Incisions And Their Closure Incisions

These may be made for procedures on the skin or through the skin to reach deeper structures. They require careful planning and placement. Whenever possible incisions should be made along tension lines, not across them. The tension lines on the face can be identified by getting the patient to smile or grimace. Critical incisions may be marked with ink before incision.

For most incisions a scalpel with a large blade is used and the belly of the knife is drawn along in a smooth line, cutting at right angles to the skin surface. For very small and crucial incisions, it may be better to use a small bladed scalpel held

Figure 6.2. Steadying the tissue when making an incision and separating the edges with the fingers of one hand.

like a pen. Skin is elastic and the drag of the knife distorts it. To avoid this, the skin is fixed with the non-dominant hand and the edges slightly separated as the knife cuts through (Fig. 6.2).

The depth of cut is as important as the line. A fold of skin can be picked up to estimate its thickness. When making the incision, the correct depth should be reached as soon as possible and cutting then continued at that depth. One of the crucial surgical skills is the knowledge of tissues and tissue planes. The plane that has been reached must be carefully identified.

Bleeding is encountered as the incision is made and can be reduced or abolished in several ways:

• For very fine surgery of the extremities, the blood may be drained and a tourniquet applied.

• The skin and subcutaneous tissues can be infiltrated with a weak (e.g. 1 in 250 000) solution of adrenaline, which produces vascular constriction.

• Simple pressure on the cut edges for a few minutes usually controls small vessel bleeding. Neurosurgeons traditionally apply the tips of fine haemostatic forceps to the dermis and evert the edges to slightly compress them and control bleeding. Haemostatic forceps can be applied to individual vessels which may be sealed by compression, by twisting or by ligature.

Cutting diathermy is becoming increasingly popular for making skin incisions. Avoid using coagulation diathermy near the skin surface for fear of causing burns that heal slowly and leave ugly scars. Bleeding from small vessels can also be avoided by using a laser beam to cut through the skin; the depth of cut determines the choice of laser.

0 0

Post a comment