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PRINCIPLES OF REPAIR OF EXCISIONAL WOUNDS

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It is important to keep the following in mind:

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  1. Plan all excisions carefully.

  2. Check previous scars for healing properties.

  3. Aim to keep incision lines parallel to natural skin lines.

  4. Take care in poor healing areas, such as backs, calves and knees; and in areas prone to hypertrophic scarring, such as over the sternum of the chest, and the shoulder.

  5. Use atraumatic tissue-handling techniques.

  6. Practise minimal handling of wound edges.

  7. Use Steri-strips after the sutures are removed.

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STANDARD PRECAUTIONS

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Mandatory safety measures

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  • Goggles

  • Gloves

  • Protective gown

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Common mistakes for excisional surgery

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  • Skimping (inadequate margins)

  • Tension on skin edges

  • Knots too strongly tied

  • Stitches too thick

  • Too large a bite

  • Stitches in too long

  • Inadequate early compression

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Minimising bleeding in the elderly

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Stop anticoagulants (if possible) before a significant procedure. Examples:

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  • warfarin—3 days

  • aspirin—10 days

  • NSAIDs—2 to 5 days (check half life).

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Suture material (Table 4.1)

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Table Graphic Jump Location
Table 4.1

Selection of suture material (guidelines)

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  • Monofilament nylon sutures are generally preferred for skin repair.

  • Use the smallest calibre compatible with required strains.

  • The synthetic, absorbable polyglycolic acid or polyglactin sutures (Dexon, Vicryl) are stronger than catgut of the same gauge, but do not use these (use catgut instead) on the face or subcuticularly.

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Instruments
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Examples of good-quality instruments:

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  • locking needle holder (e.g. Crile-Wood 12 cm)

  • skin hooks

  • iris scissors.

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Holding the needle
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The needle should be held in its middle because this will help to avoid breakage and distortion, which tends to occur if the needle is held near its end (Fig. 4.1a).

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Fig. 4.1

Correct and incorrect methods of (a) holding the needle; (b) making incisions

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Incisions
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Incisions should be made perpendicular to the skin (not angled) (Fig. 4.1b).

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Dead space
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Dead space should be eliminated, to reduce tension on skin sutures. Use buried absorbable sutures to approximate underlying tissue. This is done by starting suture insertion from the fat to pick up the fat/dermis interface so as to bury the knot (Fig. 4.2).

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Fig. 4.2

Eliminating dead space

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