reconstructive 1 - basic techniques

Initial wound tx

Clip, clean, debride, lavage

Wound closure - types

Primary - closure with suture

Delayed primary - close 1-5d after Before granulation tissue

Secondary - close >5d after injury with granulation tissue bed

Open

Wound closure - When to use secondary + why

Contaminated - granulation tissue resists inf

Wound closure - Why to do delayed primary ____

High tension

Equipment for skin reconstruction

Needle holders

Mayo + metzenbaum scissors

Fine forceps - debakey, adson

Skin hook

Skin pen, sterile methylene blue+ cotton buds

Aims of skin reconstruction + how to ensure

Square skin edges - 90 degrees scalpel

Accurate apposition - hold correct layer

No overlapping - depth

Slight eversion

Halsteds

Suturing wound based on tension lines

Parallel to skin tension lines

Closure of this wound (1hr old)

Delayed Primary - contaminated

Primary if can clean + place drain

Closure of this wound (4-5hrs old)

Secondary closure / second intention healing- Dirty

BUT no functional mouth, hard to manage

So debride, primary closure with drain

Undermining + advancing skin - when to do

Large wound so cant close with tension relieving sutures but too small for flap

Undermining + advancing skin - Process

Free from sc attachment (blunt/sharp) → use skin elasticity to close

Undermining + advancing skin - Considerations during sx

Maintain blood supply (direct cutaneous a+v)

Undermine deep to panniculus m layer to not damage BV plexus

Undermining + advancing skin - Walking suture pattern

Suture dermis/ panniculus m to deep fascia/dermis → pull skin to middle of wound, dec dead space

Absorbable

Don’t place lots / close together (BV)

Undermining + advancing skin - Tension relieving patterns A

Intermittent large simple int (tension) with small simple int (apposition)

Undermining + advancing skin - Tension relieving patterns B

Vertical mattress + simple int

Undermining + advancing skin - Tension relieving patterns C (less good than B as compress BV more)

Horizontal mattress + simple int

Horizontal vs vertical mattress

H- parallel to wound

Undermining + advancing skin - Tension relieving patterns D

Far near near far

Undermining + advancing skin - Tension relieving patterns E

Far far near near

Undermining + advancing skin - Tension relieving patterns Far vs near placement purpsoe

Far = tension relieving

Near = appositional

Undermining + advancing skin - multiple punctuate relaxing incisions

Holes in skin → dec tension on limbs as you tighten sc sutures

Holes heal by second intention → scarring, dressing

Fusiform incision closure

A= place sutures further apart on longer edge

B = place sutures halfway along each time (rule of halves)

Rectangle/ square wound closure

Start in corners + advance to centre