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Horizontal Mattress Suture

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121. Nail Surgery (Follow-up)

, trimmed, and reattached to the nail bed and the LNFs by using horizontally placed mattress sutures. Stitches are removed in 10 days, when the nail is firmly adherent to the nail bed. Anesthesia is usually not required, but, when indicated, a digital block may be performed. Repair of simple lacerations Superficial lacerations that are limited to the nail plate and involve less than 3 mm of the nail bed usually heal independent of surgical repair as the injured nail grows out. [ , ] Larger lacerations (...) original anatomical site. Hemostasis is achieved with electrocoagulation, Monsel solution, or aluminum chloride solution. The wound may be allowed to heal by secondary intention. Alternatively, the wound may be closed by passing sutures through the nail plate and the LNF. When dressing the wound, the lateral nail groove is packed with iodoform or petroleum jelly gauze. A nonadherent dressing (eg, Telfa) is applied, followed by the placement of a bulky dressing or cling that is secured with elastic tape

2014 eMedicine.com

122. Facelift, Mid Face

the cavity with saline and then with antibiotic-containing solution. The V-shaped incisions are advanced superiorly and closed in a "Y" configuration. The authors use 4-0 chromic horizontal mattress sutures. This has the effect of everting the wound edges, creating a valve system and decreasing the probability of saliva entering within the wound. Fat grafting is often used to augment facial volume or to correct asymmetry. A study by Stevens et al described the successful use of a triple-layer mid face (...) have eliminated the need to perform any periocular incision. The periosteum is raised over the entire anterior malar area and the anterior two thirds of the zygomatic arch. Tunnels are made over the zygomatic arch, and independent suture suspension of the SOOF, inferior malar soft tissues, and Bichat fat pad is performed. Next: Indications Mid face lifting has the following aesthetic and reconstructive applications: Reversal of aging changes Increasing the anteroposterior cheek dimensions

2014 eMedicine Surgery

123. Epilepsy Surgery (Diagnosis)

the skin with a foreign body in place is difficult, and CSF leaks are not uncommon. Because of this, the dressing is changed as often as needed. Some authors suggest placing a cable-retaining suture in the scalp, [ , ] both to attempt to secure the electrode and to decrease CSF leakage. The lead author has not found this to be helpful in decreasing CSF leakage, and all electrode companies manufacture quick-release connectors designed to break apart easily if tugged. Patients are monitored (...) is determined based on data gathered during the preoperative evaluation; usually, a large craniotomy is performed to accommodate up to an 8 × 8-cm grid. Prophylactic antibiotics and dexamethasone are routinely administered. Mannitol is not used unless necessary, because the putative space created by a fluid shift could adversely contribute to hematoma formation after closure. Once placed, the grid is sutured to the dura to prevent motion. Often, 1 or more strip electrodes are added to sample adjacent areas

2014 eMedicine Surgery

124. Abdominal Wall Reconstruction

, which also inserts on the pubic crest. Transversus abdominis The transversus abdominis muscle is the innermost of the 3 flat abdominal muscles. The fibers of the transversus abdominis course predominantly in a horizontal orientation. It has 2 fleshy origins and 1 aponeurotic origin. The first fleshy origin is from the anterior three fourths of the iliac crest and lateral third of the inguinal ligament, while the second origin is from the inner surface of the lower 6 costal cartilages where (...) , Matthews BD, Brunt LM. Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual. Surg Endosc . 2007 Mar. 21(3):378-86. . Vorst AL, Kaoutzanis C, Carbonell AM, Franz MG. Evolution and advances in laparoscopic ventral and incisional hernia repair. World J Gastrointest Surg . 2015 Nov 27. 7 (11):293-305. . . Hamilton JE. The repair of large or difficult hernias with mattressed onlay grafts of fascia lata: a 21-year experience. Ann Surg . 1968 Jan. 167(1):85-90

2014 eMedicine Surgery

125. Blepharoplasty, Lower Lid Ectropion Surgery

for correction of ectropion in facial paralysis. Plast Reconstr Surg . 2005 Jan. 115(1):234-9. . Media Gallery Ectropion with keratinization of the lower lid. The snap-back test. Lower lid laxity obvious after snap-back test. Preparing the lateral tarsal strip. The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion. The suture is tied to the periosteum of the lateral orbital rim and tightened. of 6 Tables Contributor Information and Disclosures Author Mounir Bashour, MD, PhD (...) , tarsal, congenital, or neurogenic/paralytic. Surgical approaches are directed toward the underlying etiologic factors. Next: Problem Ectropion is an outward turning of the eyelid margin and occurs most often in the lower eyelid. It may be mild or severe and may involve all or part of the eyelid margin. See the image below. Ectropion with keratinization of the lower lid. Previous Next: Etiology Ectropion is most commonly seen as an involutional change associated with horizontal laxity of the involved

