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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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Fixing of the Skin Flap with 3.0 Monocryl Key Sutures (Fig. 8.12)
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䊏
3.0 Monocryl™*
key sutures are placed at the incisions of the marked
points. In doing this, the correctness of the extent of the incision and
later resection can be checked once again. After fixing the skin flap, the
surplus sections of skin and possibly of fatty tissue can be seen; these
must be removed before skin resection.
Resection in Stages (Fig. 8.13)
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䊏
Resectioniscarriedoutinstageswhilekeepinganeyeontheresulting
skin tension. Following resection, subcutaneous tissue remains on the
fascia without undermining. As a result, no wound cavity is created,
which would promote seroma formation. Redon drains are not
required here.
䊏
Resection is carried out in stages with a size 15 scalpel, and the assistant holds the sections of the flap to be resected upwards under tension
with two Backhaus clamps in order to achieve a clean resection border.
* Ethicon GmbH, Ro bert-Koch-Str. 1, 22851 Norderstedt, Germany
Fig. 8.12
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Fig. 8.13
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Two-La y er Skin Closure (Fig. 8.14)
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The skin edges are closed with concealed subcutaneous interrupted
3.0 Monocryl sutures. Each successive suture bisects the wound length;
this prevents “dog ears” at the end of the sutures. It is best if the sutures
are started at the distal end and progress to the middle. Suturing can
then be started at the proximal end (axilla) and continued to the
middle.
䊏
Complete wound closure is then carried out with two-layer 4.0 Monocryl interrupted sutures. The wound is closed, therefore, with so little
tension that the cutaneous suturing (running or intracutaneous) then
only plays a minor role.
Cutaneous Sutures: Running or Intracutaneous 4.0 Monocryl (Fig. 8.15)
䊏
In general, we carry out all cutaneous suturing intracutaneously with
4.0Monocryl.Thissuturingmethodhasprovedtobethebest,asit
does not need to be removed and does not cause granulomas. It produces optimum healing of the suture line.
Running sutures should also be mentioned in this manual. A study
(n = 25) comparing running sutures with intracutaneous sutures
showed that results were similar. Running sutures are removed after
8days.
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Fig. 8.14
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Fig. 8.15
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Dressing (Fig. 8.16)
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Steri-Strips™ are first applied as a dressing to relieve the tension on the
cutaneous sutures. Afterwards, sterile cotton is wound around the
Cutiplast wound dressing. In addition, the arm is then loosely wrapped
with elastic bandages from the wrist to the shoulder.
Aftercare
The operation can be carried out either on an inpatient or outpa tient
basis.
䊏
The dressing is removed on the first postoperative day. The Steri-Strips
are left in place for 8 days and can be removed by the patient. During
this time, there should be antibiotic prophylaxis and the arm should be
elevated. The patient should avoi d physical exertion for a period of
2–3 weeks in order to permit undisturbed wound healing. To prevent
congestion of the lymphatics, lymph drainage can be carried out from
the 8th postoperative day.
After removing the Steri-Strips, the patient should treat the scar with
dexapanthenol ointment for 2 weeks and then with silicone ointment
for a further 2 months. If after 2 months it can be seen that scarring is
disturbed, it can be treated, as with all scars, with intralesional injections of triamcinolone crystal suspension 40 mg. With any scar, this
treatment should be carried out as soon as possible, as these injections
improv e erythema and bulging scars considerably in the first few
months.
In extreme cases, hypertrophic scars must be excised after a period of
12 months and treated with stimulating radiation in divided doses for
several days immediately after excision. Cooperation with an experienced radiologist is necessary for this.
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Note:
It is possible to insert a Redon drain to drain off wound secretions.
In most cases, this may be removed as early as the first day after the
operation.
Fig. 8.16
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Results
a
372
b
Fig. 8.17
a Right and b Left arm preoperative
PatientI:Thisisa64-year-oldpatientwithskinfoldsowingtoherage
in the entire axilla and upper arm region, extending to the elbow. In
this case a longitudinal, spindlelike excision was carried out.
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c
d
Fig. 8.17
c Right and d left arm postoperative
PatientI: Twelve Months After theOperation
Twelve monthsafter the operation there isno noticeable scarring,
and the skin folds have been eliminated as far as the elbow area.
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a
374
b
Fig. 8.18
a Right and b left arm preoperative
Patient II: This is a 59-year-old patient with folds of skin in the upper
third of the upper arm, extending to the axilla.
The “fish-mouth technique” was used for this patient, i.e., the incision
was only in the axilla and the upper third of the upper arm. This results
in a shorter operation time and less scarring.
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c
d
Patient II: Twel ve Months After the Operation
After eliminating the folds, the volume was also reduced. The incision
in the axilla and the upper medial part of the upper arm is not visible.
Fig. 8.18
c Right and d left arm postoperative
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