laceration Repair
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Repair of Finger Tip Amputation
Classification of Fingertip Injuries
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Thumb Amputation
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Tosoy-Kleinert Flap
Also called V-Y Technique
It is a triangular volar V-Y flap advancement forreconstruction of the distal pad.
It helps preserve length when the bone is exposed.
It is not indicated in injuries where an volar angulation ofthe wound results in extensive palmar aspect skin loss
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V-Y Technique
• Create a triangular-shaped flap with the base of the flap at the cut edge of the skin where theamputation occurred. It should be as wide as the greatest width of the amputation
• Skin incisions are made through the full thickness of the skin. Do not undermine the flap itself,because the blood supply for this island pedicle flap comes from beneath. The flap usually hasenough mobility to allow for closure of the defect.
• Advance the flap over the defected area and suture it to the nail bed with either 5-0 or 6-0nylon sutures
• Place corner stitches to avoid interference with the blood supply to the corners. Convert theV-shaped defect into a final Y-shaped wound.
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Kutler Lateral V-Y Flap
It employs two triangular flaps developed from lateralpositions and reflected to cover the tip of the digit.
This is most applicable to oblique palmar and traverse tipamputations. As the V-shaped skin flap is advanced, anincision line is created which resembles a “Y” whensutured.
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Tubular Wound Dressing Cage
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When to get Help
Greater than zone 2 amputation
Flexor tendon involvement
Open joint capsule
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Nose Injuries
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Nose Anatomy
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Nose Innervation
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Internal and External Nasal Anesthesia
Topical Anesthetic can be applied internally‒ Insertion of multiple cotton-tipped swabs or plain nasal packing
gauze soaked in 4% lidocaine solution is usually sufficient
Blocks of nerves best for external
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Skin
Small, 5-0 nonabsorbable sutures are preferable, placeda few millimeters from the wound edges.
Try to align the alar rim (the edge of the nostril) as well aspossible to prevent notching.‒ This goal is often problematic if the laceration completely tears the
alar rim.
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Cartilage
The cartilage usually is brought to an acceptable positionwhen the skin laceration is repaired.
Placement of sutures directly in the cartilage is notusually recommended.
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Nasal Mucosa
Primary repair of nasal mucosa can be challengingbecause you are working in a small, dark space;nevertheless, it is important to try.
If the nasal mucosa is not properly repaired, the resultmay be a tight scar inside the nose, which can obstructnasal breathing.
To control bleeding from the mucosa, use lidocaine withepinephrine for local anesthesia.
Use small, absorbable 5-0 chromic sutures.‒ You do not need many.
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Aftercare
Once the repair is complete, loosely pack the affectednostril with gauze coated with antibiotic ointment.
Leave the gauze in place for a few days to encouragehealing with less scar contracture.
This may also help prevent formation of a septalhematoma‒ The patient should take an oral abx while the packing is in place
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Septal Hematoma
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When to get Help
Full thickness nasal wounds‒ Involve skin, cartilage and mucosa
Cartilaginous destruction or loss
Obliteration of landmarks
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Continuous Deep Suture
Key points to remember‒ Bury the knots at the beginning and end
‒ Advance to the next pass on the top not in the pass
‒ When tying a loop-to-strand knot, ensure the knot is flat and square
‒ For a long continuous: Using multiple sections is safer
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Continuous Suture Video
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Running Subcuticular Suture
Key points to remember‒ Slightly larger-length needle makes this easier (PS-2 to PS-1)
‒ Knot placement is key
• Buried deep or come out and be taped down
‒ Each pass should start directly across from the prior pass; donot “back up”
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Running Subcuticular Suture Video
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What is the DERMABOND® Portfolio of SkinClosure Devices?
Topical skin closure method that does not puncture skin(unlike sutures and staples)
Provides strength and protection to many types ofwounds and skin incisions‒ Up to the strength of 3-0 suture1
‒ Can be used to approximate the skin edges of wounds from
• Surgical incisions2
• Port sites from minimally invasive surgery2
• Simple, thoroughly cleansed trauma-induced lacerations2
‒ Provides a microbial barrier and can inhibit bacteria1,3
1. Data on file. Ethicon, Inc. ; 2. DERMABOND Advanced™ PI; 3. Bhende et al, Surg Infect (Larchmt). 2002;3:251
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How Does DERMABOND® Work?
The core technology is the DERMABOND® Topical SkinAdhesive‒ Clinically proven, proprietary formulation of 2-octyl
cyanoacrylate combined with additives to ensure controlledapplication and consistent polymerization1
‒ Binds to skin and quickly polymerizes to create a strong, flexible film that is waterproof and provides a microbial barrier2,3
DERMABOND™ PRINEO™ combines DERMABOND®
Topical Skin Adhesive with a self-adhering polyestermesh3
‒ Polyester mesh aids in wound approximation
‒ Provides wound closure strength equivalent to 3-0 sutures
‒ Provides microbial barrier
1. DERMABOND Advanced™PI; 2. Bhende et al, Surg Infect (Larchmt). 2002;3:251; 3. Data on file. Ethicon, Inc. ;
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Why Use a Skin Closure System?
