Learning the principles and mastering the techniques of wound closure and suturing are essential to every surgical trainee, regardless of specialty. Not all wounds require definitive closure at the first emergency department (ED) encounter; however, once the decision to close a wound has been made, the clinician must select the closure technique best suited for the location and configuration of the wound. Regardless of which wound closure technique the responder chooses, it is important to remember that to achieve a thoroughly-healed incision with minimum scarring you should keep in mind the following: Line up the skin edges precisely to ensure minimal scarring. Sutures can also be applied with a subcuticular technique. According to the characteristics of the wound, the medical team can choose to encourage its closure or not. This consists of a set of sections of tape that are placed near the extremes of the wound. These include sutures, staples, and adhesives. Burns Trauma. Wounds are closed in layers, from deep to superficial. Depending on the characteristics of the wound, the medical team may choose to perform the wound closure procedure or leave the wound as … The latter allows to selectively remove some sutures in case of undue tension, hematoma or seroma formation and/or local inflammation and infection, respectively. In the past, surgeons have been taught to leave wounds associated with internally fixed fractures open at the time of the first debridement and irrigation. Non-absorbable sutures are preferred because they provide great tensile strength, and the body’s chemicals will not dissolve them during the natural healing process. Also, in the case of an infection, the entire length of sutures would not need to come out. Adhesive tapes and skin glues are a useful adjunct to deeper sutures too. This is an important consideration in: In each of these situations there frequently is an extensive zone of injury beyond the central area of nonviable tissue, and a zone of questionable tissue viability in between (chapter 3, 10.3.3). If in doubt, it is often better to leave the wound open and only close it secondarily. The deeper penetration into the skin layers minimizes tension and allowing for better closure at the wound edges. This study aimed to compare … Wound management is an essential part of emergency medicine practice. Within this method there are numerous variants and the corresponding doctor must choose the most appropriate for the wound presented by the patient. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. It can be done either as a simple suture or continuous sutures. Note that the far limb of the suture (1) remains within the dermal layer. Multiple techniques can be used for wound closure. This would cause the entire length of suture to unravel. The advantage of primary or early wound closure is not only a psychological benefit, but also shortens the wound-healing process and thus also helps to spare health-care costs. The skin is not pierced and thus has the ability to produce better aesthetic results. The kit contains skin pads, knot tying kit, and a range of equipment used to explore different wound closure techniques. This is often used in closure of heavy tissue such as fascia or joint capsules. Approximation of the subcutaneous fascia (superficial fascia of the fat) may be helpful in order to reduce the tension of a primary skin suture, but depending on the trauma mechanism (eg, avulsion injury) or the region of the body (eg, lower leg) this is not always possible. Please enable it to take advantage of the complete set of features! Whereas there are some tissue planes that lend themselves to blunt dissection (e.g., subgaleal, sub–superficial musculoaponeurotic system), sharp dissection is the general rule. COVID-19 is an emerging, rapidly evolving situation. Sutures (Video 10.1-1a–h) are used to close dead space in a wound and to close the skin. The technique may also be used to reapproximate the skin, as shown here. Presuturing probably has greatest potential application in equine wounds … I suggest review and mastery of the basic wound closure techniques before attempting these techniques in patient care. At corners or apices of flaps, it is important to avoid placing sutures, particularly the ones that are on a dermal level, so as not to compromise perfusion. Suture size is stated numerically; as the number preceding the zero in the suture size increases, the diameter of the strand decreases, eg, 4-0 is much smaller than 1-0 or even 1. Sort of like drinking urine, nobody survives because of it; they were going to survive anyway. It is usually recommended to remove the sutures from extremities within 10–14 days. Currently, one of the techniques that is most used in wound closure is the use of sutures. Sutures that undergo degradation and resorption in tissues are considered resorbable sutures. If swelling does not abate quickly, they may even lead to tissue necrosis. Many surgeons today believe that wounds of open fractures—up to Gustilo type IIIA fracture—may be closed primarily, which is, however, still controversial [1, 2]. Proper technique includes a uniform undermining of the skin for primary wound closure. The least amount of observable scar is created with a running, nonresorbable, intradermal suture with the least inflammatory response (ie, polypropylene) ( Fig. doi: 10.1002/14651858.CD012124.pub2. Such a plan should be … Not all wounds need sutures. 