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Horizontal Mattress Suture

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121. Epilepsy Surgery (Follow-up)

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

122. 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

123. 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

124. 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

125. 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

126. 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

127. Flexor Tendon Lacerations (Follow-up)

MGH suture Indianapolis four-strand suture An eight-strand cross-locked cruciate repair using 4-0 caliber double-stranded suture has also been described. [ ] Peripheral tendon (epitendinous) suture techniques are as follows: Simple running suture [ ] Running lock loop suture (Lin) Cross-stitch epitendinous repair technique (Silfverskiold) Halsted continuous horizontal mattress suture (Wade) Horizontal mattress intrafiber suture (Mashadi and Amis) A dorsal splint is recommended to keep the wrist (...) The Indianapolis protocol is indicated for patients with four-strand Tajima and horizontal mattress repair with an additional peripheral epitendinous suture. Patients should be motivated and understanding. Digits should have minimal or moderate edema and minimal wound complications. Two splints are used, the traditional dorsal-blocking splint—with the wrist at 20-30° of flexion, MCP joints in 50° of flexion, and IP joints in neutral—and the Strickland tenodesis splint. The latter allows full wrist flexion

2014 eMedicine Surgery

128. Diaphragmatic Hernias, Acquired (Follow-up)

with monofilament permanent sutures. Small lacerations may be repaired by using interrupted, horizontal mattress, or figure-eight stitches; larger lacerations may be repaired with continuous or double-layered closures. Absorbable sutures are associated with a high rate of recurrence. [ ] There is some limited evidence to suggest that the use of biologic mesh in traumatic diaphragmatic repair may be feasible, at least in chronic cases. [ ] Laparoscopic abdominal exploration in the setting of trauma has become

2014 eMedicine Surgery

129. 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

130. 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

131. Lisfranc Fracture Dislocation (Follow-up)

and the Lisfranc screw. Because no real tissue layers are present at this level of the foot, wound closure can be accomplished with an absorbable suture to close joint capsules and a nonabsorbable suture in using a vertical or horizontal mattress technique to close the skin. Plate fixation The approach and initial fracture reduction for plate fixation are similar to those for screw fixation. Once the reduction has been achieved, the dorsal plate can be applied. Typically, this procedure is used for comminuted (...) that bioabsorbable screws are safe and that they eliminate the need for screw removal. Larger studies with long-term follow-up are needed to determine the true efficacy. [ ] Suture button fixation Several papers have addressed the use of suture button fixation in Lisfranc injuries with the hope of allowing some physiologic motion and to avoid putting screws across the articular cartilage of the first cuneiform and the second MT. Ahmed et al [ ] did a cadaveric study that showed more displacement with suture

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. 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

134. Posterior Glenohumeral Instability (Follow-up)

described the reverse Bankart procedure in two patients, using drill holes placed through the glenoid rim to the medial bone and then securing the capsular flap with mattress sutures. [ ] In both of the cases described, the patient regained normal function. Reverse Putti-Platt repair The reverse Putti-Platt procedure was originally described by Severin, [ ] who shortened the infraspinatus only, and DePalma, [ ] who shortened the infraspinatus and the teres minor together. A subsequent report (...) the deltoid in line with its fibers, followed by dissection of the infraspinatus/teres minor interval. A horizontal incision is then made in the capsule to expose the joint. A Fukuda retractor is inserted to retract the humeral head and expose the posterior glenoid rim. Suture anchors are inserted into the glenoid rim. The sutures are used to perform the capsulorrhaphy and are then tied. Completion of the procedure demonstrates significant reduction of the posterior capsular redundancy. Posterior

2014 eMedicine Surgery

135. Triangular Fibrocartilage Complex Injuries (Diagnosis)

with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg . 2004 Jun. 8 (2):116-23. . Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res . 1984 Jul-Aug. 26-35. . Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study. J Hand Surg Am . 1993 Mar. 18 (2):334-40. . Tang JB, Ryu J, Kish V. The triangular fibrocartilage complex: an important component of the pulley for the ulnar wrist extensor. J (...) that the percentage of axial force transmitted through the ulna decreases by sequential removal of the horizontal portion of the TFCC. [ ] This percentage decrease is accentuated with more positive ulnar variance. In a cadaver study, Adams demonstrated that no significant kinematic or structural changes resulted from an excision that did not violate the peripheral 2 mm of the disk and that constituted less than two thirds of the disk area. [ ] TFCC tears are associated with a positive ulnar variance. Ulnar

