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Synthetic vs natural: Silk and gut are the only
natural sutures available; the rest are synthetic.
Staples
Quick closure
Good for hair-bearing regions
Use forceps to initiate wound eversion and staple in
place
Surgical adhesives
Cyanoacrylate (Dermabond)
Used in conjunction with a proper closure initiated
by suture material, which is under minimal tension
Pros: decreased time for closure, improved
cosmetic outcome, possible decreased risk of
infection due to decrease in suture use
Cons: must have a tension-free closure, must not
be used on mucosal surfaces. Increased risk of
wound dehiscence
Surgical tapes (eg, Steri-Strips): can be used in
conjunction with sutures or alone if the closure is
completely tension free
Methods of Wound Closure (See Fig. 1-3)
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Figure 1-3 A. Simple interrupted closure.
B. Interrupted vertical mattress pattern. C.
Interrupted horizontal mattress pattern. D.
Running subcuticular (intracuticular)
sutures. E. Half-buried horizontal mattress
(applicable in corners). F. Simple running
(“over-and-over”) suture. G. Stapled
closure. H. Steri-Strips (adhesive tape).
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Simple interrupted: Needle is placed perpendicular to the
skin and drawn into the targeted layers of tissue on one
side, then out through the same layers/levels of tissue on
the opposite side, then tied in place.
The needle pathway allows the width of the suture at
the base to be wider than at the epidermal entrance to
allow eversion of the skin edges.
Place sutures 5-7 mm apart and 1-2 mm from the skin
edges to allow for appropriate wound closure.
Vertical/horizontal mattress suture
Good for glabrous skin and wounds under tension.
Horizontal mattress causes more hypoxia to tissues
than vertical mattress.
Subcuticular: avoids marks on the external surface of the
incision to result in a more favorable scar; allows for
reapproximation of the epidermis.
Running suture: best used when wound edges are already
somewhat approximated, faster closure. Use locking
running stitch if hemostasis is needed.
PEARLS
1. Scars typically widen over time. Some areas, such as the back
or the legs, where the tension is higher, are especially prone to
scar widening.
2. Nicotine in any form (smoking, patches, and gum) impairs
wound healing significantly due to vasoconstrictive effects.
3. Macrophages are critical cells in wound healing and initiate the
growth factor cascade, fibroblast proliferation, and collagen
formation.
4. Prior to considering scar revision, at least 1 year should pass to
allow for complete scar remodeling.
5. Antibiotic ointments (eg, Bacitracin) should only be used for 2-3
days as patients can develop hypersensitivity and rash that may
be mistaken for cellulitis/infection.
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6. Absorbable suture should be used in children whenever
possible or when suture removal is anticipated to be difficult or
may disrupt closure.
7. Topical skin adhesives can be used in conjunction with sutures
that have achieved epithelial continuity.
QUESTIONS YOU WILL BE ASKED
1. What is the difference between wound contraction and wound
contracture?
Wound contraction is a part of secondary healing beginning a
few days after injury as myofibroblasts contract and reduce the
size of the wound to be epithelialized. Wound contractures
occur when bands of collagen are deposited at the site of
hypertrophic scar formation; these are termed “contractures”
when they impair functionality (eg, hands) or range of motion
(eg, axillae and neck).
2. What is the difference between hypertrophic scar and keloid?
Hypertrophic scar does not extend beyond the borders of the
original wound, whereas keloids grow well beyond these
borders; histologically, these two fibroproliferative disorders are
different, but they are indistinguishable under standard H&E
preparation on light microscopy. They have different type I:type
III collagen ratios. Hypertrophic scars produce smooth muscle
actin by myofibroblasts, whereas keloids do not.
3. What are the factors that impair wound healing?
Systemic conditions (eg, diabetes, autoimmune conditions, and
medications), ischemia, pressure injury, infection, malignancy,
foreign body, venous insufficiency, irradiation, hypoxia, smoking,
advanced age, and malnutrition.
4. What is the timing of wound healing and what is the final tensile
strength a wound achieves?
The wound achieves 5% of its tensile strength at 1 week, 20%
at 3 weeks, and 80% after 6 weeks. Maximum tensile strength
of a wound reaches only ~80% of noninjured skin.
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1.
2.
5. Describe the classification of sutures and what factors of a
wound/incision affect the choice of suture.
Sutures are classified as absorbable vs nonabsorbable, natural
vs synthetic, and braided vs monofilament. The suture chosen
should effectively minimize tension on the closure, promote
eversion of the skin edges, and remain in place for the optimal
length of time necessary to maintain a strong and durable
closure while minimizing the body’s inflammatory response to
the suture itself to optimize the appearance of the scar.
6. Describe the timing of suture removal for the extremities, face,
and trunk.
Extremities: 10-14 days; face: 5-7 days; trunk/breast: 7-10 days.