2019 Feb 01;85(2):162-166. The most commonly used techniques include tape, tissue adhesive, metal staples, and sutures. Tension on the suture from below is avoided by separately closing the subcutaneous tissue first at fascia level (as shown here), or at a dermal level. The vertical mattress (Donati) suture technique is often used to reapproximate thick subcutaneous tissue, with the knots buried. Surgeon preference will dictate usage of 4-0 monocryl or 4-0 vicryl for skin closure for patients randomized to the suture arm. Figure-of-eight suture technique. Care must be taken to avoid over-tightening these sutures. Depending on the properties of the injury, the corresponding medical team will determine which type of stitches would be most appropriate: 1. For many minor wounds, sutures are the gold-standard method for closure. Because of their simplified structure, they encounter less resistance as they pass through tissues than multifilament suture material consisting of several twisted or braided strands. However, monofilament sutures do not hold a knot as well as braided suture. The wound may be conditioned for closure with a synthetic-skin substitute (eg, Epigard®, Pfizer, New York, NY, USA), which is applied to the wound initially, then removed after swelling abates and primary closure is made. March 29, 2020 0 Comments . The circulating nurse will time all skin closures. Click here to Login. Excessive tension at the skin edges can compromise local blood supply as well as the healing process, but placing too many sutures may also result in local hypoxia and hence compromise vascularity, making wound closure a balancing act. As a method for closing cutaneous wounds, the technique of suturing is thousands of years old. Methods: Qualified participants will then be randomized to skin closure with either Dermabond or suture. Goals are to optimize wound strength, reduce inflammation, avoid infection, and minimize scar formation Time to wound cleaning is the most important factor To preserve viable tissue and restore continuity and function of tissue CONTRAINDICATIONS Heavily contaminated wounds Presentation time for primary closure is after 12 hours for standard lacerations Presentation time for primary closure… -, Ogawa R. Surgery for scar revision and reduction: from primary closure to flap surgery. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. 14-1 ). If necessary, the doctor may use stitches, tape or staples to unite the tissues that have been detached by the wound. Too much tension on the wound edges is the greatest enemy of primary wound closure. This can potentially make it difficult to manipulate the suture during wound closure. The outcome of wound closure (i.e., the scar) is influenced by a … Primary suture closure of wounds is often the optimal solution for soft tissue defect closure because of its simplicity and satisfactory outcome, yet Non-surgical wound closure—a simple inexpensive technique | springermedizin.de Tendons may be sutured using a number of different techniques, such as a modified Krakow, Bunnell or any of a myriad of specialty-specific sutures. Primary wound closure: Window of closure following injury: Within 4-12 hours for limbs and body and upto 24 hours for highly vascular areas like face and scalp (the proposed cut-off of golden period is highly variable in surgical textbooks and literatures) Indications: Simple, clean, non-contaminated wounds with minimal tissue loss and surgical incisions Table 10.1-2 shows representative suture types and their characteristics. The surgeon will complete a 3 question survey immediately postop. NLM This kit is for students to take home to help reinforce knowledge and support transition into practice. Many techniques are described for high-tension wounds, but not much is known about their mechanical properties. Rather place single sutures at an adequate distance from the corner or apex of the flap. Ann Plast Surg. In doing so, absorbable sutures help decrease the tension and better approximate the wound edges. The horizontal mattress suture technique may be used cautiously in thick skin, which is not in danger of being closed under too much tension, such as that of the thigh or back. A simple buried suture ( Fig 10.1-7a–b ) may be used for the fascia within the subcutaneous tissue or the dermis. 64:25. Staples are cost-effective, easily placed, require minimal training, and have similar healing times and infection rates as sutures. The goal of all these different techniques of suturing the skin is to provide a mechanical closure of the wound without putting too much tension on the wound edges, allowing for uneventful reepithelialization within 24 hours. There are two types of sutures, absorbable and non-absorbable. A resorbable intradermal suture (ie, poliglecaprone 25) can be used, but involves a prolonged inflammatory phase during suture degradation. 2007 May;58(5):566-72. doi: 10.1097/01.sap.0000245135.58229.e7. A common scenario is to extend the traumatic wound in order to provide better exposure for the debridement of recesses and the removal of debris, but also for the insertion of implants. While appropriate tension on the skin is difficult to judge clinically, signs that there is too much tension on the skin include blanching of the skin between sutures due to a lack of capillary refill, indentation of the suture into the skin, and loosening of the suture.  |  2019 Mar 28;28(6):S24-S28. The goals of wound management are to avoid infection, tamponade the bleeding, and provide a better cosmetic outcome. 2014 Feb 14;(2):CD010365. Techniques for acute wound closure Tanya Reynolds Nurse consultant, Accident and emergency care, accident and emergency department, Homerton Hospital Elaine Cole Lecturer/practitioner, Accident and emergency/trauma, St Bartholomew School of Nursing and Midwifery, City University/Barts and The London NHS Trust, London Cochrane Database Syst Rev. Sutures are a foreign body in a wound, which causes tissue inflammation and in some … Continuous versus interrupted skin sutures for non-obstetric surgery. Nonresorbable sutures are typically used for skin and tendon repair. Until recently, there was only one choice of adhesive viscosity and applicator tip. This technique with 3-0 or 4-0 nonresorbable suture material allows to approximate the skin edges at equal level without eversion or bulging, which cosmetically leaves almost invisible scars. 