MS SHAWALTUL AKHMA HARUN NOR RASHIDMS SHAWALTUL AKHMA HARUN NOR RASHID

PLASTIC SURGEON PLASTIC SURGEON

HOSPITAL RAJA PEREMPUAN ZAINAB II HOSPITAL RAJA PEREMPUAN ZAINAB II

KOTA BHARU KELANTANKOTA BHARU KELANTAN

Wound – breach of epithelium &/or deeper structure.

Type of wound healing – primary intention.

Secondary intention. Delayed

primary/tertiary intention.

Introduction

Skin edges directly apposed, normally heals

well with minimal scar formation.

Primary intention

Open wound which heals by contraction and

epithelialization.

Secondary intention/healing

Wound left open and closed as secondary

procedure.

Delayed primary healing

Demonstrate the

fundamental principle in planning closure of a defect from simple to more complex.

Reconstructive ladder

Methods of closing wounds – sutures, staples, skin tape and wound adhesives.

Principles of suturing skin – skin edges should be

Debrided everted. approximated without tension. deeper wound – closed in layers (to

eliminate dead space) Dermal suture provide strength so the

external sutures can be removed early.

Closure of skin wounds

Eversion of wound edge

Simple interrupted

sutures – gold standard and the commonest.

The suture is placed at the same depth and each side of the incision otherwise the edges overlap.

Suturing techniques

May be used when eversion of the skin edges

is desired and cannot be accomplished with simple suture alone.

Vertical and horizontal mattress sutures

Horizontal & vertical mattress

Obviate the need for external skin suture. Avoid suture marks on the skin and result in

the most favorable scar Absorbable/nonabsorbable sutures can be

used.

Subcuticular / intradermal continuous suture

Subcuticular/intradermal suture

Most often used for closure of scalp wounds

because it can be performed rapidly and hemostatic.

May be used in areas such as the face where the wound is uncomplicated and under no tension.

Locking - provided additional hemostasis. Is not nearly as precise as interrupted suture.

Continuous over and over / running suture

As a time saver for long incision/ to position a

skin closure or flap temporarily before suturing.

Grasping the wound edges to evert before placing the staples to prevent invertion.

Less inflammatory reaction than sutures. Must be removed early to prevent skin mark. Large wounds can be closed faster.

Skin staples

Skin staple

Used after skin sutures are removed to

provide added strength.

Skin tapes

Used in no tension

area or where strength of closure has been provided by a layer of buried dermal sutures.

Skin adhesives

Natural vs synthetic. Absorbable vs nonabsorbable. Braided vs monofilament. Further classification takes into consideration

the time until absorption occur, extent of tissue reaction and tensile strength.

Classification of suture materials

Catgut – derived from submocosal layer of sheep intestine

Evoke a moderate acute inflammation reaction Tensile strength is rapidly lose within 7 – 10 days. Chromization (chromic catgut) slightly prolonges. Indications – ligation of superficial vessels. - closure of tissue that heal rapidly. - to avoid suture removal as in small

children.

Absorbable sutures

Polyglactin (vicryl)/ Dexon – synthetis

material. Produce minimal tissue reaction. Completely absorbed within 90 days. Tensile strength 60-70% at 2/52, lost at 1/12. Indication – intradermal sutures - General soft tissue

approximationof skin and ligation

Absorbable sutures

Polydioxanone (PDS) – Synthetic monofilament. Minimally reactive. Complete absorption within 6/12. Less prone to bacterial seeding. Indication – all type of tissue approximation. Not to be used with prosthetic devises such as

heart valves or synthetic graft. Maxon/ monocryl – tensile strength 3 – 4 weeks General soft tissue approximation/ ligation

Absorbable sutures

The differences among the various non

absorbables are monofilament and braided. Monofilament (Nylon, prolene, dafilon,

dermalon) – minimal inflammatory reaction, slide well and easily removed.

Prolene – maintain its tensile strength longer than nylon which losses appr 15 – 20% per year.

Braided – Silk, polyester elicit an acute inflammatory reaction.

Indication – ligation.

Nonabsorbable sutures

Monofilament vs braided sutures

Def – skin that is removed from the body is

completely devascularized and is replaced in another location.

Standard option for closing defects that cannot be closed primarily.

Consist of epidermis and some or all of the dermis.

Skin graft

Split thickness skin graft and full thickness

skin graft. Split thickness skin graft (SSG)– contain

varying amounts of dermis. Full thickness skin graft (FTSG) – contains the

entire dermis.

Skin graft type

Skin graft

Skin graft can be taken from anywhere on the

body. Prefered area for ssg -- thighs, buttocks, and

abdomen, scalp. Slightly thicker grafts (0.012 to 0.014 inch) - ideal for face,

neck, hands and over joints because less scarring and more pliability would be anticipated for a thicker graft that contains more dermis.

FTSG – post auricle, upper eyelid, groin.

Skin graft donor site

FTSG

SSG

Mesh vs sheet graft

sheet graft

Meshed graft

Skin flap – has its

own blood supply.

Surgical flaps

Rotational/advancement flap

Pedicled flap

rotation flap

Free flap