Chapter 6: Plastic Surgery. - Famona Site

Where the possibility of suturing exists, skin excision should leave edges perpendicularto each other to facilitate good approximation and healing later.When excising skin, only up to 3 mm of normal skin should be removed. If ever indoubt it is better to leave alone and review at the second look stage, usually after 36 to 48hours.Puncture WoundThis should be excised and thoroughly cleaned. An elliptical excision is the usual onemade as it facilitates suturing. Deeper tissue should be explored as serious injuries have oftenbeen discovered when handling them was no longer optimar, i.e., a puncture wound on thewrist front may have a lacerated palmaris longus, median nerve and one or more of thesuperficial and deep flexor tendons.FatDevascularized fat rots quickly. It should therefore be washed out or excised becauseit forms a good medium for bacterial sepsis.FasciaIf devitalized, it should be removed to within 5 mm of normal tissue. Fascia that istense and encasing a tight compartment should be incised (fasciotomy). This is done evenif there is no wound. The presence of impending or full-blown compartment syndrome isindication enough for a fasciotomy.HaematomaThis represents a space occupied by dead tissue and should be removed. Afterevacuation the feeding vessels may be seen and it should be tied off. Otherwise, the space islaid open to heal by secondary intention.TendonsHandle with care. Avoid crushing. In clean wounds these are sutured. Never leaveexposed for they perish fast. In non-optimal conditions, clean, tag, and cover with skin ormuscle.NervesConditions are frequently not ideal for primary suturing. Dead frayed portions shouldbe excised. Save blood supply running alongside nerves. Tag and cover for later suturing orgrafting. A microscopic excision is usually helpful in determining normal tissue in nerve.Secondary procedures are usually done in 7 to 10 days.4