Wound Suturing & Skin Flaps May11

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Guide to suturing and producing better scars

Guide to suturing and producing better scars

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  • 1. Guide to suturing, achieving better scars & flaps for skin cancers Dr Charles Cope MBBS(Hons), BSc(Med), FRACS Cosmetic Plastic & Reconstructive Surgeon
  • 2. Local anaesthetics• Lignocaine – 5mg/kg, 7mg/kg with adrenaline – for 1% lignocaine 0.5mls = 5mg – faster onset, shorter duration vs Marcain – adrenaline takes 7mins or more to work – never use adrenaline in extremities (digits/penis)• Marcain – 2mg/kg (with/without adrenaline) – more cardiac toxicity (Naropin better)• Emla (topical cream) – mix 2.5% lignocaine and 2.5% prilocaine (expensive) – increasing depth penetration up to 3-4mm at 4hrs
  • 3. Traumatic wounds• ?Foreign body - ?x-ray or ultrasound• Debridement• Washout• ADT- tetanus• Antibiotics
  • 4. Skin lesion excision principles• Incision placement• Avoid tension• Avoid dead space• Intradermal (deep dermal) sutures• Skin sutures• Dressings• Scar management
  • 5. Incision• Place incision along Langer’s lines• Length scar is 2.5-3.0 times length of lesion being excised – if <2.0 then will definitely get dog-ear
  • 6. Incision• pinch skin to create Langer’s lines if no creases present
  • 7. Incision• Bevel incision outwards – avoids incomplete excision – helps to achieve eversion of wound closure
  • 8. Wound Closure• Avoid tension if possible• Avoid trauma to surrounding tissue• Undermining the skin edges helps to ease the tension• Leave a thin layer of fat underneath the dermis when undermining, to preserve the subdermal blood supply• Avoid dead space by ensuring approximation of deeper tissues – dead space increases haematoma/seroma rate and wound infection• “Halving” important if wound edges of different lengths, and helps to avoid dog-ears at the ends of the wound
  • 9. Wound Closure (continued)• Avoid excessive tightness of sutures in closure – some oedema day 2-3 - “approximation without strangulation”• Excessive tightness of skin sutures can lead to necrosis, infection and poor scar (old abdominal closures)• Lower limb in elderly – better to leave 1-2mm gap than strangulate!
  • 10. Wound tensile strength• In areas prone to stretched scars eg back, shoulder, around joints need to provide support to the wound for at least 3 months
  • 11. Intradermal (deep dermal) sutures• Use intradermal suture to take tension off skin closure• Helps to avoid dead space• By reducing tension of the superficial wound closure, allows – smaller sutures to be used in the skin – skin sutures to be removed earlier (no stitch marks)• Provides long-term support to wound, reducing stretching and depression of the scar
  • 12. Intradermal (deep dermal) sutures• Absorbable monofilament undyed suture eg Monocryl (PDS on back/shoulder)• Important to place knot on deep surface• Placing too superficially increases risk infection (esp Vicryl)• Especially useful with subcuticular sutures eg back• Can be used as only skin closure without skin sutures NB increases firmness scar (short-term), small percentage have late infection as suture dissolves (4-6 weeks)
  • 13. Simple sutures• Suture through all epidermis and some/all of the dermis• Depth of dermal placement on thickness skin (thin skin  deeper)• Slightly more dermis than epidermis in bite (needle at least at right angles to skin surface) – everting wound edges helps to achieve this
  • 14. Simple sutures• Avoid wound inversion – this leaves a depressed scar• Aim for wound eversion – scar flattens in relatively short time
  • 15. Treating the dog-ear• all methods make the scar longer• easiest way is to make the incision longer in a straight line
  • 16. Minimising scar length – serial excision• Benign lesions in cosmetically sensitive areas eg alar nose or large lesions eg congenital naevi• 2 excisions, 2-3 months apart• 1st stage - excise ellipse within lesion (removes most of lesion)• 2nd stage – excision all remaining lesion
  • 17. Subcuticular closure• Knots at the end can be difficult!• Use intradermal suture to start subcuticular suture• Alternatively, where many intra-dermal sutures present, do not tie knots at either end and steristip wound
  • 18. Continuous suture (over and over)• Advancement on underside wound• Most rapid, but technique important!• Must carefully adjust tension on suture as progress along wound• If not careful can either get excess tension (postop swelling) leading to stitch marks or separation wound• Suitable for nearly any wound where edges are equal length• If slightly uneven edges can use occasional mattress suture (reverse direction)
