[B821]Botched Plastic Surgery On

Skin staples are particularly useful as a time saver for long incisions or to position a skin closure or flap temporarily before suturing. Grasping the wound edges with forceps to evert the tissue is helpful when placing the staples to prevent inverted skin edges. Staples must be removed early to prevent skin marks and are ideal for the hairbearing scalp.

Skin tapes can effectively approximate the wound edges, although buried sutures are often required in addition to skin tape to approximate deeper layers, relieve tension, and prevent inversion of the wound edges. Skin tapes can also be used after skin sutures are removed to provide added strength to the closure. Skin adhesives have been developed, and may have a role in wound closure, especially in areas where there is no tension on the closure, or where strength of closure has been provided by a layer of buried dermal sutures. Adhesives, by themselves, however, do not evert the wound edges. Eversion must be provided by deeper sutures.

Elliptical excision of inadequate length may yield ?dog-ears,? which consist of excess skin and subcutaneous fat at the end of a closure. There are several ways to correct a dog ear. Dog-ears are the bane of plastic surgical existence and one must be facile with their elimination. Dog-ears do not disappear on their own. Lesions located at or adjacent to free margins can be excised by wedge excision. In some elderly patients, one third of the lower lip and one fourth of the upper lip can be excised with primary closure.

Three methods of removing a dog-ear caused by making the elliptical excision too short. A: Dog-ear excised, making the incision longer, or converted to a ?Y?. B: One method of removing a dog ear caused by designing an elliptical excision with one side longer than the other. Conversion to an ?L? effectively lengthens the shorter side.

Serial excision is the excision of a lesion in more than one stage. Serial excision and tissue expansion are frequently employed for large lesions such as congenital nevi.The inherent viscoelastic properties of skin are used, allowing the skin to ?stretch? over time. These techniques enable wound closure to be accomplished with a shorter scar than if the original lesion was elliptically excised in a single stage.
Skin grafts are a standard option for closing defects that can?not be closed primarily. A skin graft consists of epidermis and some or all of the dermis. By definition, a graft is something that is removed from the body, is completely devascularized, and is replaced in another location. Grafts of any kind require vascularization from the bed into which they are placed for survival. Any tissue which is not completely removed prior to placement is not a graft.
Skin grafts are classified as either split thickness or fullthickness, depending on the amount of dermis included. Split thickness skin grafts contain varying amounts of dermis, whereas a full-thickness skin graft contains the entire dermis.

All skin grafts contract immediately after removal from the donor site and again after revascularization in their final location. Primary contraction is the immediate recoil of freshly harvested grafts as a result of the elastin in the dermis. The more dermis the graft has, the more primary the contraction that will be experienced. Secondary contracture, the real nemesis, involves contraction of a healed graft and is probably a result of myofibroblast activity. A full thickness skin graft con tracts more on initial harvest (primary contraction) but less on healing (secondary contracture) than a split-thickness skin Closure of wounds following circular excision. A: Skin graft. B: Sliding triangular subcutaneous pedicle flaps can be advanced to close the circular defect; the triangular defect is closed in a V-Y fashion. C: Transposition flaps based on a skin pedicle and rotated toward each other can also be used.