Skin Tension on Closure

Ideally, any wound, excision, or repair should be designed so that the skin edges approximate under minimal tension. If not, and it is a clean laceration or elective excision, the surgeon may undermine tissue and trim to make edges approximate. Debridement or excision of the edges of dirty wounds may improve alignment and allow closure. Placement of tension-relieving sutures or deep sutures should always be considered to facilitate direct closure of noninfected wounds under tension. If a suture is less than ideal, it is best to remove and replace it.

Tips and beveled lacerations are challenges because too much tension on the narrowest edges may contribute to necrosis or wound breakdown. Ideally, the skin sutures are used to approximate slightly everted edges and not to pull primary deep tissue under high tension. If the wound or excision has a clean approximation under minimal tension, a single-layer repair is preferred. If not, consider deep interrupted sutures to close the potential space (Fig. 28-10). The goal is also to avoid deep pockets where hematomas, infection, or abscesses could develop. (See Tuggy Video: Inverted Subcuticular Stitches.)

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