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Principles of Incision and Principles of Incision and Wound ClosureWound Closure
Fuad Ridha Mahabot
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Introduction
• Pre-operative planning - important! for optimal cosmetic and functional resulthealing process wound contraction and
scarring - may compromise function and appearance
• Goalsto re-establish functional soft tissue structural
support to give the most natural aesthetic appearance
with minimal distortion
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Principles of Wound Incision
• First priority - maintain a sterile and aseptic technique to prevent infection.
THE LENGTH AND DIRECTION OF INCISION - to afford sufficient operating space and optimum exposurethe direction of wound naturally heal is from
side-to-side, not end-to-endthe arrangement of tissue fibers in the area to
be dissected will vary with tissue typethe best cosmetic results when incision
made to the direction of tissue fibers
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• Relaxed Skin Tension Lines (Langer’s line) Is the skin lines oriented
perpendicular to the direction of the underlying muscle fibers
determined by examination of patient’s natural skin creases at rest
orientation of the final scar parallel to or within a natural skin crease gives a superior cosmetic result.
Principles of Wound Incision
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• Dissection technique clean incision should be made with
one stroke or evenly applied pressure on the scalpel
preserve integrity of as many of underlying structures as possible
• Fusiform excision performed with longitudinal axis
running parallel to RSTL the length should be 4 times with the
width of the defect to produce an accurate coaptation of skin edges without dog ear formation.
Principles of Wound Incision
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• Dog ears areas of redundant skin and subcutaneous
tissue resulting from a wound margin being longer on one side than the other
dealt with either by incremental oblique placement of sutures to
redistribute the tension across the wound fusiform excision of the dog ear with lengthens
the scar considerably
Principles of Wound Incision
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removal of a ‘dog ear’• skin defect is sutured
until the “dog ear” becomes apparent
• the “dog ear” is defined with a skin hook and is incised round the base
• excess skin is removed and the skin is sutured
Principles of Wound Incision
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Principles of Wound Incision
• Tissue handlingminimum tissue trauma promotes faster
healingsurgeon must handle all tissues very gently
- and as little as possibleretractors should be placed with care to
avoid excessive pressure, since tension can cause serious complications
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Principles of Wound Incision
HAEMOSTASIS - allows surgeon to work in as clear a field as possible with greater accuracy. Without adequate control, bleeding may interfere with the surgeon’s view of underlying structures.
also to prevent formation of postoperative hematomas
collection of blood (hematomas) or fluid (seromas) can prevent direct apposition of tissue
these collections provide an ideal culture medium for microbial growth serious infection
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Principles of Wound Incision
avoid excessive tissue damage while clamping of ligating a vessel of tissue. Mass ligation necrosis, tissue death and prolonged healing time
• Maintaining moisture in tissues during long procedures irrigate wound with
normal saline, or cover exposed surfaces with saline-moistened gauze to prevent tissue from drying out
• Removal of necrotic tissue and foreign materials adequate debridement of all devitalized tissue and
removal foreign materialspresence of foreign materials - increases possibility
of infection
• Basic Surgical Skills of Wound Incisioni. mark out important landmarksii. add cross hatches with the marking pen for accurate
wound closure lateriii. apply gentle traction to the skin to avoid wrinklesiv. apply enough pressure to the scalpel to cut through to
subcutaneous fat with one strokev. always cut toward you in one motionvi. do not use a sawing motionvii. focus your attention on the segment already cut in
order to continue in a straight line and to adjust the required pressure
viii. avoid numerous cuts in different planes 11
Principles of Wound Incision
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Principles of Wound Closure
Goal: “approximate, not strangulate”
CHOICE OF CLOSURE MATERIALS - proper closure material will allow surgeon to approximate tissue with a little trauma as possible, and with enough precision to eliminate dead space
•Suture Materials - generally categorized by three characteristics:
Absorbable vs. non-absorbableNatural vs. syntheticMonofilament vs. multifilament
i. Absorbable suture - degraded and eventually eliminated (e.g. cat gut, vicryl, monocryl)
ii. Non-absorbable suture - not degraded, permanent (e.g. prolene, nylon, stainless steel)
iii. Natural suture - biological origin; may cause intense inflammatory reaction (e.g. cat gut, chromic, silk)
iv. Synthetic suture - synthetic polymers; do not cause intense inflammatory reaction (e.g. vicryl, monocryl, nilon)
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Principles of Wound Closure
v. Monofilament suture - grossly appears as single strand of suture material; all fibers run parallelties smoothlye.g. monocryl, prolene, nylon
vi.Multifilament suture - fibers are twisted or braided togethergreater resistance in tissuee.g. vicryl (braided), chromic (twisted), silk
(braided)14
Principles of Wound Closure
• Cellular response to foreign materialswhenever foreign materials such as sutures are
implanted in tissue, the tissue reacts - depending on type of material implanted• more marked if complicated by infection,
allergy, traumatissue will deflect passage of needle and suture
edema of the skin and subcutaneous tissue discomfort during recovery, as well as scarring secondary to ischaemic necrosis
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Principles of Wound Closure
Some of the Suturing Techniques
i. simple interrupted stitch - single stitches, individually knotted used for uncomplicated laceration
repair and wound closure
ii.continuous stitch - allows more rapid wound closure carries the risk of complete wound
opening if the suture breaks16
Principles of Wound Closure
iii.horizontal mattress stitch - provides added strength in fascial closure; also used in calloused skin (e.g. palms and soles)
iv.vertical mattress stitch - affords precise approximation of skin edges with eversion
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Principles of Wound Closure
v. subcuticular stitch - intradermal horizontal bites allow suture to remain for a
longer period of time without development of crosshatch scarring
better cosmetic result
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Principles of Wound Closure
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Principles of Wound Closure
• Elimination of dead space in the wound this is critical to healing!! results from separation of wound edges which
have not been closely approximated, or from air trapped between layers of tissue
if the needle is not placed perpendicular to the skin, it can create dead-space, while unequal bites will create poor apposition
collection of blood or serum ideal medium for microbial growth infection
drain insertion or pressure dressing application may help to eliminate dead space in wound
dead space in wound
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Principles of Wound Closure
• Closing with sufficient tension - to prevent exaggerated patient’s discomfort, ischaemia, tissue necrosis during healingsutures must be placed tight enough to
seal the wounds, but loose enough as to not strangulate the wounds edges and create tissue necrosis and increased scarring
the deep layer is used to minimize tension on the superficial layer
• Stress placed upon the wound after surgeryto prevent suture disruptione.g. abdominal fascia will be placed under
excessive tension after surgery if patient strains to cough, vomit, void, defecate
• Immobilization of woundadequate immobilization of the approximated
wound, but not mandatory for the entire anatomic part
for efficient healing and minimal scar formation21
Principles of Wound Closure
• Factors influencing surgical wound closure local factors
tight suturing effect vascularity necrosis and wound breakdown
overuse electrocoagulation excessive bleeding and hematoma formation creating dead space focus for infection
systemic factors age (>65), nutritional status, male, long term steroid may
lead to wound dehiscence smoking, diabetes, rheumatoid arthritis impaired
microcirculation• obesity reduced tissue oxygenation, increased
subcutaneous dead space more susceptible to haematoma and seroma formation infection
Principles of Wound Closure
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THANK YOU
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