primary wound closure - skinner

what is primary wound closure?

surgical closure of a wound that has edges apposed and will heal by 1st intention healing

what are the main goals of wound closure?

• closure

• no complications

• cosmesis

what are required to achieve the goals of wound closure?

planning and proper technique

primary wound closure

close a site right after it is damaged

delayed primary closure

delaying when to close a wound but closing before any granulation tissue forms

secondary closure

manage a wound open until it is clean and healthy with granulation tissue to then close

second intention healing

leaving a wound to close overtime on its own

what are Halsted’s 7 principles of surgery?

1) strict aseptic technique

2) gentle tissue handling

3) meticulous hemostasis

4) preservation of blood supply

5) obliteraction of dead space

6) accurate anatomic apposition

7) minimisation of tension

what area of tissue that supply blood to skin and SQ tissues?

deep or subdermal plexus

why to use primary closure?

• simple

• rapid wound healing

• reduce pain

• minimise scarring

• protect underlying tissues

• cosmesis?

• cost? → may be less than second intention healing with visits and bandage changes

what are the patient characteristics that you must consider when deciding on how to close a wound?

• systemic condition

  • immunosuppression → reduced wound healing, more prone to infection

  • metabolic disease → reduced wound healing = diabetes or cushings

  • cancer

  • radiation → causes delayed healing

• temperament

• species?

what are the wound factors that must be considered when deciding on how to close a wound?

• location → higher area or contamination or highly mobile area?

• configuration → is it even possible to close this?

• tension

• blood supply → a traumatic wound can have degloving that doesn’t declare itself for a number of days

what contamination levels are okay to close?

clean and clean-contaminated

what type of contamination is questionable to close?

contaminated wound → your judgement call/ on a case by case basis

how long does it roughly take for bacteria to grow enough in a wound to produce infeciton?

6 hours

what is the level of growth in bacteria that can occur in 6 hours?

10⁵ bacteria per g tissue

what other wound factors can cause you to question whether to close or not?

extent of tissue trauma

• tissue loss

• crushing/shearing/burn

• lag time

what is the general guidelines of skin tension lines?

• on trunk = tension runs parallel

• on limbs = perpendicular

in what oriention to the tension lines do you want to close a wound?

parallel to tension lines

how to help to promote apposition with deep lesions?

• multiple layer closures

• muscle movement can be used to decrease space superficially

what do we want to use to create good apposition of the SQ?

• distribute tension

• decrease dead space

• cruciate or mattress sutures

• can also take wider bites that and into the fascial plane

  • can then add an additional suture in the skin to fully close - intradermal

continuous horizontal intradermal pattern

• ~50% overlap of bites

• small bites

what happens with an intradermal pattern that has no overlap or larger bites?

gapping of the incision

simple interrupted

• poor tension relief

• slow to do

cruciate mattress

• some tension relief

• faster to put in

simple continuous

• fast

• not for high tension/motion

ford interlocking

• fast

• more secure if broken compared to simple continuous as it grabs onto itself

what are dog ears created by suturing a wound close?

folding up of skin after suturing an awkward wound

what are the reasons for dog ear formation?

• unequal suture spacing

• non-linear wound

are dog ears really a problem?

no more a cosmetic problem and will diminish with time

what is a technique you can use to close a very large wound?

halving to help guide your suturing placement

can halving work on a curved wound?

yes! suture bits need to be placed at different lengths across the curve so halving can help guide

how can you close a rectangular lesion?

close corners to bring middle closer together then

triangular closure

close up each side of triangle until meet in middle

what component of a primarily closed skin incision is most likely to fail with excess tension?

tissue

excessive tension of skin can lead to what?

dehiscence and tissue necrosis

what is another aspect that can cause dehiscence?

excessive activity that puts too much motion and tension on healing wound

what are the two methods of tension relief?

• redistribution

• creep

what are the two forms of creep?

• mechanical

• biological

what is mechanical creep?

• stretching/breaking collagen and elastin

• takes hours to days

• common to use with larger defects

what is biological creep?

• allowing new skin to grow

• takes weeks

what is undermining?

mobilizing skin by separating it from deeper levels but going deep to the cutaneous trunci

why do keeping the cutaneous trunci with the tissue in undermining important?

• preserves subdermal plexus

• preserve vessel

all this keeps the skin viable

walking sutures

• tension relieving

• move skin across a defect → offset deep and superficial bites

• stretching skin out

• close dead space

what are the types of external sutures that help to relieve tension?

• mattress sutures (horizontal, vertical, cruciate)

• far-far-near-near/far-near-near-far

bolster/stent sutures

• pre-place with wide bites

• padding to distribute tension

what are releasing incisions?

• incisions in healthy skin

• heal by second intention

• distal limbs is an optimal area to use this technique

mesh releasing incisions

~ 1 cm or less incisions parallel to the closure and staggered

what is another way to close a large defect?

skin stretching

what are the options of skin stretching?

• commerical/homemade

• velcro/suture

• adjusting the tension over time