Incisions Flap design Closure of Wounds

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1 Incisions Flap design Closure of Wounds Intekhab Islam Oral and Maxillofacial Surgery Incision and Flap Design 1

2 Outline Incisions Flaps Closure of wounds Incision and Flap Design 2

3 Incisions Access to operating site is obtained by cutting skin or mucous membrane and by dissecting through this incision to elevate a flap Best possible approach Least danger to important structures Site Size Form Incision and Flap Design 3

4 Access Visual Mechanical Operative site visible and accessible to instrumentation Incision and Flap Design 4

5 Incisions Swann Morton No 15 blade most commonly used No 11 for draining abscess : Hiltons method Incision and Flap Design 5

6 Incision: Principles Sharp Blade Clean incisions Change blade after cutting bone and ligament Firm long continuous strokes Repeated tentative strokes damage tissue Impair healing More bleeding Avoid vital structures parotid duct Mental nerve Incision and Flap Design 6

7 Incision :Principles The scalpel should move at uniform speed and with sufficient firmness to cut through not only the mucosal surface but also the periosteum overlying the bone. Blade perpendicular to surface Avoid chamfering the edges Wound edges less susceptible to necrosis Easier to reorient and reappose Incise over healthy bone, attached gingiva Incisions near teeth should be made in the gingival sulcus Incision and Flap Design 7

8 Anatomical considerations Maxilla: Air sinuses Nasopalatine canal Infra orbital nerve Floor of nose Palatine and pterygoid vessels Incision and Flap Design 8

9 Anatomical Considerations Mandible Mental nerve Inferior alveolar nerve Sublingual vessels Lingual nerve Available Bone Ridge morphology Local deformities Cyst Granulomas Presence of teeth Incision and Flap Design 9

10 Surgical Flap Design Purpose of flap is to gain access to surgical site, to obtain adequate visualization of field avoid trauma to soft tissues. Should be based on anatomy, blood supply Base broader than apex Incision and Flap Design 10

11 Flap Design Wide base: good blood supply Adequate visibility and access Minimal tension Avoid damage to vital structures Margin of flap away from operative site Wound margins resting on healthy bone Incision and Flap Design 11

12 Complications of Flap design Flap necrosis Dehiscence Infection Excessive trauma Incision and Flap Design 12

13 Necrosis Base wider than apex Sides run parallel or converge at the apex Base of the flap should be greater than length Axial blood supply should be included in the base of the flap Gentle handling of base of flap Incision and Flap Design 13

14 Dehiscence Approximate edges on healthy bone Handle edges gently Do not close under tension Incision and Flap Design 14

15 Tearing Flaps heal across incisions Long and short incisions take same time to heal Adequate exposure prevents tearing Tissue handling Do not pinch tissue forceps Use toothed forceps, tissue hooks Do not retract aggressively Incision and Flap Design 15

16 Flap Design Full Thickness Mucoperiosteal Partial Thickness Incision and Flap Design 16

17 Flap Design Crestal: Over edentulous ridge Envelope Two sided Easy to suture Can be extended Triangular / Trapezoidal / Rhomboidal Three sided Increased degree of surgical access Incision and Flap Design 17

18 Size of flap depends on purpose Flap should be broader at base Releasing incision Incision and Flap Design 18

19 Trapezoidal flaps Incision and Flap Design 19

20 Envelope flaps Incision and Flap Design 20

21 Biopsy Excise down to connective tissue layer If ulcerative, biopsy near edge If suspect malignancy, biopsy worst area If excising, excise completely, consider closure Incision and Flap Design 21

22 Flap elevation Instuments Howarths Periosteal elevator Ash Molt Mitchell osteotrimmer Warwick James Dry sterile swab Rest On Bone Incision and Flap Design 22

23 CLOSURE OF WOUNDS Be kind when possible: it is always possible The Dalai lama Incision and Flap Design 23

24 Suture Material 3 ways of classifying suture material: Natural or Synthetic Absorbable or Non-Absorbable Monofilament or Braided/Twisted Incision and Flap Design 24

25 Silk Catgut Natural Silk, linen, catgut Synthetic polymer Polypropylene, polyester, polyamide Polypropylene Polyester Incision and Flap Design 25

26 Suture Classification Monofilament Multifilament (braided) Incision and Flap Design 26

27 Resorbable Multifilament Polyglactin 910 (Vicryl) Polyglycolic acid (Dexon) Monofilament Polyglyconate (Maxon) Polydioxanone (PDS) Catgut : chromic, plain Incision and Flap Design 27