2. In general, the goal of treatment is to obtain a clean, closed wound involving as little time and the least possible physical and emotional commitment for the patient. Adhesive tape. The running percutaneous suturing technique is a nice technique to help you speed up lengthy wound closures. -. Dermabond comes in a sterile, plastic-covered glass vial with an applicator tip ( Fig. The clinicians care for wounds ranging from minor and simple lacerations or abrasions to complex wounds.  |  Tapered needles are used for easily penetrated tissues, whereas cutting or reverse-cutting needles are used for skin or heavy fascia. Some surgeons believe that no open fracture wound should be closed primarily, but among those who do close open fractures primarily, debridement within the above guidelines is a prerequisite. The inflammatory and proliferative phases of wound healing are considerably shortened if primary or early closure of clean wounds is obtained. Their application is quick, but not very precise and removal must occur within a few days in order to avoid a stepladder pattern, which may cause secondary widening or dehiscence of the skin, resulting in ugly scarring. The clinicians care for wounds ranging from minor and simple lacerations or abrasions to complex wounds. These sutures have been adequately described in numerous textbooks or specialized manuals and do not need repeating here. Wound closure techniques have evolved significantly and now range from simple sutures to adhesive compounds, and techniques have also improved. Techniques of wound closure Although many wounds in horses heal successfully by second-intention healing or delayed closure, some wounds can be sutured primarily, with reasonably high expectations of first-intention healing. These are small metallic threads that come in … 3 Superficial fascia of the fat (hypodermis/subcutaneous tissue). The skin edge with the more problematic vascular supply, eg, the side of a flap and not the side of the local skin, is chosen for the intradermal part of the backstitch in order to have the knot lying on the well-perfused side of the wound. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Would you like email updates of new search results? Simple interrupted sutures have the advantage of more cosmetically appealing results as the use of separate stitches allows for a better approximation of the skin and fascia. How to Eliminate Drainage? Gurusamy KS, Toon CD, Allen VB, Davidson BR. -, Fayyaz GQ, Gill NA, Alam I, Chaudary A, Aslam M, Ishaaq I, Hameed A, Ganatra A, Sheikh T, Bilal M. Continuous Versus Interrupted Sutures for Primary Cleft Palate Repair. Caring for and closing wounds in certain areas involve additional risks and require special techniques. These sutures possess many characteristics, among which size, configuration and resorbability are the most important. The degree of contamination, either based on history, mechanism of trauma or examination, is another important variable to assess. Keep in mind that edema is common after injury or surgery, so the degree of tension on the skin will often increase during the first few days after closure. 17 The technique has been evaluated experimentally in pigs and has also been used clinically in select cases in humans when a skin graft or excessive undermining would otherwise be required for skin closure. The choice of suture and technique depends on the type of wound, depth, the degree of tension, and desired cosmetic results. The disadvantage of running sutures is the risk of dehiscence if part of the suture material ruptures. Wound closure techniques have evolved significantly and now range from simple sutures to adhesive compounds, and techniques have also improved. Staples, although popular and frequently used, are not considered first choice, if cosmetically nice-looking scars are expected. A good measure to judge the tension of skin edges is impaired vascular perfusion or lack of capillary refill when tying the sutures, as may best be seen when the skin appears blanched between stitches. Soft tissue dissection is an essential component of wound closure. The accepted surgical practice is to use the smallest diameter suture that will adequately hold the mending wounded tissue. Fine approximation of the corner or apex can be performed with single knots using thin suture material or Steri-Strip™. Complications of excessive tension include dehiscence, infection, and ischemic necrosis and could be prevented. A perfect ellipse balances tensile and compressive forces in a wound to create an elegant linear closure. Such sutures must be used with care, since they may exert a tremendous amount of tension on the skin. Simple, interrupted suture technique. For injuries that require further management, it is imperative to assess the wound and determine how best to treat it. If there is still tension after wound closure, the mattress stitch can be left in place to decrease the risk of dehiscence. Clinical photographs of an open wound on the ankle. In fact, there are many great reasons to avoid suturing when feasible. Variations on the ellipse can be utilized on particular surfaces such as those that are convex, curvilinear, or limited by anatomic boundaries. It is important to remember that no method of wound closure or treatment is able to guarantee success and other options may have to be implemented should initial attempts fail. Local skin flaps are used to close defects immediately adjacent to the donor site and are classified according to the respective technique of transfer ( chapter 10.4 ): Advancement: advances along the long axis of the flap, from the base towards the defect. Wound management is an essential part of emergency medicine practice. 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