Wound Management and Basic Suturing Techniques€¦ · • Basic Suturing technique • Good...

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Wound Management and Basic Suturing Techniques

10 July 2016Douglas Winstanley, DO FAAD FACMS

West Michigan DermatologyGrand Rapids MI

Hugh Greenway’s 33nd Annual Cutaneous Anatomy and Surgery Course

La Jolla, CA

Disclosures

• No relevant disclosures

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Outline

• Wound Healing– Stages of Healing

• Basic Suturing– Suture review

– Subcutaneous Suturing

– Cutaneous Suturing

• Bandages/Dressings

WOUND HEALING

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Stages of Wound Healing

• Inflammatory

• Proliferative

• Remodeling

Diagram from Surgery of the Skin, Robinson et al. 2nd ed. 2010

Inflammatory Stage (Day 0-5)

• Vascular Response– Platelet Degranulation

•Serotinin, ADP, TA2, Fibrinogen, Fibronectin, VWF VIII

– Clot serves as reservoir for growth factors•TGF α, TGF β, PDGF, EGF

• Cellular Response– PMNs release chemotactic factors, initiate

debridement and bacterial ingestion

– Macrophages phagocytize, release chemotactic factors for fibroblasts

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Proliferative Stage (Day 6-14)

• Keratinocyte Migration– “Leap frogging”

– MMPs

• Restoration of BMZ

• Fibroplasia

• Contraction

• Angiogenesis

Remodeling (Day 14-12 months)

• Contraction and remodeling– Wound strength approx 5 % after 2 weeks, then

40% by 1 month, 75-80 % by month 6

– Type III collagen production peaks at day 5-7, then degrades while Type I collagen increases

– Remodeling most active 1st year, then return to normal levels of collagen metabolism

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Factors in Wound Management

• Age

• Comorbidities

• Size

• Depth

• Skin Color

• Ease of closure

• Tumor type and risk of recurrence

• Advantage to delayed closure or graft

Options for management of surgical wound

• Granulation

• Primary closure

• Flap

• Graft

• Referral

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Granulation

Pros• Easy to monitor

• Low rate of infection

• No hematoma, suture reaction

• Minimizes procedure time

• Cosmesis

Cons• Greater likelihood of

bleeding post-operatively

• Long healing time

• Patient dependent

• Variable outcomes

Granulation

• Concavities– Temple

– Ear

– Eye: 50/50 rule

– Nose: perinasal folds, alar groove

• Superficial convexities: nose, mucosal lip, ear, scalp

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SUTURING

Sutures

• Absorbable vs. Nonabsorbable

• Properties– Coefficient of Friction

– Reactivity

– Memory

– Degradation

– Tensile Strength (size)

– Elasticity

– Plasticity

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Sutures

Diagram from Dermatology, Bolognia et al. 3rd ed. 2012


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Needle

• Point– Reverse

Cutting

– Cutting

– Round

• Body

• Swage


Suturing Objectives

• Minimize Tension

• Approximate wound edges

• Achieve wound edge eversion

• Minimize epidermal tracking

• Minimize transepidermal elimination (spitting) of buried sutures

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Suturing Basics

• Subcutaneous– Traditional

– Buried Vertical Mattress

– Dermal Setback Sutures

• Cutaneous– Simple Interrupted

– Simple Running

– Running Locked

– Mattress• Vertical

• Horizontal

• Half Buried Horizontal (tip)

– Subcuticular

Buried Dermal Sutures

• Traditional– Close dead space and

approximate wound

• Buried Vertical Mattress– Better wound edge

eversion than traditional

• Dermal Setback Suture (Butterfly)– Greater wound edge

eversion than traditional, BVM


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Simple Interrupted Suture

• Basic Suturing technique

• Good control of wound edges

• Time consuming

• Track marks


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Simple Running

• Less time consuming

• Less strength of closure

• Distance of side-to-side placement should approximate interval between sutures


Running Locked

• Better hemostasis

• Posterior ear and scalp

• Higher risk of tissue strangulation, epidermal track marks


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Vertical Mattress

• Decreases wound edge tension

• Eversion of wound edges

• Closure of dead space

• Be mindful of strangulation

• Time consuming


Horizontal Mattress

• Good eversion

• Closes dead space

• Can strangulate tissue

• Time consuming


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Tip Stitch

• AKA half-buried horizontal mattress suture, corner stitch

• Minimizes stress to tip at angles of repair, making tip necrosis less likely

• More difficult to achieve level tissue planes when first utilizing


Running Subcuticular

• Use suture with low coeff. of friction

• May be left in place longer

• Decreases suture tracks


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Tips

• Debevel edges, refine your wounds• Achieve eversion with deep sutures• Minimize tension at the edges of the defect

– Pexing, plication, imbricating sutures• Epidermal Suturing

– Remember to enter the skin at a perpendicular angle– Apply your first throw loosely, then secure with

subsequent throws• Take epidermal sutures out sooner rather than

later

DRESSINGS

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Dressings


Dressings


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Dressings: Post Op

• Immobilize wound

• Provide pressure– Hemostasis

• Barrier for microbial contamination

• Protect site

• Maintain moist environment

• Post op instructions

References

• Weitzel, S Taylor R. “Suturing Technique and Other Closure Materials” In Surgery of the Skin: Procedural Dermatology, edited by June Robinson p.189-208.New York, Mosby-Elsevier 2010

• Amarrati C, Goldman G. “Wound Closure Materials and Instruments” In Dermatology, edited by Bolognia J, Jorrizo J, Schaffer J. Ch144. New York, Elsevier 2012.

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Thank you

• Douglas Winstanley, DO FAAD – Private Practice: Grand Rapids, MI

• [email protected]

• 619 840 9762

Wound Management and Basic Suturing Techniques€¦ · • Basic Suturing technique • Good...

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