What are Langer’s Lines?
- “Cleavage lines”
- Lines drawn on a map of the human body that correspond to the natural orientation of collagen fibers in the dermis and parallel to the orientation of the underlying muscle fibers
- Following them when making incisions results in better healing
What are two advantages of using the knowledge of Langer’s Lines when doing minor surgery?
- Minimize wound tension
- Heal faster
- Produce less scarring than when cut across lines
What are the problem areas of the body for increased risk of scarring/keloids?
- Upper chest and back
- The shoulders
How do Kraissl’s lines compare to Langer’s Lines?
- They were based off of observations in living people
When a wound occurs, what, essentially, is the body’s only interest?
- Survival
List and describe (what is occurring in each stage) the three phases of healing.
Phase 1 (Inflammatory)
- Immediate to 2-5 days
- Bleeding stops
> Constriction of the blood supply
> Platelets start to clot
> Formation of a scab
- Inflammation
> Opening of the blood supply
> Cleansing of the wound
Phase 2 (Proliferative)
- 5 days - 3 weeks
- Granulation
> New collagen tissue is laid down
> New capillaries fill in defect
- Contraction
> Wound edges pull together
- Epithelialization
> Cells cross over the moist surface
> Cells travel about 3cm from point of originPhase 3 (Maturation)
- 3 weeks - 2 years
- Collagen forms and increases tensile strengths to wounds
- Scar tissue is only 80 percent as strong as original tissue
What is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?
- 5-6 percent
What are the differences between clean, clean-contaminated, dirty/contaminated, and infected wounds?
Clean
- Free from microorganisms
- Ex. heart surgery
- Most minor surgeries done at NUNM
- Done under sterile conditions
- Primary closure
Clean-contaminated
- Non-significant contamination and less than 6 hours elapsing until medical care received
- Ex. Biliary and gastric surgeries
- Increased risk of scarring
- Some risk of loss of function
Dirty/contaminated
- Without local infection and more than 6 hours elapsing until medical care received
- Ex. Colon surgeries
- Increased chance of infection
- Much increased degree of scarring
- Some loss of function
- May leave it to close by secondary intention
Infected
- Intense inflammatory reaction and frank infectious process
- Ex. Appendicitis
Is there a “golden period” of time for closing lacerations?
- Historically, they thought it was within 8 hours on the body and 12-24 hours on the face
- Now we know they’re no longer applicable
What are the four “goals of surgery?”
- Close the wound efficiently
- Have no infection
- Result in as small and inconspicuous a scar as possible
- Have no loss of function
What factors involving the patient and surgeon affect wound repair?
Surgeon
- Responsible for creating/maintaining asepsis and the quality of technique
Patient
- Overall health status
- Must follow specific instructions from the doctor about proper wound care
- Must understand that they must contact the doctor if any questions or problems arise before the follow up visit
What is healing by first (primary) intention?
- Wound is closed to heal
What are the goals and outcomes of healing by first intention?
- Minimal edema
- No local infection
- No serious damage
- Normal healing time
- Minimal scar formation
What are the two possibilities that lead to a wound healing by secondary intention?
Wound is left open on purpose
- Ex. paper cut abrasion or draining an abscess
- Heal without closure
- Heals from the inner layers toward the surface (“granulation from below”)
Wound fails to heal via primary intention
- Excessive tissue trauma or loss
- Imprecise tissue approximation
- Wound infection
- More complicated and prolonged process
Can healing by secondary intention be a reasonable choice made by the patient or surgeon?
- Yes, suturing may not offer any advantages over conservative treatment of small hand lacerations
- Most patients and physicians feel uncomfortable leaving wounds open
What are the advantages of healing by secondary intention?
- Simplicity
- Relatively low risk of infection
What are the disadvantages of healing by secondary intention?
- May take forever to heal
- Tends to cause larger scars
What are the steps in delayed primary closure?
- Debride the wound of non-vital tissues
- Leave the wound open
- Pack the wound with sterile dressing
- Cover with supporting bandage
- Repeat process daily
- Wound gradually gains sufficient resistance to infection and then granulation tissue covers the raw edges
- Once healthy granulation tissue develops (4-6 days), it’s ready to be closed
- Approximate edges and close in same manner as primary closure
When should delayed primary closure be used?
- Infection
- Wound will need further debridement
What are the advantages of delayed primary closure?
- Uncomplicated closure
- Low risk of infection
- A “reasonable” scar
- Better overall than an infected wound
What are the advantages of using a running stitch?
- Convenient
- Rapid to perform
- Provide good approximation of wound edges
- Provide good eversion
- Provide proper tension
- Good for areas of loose skin
Where on the body is a running stitch a good stitch to use?
- Eyelids
- Scrotum
- Any loose skin