2014 eMedicine Surgery

126. Epilepsy Surgery (Overview)

the skin with a foreign body in place is difficult, and CSF leaks are not uncommon. Because of this, the dressing is changed as often as needed. Some authors suggest placing a cable-retaining suture in the scalp, [ , ] both to attempt to secure the electrode and to decrease CSF leakage. The lead author has not found this to be helpful in decreasing CSF leakage, and all electrode companies manufacture quick-release connectors designed to break apart easily if tugged. Patients are monitored (...) is determined based on data gathered during the preoperative evaluation; usually, a large craniotomy is performed to accommodate up to an 8 × 8-cm grid. Prophylactic antibiotics and dexamethasone are routinely administered. Mannitol is not used unless necessary, because the putative space created by a fluid shift could adversely contribute to hematoma formation after closure. Once placed, the grid is sutured to the dura to prevent motion. Often, 1 or more strip electrodes are added to sample adjacent areas

2014 eMedicine Surgery

127. Rhinoplasty, Vertical Dome Division

and Reconstructive Surgery . Lippincott-Raven; 1998. Simons RL. Vertical dome division in rhinoplasty. Otolaryngol Clin North Am . 1987 Nov. 20(4):785-96. . Media Gallery Goldman technique. Simons modification. Adamson technique. of 3 Tables Table. Summary of VDD Techniques Technique Summary Goldman Excise vestibular skin Divide dome at apex Reapproximate medial crura with horizontal mattress suture Trim ventral margin of repositioned medial crura Excise cephalic margin for bulbosity Lipsett Divide domes after (...) Next: Indications Selection principles Vertical dome division (VDD) is a philosophical and technical approach to management of the nasal tip. This philosophy is based on the belief that vertical dome division (VDD) is a more conservative maneuver than horizontal excisional techniques traditionally used in tip refinement surgery. Adherents to this principle argue that horizontal excisional techniques rely too heavily on unpredictable and uncontrollable postoperative scarring to produce desired tip

2014 eMedicine Surgery

128. Rhinoplasty, Tripod Theory

with septoplasty, columellar strut, spreader grafts, and tip sutures. Suturing In keeping with the tripod theory, many of the supporting structures to the tip are interrupted during rhinoplasty, thus increasing tip definition during surgery is necessary. In the lateral crural steal, which is performed through an open rhinoplasty approach, an increase in length of the medial crura is provided at the expense of the lateral crura. Inferior to superior horizontal mattress suturing first stabilizes the medial crura (...) crura immediately lateral to the dome and the middle or intermediate crus immediately below the dome. Use a horizontal mattress suture to pull the tip-defining point centrally and to carry the alar cartilages medially, narrowing the lobule and increasing the vertical height of tip-defining points. These maneuvers are most applicable when the tip-lobule complex is broad and the excess width can be converted aesthetically into vertical projection. Resection techniques Resect the lateral crus lateral

2014 eMedicine Surgery

129. Rhinoplasty, Tip Surgery

the nose and push the tip inferiorly. (C, D) Dome-spanning sutures or horizontal mattress sutures placed through the junction of the middle and lateral crura, which, on tightening, narrow the domes. (E) A projection control suture can be placed between the septal angle/ caudal border of the septum to the columellar strut and medial crura. The tip complex can be advanced anteriorly or posteriorly, with these sutures, to increase or decrease tip projection and tip stability. This suture can also (...) mattress sutures (dome-spanning sutures) span the junction of the middle and lateral crura, increasing tip projection and definition. (F) An onlay tip graft can be positioned over the paired alar cartilages to augment projection or alter infratip fullness or tip contour. Loss of caudal septal support causes the nasal tip and cartilaginous dorsum to fall posteriorly, creating loss of tip projection and a saddle nose deformity. The upper lip is displaced posteriorly, due to the loss of the caudal septum

2014 eMedicine Surgery

130. Scar Revision

traumatized during closure may develop wound dehiscence or undergo skin-edge necrosis, thus leaving unsightly scars. Likewise, wounds that are unevenly or improperly repaired, become infected, or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Traumatic wounds traditionally yield poorer eventual scars. Common etiologies of widened or dehisced scars include wounds closed under tension, repairs not formed parallel to relaxed skin tension lines (RSTLs), or wounds (...) realignment of the cutaneous landmarks may be performed on scars that are appropriately oriented in RSTLs. Z-plasty can be used to realign scars within RSTLs or correct any step-off deformity at the vermilion border. Scars crossing horizontally over the mentum generally follow RSTLs and therefore are best treated with a running W-plasty (see image below). Laterally based and more obliquely directed scars are good candidates for Z-plasty because the primary objective here is to redirect the scar

