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TISSUE HANDLING AND WOUND CLOSURE

SIU School of Medicine

DESCRIPTION OF THE LABORATORY MODULE The participants will be introduced to the various surgical instruments required in tissue handling and tissue dissection. Wound tension g. KH. Fresh forearm cadavers will be brought in for the procedures so that experience with tissue handling can be obtained. ς a. Mosby) 2000 Chapter 13. Evaluation and Management of Traumatic Laceration Current Concepts New England Journal of Medicine 237. OBJECTIVES Ι ΙΙ The residents should be able to understand and perform the following principles of wound management. Hollander J. SUGGESTED READINGS Preuss. ΙΙΙ a. I. Tissue techniques. In Plastic Surgery. Fascial dissection b. Singer A. Debridement d. Plastic Surgery Techniques. Breuing. tissue handling and tissue dissection will be covered. Quinn J. Obliterating dead space h. Handling of the surgical instruments b. Basic surgical skills of tissue handling c. General anatomy of muscles and bones should be understood.OVERVIEW This module is designed to orient participants in the use of basic surgical instruments. Operations & Outcomes. Irrigation e. Indications. III. Vessel dissection d. 147-161.1142-1148 1997 IV. S. ASSUMPTIONS A basic knowledge of the anatomy of the major peripheral nerves and vessels in the upper extremities required. Skin Closure Ις The residents should be able to understand and perform the following tissue planes. Tendon handling II. Tissue planes will be dissected by one resident . Wound debridement and skin closure will be carried out. Eriksson E. Nerve dissection c. (Ed. You will work on cadavers of the upper limbs to suture various wounds and to dissect various tissues in their respective planes. Hemostasis f.

All involved tissue planes are irrigated to mechanically decrease the bacterial load and decrease the chance of infection. Drains are often required. this is accomplished by deep suture fixation. tendons. and promote wound infection. The first principle involves wound management. The wound is then irrigated and closed in layers. incisions made on the proximal dorsal aspect of the upper extremity. Meticulous hemostasis is a necessary step in wound preparation and is facilitated by the use of cautery. DESCRIPTION OF TECHNIQUE/PROCEDURE 1. whereas in moderate or larger size defects. This is accomplished by ensuring that the insertion and pull through of the needles are in . In small wounds. nontraumatic fashion so that the remaining tissue does not become compromised. The participant will practice deep wound suturing. SKIN CLOSURE This goal is to produce an absolutely accurately coapted yet atraumatically closed wound. and muscles while the other participant retracts to provide appropriate visualization. The participant will exercise the use of appropriate debridement back to good viable wound edges. Scar hypertrophy or widening is minimized if tension is decreased. This also further defines those tissues that are compromised. The participant will practice handling the wound edges in a delicate. This is difficult to perform in our workstation but large vessels may be tied off with 4-0 or 3-0 Vicryl suture. V. Forceps with fine teeth are utilized. devitalized or otherwise traumatized by remaining clot and debris.specifically identifying and isolating the neurovascular bundles. A deep dermal suture is utilized to close the wound edges and the skin closed definitively with non-absorbable sutures. REDUCTION OF WOUND MARGIN TENSION Proper reduction of tension across the wound margins minimizes potential complications resulting from wound dehiscence. The participant will practice decreasing wound tension by undermining the edges of the wound using deep dermal absorbing sutures. OBLITERING DEAD SPACE Obliteration of the dead space between the skin and the underlying tissue prevents formation of seromas or hematomas. this is optimally achieved by the use of deep tissue mobilization. delay wound healing. HEMOSTASIS Hematomas increase wound tension. IRRIGATION The wounds need to be copiously irrigated with saline prior to debridement and closure. PRINICPLES OF WOUND MANAGEMENT DEPBRIDEMENT There are three main objectives that need to be understood and practiced throughout this station. The wound edges are excised to develop smooth regular edges for primary closure.

