> Good closure starts before the operation with optimization of [[Wound Healing#Factors affecting wound healing]] and general closure techniques need to respect the [[Wound Healing#3 Phases of Wound Healing]] ## Wound assessment - consider etiology, location, dimensions, timing, local and systemic factors ## Wound preparation - Irrigation - cleaning the wound bed, typically with normal saline - **Multicenter RCT suggests that low pressure lavage technique (more important than fluid choice)** may decrease reoperation due to infection, healing problems, and nonunion in open fracture wound^[FLOW Investigators, Petrisor B, Sun X, Bhandari M, Guyatt G, Jeray KJ, Sprague S, Tanner S, Schemitsch E, Sancheti P, Anglen J, Tornetta P, Bosse M, Liew S, Walter S. Fluid lavage of open wounds (FLOW): a multicenter, blinded, factorial pilot trial comparing alternative irrigating solutions and pressures in patients with open fractures. _J Trauma_. 2011;71(3):596-606. doi:[10.1097/TA.0b013e3181f6f2e8](https://doi.org/10.1097/TA.0b013e3181f6f2e8)] - Antiseptics - iodine - bactericidal and water soluble - SAFE around the eyes - hydrogen peroxide - May need higher concentration compared to iodine (d/t high catalase load in some bacteria) - AVOID around the eyes (d/t corneal dmg) - chlorohexidine - In clean-contaminated operations, recommended over iodine (based on meta-analysis) - Best against gram (+), poorer with gram (-), bad for fungus - AVOID around the eyes (d/t corneal dmg) > Surgical finesse: Syringe with blunt needle can pressure wash small particulate in smaller wounds. - Debridement - removing necrotic tissue and/ or biofilm ([[Wound Healing#Local factors]]) - Use atraumatic technique with a scalpel, scissors, curette, rongeur, or hydrosurgical instrument (Versajet) (AVOID electrocautery), with the goal of: - healthy skin edges with bleeding, dense dermis - viable, soft, and yellow subcutaneous fat - solid tendon substance - red bleeding muscle - hard, healthy bone with pinpoint bleeding (paprika sign) > Surgical wisdom: If viability of the tissue is tenous, delay debridement to allow for full demarcation (2-3 days after injury) as early debridement can leave you with a subsequent necrosis front d/t retrograde thrombosis. ## Atraumatic technique - Suture selection - Suture technique - [[Suture techniques]] basic principles: - Aim for skin eversion, which creates a greater apposition of the dermis ridge, leading to ↘ dehiscence and [[Scars#Widened scars]] plus better cosmesis - ![[Pasted image 20250119131705.png]]^[Dunn C, Yag-Howard C, Nathoo R, Dane A, Leavitt A, Sutton A, Wysong A. Dermal suture height differential: The secret to simplifying and optimizing wound edge eversion. _Journal of the American Academy of Dermatology_. 2024;90(5):e169-e170. doi:[10.1016/j.jaad.2023.12.013](https://doi.org/10.1016/j.jaad.2023.12.013)] - Inversion is desired to deepen the scar line in areas of natural concavity, e.g. alar crease and scaphoid fossa > Heaped-up appearance of an everted closure improves outcome, and will resolve. ## Obliteration of dead space (+/− drains) ## Tension-free closure ## Skin eversion #### Postoperative care → Need to account for patient's conscientiousness: - Avoid permanent skin sutures for patients with low adherence, or follow-up is hard - Avoid icing (though it reduces swelling and pain) as it ↘ perfusion and oxygenation needed for [[Wound Healing#3 Phases of Wound Healing]] - Do wash the incision the day after surgery as the moisture improves [[Epithelialization]] without ↗ complications - Use moisture wicking fabric in (obese) patient with redundant skin fold (fungal nidus) to prevent excess moisture, skin maceration, and wound breakdown #### Complications - Mass build up: hematoma, seroma - Dehiscence - Infection - Necrosis - Scar #clinicalscience #technique