Professional Documents
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The goal is to learn, comprehend, and master the principles of surgery and to
exercise all useful techniques. Plastic surgeons must know several of the best
techniques for optimum treatment of patients. Therefore titles such as
"microsurgeon" and "laparoscopic surgeon" are paradoxic. For example, a
microsurgeon not only must master the techniques in microsurgery, but also must
be equally proficient in the use of non microsurgical techniques when treating
patients.
TRAUMA OF WOUNDING
A patient becomes much more ill from a large injury than a small one. The
patient with a full-thickness bum to 50% of the body surface area becomes much
sicker than the patient with a 1% surface bum. The same is true with trauma to a
limited part of the body. For example, the patient with a linear fracture of the
midtibia from a skiing accident has much less of a problem than the patient who
receives a tibial fracture from being pinned between the bumpers of two cars and
also has significant soft tissue injury.
The same observaitions apply to surgical trauma. For example, (the surgical
removal of a small skin lesion on the face makes the patient less ill than the patient
who has a colectomy. It is therefore logical always to minimize the trauma from
surgery. Most surgeons would agree with this principle, but many, including plastic
surgeons, do not apply it to their technical execution. Use of crushing instruments,
desiccation of tissues, injudicious use of cautery, and application of cytotoxic
substances (e.g. peroxide, chlorine) to wounds are examples of the disconnection
between knowledge of principle and execution of technique.
The two main determinants of post surgical wound complications are the type
of surgical procedure and the surgeon. Some surgeons have complication rates up
to one order of magnitude greater than the complication rates of the best surgeons,
probably because they do not use optimal surgical technique. All surgical
procedures are traumatic, and every surgeon must continually strive to minimize
surgical trauma.
A practical strategy for debridement was developed during the Vietnam War.
Traumatic wounds were debrided on admission to the surgical unit, packed with
saline gauze and then debrided again at intervals of 48 hours until deemed
sufficiently free of devitalized tissue and contamination to be closed. This has
become a useful practical strategy when, for example, treating victims of high-
speed automobile accidents and gunshot wounds. It does not solve the problem of
desiccation, however, because the water in the saline gauze soon evaporates and
transforms the dressing into a dry one. This technique of debridement it also labors
intensive and consumes significant resource.
WOUND CLOSURE
Traumatic wounds illustrate the spectrum of problem» and possible solutions
when attempting wound closure. When dealing with a wound, the first major
consideration is the diagnosis, Anatomic, radiologic, and microbial diagnosis are
probably most important in the diagnosis of an acute wound. The diagnosis of a
chronic wound is much more complex. For many chronic wounds, a precise
diagnosis cannot be established despite optimal effort (Table 13-1).
Once a diagnosis has been established, the next step is to determine the
expertise and the resources needed to treat the wound. These factors have been well
defined for burn wounds but have not been as well established for other traumatic
wounds. Most plastic surgeons are experts at treating traumatic wounds, and
suboptimal treatment often results from the ER triage person failing to recognize
the wound's severity and the difficulty of treatment.
Timing
The principle governing the timing of wound closure is that any traumatic
wound should be closed as soon as possible with minimal complications.
Traditional teaching was that a laceration should be closed within 6 hours or, if this
was not possible left open to healing by so-called secondary intention. Gradually
the 6 hours became 8 hours and 12 hours in some cases. Biology and
pathophysiology represent a continuum, however, outside the arbitrary time limits
set by physicians. In many patients, therefore, particularly those with facial
lacerations, the surgeon might elect to close the wound after as long as 24 or 48
hours after adequate debridement, irrigation, and antibacterial treatment.
When expanding the time from laceration to closure. which can be equated
with a longer inoculation phase for bacteria in the wound, the rate of wound
complications is higher. Therefore, this must be stressed to the patient when
providing the informed consent before wound treatment. The general rule is still
that a laceration should be closed within approximately hours and preferably
shorter, although a plastic surgeon can often achieve uncomplicated closure later
than that.
