principles of incision and wound closure

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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.


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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.


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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


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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


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• 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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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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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


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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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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


• 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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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


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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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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• 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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• 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


• 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


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principles of incision and wound closure

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