Tuesday, 28 February 2017

Skin Closure/Suture Techniques (Fine Art)


Scarless Suturing


Scarless Skin Closure Techniques

Melanesians have a High Risk for Hypertrophic Scars and Keloids. Therefore, to achieve a scarless closure of any Open Surgical Wounds, carried out on the Melanesian Skin is a great challenge. Most times, we choose Minimally Invasive Techniques such as ‘Sclerotherapy. However, sometimes, it is absolutely necessary to do an Open Surgical Excision to remove any lumps or bumps beneath the skin & then manually suture the opened skin edges together.

Requirements & Guidelines to Achieve Scarless Skin Closure in the Melanesian:

1. Clean/Straight Incisions/Cuts
2. Hemostasis (Stopping of Bleeding) Without Much Use of Diathermy Heat or Use a Bipolar Instead
3. Choice & Size of Suture Materials
4. Choice of Suturing/Closure Technique
5. Anatomic Location of Wound (Tension, Sebaceous Glands, Skin Thickness, etc.)
6. Skin Undermining (tunneling) & Excision of Sebaceous Glands (skin glands that produce oil/sebum)
7. Contour & Skin Color (Avoid ‘Dog Ear’, etc.)
8. Consider Closing Corners First, Inside/Median Side First then Outside/Lateral Side
9. Consider Scar Contractures on Joints (Z-Plasties)
10. Good Diet & Avoid Strenuous Physical Activities, Post Operative
11. Wound Dressing Methods & Timing
12. Avoid Stitch/Suture Marks (Timing of Stitch Removal, etc.)
13. Infection Control (Choice of Antiseptics & Antibiotics)
14. Non-Smoker (Avoid Active & Passive Smoking)
15. Monitoring/Follow-up of Scar & Continued Treatments (Pressure Therapy, etc.)


Notes on Multiple Flaps/Corners for Closure Including Multiple W-Plasties:

1. It takes a lot of time plus effort & may be difficult to incise (execute precisely)

2. Small & Multiple corners on flat surfaces are difficult to stitch-up, have poor blood supply & there is high risk for tip necrosis

3. We prefer a straight line closure, blending into natural creases & wrinkle lines & simple & single Z-plasties across/over joint surfaces/creases (perpendicular to)


A Case of a Nose Lump (Exostosis/Osteoma or Benign Bony Outgrowths of the Nasal Bone), Excised & the Skin Edges Were Sutured Using our Finest Suturing Technique. Note the skin darkening from excess skin but a tiny straight scar line.



Another case of Naso-Labial Flap, Donor Site Straight Line Closure Technique.
-The flap is attached to the defect & delayed (left attached) for 3-4 weeks.
-This will allow blood vessels to grow in through the contact skin edges
-After that the flap can be safely divided & the part of the skin covering the defect can survive


The blood supply of the Naso-Labial Flap is from the Facial Artery. During the time of harvest, this artery must be included  within the flap, otherwise there will be flap necrosis (skin becomes black due to no blood supply).



Achieving Almost a Scarless Healing with a Z-Incision for Open Rhinoplasty. A 'Z' Makes it Easy to Incise and to Close Later on, with Good Healing.



We also apply our technique of scarless skin closure to large defects. See here, our technique of closing a scalp (head) defect and also the harvesting of a Latissimus Dorsi Flap to Reconstruct a Neck Defect & the closure of the donor site defect. We prefer a straight line closure.

Scalp Alopecia (Defect) Using a Single Straight Line Closure.







Estimating the tension of skin closure.



Design (Drawing over scar to be excised) & trimming of surrounding hair.



The defect after excision of scar.



Undermining, to reduce tension of skin closure.


Skin edge approximation, to check if undermining is enough (reduced tension).



The defect is closed using a one-layered Nylon, running/continuous  suturing, locked (a knot is tied) at 4 intervals only.





One week after removal of stitches. Take note of the tiny linear scar.



The Harvesting of a Latissimus Dorsi Flap to Cover Defect of the Neck, followed by the closure of a very large donor site defect, using our fine technique. Marking out of the maximum size of skin that can be harvested.


Skin undermining to release/minimize tension.


A very large donor site defect, after complete flap elevation, that needs to be closed.


Partial Donor Site Closure before application of flap, to reconstruct a neck defect.


Appearance of donor site scar after 1 week.



This is the First Case of Latissimus Dorsi (LD) Flap Reconstruction Done in PNG by a Local Surgeon, Using a High Level of Scarless Skin Closure Technique. 

Despite that, there was No Water Running in the Operation Theatre Taps for Scrubbing (Washing Hands). Rain Water Fetched in a Plastic Container the Previous Day & Ordinary Laundry Bar Soap, was provided instead, for Scrubbing (Washing Hands). Despite that, the Surgery Went Well and Its Post-Operative Outcome was Superb.


