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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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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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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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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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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


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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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91

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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99

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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103

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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112

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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115

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™


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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


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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

expert wound closure - capanet.org€¦ · expert wound closure presented by: dennis tankersley...

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