Methods
The goal is to achieve wound closure as soon as safely possible with the
fewest complications using the technique that is the most advantageous to the
patient in regard to complexity, pain. time of recovery, functional and aesthetic
recovery, and cost. The techniques in the reconstructive ladder are as follows:
1. Linear closure
2. Skin graft
3. Skin flap
4. Muscle flap
5. Skin-muscle flap
6. Bone-tendon-nerve flap
7. Skin-muscle-bone flap
8. Skin-muscle free flap
The first choice is always a linear closure with or without undermining the
adjacent skin, provided that the closure can be achieved without unacceptable
tension. (The proper term is linear closure; “primary closure" describes only the
timing of the closure in relation to elective incisions or wounding). Exceptions to
this rule include most notably pressure sores, where the first choice usually is a flap
procedure. If linear closure is attempted for the common pressure sore, the closure
is placed under tension immediately over the bony prominence. It is therefore
preferable to use a flap that allows a tension free closure away from the bony
prominence. A similar principle applies to closures in the plantar surface of the foot,
where flaps are sometimes used to move the suture line away from a pressure point,
particularly over the metatarsal heads.
ANTIBIOTIC PROPHYLAXIS
Antibiotic prophylaxis is considered mandatory in patients who have
prosthetic heart valves, as well as in patients who are immune depressed or
otherwise at high risk for infection. It is also indicated for patients with
contaminated or infected wounds. Many surgeons provide antibiotic prophylaxis in
“clean” operation as well.
An area that has been studied extensively is the treatment of dog bites, for
which copious irrigation and debridement are recommended, but not antibiotic
prophylaxis.
SKIN INCISIONS
The following principles apply to the placement of skin incision.
1. Place incisions inconspicuously, ideally so that neither the patient nor others can
see them. An example is the facelift incision, a significant portion of which is placed
in the hair or hairline.
2. Place the incisions in the relaxed skin tension lines (Figure 13-1).
3. Make the incision as short as possible.
4. If an excision is made, make certain that the incision is placed so that an adequate
amount of skin can be mobilized to allow a closure with acceptable tension. This is
particularly true in the extremities, where a longitudinal incision usually allows for
more mobilization of the skin than a transverse incision.
5. Ensure that the operation can be made through the incision used. In particularly
traumatic cases, this also means that the surgeon can lengthen the incision, if
necessary.
6. If the patient may need a local or regional flap, place the incision so that it does
not limit flap design.
7. Be compulsive about minimizing scarring. In particular, avoid making a scar in
the triangle over the anterior chest, which is created by connecting lines between
the tips of each shoulder and the xiphoid process. Incisions in this area heal with a
conspicuous scar, which is often hypertrophic or keloidal (Figure 13-2, A).
8. If possible. avoid incisions in the plantar area of the foot because temporary or
permanent pain in the area of the scar is common (Figure 13-2, B).
Sutures
Other absorbable sutures are synthesized with chemical methods and then
modified physically to be maximally functional for the intended purpose. In
general, fast-absorbing sutures are used for approximation of mucosa, whereas
slow- absorbing sutures are preferred when used for approximation of the dermis.
Nonabsorbable sutures can consist of multiple natural fibers, such as linen, cotton,
or silk, that are twisted or braided. Synthetic fibers such as nylon also can be
braided. Generally, smooth monofilament synthetic sutures are preferred because
they cause less tissue reaction. The most common sutures are made of
polypropylene or polyethylene (nylon).
Stainless steel sutures can be used either as a monofilament or as a
multifilament twisted suture. Stainless steel has excellent breaking strength but is
often difficult to handle.
Needles
Needles are usually attached to the suture and can be straight or curved. The
curve of a needle can be anywhere from one quarter to five eighths of a circle. We
generally prefer needles that are three eighths of a circle. The needle tip can be
either tapered or cutting.
