MS SHAWALTUL AKHMA HARUN NOR RASHID PLASTIC SURGEON HOSPITAL RAJA PEREMPUAN ZAINAB II KOTA BHARU KELANTAN

Introduction Wound breach of

epithelium &/or deeper structure. Type of wound healing primary intention. Secondary intention. Delayed primary/tertiary intention.

Primary intention
Skin edges directly apposed, normally heals well with minimal scar formation.

Secondary intention/healing

Open wound which heals by contraction and epithelialization.

Delayed primary healing

Wound left open and closed as secondary procedure.

FIGURE 1.20. The W-plasty can also be used to break up a long scar that does not lie in the direction of the skin lines.

Reconstructive ladder
FREE TISSUE TRANSFER

Both the Z -plasty and the W-plasty have the additional attribute of breaking up a linear scar into an accordion-like scar that has some degree of elasticity to it. This change permits the skin to be more mobile in its contribution to facial expressions. To their detriment, both techniques more than double the length of the scar. If the W-plasty is employed, the triangles

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

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REGIONAL TISSUE TRANSFER

LOCAL TISSUE TRANSFER

SKIN GRAFT

DIRECT TISSUE CLOSURE

ALLOW WOUND TO HEAL BY SECONDARY INTENTION

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Closure of skin wounds 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.

Eversion of wound edge

Suturing techniques 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.

Vertical and horizontal mattress sutures

May be used when eversion of the skin edges is desired and cannot be accomplished with simple suture alone.

Horizontal & vertical mattress

Subcuticular / intradermal continuous suture

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 suture

of scalp wounds because Most often used for closure

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

Skin staples
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 staple

Skin tapes
Used after skin sutures are removed to provide added strength.

Skin adhesives
Used in no tension area or where strength of closure has been provided by a layer of buried dermal sutures.

Classification of suture materials

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.

Absorbable sutures 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

Nonabsorbable sutures various non absorbables The differences among the

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.

Monofilament vs braided sutures

Skin graft
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 type

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

Skin graft donor site

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.

FTSG

SSG

Mesh vs sheet graft

sheet graft

Meshed graft

Surgical flaps
Skin flap has its own blood supply.

Rotational/advancement flap

Pedicled flap

rotation flap

Free flap