line with the curve of the needle and placed in such a matter that the wounds are appropriately everted when the knot is secured.*cutting edge is predominantly straight except for its distal end *used for sharp debridement *use to cut long linear incisions *if you hold this knife like a pencil it will be difficult to control the blade and a jagged incision will result No 15. 2.*sharp point is the major cutting end *used primarily for incision and drainage *hold this knife like a pencil Tissue Forceps . The dissection will be carried down from proximal to distal over the anti-brachial fascia. The major peripheral nerves (ulnar. The fascia will then be incised to reveal the muscle bellys. The dissection within these planes will be carried out with blunt and sharp dissection using the equipment supplied. vertical mattress. Each participant will practice the art of skin coaptation with simple sutures. The participant will dissect the muscle compartments of the forearm. running sutures. The opposing edge of the tissue site is everted as the needle is brought out through this opposite side. there are a number of flexor tendons that enter carpal tunnel. ABOUT THE SURGICAL INSTRUMENTS Surgical Knife Blade and Handling No 10. WOUND CLOSURE A description of the various means of obtaining wound closure is described in the syllabus. Dissection of these tendons will ensue so that the participant will fully understand the synovial sheaths that surround the tendons and note their relationship between each other and the surrounding structures. and nerves along the anti-brachial fascia. Equal bites from each side of the wound will ensure adequate closure. Introduction of the surgical needle should be placed through the skin at a greater than 90° from the skin surface. Various suture materials will be available to achieve these goals. The median nerve will be dissected in its entirety in the volar forearm down to the wrist and through the carpal tunnel. The cephalic vein will be dissected the dorsoradial aspect of the forearm. In the distal forearm on the volar aspect. and subcuticular sutures. tortuous or angulated incisions *hold the knife like a pencil to have optimal control No 11. Each of the flexor muscle bellys will be identified. Blunt and sharp dissection techniques will ensue to fully identify superficial veins. The participant will practice in laying down the square knots and slip knots.*curved distal end is the major portion of its cutting edge *use to cut short. median and radial) will be identified in their appropriate planes. The dissection of this vein is made easier in a distal to proximal direction. Arterial and venous dissection will also be carried out along these tissue planes. TISSUE PLANES A separate incision on the volar aspect of the forearm will be made. horizontal mattress. The carpal ligament will be transected to reveal the trifurcation of the median nerve in the palm.

tapercut The swage is more susceptible to bending or breaking by the needle holder jaws than the body. damaging the tissues defenses and inviting infection. BASIC SURGICAL SKILLS Incision 1) 2) 3) 4) 5) 6) 7) 8) 9) Mark out important landmarks Add cross hatches with the marking pen for accurate wound closure later Apply gentle traction to the skin to avoid wrinkles Use the belly of the No. *use the tips of the scissors *insert the tips of the scissors and spread them open *useful for dissecting vital structures such as neurovascular bundles 3. Surgical Scissors Sharp dissection. Taper: . reverse cutting. it is best to hold the needle well beyond the site of the swage. This will crush the tissue.Non-Toothed. cutting. Toothed. 10 blade holding it like a violin bow perpendicular to the skin Apply enough pressure to the scalpel to cut through to subcutaneous fat with one stroke Always cut toward you in one motion Do not use a sawing motion Focus your attention on the segment already cut in order to continue in a straight line and to adjust the required pressure Avoid numerous cuts in different planes Dissection 1) 2) 3) 4) 5) Use the tips of the instruments Cut only 5 mm of tissue at a time (only cut what you can see!) Maintain traction on surrounding tissue Work between tissue planes Use blunt dissection to isolate neurovascular structures Wound Healing and Wound Closure Surgical Needles 3 basic components: swage = attachment to suture body = can have difference radii or curvature point = can be tapered. *use the tips of the scissors for sharp dissection Blunt dissection. *can be more damaging to tissue *used to stabilize suture material * hold so that one arm is an extension of your thumb and other arm an extension of your fingers *use the thumb extension arm to elevate tissue planes or wound edges *avoid compressing the tissue between the teeth. therefore.

In general.• • Cutting: • • • • spreads tissue rather than cutting it used for closing muscle or fascia 2 to 3 cutting edges designed to cut through tough tissue when the apical point is on the inner aspect of the needle curvature it is a conventional cutting when the apical point is on the opposing side it is a reverse cutting reverse cutting are used for skin and dermis and produce a hole that is very resistant to suture cut-through Tapercut: • cutting edges extend only a short distance • recommended for closing oral mucosa Healing First intention: surgical re-approximation allows for minimal healing time and scarring. Relaxed Skin Tension Lines are generally oriented perpendicular to the direction of the underlying muscle fibers. The specific location can be determined by examination of patient’s natural skin creases at rest and during animation. 4. Second intention: used for infected wounds to allow for spontaneous formation of granulation tissue Third intention: delayed primary closure for infected wounds or dehiscence lessening the duration for packing or dressing changes Wound dehiscence is a serious complication associated with prolonged morbidity and increased mortality. . incisions should be placed parallel to the Relaxed Skin Tension Lines. as they provide the surgeon with considerable control over the final appearance and orientation of the resulting scar. ELECTIVE INCISIONS Elective incisions should be well thought-out. An example of the proper orientation in various portions of the face is shown below.

