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Rosadi Seswandhana
Reconstructive & Aesthetics Plastic Surgery Division
Department of Surgery
Faculty of Medicine - Universitas Gadjah Mada
Wound ?
Clinical Observation
Cellular Biomoleculair
Surgical Intervention
Clinical Observation
Epithelization
Connective tissue deposition
Wound contraction
Tissue Repair
Injury 3d 7d 3w 1-2y
Major Even Clot formation Growth factor Collagen deposition Collagen cross-linking
Hemostasis Elaboration
INFLAMMATORY
Repair
PROLIFERATION
phase
REMODELING
Fibroblast
Lymphocytes
Cellular Macrophages
influx
Neutrophils
Vascular Vasoconstriction
response Vasodilatation
Surgical Intervention
Primary intension
Secondary intension
Delayed primary intension
Principles of soft tissue injury management
Debride and irrigate devitalized tissue
Cleanse wound and traumatic tattoos
Remove any foreign body
Obtain meticulous hemostasis
Obliterate any dead space
Handle tissues gently
Use atraumatic technique
Avoid tension in wound closure
Use buried sutures judiciously
Leave contaminated wounds open
(Weinzeig, 1994)
WOUND CLOSURE
MATERIAL SUTURE
Suture Classification
Natural or Synthetic (man made)
Monofilament or Multifilament (braided)
Absorbable or Non-Absorbable
Suture Classification
Monofilament Multifilament (Braided)
Type of suture material
Non-Absorbable
Organic / Nature Syntethic / Man Made
Braided Braided Monofilament
Silk Braided-Nylon Nylon
Polyester Polypropelene
Absorbable
Short term Medium term Long term
Natural Syntethic Braided Monofilament Braided Monofilament
Cat gut Polyglactine Polyglactin Poliglecaprone PGA/PPLA PDO
rapide 910 25
Braided v Monofilament
Has capillary action No capillary action
Increased infection Less infection risk
risk
Less smooth Smooth tissue passage
passage
Less tensile strength Higher tensile strength
Better handling Has memory
A+E
5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0
General
Thick Thin
Suture Selection
Size originally scaled from 0-3
As technology advanced and sutures became smaller, extra
0s were added
Scale now ranges from 3 (largest) to 12/0 (smallest)
Size Uses
7/0 and smaller Ophthalmology, microsurgery
6/0 Face, blood vessels
5/0 Face, neck, blood vessels, penile
Mucosa, neck, hands, limbs, tendons, blood
4/0
vessels
3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
Abdominal wall, fascia, drain sites, arterial
0 and larger
lines, orthopaedics
Needle Shape
Needle Curvature
Local Anesthetic
Mechanisme of Action
A blockade of excitation of nerve endings
Inhibition of the process of conduction in
peripheral nervous system
Dosage
Agent Onset Maximum Maximum Duration Duration
Dose Dose w/o with
(mg/kg) (mg/kg) epinephrin epinephrin
w/o with
epinephrin epinephrin
Lidocaine Rapid 3.5 5-6 1-1.5 hrs 2-3 hrs
Bupivacaine Slow 2.5 3.5 4 hrs 6-8 hrs
Toxicity
Local
Rare
Nerve injury c.o. needle trauma, high pressure
intraneural injection
Systemic
Accidental intravascular injection
Overdose
CNS & CVS
Systemic Toxic Effects of Lidocaine with rising
Plasma concetration (mcg/ml)
CVS depression 24
Respiratory depression 18
Coma 14
Unconsciousness 10
Convulsion 8
Muscular twitching 6
Visual disturbance 4
Lightheadedness, tinnitus,circumoral 2
& tongue numbness
Technique of Suturing
Knotting
Reef knot Surgeon knot Granny knot
Timing for Wound Closure
Principle governing: as soon as possible with
minimal complication
Traditional teaching:
after 6 hours secondary intention
before 6 hours primary intention
Gradually 6 hours became 8 up to 12 hours
Techniques for Wound Closure
Suturing