28 Non-Resorbable Multifilament : Silk Monofilament Nylon (Ethilon) Polypropylene (Prolene) Incision and Flap Design 28

29 Absorbable catgut, polydioxanone, polyglycolic acid Used for deep tissues, membranes, & subcuticular skin closure Non-Absorbable polyester, nylon Used for skin (removed) & some deep structures (tendons, vessels, nerve repairs not removed) Incision and Flap Design 29

30 The Ideal Suture Minimal tissue reaction Smoothness - minimum tissue drag Low Capillarity Max tensile strength Ease of handling - Minimum memory Knot security Consistency of performance Predictable performance Cost effectiveness Incision and Flap Design 30

31 Braided v Monofilament Has capillary action Increased infection risk Less smooth passage Less tensile strength Better handling Better knot security No capillary action Less infection risk Smooth tissue passage Higher tensile strength Has memory More throws required Incision and Flap Design 31

32 Absorbable Sutures These are absorbed within the living tissue Two main characteristics are: Tensile strength retention Absorption rate Incision and Flap Design 32

33 Characteristics of Non-Absorbable Sutures Permanent Only used when long term support is required Removed when used for skin Tissue reaction generally low However silk, linen and even nylon will lose tensile strength over a period of time True non-absorbable sutures include polyester, polyethylene, polybutester, polypropylene and steel Incision and Flap Design 33

34 Suture Size USP (United States Pharmacopoeia) /0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0 Thick Thin Incision and Flap Design 34

35 Incision and Flap Design 35

36 Incision and Flap Design 36

37 Needles Taper-Point Reverse cutting Convention al Cutting Tapercutting Suited to soft tissue Dilates rather than cuts Very sharp Ideal for skin Cuts rather than dilates Very sharp Cuts rather than dilates Creates weakness allowing suture tearout Ideal in tough or calcified tissues Mainly used in Cardiac & Vascular procedures. Incision and Flap Design 37

38 Needles Blunt Premium point spatula Spatula Also known as Protect Point Mainly used to prevent needle stick injuries i.e. for abdominal wall closure. Ophthalmic Surgery Ophthalmic Surgery DermaX* NEW: ½ The Penetration force ½ The Penetration force Superior Cosmetic Effect Incision and Flap Design 38

39 Needle Curvature Incision and Flap Design 39

40 Needle Curvature Straight needle ¼ circle Needle of choice for skin Limited use in OS Used for nose, pharynx, tendon Microsurgery associated with very fine sutures: eg ophthalmic 3/8 circle Oral surgery Almost all surgical wounds ½ circle Oral surgery: wide surgical uses 5/8 circle Urogenital tract Incision and Flap Design 40

41 Using needle holder, grasp needle about 2/3 rds of the way back from point. Incision and Flap Design 41

42 Needle Holder Castroveijo Needle Holder Incision and Flap Design 42

43 Mayo needle holder Incision and Flap Design 43

44 Index finger stabilizes the instrument by resting on the shaft. Incision and Flap Design 44

45 Surgical Scissors Incision and Flap Design 45

46 FORCEPS Grasp forceps between thumb & middle finger, while index finger is used for stabilization. If possible, use forceps to grasp dermis, rather than epidermis or skin surface itself. This helps prevent marking & injuring of skin at wound edge. Incision and Flap Design 46

47 Suture Materials Choice of suture material Mucosa, deep layers (multi- or monofilament) Skin (monofilament) Choice of suture size Mucosa, deep layers (3/0, 4/0) Skin (5/0, 6/0) Incision and Flap Design 47

48 Closure Technique Incision and Flap Design 48

49 Closure Technique Incision and Flap Design 49

50 Closure Technique Needle inserted at unequal depth on either side of wound Overlapping of margins result in an ugly scar Incision and Flap Design 50

51 Closure Technique Failure to include an adequate amount of subcutaneous tissue Inverted margins result in a depressed scar Incision and Flap Design 51

52 sutures Interrupted Mattress Horizontal Vertical Continuous Simple Continuous Incision and Flap Design 52

53 Interrupted sutures Most widely used sutures Easy Fast Reliable Less surface contact Susceptible to laceration Incision and Flap Design 53

54 Mattress Sutures Horizontal Vertical Buried SUPPORTS FLAP DISPLACEMENT Brings surfaces of wounds together Contact between wider areas leads to better contact between wound margins and better healing Difficult to remove May leave gaps between flaps coronally Incision and Flap Design 54

55 Continuous sutures Logical progression to interrupted sutures Linked interrupted sutures with proximal and distal knots Examples Apicoectomy Surgical approach to maxilla Fast and easy Point contact rather than uniting surfaces Risk of wound dehiscence Incision and Flap Design 55

