Wound Management and Basic Suturing Techniques. Disclosures

Wound Management and Basic

Suturing Techniques

10 July 2016

Douglas Winstanley, DO FAAD FACMS

West Michigan Dermatology Grand Rapids MI

Hugh Greenway’s 33nd_{Annual Cutaneous Anatomy and Surgery}

Course La Jolla, CA

Disclosures

Outline

• Wound Healing

• Basic Suturing

• Bandages/Dressings

WOUND HEALING

Stages of Wound Healing

• Inflammatory

• Proliferative

• Remodeling

Diagram from Surgery of the Skin, Robinson et al. 2nd_{ed. 2010}

Inflammatory Stage (Day 0-5)

• Vascular Response

•Serotinin, ADP, TA2, Fibrinogen, Fibronectin, VWF VIII

– Clot serves as reservoir for growth factors •TGF α, TGF β, PDGF, EGF

• Cellular Response

– PMNs release chemotactic factors, initiate debridement and bacterial ingestion

Proliferative Stage (Day 6-14)

• Keratinocyte Migration

• Restoration of BMZ

• Fibroplasia

• Contraction

• Angiogenesis

Remodeling (Day 14-12 months)

• Contraction and remodeling

– Wound strength approx 5 % after 2 weeks, then 40% by 1 month, 75-80 % by month 6

– Type III collagen production peaks at day 5-7, then degrades while Type I collagen increases

– Remodeling most active 1st_{year, then return to}

Factors in Wound Management

• Age

• Comorbidities

• Size

• Depth

• Skin Color

• Ease of closure

• Tumor type and risk of recurrence

• Advantage to delayed closure or graft

Options for management of

surgical wound

• Granulation

• Primary closure

• Flap

• Graft

• Referral

Granulation

Pros

• Easy to monitor • Low rate of infection • No hematoma, suture

reaction

• Minimizes procedure time • Cosmesis

Cons

• Greater likelihood of bleeding post-operatively • Long healing time • Patient dependent • Variable outcomes

Granulation

• Concavities

– Nose: perinasal folds, alar groove

• Superficial convexities: nose, mucosal lip, ear,

scalp

SUTURING

Sutures

• Absorbable vs. Nonabsorbable

• Properties

– Tensile Strength (size) – Elasticity

Sutures

Diagram from Dermatology, Bolognia et al. 3rd ed. 2012

Needle

• Point

• Body

• Swage

Diagram from Dermatology, Bolognia et al. 3rd ed. 2012

Suturing Objectives

• Minimize Tension • Approximate wound

edges

• Achieve wound edge eversion • Minimize epidermal tracking • Minimize transepidermal elimination (spitting) of buried sutures

Suturing Basics

• Subcutaneous – Traditional

– Buried Vertical Mattress – Dermal Setback Sutures

• Cutaneous – Simple Interrupted – Simple Running – Running Locked – Mattress • Vertical • Horizontal

• Half Buried Horizontal (tip)

– Subcuticular

Buried Dermal Sutures

• Traditional

– Close dead space and approximate wound • Buried Vertical Mattress

– Better wound edge eversion than traditional • Dermal Setback Suture

(Butterfly)

– Greater wound edge eversion than traditional, BVM

Simple Interrupted Suture

Diagram from Surgery of the Skin, Robinson et al. 2nd_{ed. 2010}

Simple Running

Diagram from Surgery of the Skin, Robinson et al. 2nd_{ed. 2010}

Running Locked

• Better hemostasis

• Posterior ear and scalp • Higher risk of tissue strangulation, epidermal track marks

Diagram from Surgery of the Skin, Robinson et al. 2nd_{ed. 2010}

Vertical Mattress

• Decreases wound edge tension

• Eversion of wound edges • Closure of dead space • Be mindful of

strangulation • Time consuming

Diagram from Surgery of the Skin, Robinson et al. 2nd_{ed. 2010}

Horizontal Mattress

• Good eversion • Closes dead space • Can strangulate tissue • Time consuming

Tip Stitch

• AKA half-buried horizontal mattress suture, corner stitch • Minimizes stress to tip at

angles of repair, making tip necrosis less likely • More difficult to achieve

level tissue planes when first utilizing

Diagram from Surgery of the Skin, Robinson et al. 2nd_{ed. 2010}

Running Subcuticular

• Use suture with low coeff. of friction • May be left in place longer • Decreases suture tracks

Diagram from Surgery of the Skin, Robinson et al. 2nd_{ed. 2010}

Tips

• Debevel edges, refine your wounds

• Achieve eversion with deep sutures

• Minimize tension at the edges of the defect

– Pexing, plication, imbricating sutures

• Epidermal Suturing

– Remember to enter the skin at a perpendicular angle – Apply your first throw loosely, then secure with

subsequent throws

• Take epidermal sutures out sooner rather than

later

Dressings

Diagram from Dermatology, Bolognia et al. 3rd ed. 2012

Dressings: Post Op

• Immobilize wound

• Provide pressure

– Hemostasis

• Barrier for microbial contamination

• Protect site

• Maintain moist environment

• Post op instructions

References

• Weitzel, S Taylor R. “Suturing Technique and

Other Closure Materials” In

Surgery of the Skin:

Procedural Dermatology,

edited by June Robinson

p.189-208.New York, Mosby-Elsevier 2010

• Amarrati C, Goldman G. “Wound Closure

Materials and Instruments” In Dermatology,

edited by Bolognia J, Jorrizo J, Schaffer J. Ch

144. New York, Elsevier 2012.

Thank you

• Douglas Winstanley, DO FAAD

•

[email protected]