  • 19. Dressings/topical ointments• Applied for haemostasis, to absorb exudate, protect wound surface, reduce pain• Remove initial dressing at 24-48 hrs if expecting ooze• Topical antibiotic may assist in healing – keeps surface moist, preventing contamination, bactericidal• Remove dressing and apply tds eg chloromycetin• Useful for facial wounds where some ooze expected
  • 20. Wounds where some ooze expected• Chloromycetin/betadine ointment• Jelonet & gauze• Occlusive Tegaderm• Instruction to remove dressing if excessive ooze or seal broken and dressing wet
  • 21. Steristrips/micropore• Useful where minimal ooze expected (small lesion, not on aspirin etc)• Opsite spray helps to stick• Patient can shower – simply pat dry• Often stays on until suture removal
  • 22. Suture removal• Be careful if removing sutures at 4-5 days!• Technique is more important• Grasp suture near knot and cut between knot and skin• Pull the suture towards and over the incision• Steristrip wound
  • 23. What I use for wound closure Site Intradermal Skin suture Suture Dressing suture removalFace 5/0 Monocryl 5/0 or 6/0 4-5 days Steristips or ointmentScalp 4/0 4/0 or 5/0 7 -10 days OintmentArm, chest, 3/0 to 5/0 Subcuticular 7-10 days Steristips orback, abdo ?PDS or 5/0 OcclusiveLeg 3/0 to 5/0 4/0 10-14 days Steristips or Occlusive
  • 24. Postoperative scar management• Important on face/neck/sternum/back/previous hypertrophic scars• Alternatives – Micropore tape applied along scar – Massage (firm) – Hyperfix/Fixomull• Start at day 10-14• Continue for minimum 3 months postoperatively• Other scar management EARLY if scar becoming raised
  • 25. Corticosteroids• Used alone variable response rate (50-100%)• Most effective EARLY• Soften and flattens scar• Kenacort A10 4 weeks apart until no further regression (A40 if no reponse from A10)• Side effects – hypopigmentation, fat atrophy, telangiectasias, necrosis – inject into scar only (see blanching)
  • 26. Silicone gel sheeting• Has to be on all the time! – better tolerated than pressure garments• May need to be supervised by physiotherapists• Need to hold silicone sheet to scar in many areas eg around joints (difficult on face) eg Hyperfix• Treatment may need to be for > 6 months• Preventative following excision if history of hypertrophic scars
  • 27. Laser therapy• Vascular specific laser (585nm) or Fraxel®• Scars softer, less erythematous, pruritic and hypertrophic• 80% response after 2 treatments• Most effective early (1st 2-3 months)
  • 28. Fraxel laser – surgical scar
  • 29. Pressure therapy (Jobst garment)• Action secondary to tissue ischaemia• Poorly tolerated by patients• Increases success to 90-100%
  • 30. Treatment hypertrophic scars - ?scar revision• If there was a problem with the original wound healing eg infection, wound breakdown, then scar revision more likely to improve the appearance of the scar• Surgical excision best treatment for small-moderate sized hypertrophic scars• Always use other modalities (steroids, silicone etc) as well – high recurrence (50-80%) with surgery alone• Sometimes use z-plasty or w-plasty to reorientate contraction forces
  • 31. Z-plasty and W-plasty• Redistributes line of tension across the wound
  • 32. W-plasty & laser
  • 33. Summary of skin lesion excision principles• Use intradermal sutures to avoid tension and dead space• Take out skin sutures early• Prophylactic treatment scar• Treat or refer problem scars EARLY (within 6-8 weeks)
  • 34. Skin flaps• Better cosmetic result than skin grafts• Useful when: – cannot close wound primarily – primary closure would distort surrounding important structures eg nose, eyelid• But – take longer to settle (often swelling for months) – some need revision• Need better haemostasis
  • 35. Skin flaps for skin cancers• Principle = distribute tension over larger area to achieve closure (but results in bigger scar)• General principle – larger flap = better blood supply, less tension on closure• Nearly all have prolonged swelling requiring massage (months to settle)• The same flap does not work all the time in the same position esp. on nose!
  • 36. Useful flaps• Hatchet – preauricular, temple, forehead – legs (1 or 2) caution!• V-Y advancement – cheeks, nose• Keystone – lower leg, forearm, torso – hand/foot (caution)
  • 37. Hatchet flaps - Emmett
  • 38. V-Y advancement flaps• Useful on cheek, nose & sometimes eyelid• leaves subcutaneous pedicle• undermine leading edge (20-25%)• mobilise remainder with blunt dissection using spreading scissors to maintain blood supply
  • 39. V-Y advancement flaps
  • 40. V-Y advancement flaps
  • 41. Keystone flap – Felix Behan 2003• Often has larger blood vessels/perforators going into the flap• Useful to avoid grafting• Lower leg, forearm, trunk• Hand & foot (caution)
  • 42. Keystone flap
  • 43. Keystone flap• Useful to avoid grafting• Lower leg, forearm, torso• Hand & foot (caution)
  • 44. • Questions?• Practical suturing session – use of intradermal sutures