Principles of Incision and
Wound Closure
Fuad Ridha Mahabot
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Introduction
• Pre-operative planning - important!
for optimal cosmetic and functional result
healing process wound contraction and scarring -
may compromise function and appearance
• Goals
to re-establish functional soft tissue structural support
to give the most natural aesthetic appearance with
minimal distortion
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Principles of Wound Incision
• First priority - maintain a sterile and aseptic
technique to prevent infection.
THE LENGTH AND DIRECTION OF INCISION -
to afford sufficient operating space and optimum
exposure
the direction of wound naturally heal is from side-to-side,
not end-to-end
the arrangement of tissue fibers in the area to be dissected
will vary with tissue type
the best cosmetic results when incision made to the
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direction of tissue fibers
Principles of Wound Incision
• Relaxed Skin Tension Lines
(Langer’s line)
Is the skin lines oriented perpendicular
to the direction of the underlying
muscle fibers
determined by examination of patient’s
natural skin creases at rest
orientation of the final scar parallel to
or within a natural skin crease gives a
superior cosmetic result.
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Principles of Wound Incision
• Dissection technique
clean incision should be made with one stroke
or evenly applied pressure on the scalpel
preserve integrity of as many of underlying
structures as possible
• Fusiform excision
performed with longitudinal axis running
parallel to RSTL
the length should be 4 times with the width of
the defect to produce an accurate coaptation
of skin edges without dog ear formation.
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Principles of Wound Incision
• Dog ears
areas of redundant skin and subcutaneous tissue
resulting from a wound margin being longer on one
side than the other
dealt with either by
incremental oblique placement of sutures to redistribute the
tension across the wound
fusiform excision of the dog ear with lengthens the scar
considerably
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Principles of Wound Incision
removal of a ‘dog ear’
• skin defect is sutured until the
“dog ear” becomes apparent
• the “dog ear” is defined with a
skin hook and is incised round
the base
• excess skin is removed and the
skin is sutured
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Principles of Wound Incision
• Tissue handling
minimum tissue trauma promotes faster healing
surgeon must handle all tissues very gently - and as
little as possible
retractors should be placed with care to avoid
excessive pressure, since tension can cause serious
complications
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Principles of Wound Incision
HAEMOSTASIS - allows surgeon to work in as
clear a field as possible with greater accuracy.
Without adequate control, bleeding may interfere
with the surgeon’s view of underlying structures.
also to prevent formation of postoperative hematomas
collection of blood (hematomas) or fluid (seromas) can
prevent direct apposition of tissue
these collections provide an ideal culture medium for
microbial growth serious infection
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Principles of Wound Incision
avoid excessive tissue damage while clamping of ligating
a vessel of tissue. Mass ligation necrosis, tissue death
and prolonged healing time
• Maintaining moisture in tissues
during long procedures irrigate wound with normal
saline, or cover exposed surfaces with saline-moistened
gauze to prevent tissue from drying out
• Removal of necrotic tissue and foreign materials
adequate debridement of all devitalized tissue and removal
foreign materials
presence of foreign materials - increases possibility of
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Principles of Wound Incision
• Basic Surgical Skills of Wound Incision
i. mark out important landmarks
ii. add cross hatches with the marking pen for accurate wound closure
later
iii. apply gentle traction to the skin to avoid wrinkles
iv. apply enough pressure to the scalpel to cut through to subcutaneous
fat with one stroke
v. always cut toward you in one motion
vi. do not use a sawing motion
vii. focus your attention on the segment already cut in order to continue
in a straight line and to adjust the required pressure
viii. avoid numerous cuts in different planes
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Principles of Wound Closure
Goal: “approximate, not strangulate”
CHOICE OF CLOSURE MATERIALS - proper
closure material will allow surgeon to approximate tissue
with a little trauma as possible, and with enough precision
to eliminate dead space
•Suture Materials - generally categorized by three
characteristics:
Absorbable vs. non-absorbable
Natural vs. synthetic
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Monofilament vs. multifilament
Principles of Wound Closure
i. Absorbable suture - degraded and eventually
eliminated (e.g. cat gut, vicryl, monocryl)
ii. Non-absorbable suture - not degraded, permanent
(e.g. prolene, nylon, stainless steel)
iii. Natural suture - biological origin; may cause
intense inflammatory reaction (e.g. cat gut, chromic,
silk)
iv. Synthetic suture - synthetic polymers; do not cause
intense inflammatory reaction (e.g. vicryl, monocryl,
nilon)
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Principles of Wound Closure
v. Monofilament suture - grossly appears as single
strand of suture material; all fibers run parallel
ties smoothly
e.g. monocryl, prolene, nylon
vi. Multifilament suture - fibers are twisted or braided
together
greater resistance in tissue
e.g. vicryl (braided), chromic (twisted), silk (braided)
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Principles of Wound Closure
• Cellular response to foreign materials
whenever foreign materials such as sutures are
implanted in tissue, the tissue reacts - depending on
type of material implanted
• more marked if complicated by infection, allergy,
trauma
tissue will deflect passage of needle and suture
edema of the skin and subcutaneous tissue
discomfort during recovery, as well as scarring
secondary to ischaemic necrosis
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Principles of Wound Closure
Some of the Suturing Techniques
i. simple interrupted stitch - single
stitches, individually knotted
used for uncomplicated laceration repair
and wound closure
ii. continuous stitch - allows more rapid
wound closure
carries the risk of complete wound opening if the
suture breaks
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Principles of Wound Closure
iii. horizontal mattress stitch - provides
added strength in fascial closure; also used in
calloused skin (e.g. palms and soles)
iv. vertical mattress stitch - affords precise
approximation of skin edges with eversion
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Principles of Wound Closure
v. subcuticular stitch - intradermal
horizontal bites
allow suture to remain for a longer period
of time without development of
crosshatch scarring
better cosmetic result
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Principles of Wound Closure
• Elimination of dead space in the wound dead space in wound
this is critical to healing!!
results from separation of wound edges which have not
been closely approximated, or from air trapped between
layers of tissue
if the needle is not placed perpendicular to the skin, it
can create dead-space, while unequal bites will create
poor apposition
collection of blood or serum ideal medium for
microbial growth infection
drain insertion or pressure dressing application may
help to eliminate dead space in wound
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Principles of Wound Closure
• Closing with sufficient tension - to prevent
exaggerated patient’s discomfort, ischaemia, tissue
necrosis during healing
sutures must be placed tight enough to seal the
wounds, but loose enough as to not strangulate the
wounds edges and create tissue necrosis and increased
scarring
the deep layer is used to minimize tension on the
superficial layer
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Principles of Wound Closure
• Stress placed upon the wound after surgery
to prevent suture disruption
e.g. abdominal fascia will be placed under excessive
tension after surgery if patient strains to cough, vomit,
void, defecate
• Immobilization of wound
adequate immobilization of the approximated wound,
but not mandatory for the entire anatomic part
for efficient healing and minimal scar formation
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Principles of Wound Closure
• Factors influencing surgical wound closure
local factors
tight suturing effect vascularity necrosis and wound
breakdown
overuse electrocoagulation excessive bleeding and hematoma
formation creating dead space focus for infection
systemic factors
age (>65), nutritional status, male, long term steroid may lead to
wound dehiscence
smoking, diabetes, rheumatoid arthritis impaired microcirculation
• obesity reduced tissue oxygenation, increased subcutaneous dead
space more susceptible to haematoma and seroma formation
infection
THANK YOU
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