Wound closure

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Wound closure
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• Aesthetic closure
• knowledge of healing mechanisms
• skin anatomy
• suture material and closure technique
• Ensures optimal healing

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• Three distinct phases
• Inflammation
• inflammatory cells into the wound
• inflammatory phase occurs in the first few days
  as inflammatory cells migrate into the wound
• tissue formation
• epithelial cells has been shown to occur within
  the first 12-24 hours
• further new tissue formation occurs over the next
  10-14 days
• tissue remodeling
• wound contraction and tensile strength is
  achieved
• occurs in the next 6-12 months

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• Affect wound healing
• systemic illness
• local factors

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• Two types of wound healing
• primary intention
• surgical wound closure facilitates the biological
  event of healing by joining the wound edges
• minimize new tissue formation
• elimination of dead space by approximating the
  subcutaneous tissues
• minimization of scar formation by careful
  epidermal alignment
• avoidance of a depressed scar by precise eversion
  of skin edges
• secondary intention
• spontaneous healing

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Suture materials
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• natural and synthetic
• synthetic materials
• less reaction
• less inflammatory reaction
• absorbable and nonabsorbable
• nonabsorbable sutures offer longer mechanical
  support
• monofilament and multifilament
• monofilaments have less drag
• Infection is avoided

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• Absorbable suture materials
• lose tensile strength before complete absorption
• gut last 4-5 days in terms of tensile strength
• chromic form, gut can last up to 3 weeks
• Vicryl and Dexon
• maintain tensile strength for 7-14 days
• complete absorption takes several months
• Maxon and PDS
• long-term absorbable sutures
• lasting several weeks
• requiring several months for complete absorption

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• Nonabsorbable sutures
• silk has the lowest strength
• nylon has the highest

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Suture technique
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• Running, or continuous stitch
• made with one continuous length of suture
  material
• close tissue layers which require close
  approximation
• speed of execution, and accommodation of edema
  during the wound healing process
• greater potential for malapproximation of wound
  edges with the running stitch than with the
  interrupted stitch

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• needle at a 90 angle to the skin within 1-2 mm
  of the wound edge and in the superficial layer
• exit through the opposite side equidistant to the
  wound edge and directly opposite the initial
  insertion

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• Interrupted stitch
• stitch is tied separately
• used in skin or underlying tissue layers
• more exact approximation of wound edges can be
  achieved with this technique than with the
  running stitch

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• Mattress suture
• a double stitch that is made parallel (horizontal
  mattress) or perpendicular (vertical mattress) to
  the wound edge
• advantage of this technique is
• strength of closure
• each stitch penetrates each side of the wound
  twice
• inserted deep into the tissue

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• Purse string
• continuous stitch paralleling the edges of a
  circular wound
• wound edges are inverted when tied
• used to close circular wounds, such as hernia or
  an appendiceal stump

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• Smead-Jones/Far-and-Near
• a double loop technique alternating far and near
  stitches
• greater mechanical strength than continuous or
  simple interrupted sutures
• used for approximating fascial edges, especially
  for patients at risk for fascial disruption or
  infection

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• Continuous Locking, or Blanket Stitch
• a self-locking running stitch used primarily for
  approximating skin edges

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• good approximation edges is paramount to proper
  wound closure technique
• deep sutures serve to eliminate the dead space
  and relieve tension from the wound surface
• deep sutures also ensure proper alignment of the
  wound edges and contribute to their final
  eversion
• wound closure may require sharp undermining of
  the tissues to minimize tension on the wound
• achieve hemostasis
• eversion of all skin edges avoids unnecessary
  depression of the resultant scar

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• Immediate and delayed complications may occur
  with wound closure
• immediate complications
• formation of hematoma
• wound infectionp
• prophylactic antibiotics
• late complications
• scar formation
• excess tension
• lack of eversion of the edges
• hypertrophic scarring and keloid formation\
• stitch marks
• wound necrosis

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• Suture removal
• face 3-4 days
• scalp 5 days
• trunk 7 days
• arm or leg 7-10 days
• foot 10-14 days

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Thanks for your attention !!!