The cutting needle can have either a conventional or a reverse cutting design.
We also generally prefer a reversed cutting needle, except for vascular sutures,
when we use a tapered needle. Straight needle, are not often used for routine
surgical procedures but are sometimes found in emergency suture kits. They do not
require a needle holder, and the suture can be cut with a needle, eliminating the
need for scissors.
Suturing Techniques
Figure 13-4 to 13-8 illustrate various skin suturing techniques. In general the
authors prefer deep dermal interrupted sutures with a buried knot. The superficial
dermis and epidermis are then approximated with an intradermal running suture
(Figure 13-6). The preferred suture for this closure in the skin is a slowly absorbable
suture such as Polydioxanone or Poliglecaprone (see Table 13-3). The closure is
then reinforced with surgical tape (Figure 13-9).
Surgical tape can be used alone or with sutures and glue. The surgeon must
be careful not to place too much tension on the tape because this can result in
blistering of the skin. In the face the surgical tape is often placed longitudinally. In
addition to supporting the wound closure, tape also acts as a dressing that protects
and conceals the wound during healing. Surgical tape is usually left on the wound
as long as it stays there.
A number of biologic or synthetic wound adhesives are being tested for use
in wound closure. The fibrin-type adhesives are not as strong as the synthetic
adhesives but seem to be better tolerated by the tissue. They can be used alone or
with sutures.
Synthetic adhesives such as acrylic glues are used on top of the wound. The
wound glues are useful because they often eliminate the need for local anesthetics
when closing a wound. Their precise role in elective and nonelective surgical
procedures has yet to be determined (Figure 13-10).
Staples
1. With staples it is difficult to achieve the precision and approximation of the skin
edges possible with sutures.
The stapling device that eliminated these two disadvantages would be of great
practical use.
The earlier that sutures that penetrate the epidermis can be removed, however,
the less likely that suture marks are seen when the wound is healed. This is also true
for staples. Surgical tape rarely leaves any permanent marks, and it is therefore
advisable to keep the wound taped together as long as possible. It is also advisable
to tape the wound after removal of sutures or staples if there is a significant risk of
wound separation.
The time of healing until the wound can withstand the skin tension varies
greatly from one area of the body to the other. Although the suture in the eyelid can
usually be removed after 3 to 5 days, a wound in the lower leg or lumbar back may
need to have the sutures in place for more than 2 weeks. If a strong closure can be
achieved with buried dermal sutures, this period is shortened, sometimes to the
point that no trans epidermal sutures are needed. In some older patients, however,
it may be impossible to place adequate buried dermal sutures because of the
thinness of the atrophic dermis.
Table 13-5 lists the average interval between the operation and suture
removal.
1. Protection
2. Absorption
3. Compression
4. Immobilization
3. Aesthetics
All these functions are not important in every wound, but one or more are
usually to healing. The current surgical leasing is that a wound will be "sealed"
within 8 hours postoperatively. Studies have shown that a closed wound is unlikely
to be contaminated from the outside after this period. It takes at least 4 days,
however, until the epidermal barrier has reduced protein leakage to normal.
Many weeks must pass before water vapor permeability begins to approach
normal. Therefore a controlled hydration dressing should be used over a wound
several weeks after the operation to minimize wound desiccation and scarring. Once
the dressing has been removed, an ointment or water-retaining cream can be used.
Every surgical or traumatic wound heals with a scar (see Chapters 5 and 7).
Scarring can be reduced by (1) optimal placement of incisions, (2) minimization of
trauma during the operation, and (3) use of proper suturing and dressing
“technique”. Scarring usually is worse in very young patients and in African and
Asian populations. Also, some patients of any skin type seem to scar more than
other individuals.