2014 eMedicine Surgery

136. Hand Injury, Soft Tissue (Treatment)

mattress sutures. [ ] Deep sutures should seldom, if ever, be placed in the ED because of the risk of infection and granuloma formation. Hand wounds older than 6-8 hours should not be closed primarily because of an increased likelihood of infections. Irrigate and explore such wounds and apply a sterile dressing. Recheck the wound in 2-4 days, with consideration of delayed primary closure at 4 days. Similarly, most bite wounds and wounds sustained by blunt injury to another person's mouth (a "fight-bite (...) a full range of motion. Search vigorously for foreign bodies or evidence of tendon injuries. To achieve hemostasis during wound exploration, fasten a sterile Penrose drain to the base of a digit. Do not use a rubber band, which can easily be overlooked and lead to an ischemic digit. Inflate a blood pressure cuff to over 200 mm Hg, then clamp the tube to achieve good hemostasis. Total tourniquet time in the ED should not exceed 2 hours. Close the skin wound with a single layer of simple or horizontal

2014 eMedicine Emergency Medicine

137. Nailbed Injuries (Follow-up)

as a stent and held in position by 5-0 or smaller nylon sutures placed by one or a combination of the techniques below: Distally through the hyponychium and the nail. Through the nail and proximal to the nail fold. [ ] Through a half-buried horizontal mattress suture placed down proximal to the nail fold into proximal nail then back out the nail fold. Through the paronychia and nail bilaterally. As a dorsal figure-of-eight suture [ ] - A suture is placed transversely just distal to the hyponychium (...) as it is removed. Care must again be taken to avoid further damage to the underlying nailbed or overlying nail fold. Once the nail is sufficiently separated from the nailbed, it is gently removed by applying firm and steady distal traction using a hemostat. Lacerations to the nailbed should be repaired using 6-0 or smaller absorbable sutures. Minimal to no debridement should be performed because aggressive debridement may cause undue tension on the repair and results in scarring. When repairing avulsed nails

2014 eMedicine Emergency Medicine

138. Replantation (Follow-up)

tendon is repaired by using horizontal mattress 4-0 polyester sutures. A tendon graft may also be necessary if a sufficient length of tendon is not available. Finally, if extension is deemed expendable, arthrodesis (joint fusion) may be performed. Then, the flexor tendon is repaired with sutures. Arterial repair is performed next. Brisk blood flow from the proximal vessel should be confirmed prior to vascular anastomosis. Restoration of proximal blood flow may require relief of vascular compression

2014 eMedicine Emergency Medicine

139. Nailbed Injuries (Treatment)

as a stent and held in position by 5-0 or smaller nylon sutures placed by one or a combination of the techniques below: Distally through the hyponychium and the nail. Through the nail and proximal to the nail fold. [ ] Through a half-buried horizontal mattress suture placed down proximal to the nail fold into proximal nail then back out the nail fold. Through the paronychia and nail bilaterally. As a dorsal figure-of-eight suture [ ] - A suture is placed transversely just distal to the hyponychium (...) as it is removed. Care must again be taken to avoid further damage to the underlying nailbed or overlying nail fold. Once the nail is sufficiently separated from the nailbed, it is gently removed by applying firm and steady distal traction using a hemostat. Lacerations to the nailbed should be repaired using 6-0 or smaller absorbable sutures. Minimal to no debridement should be performed because aggressive debridement may cause undue tension on the repair and results in scarring. When repairing avulsed nails

2014 eMedicine Emergency Medicine

140. Triangular Fibrocartilage Complex Injuries (Follow-up)

to the dorsal radioulnar (DRU) ligament. Reflect the DRU ligament and the periosteum over the lunate fossa. Place horizontal mattress sutures in the TFCC through drill holes placed in the dorsoulnar aspect of the distal radius. Wrist arthroscopy Indications for wrist arthroscopy include acute unstable tears, acute tears that fail to respond to conservative management, and chronic tears for which conservative management fails. [ , , , ] General arthroscopic principles are as follows: Debride to a stable (...) in the triangular fibrocartilage of the wrist joint. J Anat . 1978 Jun. 126 (Pt 2):367-84. . Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg . 2004 Jun. 8 (2):116-23. . Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res . 1984 Jul-Aug. 26-35. . Adams BD. Partial excision of the triangular fibrocartilage complex

2014 eMedicine Surgery

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