Principles of Wound Closure

Rosadi Seswandhana
Reconstructive & Aesthetics Plastic Surgery Division
Department of Surgery
Faculty of Medicine - Universitas Gadjah Mada
Wound ?

Wound Man from a text

book of surgery by Ambroise
Par (mid 1500s)
Wound Type
Acute Chronic
Abrasion Diabetic ulcers
Stab Decubitus ulcers
Laceration Venous stasis ulcers
Avulsion
Burns
Bite
Meaning of Wound Healing

Symphony of biological processes

Initiated by tissue injury
Culminates in restoration of tissue integrity
Wound Healing

Clinical Observation
Cellular Biomoleculair
Surgical Intervention
Clinical Observation

Epithelization
Connective tissue deposition
Wound contraction
 Tissue Repair
Injury 3d 7d 3w 1-2y

Major Even Clot formation Growth factor Collagen deposition Collagen cross-linking
Hemostasis Elaboration
INFLAMMATORY
Repair
PROLIFERATION
phase
REMODELING
Fibroblast
Lymphocytes
Cellular Macrophages
influx
Neutrophils

Vascular Vasoconstriction
response Vasodilatation
Surgical Intervention

Primary intension
Secondary intension
Delayed primary intension
Principles of soft tissue injury management
Debride and irrigate devitalized tissue
Cleanse wound and traumatic tattoos
Remove any foreign body
Obtain meticulous hemostasis
Obliterate any dead space
Handle tissues gently
Use atraumatic technique
Avoid tension in wound closure
Use buried sutures judiciously
Leave contaminated wounds open
(Weinzeig, 1994)
WOUND CLOSURE
MATERIAL SUTURE
 Suture Classification
Natural or Synthetic (man made)
Monofilament or Multifilament (braided)
Absorbable or Non-Absorbable
 Suture Classification
Monofilament Multifilament (Braided)
 Type of suture material
Non-Absorbable
Organic / Nature Syntethic / Man Made
Braided Braided Monofilament
Silk Braided-Nylon Nylon
Polyester Polypropelene

Absorbable
Short term Medium term Long term
Natural Syntethic Braided Monofilament Braided Monofilament
Cat gut Polyglactine Polyglactin Poliglecaprone PGA/PPLA PDO
rapide 910 25
Braided v Monofilament
Has capillary action No capillary action
Increased infection Less infection risk

risk
Less smooth Smooth tissue passage
passage
Less tensile strength Higher tensile strength
Better handling Has memory

Better knot security More throws required

Suture Degradation
 Suture Size
USP (United States Pharmacopoeia)

A+E

5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0

General

Thick Thin
Suture Selection
Size originally scaled from 0-3
As technology advanced and sutures became smaller, extra
0s were added
Scale now ranges from 3 (largest) to 12/0 (smallest)

Size Uses
7/0 and smaller Ophthalmology, microsurgery
6/0 Face, blood vessels
5/0 Face, neck, blood vessels, penile
Mucosa, neck, hands, limbs, tendons, blood
4/0
vessels
3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
Abdominal wall, fascia, drain sites, arterial
0 and larger
lines, orthopaedics
Needle Shape
Needle Curvature
Local Anesthetic
Mechanisme of Action
A blockade of excitation of nerve endings
Inhibition of the process of conduction in
peripheral nervous system
 Dosage
Agent Onset Maximum Maximum Duration Duration
Dose Dose w/o with
(mg/kg) (mg/kg) epinephrin epinephrin
w/o with
epinephrin epinephrin
Lidocaine Rapid 3.5 5-6 1-1.5 hrs 2-3 hrs
Bupivacaine Slow 2.5 3.5 4 hrs 6-8 hrs
Toxicity
Local
Rare
Nerve injury c.o. needle trauma, high pressure
intraneural injection
Systemic
Accidental intravascular injection
Overdose
CNS & CVS
 Systemic Toxic Effects of Lidocaine with rising
Plasma concetration (mcg/ml)
CVS depression 24

Respiratory depression 18

Coma 14

Unconsciousness 10
Convulsion 8
Muscular twitching 6
Visual disturbance 4
Lightheadedness, tinnitus,circumoral 2
& tongue numbness
Technique of Suturing
Knotting
Reef knot Surgeon knot Granny knot
 Timing for Wound Closure
Principle governing: as soon as possible with
minimal complication
Traditional teaching:
after 6 hours secondary intention
before 6 hours primary intention
Gradually 6 hours became 8 up to 12 hours
Techniques for Wound Closure
Suturing

Tape and adhesive Staples

 Suturing Techniques
Proper handling and choice of suturing needles and
tools (needle holder positioning) is critical
Superficial Skin Wounds:
Interrupted Suture Stitch
Deep Subcutaneous Wounds:
Vertical Mattress Suture
Wound-Edge Eversion:
Securing tissue properly so scars become less visible
Interrupted Suture Stitch
 Subcutaneous Stitch
Deeper wounds or
wounds under tension.
Inverted knot.
Begin at bottom of
wound edge and come
up.
Go straight across
incision and down.
 Running Stitch
Indicated for low risk
repairs.
Tie knot at one end, do
not cut until repair
complete.
Faster technique.
Plastic surgery quality.
 Running Locked Stitch
Modified running
stitch.
Used to prevent
slippage of loops as
running stitch
continues.
Allows for continuing
stitch along irregular
laceration.
 Vertical Mattress Stitch
Promotes eversion of
the skin.
Tension or very thick
skin.
Enter wound on one
side, pierce other side
twice, and exit on side
entered.
 Horizontal Mattress Stitch
Needle is introduced
in normal fashion.
Second bite is placed
cm adjacent to exit
site.
Brought back next to
original insertion.
Tie knot.
 Intracuticular running suture
Used to close linear
wounds that are not under
much tension.
Yields an excellent
cosmetic result.
The ends of the suture do
not need to be tied.
Taping under slight
tension will preserve
approximation.
 Three-point or half-buried
mattress suture
Closure of the acute
corner of a laceration
without impairing
blood flow to the tip.
 Three-point or half-buried
mattress suture
Needle is inserted into
nonflap portion of the
wound at the mid-dermis
level; and then at the same
level, the suture is passed
transversely through the
tip and returned on the
opposite side of the
wound paralleling the
point of entrance.
 Three-point or half-buried
mattress suture
The suture is tied,
drawing the tip snugly
into place in good
opposition. This same
approach can be
utilized in closing a
stellate 4- or 5-point
laceration, drawing the
tips together in a
purse-string fashion.
 Parallel Lacerations
The horizontal
technique is used to
cross all lacerations
Wound tapes can be
used if low tension
If island in middle is
wide enough,
interrupted sutures can
be used
Suture removal timing
Scalp: 6-8 days
Face, Eyelid, Eyebrow, Nose, Lip: 3-5 days
Follow with papertape or steristrips
Ear: 10-14 days
Chest and abdomen: 8-10 days
Back: 12-14 days
Extremities: 12-14 days
Hand: 10-14 days
Foot and sole: 12-14 days
Penis: 8-10 days
Condition delaying Wound Healing: 14 to 21 days
Chronic Corticosteroid use
Diabetes Mellitus