7. What are the contraindications to wound VAC therapy?
Do not use a wound VAC over normal skin, infected tissues,
tissues harboring malignant cells, inadequately débrided
wounds, or directly on top of neurovascular structures.
8. What dressings are good for highly exudative wounds?
Alginates and foam (eg, Mepilex) are good for highly exudative
wounds and can decrease dressing change frequency.
9. Describe the treatment of animal/human bite wounds.
Bite wounds should be washed out aggressively and thoroughly
on presentation given the predisposition of such wounds for
infection. If closure is needed, tissues should be loosely
approximated to allow for egress of débris and infected fluid.
Antibiotics that provide coverage against anaerobic and Grampositive organisms, namely Eikenella corrodens and group A
Streptococcus, should be prescribed. Amoxicillin-clavulanate
has good activity against common oral pathogens. Patients
should be followed closely to monitor for signs of infection.
Recommended Readings
Broughton G, Janis JE, Attinger CE. The basic science of wound healing. Plast
Reconstr Surg. 2006;117(7 Suppl):12S‐34S.
Garner WL, Rahban SR. Fibroproliferative scars. Clin Plast Surg.
2003;30(1):77‐89.
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3.
4.
5.
6.
7.
Janis J, Harrison B. Wound Healing: Part II. Clinical Applications. Plast
Reconstr Surg. 2014;133(3):383e‐392e.
Janis J, Harrison B. Wound Healing: Part I. Basic Science. Plast Reconstr
Surg. 2016;138(3S):9S‐17S.
Leach J. Proper handling of soft tissue in the acute phase. Facial Plast Surg.
2001;17(4):227‐238.
Maggi SP, Lowe JB III, Mackinnon SE. Pathophysiology of nerve injury. Clin
Plast Surg. 2003;30(2):109‐126.
Ueno C, Hunt TK, Hopf HW. Using physiology to improve surgical wound
outcomes. Plast Reconstr Surg. 2006;117(7 Suppl):59S‐71S.
*
Denotes common in-service examination topics.
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2
Grafts
Jennifer C. Lee and Widya Adidharma
BASIS OF RECONSTRUCTION
Reconstructive Goals
Restore form and function to the defect.
Minimize donor site morbidity.
Reconstructive Ladder (Fig. 2-1)
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Figure 2-1 Reconstructive ladder. (From
Thorne CH, ed. Grabb and Smith’s Plastic
Surgery. 7th ed. Wolters Kluwer; 2014.
Figure 1.21.)
Systematic approach to facilitate decision-making for
reconstruction of defects.
Least complicated technique is generally chosen to address
the reconstructive goals.
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Reconstructive Elevator
Sometimes, the best solution is not the simplest.
Option is chosen that will give patient best aesthetic and
functional result, often requiring a “jump” in the ladder (eg,
free flap may be the best first choice if superior result is
unmatched by other options, even if simpler option can also
be used).
In reality, this is the method in which flap selection is
typically done.
OVERVIEW
Unlike flaps (Chapter 3: Flaps), grafts do not bring independent
blood supply to a recipient bed.
*Autograft: from same individual
*Allograft: from another individual of same species (ie,
homograft/cadaver graft)
*Xenograft: from another species (ie, heterograft)
Skin, dermis, fat, bone, tendon, cartilage, nerve, fascia, or
combinations of tissues can be transferred as grafts.
EVALUATION
History
Assess for factors that impact graft survival (anything
that would influence new vascular growth into the
graft): systemic diseases/conditions (nutritional status,
diabetes, anticoagulants, immunosuppression, and
nicotine), local conditions (prior radiation and
venous/arterial insufficiency), and anticipated compliance
Physical Exam
Recipient site considerations
Wound site preparation removes devitalized tissue and
contamination, which is critical to success of graft.
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Viability: adequate blood supply, no devitalized
tissue.
Hemostasis: hematoma is a major cause of graft
failure.
Bacterial load: contamination prevents graft
survival.
*Perform recipient site tissue culture if history or
concern for infection (counts <105 CFU/g tissue for
most pathogens required before grafting).
Donor site considerations: defect is best replaced with
like tissue. For example, an eyelid skin defect requires a
thin skin graft best harvested from “like” tissue, such as
preauricular or cervical thin skin, rather than thicker skin of
inguinal region.
Also consider donor site availability
Location based on patient preference for location of
scar, ease of donor site care, anticipated match of
donor skin to recipient site, availability of sufficient
quantity of tissue, decreased donor site morbidity
TYPES OF GRAFTS
SKIN GRAFTS
General Indications
Primary closure not feasible
Lack of adjacent tissue for coverage (poor quality,
insufficient quantity, and inferior aesthetic appearance)
Uncertain tumor clearance
Patients with significant comorbid conditions who may not
tolerate the potential risks or complications of more
complex reconstructive options
Benefits compared to healing by secondary intention:
quicker healing, decreased scar contraction, improved
aesthetic appearance, and less fluid loss
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