Potential Benefits Features
Effective microbial barrier proven in vivo1 Rapid application
Excellent clinical outcomes2 Strong closure/additional strength Excellent cosmesis
Excellent patient satisfaction1-3
Excellent cosmesis Reduced follow-up Less pain and anxiety Well-accepted by patients
1. Singer et al. Am J Emerg Med. 2008;26:490.2. Toriumi et al. Plast Reconstr Surg. 1998;102:2209.3. Scott et al. Plast Reconstr Surg. 2007;120:1460.
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The DERMABOND® Portfolio Includes3 Forms to Best Suit Clinical Needs
DERMABOND™PRINEO™
DERMABONDAdvanced™
DERMABOND®Mini
Purpose An alternative to suturesfor closing medium tolong incisions
In combination with suturesfor closing short to mediumincisions
For closing easilyapproximated smallincisions/lacerations
Examples of use Abdominoplasty Sternotomy Hip arthroplasty Breast reconstruction Brachioplasty
C-section Hernia repair Complex lacerations Knee arthroplasty Laparotomy
Laparoscopic port sites Simple lacerations Mohs procedures Minimally invasive
procedures
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DERMABOND™ PRINEO™ Skin Closure SystemIs an Alternative to Traditional Closure Options
Supports wounds with strength equivalentto 3-0 sutures1
Provides a flexible microbial barrier with>99% protection in vitro for 72 hours againstorganisms commonly responsible for SSIs1*
May reduce final layer of skin closure timeby up to 75%1
Excellent cosmesis results at 90 daysthrough 1 year1
*Staphylococcus epidermidis, Staphylococcus aureus, Escherichia coli, Enterococcus faecium,Pseudomonas aeruginosa.1. Data on file. Ethicon, Inc.
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How to Use DERMABOND™ PRINEO™
Skin Closure System
Gently extract the leader andpull out the mesh 1 cm past the
roller. Wrap the leader underthe applicator
Position and gently PUSH themesh applicator to cover and
overlap the approximatedwound by 1 cm on each end
Trim the mesh and leaderfrom the applicator
Activate the adhesive by twisting thepurple dial. Pinch the applicator tipbefore squeezing and releasing the
bulb to fill the reservoir with adhesive
Lightly apply a single coat evenlyover the entire length of the mesh
and a small margin of skin
After ~60 seconds, the woundwill be closed and sealed
See Instructions for Use for full prescribing information.
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DERMABOND PRINEO Closure Video
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DERMABOND ADVANCED™ Topical Skin Adhesive:A Protective Barrier That Adds Strength & Reduces Bacteria
When used in addition to sutures, wasshown in vitro to add 75% morestrength to the wound closure thansutures alone1
Shown in an in vitro study to reducebacteria count (MRSA, MRSE, E coli)by 99.9% beneath the adhesive film1
Creates a microbial barrier with >99%protection in vitro for at least 72 hoursagainst organisms commonlyresponsible for SSIs2*
*S epidermidis, S aureus, E coli, E faecium, P aeruginosa.MRSA = methicillin-resistant S aureus; MRSE = methicillin-resistant S epidermidis.
1. Data on file: Ethicon, Inc. 2. Bhende et al, Surg Infect (Larchmt). 2002;3:251
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Hold the applicator awayfrom the patient with the tip
pointed downward
Squeeze the bulb to crushthe ampoule inside, andthen release pressure
Gently squeeze the bulbagain to moisten the internal
filter with adhesive
Approximate the woundedges with gloved fingers or
forceps
Apply DERMABOND ADVANCED™in a single continuous layer
maintaining steady bulb pressure
Hold skin edges for about 60seconds, full polymerization in
about 95 seconds
How to Apply DERMABOND ADVANCED™
See Instructions for Use for full prescribing information.
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DERMABOND ADVANCED Closure Video
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DERMABOND® Mini Creates a Protective BarrierThat Adds Strength and Inhibits Bacteria
Clinically shown to provide 7-day wound-holdingstrength in just 3 minutes1
Demonstrates in vitro inhibition of gram-positivebacteria (MRSA and MRSE) and gram-negativebacteria (E coli)2
Provides a flexible microbial barrier with >99%protection in vitro for 72 hours against organismscommonly responsible for SSIs3*
*S epidermidis, S aureus, E coli, E faecium, P aeruginosa.
1. Quinn et al. JAMA. 1997;277:1527; 2. Data on file. Ethicon, Inc.; 3. Bhende et al. Surg Infect (Larchmt). 2002;3:251.
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How to Apply DERMABOND® Mini
Hold the applicator awayfrom the patient with the tip
pointed upward
Squeeze the bulb to crushthe ampoule inside, andthen release pressure
Gently squeeze the bulbagain to moisten the internal
filter with adhesive
Approximate the woundedges with gloved fingers or
forceps
Apply DERMABOND® Mini ina single continuous layermaintaining steady bulb
pressure
Hold skin edges and waitapproximately 30 seconds. Applya second coat, full polymerization
in about 3 minutes
See Instructions for Use for full prescribing information.
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DERMABOND Mini Closure Video
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Program Outline
Introduction to Wound Healing
Traditional Wound Closure Options
Innovative Wound Closure Options
Recommendations for Skin and Fascia ClosureWith Current Devices and Methods
Wound Closure Hands-on Lab
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Recommendations for Closure
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Thank You!Thank You!
EP-337-12