2014 eMedicine Surgery

131. Rhinoplasty, Spreader Grafts

region in preparation for spreader graft placement. Notice separation of the medial edge of the upper lateral cartilage from the dorsal septum margin. Also note how crooked the dorsal septum is in this patient. The primary indication for placement of the spreader grafts in this patient was to achieve more bridge symmetry. Diagram of spreader graft placement with use of horizontal mattress sutures for secure positioning. This is an example of spreader graft placement for a crooked nose deformity (...) of spreader grafts in rhinoplasty: a critical review. Eur Arch Otorhinolaryngol . 2011 Nov 19. . de Pochat VD, Alonso N, Mendes RR, Cunha MS, Menezes JV. Nasal patency after open rhinoplasty with spreader grafts. J Plast Reconstr Aesthet Surg . 2011 Dec 22. . Xavier R, Azeredo-Lopes S, Papoila A. Spreader grafts: functional or just aesthetical?. Rhinology . 2015 Dec. 53 (4):332-9. . Jalali MM. Comparison of effects of spreader grafts and flaring sutures on nasal airway resistance in rhinoplasty. Eur Arch

2014 eMedicine Surgery

132. Wound Closure Technique

distance from the wound edge than the original needle entrance site. Place the knot at the surface. A knot placed under tension risks a stitch mark. See the image below. Far-near near-far modification of vertical mattress suture, creating pulley effect. The horizontal mattress can be used to oppose skin of different thickness. With this stitch, the entrance and exit sites for the needle are at the same distance from the wound edge. Half-buried mattress sutures are useful at corners. On one side (...) to the skin edges. Another variant is the simple locked running suture, which has the same advantages and similar risks. The locked variant allows for greater accuracy in skin alignment, and, in some wounds, it can help with hemostasis. This can be particularly beneficial in patients who are on anticoagulation therapy and cannot be taken off these medications for simple surgical procedures. Both styles are easy to remove. Additionally, the running sutures are more watertight. Mattress suture procedure

2014 eMedicine Surgery

133. Craniofacial, Bilateral Cleft Nasal Repair

to expose the genu of the LLC, but later found that incision was unnecessary, as the LLCs could be approached through rim incisions. [ ] He now advocates bilateral vestibular rim incisions and alar base incisions. The LLCs are freed on their anterior surfaces through the nasal incisions. He then elevates and sutures the genu of the LLCs together. The lateral portion of each dome is suspended to the ipsilateral ULC near the septum. The freed alar bases are held to the prolabium medially via a mattress (...) in the cleft margin. The soft tissue between the domes is removed, and the domes are then sutured together. The nasal flap is closed in a V-Y advancement, lengthening the columella by approximately 5 mm. Mattress sutures over bolsters are placed to eliminate any dead space in the tip. At the second stage, 1 month later, the prolabium is lifted and mucosalmuscular flaps are sutured behind it, completing the lip repair. [ , ] Salyer Salyer performs his lip repair procedure, along with a limited nasal repair

2014 eMedicine Surgery

134. Craniofacial, Cleft Palate

posteriorly based flap is then elevated. The palatal muscles are detached from the hard palate. The eustachian tube orifice is identified. The nasal mucosal incision is made, leaving a free edge in the nasal mucosa. The palatal aponeurosis is divided, exposing the flap's palatal muscle for separation from the superior constrictor fibers lateral to it. Closure of the nasal side is then begun with 4-0 Vicryl, suturing the uvular tags with horizontal mattress sutures to minimize notching of the uvula (...) the palatal muscle flank. The anteriorly based flap on the right side is then brought across the cleft. The flap is somewhat difficult to mobilize adequately, and a small back-cut from its lateral end medially around the posterior margin of the alveolus improves mobility and facilitates dissection around the greater palatine vessels. Horizontal mattress sutures are then used to evert the stiff mucoperiosteum on the hard palate for closure. The closure is carried to the back of the mucoperiosteal incision

2014 eMedicine Surgery

135. Upper Gastrointestinal Bleeding (Follow-up)

is a horizontal mattress placed to control hemorrhage from the transverse pancreatic branch of the gastroduodenal artery. Failure to place this third stitch may result in recurrent bleeding that requires another emergent laparotomy of the abdomen. Vagotomy with antrectomy is reserved for patients whose conditions have failed to respond to more conservative attempts at surgical intervention and for those with aggressive and recurrent duodenal ulcer diathesis, such as gastric outlet obstruction. When performing (...) vagotomy 10 5 0.1 Truncal vagotomy and drainage 7 20-30 < 1 Truncal vagotomy and antrectomy Billroth I or Billroth II 1 30-50 0-5 Truncal vagotomy and antrectomy Roux-en-Y 5-10 50-60 0-5 The 3 most common operations performed for a bleeding duodenal ulcer are as follows [ ] : Truncal vagotomy and pyloroplasty with suture ligation of the bleeding ulcer Truncal vagotomy and antrectomy with resection or suture ligation of the bleeding ulcer Proximal (highly selective) gastric vagotomy with duodenostomy

