Problem Wounds, Flaps and Grafts

Wound care priorities

Discover and treat injuries to critical deep structures

Cover critical deep structures with skin Prevent infection, suture only when necessary Maintain function unhindered by contracture Cosmesis is a distant fifth priority

Problem Closures

Important tissues deep to wound must be explored

Wound contaminated or skin nonviable Closure under tension or inadequate skin to

close Edges uneven or complex shapes

Extend wound for exploration, parallel to important deep structures

Problem Closures

Important tissues deep to wound must be explored

Wound contaminated or skin nonviable Closure under tension or inadequate skin to

close Edges uneven or complex shapes

Debride contaminated sub Q fat and nonviable skin

Debride and undermine to give everted closure

Defatting flaps improves viability

Apical stitch salvages viability

V-Y closure for nonviable edge

Closing a nonviable flap

Problem Closures

Important tissues deep to wound must be explored

Wound contaminated or skin nonviable Closure under tension or inadequate skin

to close Edges uneven or complex shapes

Undermining first choice to relieve tension, but leaves dead space

Closing dead space prevents fluid collection but adds foreign body

Cotton pledgets may help when you must close under tension

Closing circular defect

V-Y double advancement flap

Curvilinear flap

Z-plasty changes direction of wound to align with skin tension; use 60 degree angles

Donor sites for full thickness grafts

Measure site and prepare graft

Hold the graft down to the bed

Preferred method to bolster graft in place

Problem Closures

Important tissues deep to wound must be explored

Wound contaminated or skin nonviable Closure under tension or inadequate skin to

close Edges uneven or complex shapes

Avulsion closure: larger bite on flap side prevents override

Use apical stitches first on geographic lacerations

Apical first for stellate lacerations too

Half buried horizontal for edges of differing thickness

Fixing Bowser

Closing parallel lacerations; where ample skin, could also simply excise island

Dermal suture to close laceration within abrasion

Moist occlusive dressing leads to more rapid healing of open wounds