. The use of triangular excisions in certain areas of the face prevents distortion of adjacent structures. The “dog-ear” is defined with a skin hook and is incised round the base (B). Closure is achieved by medial advancement of flaps in an inverted “T”. Fusiform excision of skin lesions are therefore performed with the longitudinal axis running parallel to the Relaxed Skin Tension Lines. the skin defect is sutured until the “dog-ear” becomes apparent (A).Orientation of the final scar parallel to or within a natural skin crease gives a superior cosmetic result. The length of the fusiform defect should be fourth times with width of the defect to produce an accurate coaptation of skin edges without dog ear formation. Dog ears are areas of redundant skin and subcutaneous tissue resulting from a wound margin being longer on one side than the other. Excess skin is defined and removed and the skin is sutured(C). Removal of a “dog-ear”. The dog ear is dealt with by one of two methods: 1) incremental oblique placement of sutures to redistribute the tension across the wound 2) fusiform excision of the dog ear with lengthens the scar considerably. Following excision of the lesion.

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In Plastic Surgery.residentnet. Breuing. Wound Healing and Closure Selected Readings in Plastic Surgery. Francel.com www. 2000 Freedman J. MJ. Hollander J. Closure and Material (Operative Plastic Surgery (Ed.nejm. Evaluation and Management of Traumatic Lacerations Current Concepts New England Journal of Medicine 337:1142-1148 1997. S. Plastic Surgery Techniques. Place.VI. Lippincott Raven) 4th Edition Chapter 2. Indications. McGraw Hill) Chapter 3. 13-25. EQUIPMENT NEEDED Cadaver forearms No 10 blades No 15 blades No 11 blades 5-0 Nylon suture 4-0 Nylon suture cutting needles Army/Navy retractors Suture scissors Adson forceps Dissecting scissors Vascular forceps Rat tooth forceps Skin Hooks Weitlander retractors VII. REFERENCES Singer A. Mosby) 2000 Chapter 13. Hardesty. Herber SC. KH.synature. Quinn J. 18-25. July 1990 Vol 6 No 1 Pages 1-38. Operations & Outcomes. Basic Techniques & Principles in Plastic Surgery In Grabb & Smith Plastic Surgery (Ed. Eriksson E. www. McGraw Hill) Chapter 4. Moser S.pdf? ijkey=8d8c4d06bcb72722ca81204fb5f259daeb22103c Preuss.org/cgi/reprint/337/16/1142. RA. T Wound Closure Operative Plastic Surgery (Ed. http://content.com . 147-161. 26-32. 2000 Rohrich R. (Ed.

com .Absorbable Suture Profile Chart From www. Braided Monofilament Monofilament Monofilament Gut Fiber with Chromium Salt Gut Fiber with Chromium Salt Gut Fiber Effective Wound Support 10 Days 3 Weeks 3 Weeks 3 Weeks 3 Weeks 6 Weeks 6 Weeks 10 . Braided Uncoated .90 90 .14 Days 7 .Coated STEEL Monofilament Steel From wwww.com Product Material Effective Wound Support Gradual Loss Gradual Loss Gradual Loss Permanent Permanent Permanent Permanent Permanent Permanent Gradual Loss Permanent Absorption Time (Days) Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent DERMALON™ Monofilament Nylon MONOSOF™ Monofilament Nylon SURGILON™ Braided Nylon SURGIDAC™ Uncoated Braided Polyester TI•CRON™ Coated Braided Polyester SURGIPRO™ Monofilament Polypropylene SURGIPRO™ II Monofilament Polypropylene NOVAFIL™ Monofilament Polybutester Coated Monofilament VASCUFIL™ Polybutester FLEXON™ Multistrand Steel SOFSILK™ Silk .com Product CAPROSYN™ POLYSORB™ DEXON™ II DEXON™ S BIOSYN™ MAXON™ MAXON™ CV Chromic Gut Mild Chromic Gut Plain Gut Material Monofilament Coated & Braided Coated .70 60 .110 180 180 within 90 within 90 within 70 Non Absorbable Suture Profile Chart From www.90 60 .Residentnet.14 Days 10 .syneture.syneture.10 Days Absorption Time (Days) < 56 56 .

May also be used in skin or blood vessels. More exact approximation of wound edges can be achieved with this technique than with the running stitch. such as the peritoneum. The advantages of the running stitch are speed of execution and accommodation of edema during the wound healing process. However.Running or Continuous Stitch The "Running" stitch is made with one continuous length of suture material. Chief advantage of this technique is strength of closure. there is a greater potential for malapproximation of wound edges with the running stitch than with the interrupted stitch. Interrupted Stitch Each stitch is tied separately. and is inserted deep into the tissue. Vertical Mattress Suture A double stitch that is made parallel (horizontal mattress) or perpendicular (vertical mattress) to the wound edge. May be used in skin or underlying tissue layers. . each stitch penetrates each side of the wound twice. Used to close tissue layers which require close approximation.

Running Subcuticular Suture .