2014 eMedicine.com

136. Ectropion (Follow-up)

at the gray line with either sharp Westcott scissors or a 15 blade. (The author does not find it necessary to split the lid.) The meibomian orifices of the lateral strip are trimmed away. The lateral conjunctiva is scraped to avoid epithelial inclusion cysts. To secure the lateral strip of tarsus to the periosteum, 2 sutures (or a single horizontal mattress suture) can be placed about 4 mm posterior to the lateral orbital rim at the Whitnall tubercle (at or above the level of the inferior pupil). Suitable (...) . [ ] Next: Surgical Care The correct surgical treatment of ectropion depends on the etiology. [ ] Horizontal lid laxity is often seen with ectropion and usually can be corrected with a lateral tarsal strip procedure. Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure. Tarsal ectropion requires reinsertion of the lower lid retractors. Augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial ectropion. The use

2014 eMedicine.com

137. Superior Labrum Lesions (Diagnosis)

Med . 2005 Apr. 33(4):507-14. . Silberberg JM, Moya-Angeler J, Martín E, Leyes M, Forriol F. Vertical Versus Horizontal Suture Configuration for the Repair of Isolated Type II SLAP Lesion Through a Single Anterior Portal: A Randomized Controlled Trial. Arthroscopy . 2011 Dec. 27(12):1605-13. . Coleman SH, Cohen DB, Drakos MC, et al. Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients. Am J Sports Med . 2007 (...) of a type II superior labrum anterior posterior (SLAP) lesion. Arthroscopic placement of a suture anchor in the superior glenoid. Arthroscopic suture placement for superior labrum anterior posterior (SLAP) lesion repair. Arthroscopic appearance of a superior labrum anterior posterior (SLAP) lesion after repair with a suture anchor. Simple mattress suture configuration with a single anchor. (Arthroscopy. 2007 Feb;23(2):135-40.) of 8 Tables Contributor Information and Disclosures Author Riley J Williams

2014 eMedicine.com

138. Superior Labrum Lesions (Follow-up)

labral lesions. J Bone Joint Surg Am . Jun 2002. 84-A(6):981-5. . Ide J, Maeda S, Takagi K. Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes. Am J Sports Med . 2005 Apr. 33(4):507-14. . Silberberg JM, Moya-Angeler J, Martín E, Leyes M, Forriol F. Vertical Versus Horizontal Suture Configuration for the Repair of Isolated Type II SLAP Lesion Through a Single Anterior Portal: A Randomized Controlled Trial. Arthroscopy . 2011 Dec. 27(12):1605-13 (...) repair with a suture anchor. Simple mattress suture configuration with a single anchor. (Arthroscopy. 2007 Feb;23(2):135-40.) of 8 Tables Contributor Information and Disclosures Author Riley J Williams, III, MD Associate Professor, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College; Director, HSS Institute for Cartilage Repair Riley J Williams, III, MD is a member of the following medical societies: , , , Disclosure: Received royalty from Arthrex Inc

2014 eMedicine.com

139. Mandibular Reconstruction, Plating

undue tension on the suture line because of their distance from the pedicle. This tension can also stretch and compromise the vascular pedicle, causing decreased blood flow, especially in the distal suture line where blood flow is already low. Also, regional flaps can be bulky and difficult to wrap around reconstruction plates, adding to the traction of the shoulder-based pedicle. Lastly, regional flaps and plates offer poor cosmetic and functional alternatives to osteocutaneous free flaps

2014 eMedicine Surgery

140. Lower Eyelid Reconstruction, Ectropion

passing the same sutures through the superior wound edge from the conjunctival surface to the subtarsal space to form a double vertical mattress stitch. Medial spindle tarsoconjunctival resection. (E) Pass both needles anteriorly through the center of the spindle-shaped defect to emerge on the skin surface. (F) Tie the suture on the skin surface with enough tension to pull the wound edges together and to invert the lid margin and punctum. The modified "lazy-T" procedure. (A) Hold the lid margin with 2 (...) into the canaliculus to mark its location. Cut a horizontal V-shaped segment of conjunctiva and capsulopalpebral fascia 4 mm below the canaliculus. The excised wedge should measure about 5 mm vertically by 8 mm horizontally, and should have its broad base laterally, at the previously cut vertical eyelid defect. The modified "lazy-T" procedure. (E) Close the horizontal incision with several 6-0 plain or chromic gut sutures to shorten the posterior lamella. Bury the knots to prevent corneal abrasion. (F) Pass a 6-0

2014 eMedicine Surgery

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