56 SIMPLE INTERRUPTED suture Incision and Flap Design 56

57 Incision and Flap Design 57

58 Needle passed through flap from outside inwards: Always pass through free flap first Incision and Flap Design 58

59 Pierce the second flap from inside out:maintain same penetration distance to avoid asymmetry Incision and Flap Design 59

60 1.5-2 mm from margins is ideal: avoid too deep bites as these can constrict blood supply Incision and Flap Design 60

61 Two loops in the clockwise direction Incision and Flap Design 61

62 Place knot lateral to incision Incision and Flap Design 62

63 Continuous suture: Place first suture like interrupted: cut tail only Incision and Flap Design 63

64 Enter the first or free flap again Incision and Flap Design 64

65 Pierce second flap from inside out: Pierce flaps individually to be more precise Incision and Flap Design 65

66 Needle is passed external to the flap and the process is repeated to enter the first flap again Incision and Flap Design 66

67 Incision and Flap Design 67

68 Incision and Flap Design 68

69 Traction must be applied to make the tension uniform throughout the suture and to avoid loose threads Incision and Flap Design 69

70 Incision and Flap Design 70

71 The final loop is grasped and sutured Incision and Flap Design 71

72 Horizontal mattress: First flap pierces as for interrupted suture Incision and Flap Design 72

73 Second flap also pierces from inside out at equal distance Incision and Flap Design 73

74 Pierce mucosa of second flap from outside in on a plane parallel to the incision line Incision and Flap Design 74

75 Pierce first flap from inside out: seek to emerge parallel to the incision with the first bite. Incision and Flap Design 75

76 Will result in a U shape Incision and Flap Design 76

77 Knot placed lateral to incision Incision and Flap Design 77

78 Vertical Mattress: First bite as interrupted but at a larger distance from incision Incision and Flap Design 78

79 Second bite equi-distant from first bite from inside out Incision and Flap Design 79

80 In a plane perpendicular to the incision pierce flap from outside in closer to the incision Incision and Flap Design 80

81 Exit first flap close to incision line with both ends of the thread ending on the same side of the incision Incision and Flap Design 81

82 Vertical Mattress Incision and Flap Design 82

83 Suture Source Filament resorption Catgut Natural Mono Cell medated,70 days PGA(Dexon) Synthetic Multi Hydrolysis, 120 days Polyglactin 910(vicryl) Polyglactin 910 (rapid) Synthetic Multi Hydrolysis, 70 days Synthetic Multi Hydrolysis, 14days PDS(polydioxanone) Synthetic Mono Hydrolyis,240 days Silk Natural Multi None Polyester Synthetic Multi None Incision and Flap Design 83

84 Suturing 101 The needle holder must be an appropriate size instrument for the size needle selected. Needles should be grasped in an area about 1/3 of the distance from the swaged area to the point. Avoid placement on or near the swaged area. The needle should be placed securely in the tip of the needle holder jaws. Do not damage taper points or cutting edges when using the needle holder to pull the needle out through the tissue. Grasp as far back as possible. Incision and Flap Design 84

85 Suturing 101 When placing the needle in tissue, any force applied should be in the direction following the curve of the needle Do not take excessively large bites of tissue with small needles. Do not force or twist the needle in an effort to bring the point out through the tissue withdraw the needle and retry Do not force a dull needle through tissue obtain a new one. If the needle is held too tightly in a sharp or hard jawed or defective needle holder, the needle may be damaged or notched in such a manner that it will have more of a tendency to bend or break on successive passes through tissue. Incision and Flap Design 85

86 Suturing 101 Tightly tied sutures can cause ischaemia & wound edge necrosis. Gentle but firm knots & minimal wound tension will minimize these factors. Remember, keep skin edges everted, NOT inverted! Three knots for braided materials: 5-6 knots for monofilaments. Cut sutures with tail around 5 mm: check with surgeon for preference: cut buried sutures short Tail is left because it helps prevent loosening or undoing of sutures. Incision and Flap Design 86

87 Suture removal Face: 5-7 days Neck: 7 days Abdomen: days Upper Extremity:10-14 days Lower extremity:21 days Scalp: 10 days Remove alternate sutures if wound gapes Incision and Flap Design 87

88 Alternate methods Staples Adhesives Steri-strips Incision and Flap Design 88

89 "Champions aren't made in gyms. Champions are made from something they have deep inside them: A desire, a dream, a vision. They have to have last-minute stamina, they have to be a little faster, they have to have the skill and the will. But the will must be stronger than the skill." - Muhammad Ali Thank you Incision and Flap Design 89