Before Reconstruction of the Neck Defect (Scar Contracture, which was excised totally) using the above harvested Latissimus Dorsi Flap.




After Reconstruction (covering of the excised scar tissue defect, using the latissimus dorsi flap).




Other Methods for Obscuring Scars:

1. Blending Incision/Suture Lines into Natural Crease & Wrinkle Lines

2. Putting Incision/Suture Lines in Non-Visible Areas

Hiding the Scar Within the Naso-labial Natural Crease Line. 

This patient underwent Open Intra-Arterial Sclerotherapy for Artherio-Venous Malformation of the Upper Lip. The incision is done to visually locate the main artery (feeder) that feeds blood into the swelling, rather than through a catheter; The Superior Labial Branch of the Facial Artery! The Sclerosants convert the vascular malformation into a lump of scar, which was later excise through the inner part of the upper lip (obscuring/hiding the scar).

It was found by Taylor, a famous Australian Plastic Surgeon, that somehow Arterio-Venous Malformations form along Choke Zones. Choke Zones are borders of Angiosomes (1 area supplied by a single vessel or arterial branch)



Take note that the scars are successfully hidden along the naso-labial crease and the intra-oral side of the lip. Note almost the scarless final appearance of the incision sites as well as the total shrinkage of the Arterio-Venous Malformation.


The Anatomy of the Facial Artery & its Main Branches.

Arterio-Venous Malformation Explained by Dr. William Mol (Vascular Anomalies Specialist).



*Truncal means more central, large vessel (Artery, Vein or Lymph Vessel)

In our patient above, we noted the absence of the superior labial Arterial Branch on the right side only. We then deduced that the branches from the Superior Labial Artery on the Left side connected directly to the branches of the Superior Labial Vein from the Left Side, Without any Capillary Interposition










Saturday, 25 February 2017

Gynecological Reconstructive Surgery

WHAT IS UTERO-RECTAL PROLAPSE?

The uterus (womb) and/or rectum (end of large intestine that hold feces before defecation) can prolapse (fall through) the vaginal opening or anal opening. This can happen because of weakness in the muscles that form the floor (Pelvic Floor Muscles) and holds them up into the pelvic cavity (small room/space below the abdominal cavity) by these muscles contracting. The floor may become weak, because or Old Age or Disease.

We have successfully reconstructed the supporting structures in an 87-Year-Old Woman with Utero-Rectal Prolapse due to Old Age (reported below).

The Normal Anatomy of the Female Pelvis (Pelvic Organs).

Note the Black Line (Level) of Pelvic Muscles that forms the floor (Below), supports & holds the Urinary Bladder, the Uterus & the Rectum above and in place, without them collapsing down & outwards. 

Prolapsed Uterus (Uterus or Womb falling through & out through the vaginal canal, inside out)



Prolapsed Rectum (Part of or the end of the large intestine, falling through & out the anal canal opening, inside out)


RECONSTRUCTION OF UETRO-RECTAL PROLAPSE (HERNIATION) IN AN 87-YEAR- OLD WOMAN

STEPS:


1. Anesthesia (Sedation, Analgesia, Oxygen via Mask, IV Antibiotics & IV Fluids


2. Positioning (Lithotomy Position)



3. Close-up View of Utero-Rectal Prolapse*Note the Catheter Inserted into the Urethral Opening to Secure the Removal of Urine into a Urine Bag (Yellow/Golden Tube)



4. Reduction of Rectal Prolapse Commences



5. Reduction of Rectal Prolapse Ends



6. Reduction of Uterine Prolapse Commences



7. Reduction of Uterine Prolapse Ends



8. Reconstruction of Structures that Holds the Uterus & Rectum into the Pelvic Cavity
-After Reconstruction of the Vaginal Vault, Now Reconstructing the Anal Canal & Anal Opening



9. Post Reconstruction, After 3 Days-Note the Urine Catheter Still Left in Place & Some Degree of Tissue Swelling that may Regress Over Time



*The patient was discharged home uneventfully
*The Remaining Quality of Life (QOL) of the Patient has been improved

Dr. William Nimle Mol can also work closely with Gynecologic Surgeons in 'Team Surgery' to reconstruct any defects within the Pelvic Region.

If you have any questions, regarding this procedure/technique or would like to enquire & know more in-depth information, then contact Dr. William Nimle Mol on this email address: molwillie@yahoo.com 

WHAT ARE THE PELVIC FLOOR MUSCLES.....????

INCASE YOU STILL WONDER! 

BELOW ARE ILLUSTRATIONS BY DR. GRANT, THE GREATEST ANATOMY ILLUSTRATOR & TEACHER OF ALL TIMES!




Most Viewed Postings: