Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4581_Библиотеки_им_академика_М_И_Перельмана

It is essential not to further traumatize the wound edges. The more these are damaged, the less pleasing the outcome will be. The skin hook is the least traumatic instrument to grasp the wound edges (Fig.3.9). Its use, however, requires skill and expertise. The dissecting forceps are more routinely used; individual preference will dictate the choice of the toothed or non-toothed varieties. In both cases, the surgeon should be aware of the possible “crushing” of tissue, when using them without the appropriate delicacy and care. It is the author’s experience that one tends to exert less pressure when using the toothed for-

When there is no tension, interrupted skin sutures properly placed are adequate. When there is tension, placement of buried absorbable sutures which hold the deep tissues (muscle, subcutane­ous tissue) allows early removal of skin sutures without wound disruption or stretching.

brought freely into place so that insertion and pull through of the needle are in line of its curve (Fig. 3.12). When tying the knot, the surgeon should take into account that a degree of postop­erative edema will develop. If the knot is too tight, it will cut in more rapidly and make a suture mark.

then brought through the skin cutting vertically and following a segment of an imaginary circle (Fig.3.15). It is preferable to exit the whole nee­dle through the wound before entering the second wound edge (Fig. 3.12). It is also technically easier, and advisable, to suture the more mobile side of the wound to the more xed side.

The sutures ought to be removed at the earliest time judged safe, and this depends on so many factors: degree of tension, site, line of wound, etc. In the face, one tends to remove sutures rather earlier than later. One must remember, however, that the tensile strength of the wound is minimal and dehiscence is liable to occur on the slightest provocation. Good light, sharp scissors which cut to the point, and ne non-toothed for­ceps which grip properly are necessary. Absolute gentleness is required when removing facial sutures. One should always remember to pull out the cut suture towards the wound and not away from it. Instead of the scissors, one can also use the tip of a No. 11 or 12 scalpel blade (Fig.3.17). It is advisable to have the patient’s head sup­ported so that the suture line remains absolutely still. Because of the minimal tensile strength, the wound should be supported with steristrips for 4–6days after suture removal. It is seldom prac­ticable to support the wound much beyond this, and attempts to prevent later stretching of the wound by prolonged support are of limited value (McGregor 1989).

who presented with right facial paralysis caused by parotid hematoma after a low-energy facial blunt trauma. These hematomas require serial aspirations for hematoma evacuation after which regression and complete remission of symptoms occur (Coltro et al. 2010). Physicians should always bear in mind that a hematoma is quite often indicative of more signicant underlying bone injury (Fig.3.7).

accidents. They seem to occur rather often; how­ever, most patients do not seek hospital assistance due to the limited extent of the injury. The face is involved in 13–17% of the cases (Agrawal etal.

parts of the face (forehead, nose, chin) are usu­ally affected (Fig. 3.21b). Exposure of several nerve endings is the reason for the disproportion­ate pain, compared to lacerations, that these patients suffer.

A complete avulsion of the eyelid is a true sur­gical emergency. Immediate coverage is required in order to prevent further corneal damage, decreased visual acuity, and exposure keratopa­thy (Ioannides etal. 1988). Acute care consists of an ophthalmological consultation, placing an antibiotic patch over the cornea, and covering the eye with a non-permeable occlusive eye shield. Trapping moisture within the orbit should pre­vent dryness and further desiccation of the super-

Complete avulsion of the ear requires immedi­ate replantation. Microvascular ear replantation is a rare event having been reported only 25 times from the rst case in 1980 till 2002 (Kind 2002). It requires a lengthy operative time and hospital stay and has a signicant failure rate. Microvascular reconstruction is necessary to anastomose one ear artery and vein. Venous inter­position is often required, due to intima tears of the small ear vessels. Occasionally, venous anas­tomosis is not feasible or fails, resulting in venous congestion and eventual ear loss. Leeches have been shown to be of value in such cases, decon­gesting the congested ear and saving the replanta­tion (Otto etal. 1999; Frodel etal. 2004). Akyürek et al. (2001), however, reported a case of a replanted ear where no suitable veins were found; therefore, medicinal leech therapy was used for venous drainage. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. The auricle was found to be necrosed totally the following day. The authors thought that inadequate debridement of non-vital tissues may have led to failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of

Traumatic avulsion of the lip is a rare yet dev­astating event affecting both form and function. Conservative management allowing the wound to heal by secondary intention has been reported to provide good results in certain cases, especially in younger patients (Rhee etal. 2004).

Successful reattachment of a lip shred mea­suring 25 × 15 mm without vessel anastomosis has been reported by Trogues and Danan (1981). When feasible, replantation of the amputated lip segment offers an ideal solution for reconstruc­tion. Walton etal. (1998) assessed the outcome of a group of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. All injuries were the results of bites, 11 from dog and two from human. The injury site more commonly involved the upper lip by a factor of 2:1. Defect size was highly variable ranging from 3.0 to 36.0cm2. All replants survived. One patient suffered partial loss of the replanted lip segment owing to iatro­genic injury. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Sensibility return was quite good with 12 of 13 patients demonstrating at least pro­tective sensibility (two-point sensibility <10 mm). Although color match was deemed excellent, scarring was often suboptimal with six patients requiring 12 operative revisions. Hypertrophic scarring was seen in half of the patients, notably the younger ones. Although labial arteries were repaired in all patients, venous anastomoses were not possible in 7/13 patients. Postoperative venous congestion was observed in the replanted lip segment in all patients, necessitating alternative measures for venous egress. Medicinal leeches were used in 11/13 patients beginning in the early postopera­tive period and averaging 5.5 days (range 1–8days). One or more forms of anticoagulant therapy were used in the majority of patients. All patients received some form of heparin antico­agulation, and 10/13 were systematically hepa­rinized. Seven patients (>12 years of age) received oral and/or rectal aspirin. Low­molecular- weight dextran was administered to seven patients. The combined effect of daily leeching and anticoagulation resulted in blood

Penetrating injuries to the face (Fig. 3.24) and neck (Fig. 3.25) often present with vascular lesions and airway compromise and may be life­threatening. They are caused by a variety of non­projectile wounds (e.g., pencils, knives, and other sharp implements such as screwdrivers or glass, as well as accidental sporting or occupational impalement injuries caused by metal railings, garden materials such as sharp wooden poles and