Lacerations subjected to strong skin tensions are prone to wound dehiscence and healing with wide, hypertrophic scars. Ihese lacerations can be identified by retraction of their wound edges more than 5 mm and the alignment of the long axis of the wound with the wrinkle lines or transverse axis of the joint. Undermining the wound edges is one method to reduce tension, but this technique can diminish the blood supply to the wound, thereby damaging wound defenses and inviting the development of infection. Attempting to reduce tension by closure of adipose tissue is to be avoided because it enhances infection without strengthening the wound.
Dermal skin closure is recommended in these wounds to maintain their strength and prevent the development of wound dehiscence after removal of the skin sutures or the exfoliation of skin-closure tapes or tissue adhesives. Because dermal sutures allow early removal of the percutaneous suture, needle puncture scars and tracts do not develop, but there is no reduction in scar width. Dermal repair should be accomplished with the least number of interrupted sutures and with buried knots using braided synthetic absorbable sutures. Ihe suture ends are cut flush with the knot. Interrupted percutaneous synthetic monofilament sutures positioned between the dermal sutures are then used to close the skin edges ( Fig 37:28). Alternatively, if the skin edges are close together after dermal suturing, the epidermis can be closed with skin-closure tapes or tissue adhesives.
FIG. 37-28. A. Linear laceration of left forehead subjected to strong static skin tensions. B. Ihree interrupted dermal skin sutures bring the retracted wound edges together. C. Four interrupted percutaneous sutures positioned between the dermal sutures provide meticulous approximation of the wound edges.
Wound undermining reduces wound tension by releasing the dermis and superficial fascia from their deeper attachments, allowing the wound edges to be brought together with less force. Undermining is potentially useful in the scalp, forehead, and lower legs, particularly in the tibia area, where the skin is under a great deal of natural tension. Caution must be taken because this procedure can spread bacteria into deeper tissues as well as creating a deeper and larger dead space. Undermining is performed by using scissors placed underneath the dermis and gently spreading them to bluntly dissect in a parallel fashion, releasing the dermis from deeper attachments. Cutting is kept to a minimum to minimize bleeding.
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