During the first year after trauma or an elective operation. The scar usually
becomes more conspicuous for approximately 3 months, then regresses over the
ensuing months. In general, the scar has attained its final appearance by 1 year, but
some scars continue to improve or worsen for 2 or more years. After removal of the
initial dressing and the sutures, scarring can be reduced by prolonged treatment with
controlled hydration dressings, treatment with silicone sheets, pressure treatment,
and topical therapy with steroids and bleaching agents.
Surgical correction of scars is usually delayed until the scar has matured for
1 year, except for patients in whom earlier scar revision becomes clinically
necessary to maintain joint mobility or prevent corneal desiccation in an ectropion.
Post traumatic scars involving a significant area of skin may require resurfacing
with either a skin graft or a skin flap. Depressed scars may require a flap to replace
a tissue deficit. Tissue expansion may be useful in many of these situations. The
most common scars are either linear or close to linear, and these scars are usually
treated with excision alone or in conjunction with a Z-plasty or W-plasty.
In the face the W-plasties are usually preferred in the forehead, zygomatic
region, nose, and chin. In these locations it is important to undermine the skin
widely to allow advancement without tension.
SKIN CRAFTING
Split-thickness Grafts
STSGs consist of epidermis and a portion of the underlying dermis. They are
measured in thousandths of an inch, with the thickness of the space set in the
dermatome being measured, not the graft's thickness. The thickness should
therefore be considered relative. A thin graft is usually 0.005 to 0.012-inch-thick,
intermediate graft 0.012 to 0.018-inch-thick, and a thick graft 0.018 to 0.028-inch-
thick. The grafts are generally harvested with a dermatome from an available donor
site.
Once harvested, grafts can be either used as they are or meshed with or
without expansion. We believe that skin grafts to the face, hand, and forearm should
not be meshed unless absolutely necessary. In other areas, meshing is an option,
particularly if large surface areas need to be covered. Meshing gives the graft a
waffled appearance and allows expansion up to approximately six times. A meshed
graft conforms better to an uneven surface and allows drainage from the recipient
site through its openings.
After the recipient site has been cleared of necrotic tissue and hemostasis
established, an STSG is secured in place with sutures (we prefer 5-0 chromic
sutures). When skin grafting very large areas, such as in burns, staples can be used
to save time. A tie-over dressing is useful to stabilize the STSG to the underlying
recipient tissue, except over bony prominences, where it could cause necrosis. In
the scalp, we cautiously use a tie-over dressing to avoid pressure necrosis of the
galea or periosteum.
If the recipient site is clean and uncontaminated, the dressing is left in place
for 1 week, whereas in contaminated wounds it is usually changed after 48 to 72
hours. To prevent relative motion between the graft and the underlying recipient
tissues, a plaster splint can be used to immobilize the body part being grafted. An
elastic wrap is used for compression, and the grafted site usually is elevated for at
least 1 week.
The donor site should be protected from desiccation and contamination and
therefore preferably covered with a controlled hydration dressing. Compared with
any dry dressing technique, such as Xeroform gauze treatment, a controlled
hydration dressing allows faster healing (on average by about 50%) and greatly
reduces pain. If the grafted area is small, the procedure can usually be done without
hospitalization.
FTSGs contain both dermis and epidermis, and composite grafts may contain
fat, cartilage, or muscle as well. In principle the graft should be of approximately
the thickness required to fill the defect. A thick composite graft will only survive in
a well-vascularized bed and if it has a "pie crust" to allow drainage.
FTSGs usually heal with a better match in color and texture compared with
STSGs. FTSGs, however, tend to undergo "biscuiting", or elevation of the graft’s
center and depression of its periphery. FTSGs also benefit from tie-over dressings.
Few skin grafts fail unless the recipient site provides poor vascularity or is
heavily contaminated or some technical error has occurred.
Composite grafts from the ear are sometimes used to reconstruct the ala of
the nose. In these grafts the upper limit in site is 1 cm2.
Once healed, the donor site and the grafted site frequently need to be treated
with compression, silicone sheets, topical steroids, and bleaching creams.