Wound Management and Basic Suturing Techniques. Disclosures

Transcription

1 Wound Management and Basic Suturing Techniques 10 July 2016 Douglas Winstanley, DO FAAD FACMS West Michigan Dermatology Grand Rapids MI Hugh Greenway s 33 nd Annual Cutaneous Anatomy and Surgery Course La Jolla, CA Disclosures No relevant disclosures 1

2 Wound Healing Stages of Healing Basic Suturing Outline Suture review Subcutaneous Suturing Cutaneous Suturing Bandages/Dressings WOUND HEALING 2

3 Stages of Wound Healing Inflammatory Proliferative Remodeling Diagram from Surgery of the Skin, Robinson et al. 2 nd ed Inflammatory Stage (Day 0-5) Vascular Response Platelet Degranulation 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 Macrophages phagocytize, release chemotactic factors for fibroblasts 3

4 Proliferative Stage (Day 6-14) Keratinocyte Migration Leap frogging MMPs Restoration of BMZ Fibroplasia Contraction Angiogenesis Remodeling (Day months) Contraction and remodeling Wound strength approx 5 % after 2 weeks, then 40% by 1 month, % by month 6 Type III collagen production peaks at day 5-7, then degrades while Type I collagen increases Remodeling most active 1 st year, then return to normal levels of collagen metabolism 4

5 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 5

6 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 Concavities Granulation Temple Ear Eye: 50/50 rule Nose: perinasal folds, alar groove Superficial convexities: nose, mucosal lip, ear, scalp 6

7 SUTURING Sutures Absorbable vs. Nonabsorbable Properties Coefficient of Friction Reactivity Memory Degradation Tensile Strength (size) Elasticity Plasticity 7

8 Sutures Diagram from Dermatology, Bolognia et al. 3rd ed Diagram from Dermatology, Bolognia et al. 3rd ed

9 Needle Point Reverse Cutting Cutting Round Body Swage Diagram from Dermatology, Bolognia et al. 3rd ed Suturing Objectives Minimize Tension Approximate wound edges Achieve wound edge eversion Minimize epidermal tracking Minimize transepidermal elimination (spitting) of buried sutures 9

10 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 Diagram from Surgery of the Skin, Robinson et al. 2 nd ed

11 Simple Interrupted Suture Basic Suturing technique Good control of wound edges Time consuming Track marks Diagram from Surgery of the Skin, Robinson et al. 2 nd ed

12 Simple Running Less time consuming Less strength of closure Distance of sideto-side placement should approximate interval between sutures Diagram from Surgery of the Skin, Robinson et al. 2 nd ed 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. 2 nd ed

13 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. 2 nd ed Horizontal Mattress Good eversion Closes dead space Can strangulate tissue Time consuming Diagram from Surgery of the Skin, Robinson et al. 2 nd ed

14 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. 2 nd ed 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. 2 nd ed

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16 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 16

17 Dressings Diagram from Dermatology, Bolognia et al. 3rd ed Dressings Diagram from Dermatology, Bolognia et al. 3rd ed

18 Immobilize wound Provide pressure Hemostasis Dressings: Post Op 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 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

19 Thank you Douglas Winstanley, DO FAAD Private Practice: Grand Rapids, MI