Methods of Closure

Several different techniques have been described, and the techniques employed include: excision and primary closure, excision followed by secondary healing, excision and split thickness skin grafting, excision and delayed grafting, and skin excision and plastic reconstruction using rotation flaps and pedicle flaps. Controversy exists about closure of the skin defect. Adequate excision will usually result in a defect that precludes primary closure, and various techniques are described to obtain skin cover, such as applying split skin grafts, transposed or pedicle flaps. Primary closure and rotation flaps, including the use of wide undermining and elliptical sutures, VY-plasty, and WY-plasty, are rarely used because of the extensive nature of the excisions; however, they usually give satisfactory results for small axillary defects, the inguinal regions, mammary folds, and the upper part of the thighs. Primary closure is reported to be more effective in axillary excisions in women because of the extra skin available in the lateral mammary area. Pollock et al. [50] have demonstrated the use of a transverse primary closure. Another possibility is a combination of primary closure and healing by granulation.

The excision defect can be left open to granulate and epithelialize. The certainty of wound healing, avoidance of a donor site, rapid mobilization with minimal discomfort, and uncomplicated management of the wound after discharge from hospital recommend its use. Healing by granulation (secondary intention) is associated with a predictable result that is as good or even superior to that obtained by skin grafting. However, complete wound closure may take up to 2-3 months. Healing by granulation is a method especially suitable for the nape of the neck and the perianum and perineum, and furthermore for controlling severe HS of the axillary and inguino-perineal areas [61, 68]. A study by Morgan et al. [44] of patients with bilateral axillary involvement compared granulation on one side with grafting on the other. Most patients preferred granulation with a silastic foam dressing. In another study, subjects reported minimal inconvenience or interruption of daily activities and minimal analgesic requirements after healing by secondary intention; wound closure was uncomplicated, with unrestrictive, stable, and cosmetically acceptable scars. As soon as patients are confident that they can handle these areas with sitz baths or compresses, as the case may be, they are discharged. To decrease healing time, free skin grafts can be secondarily applied to the granulating surface.

The principle reason for skin grafting is to prevent contracture and shorten the period of morbidity. Split-skin grafting, either immediate or delayed, has the advantage of rapid healing with complete wound healing, often in 2-3 weeks. Excision and free skin grafting is most satisfactory for shallow axillary, suprapubic, and buttock defects. For the perineum, pubis, and intercrural regions, split thickness grafts yield shortest healing times and satisfactory cosmetic results [8]. Disadvantages include an unsightly cosmetic result and the discomfort and poor cosmesis associated with the donor site [12]. In addition, the affected limb must be immobilized for several days. These can be applied immediately at the time of excision. Otherwise, a delay of 4-6 days will allow for a healthy bed of granulation tissue to form which does not bleed if the dressings are soaked off and split grafts can be applied at that time. Mustafa et al. [46] reported a preference for a 1-week delay before skin grafting to avoid missing any retained sinus tracts not completely excised. Others recommend a shorter (48-72 h) delayed skin graft to speed up the process [8]. Free grafts are complicated by the technical problems of fixation and immobilization, lengthy hospitaliza-tion, time-consuming dressings, possible partial loss, and contraction of the grafted axilla.

Excision and closure with a pedicle rotation flap or tube flap is used mainly in deep defects of the axilla [20, 27, 47, 63] and occasionally the inguinal, scrotal, and perineal regions, where vessels or vital organs may be exposed and a healthy protective covering is required immediately. The rotation of a regionally based flap is advantageous in closure when the disease process has penetrated deeply. Total excision results in an especially cavernous defect, which is likely to expose the large vessels. It is particularly ad vantageous in repairing the axillary wound of obese robust patients. Posteriorly based flaps are elevated from the inframammary area and rotated into the defect of the axilla [25]. The submammary donor site is closed primarily. Local flaps have been used by many for this repair. The combination of a regional flap and split thickness skin graft furnishes another means of axillary repair. Z-plasty is one of the most useful plastic surgery procedures and deserves first consideration in the prevention and contracture of scars. Generally, the length of the arms of the Z should be equal. In modified Z-plasty, first the upper and lower portions of the wound are approximated to form an elliptical central defect, which lies in the line of election. The Z-plasty is then carefully planned and the flaps developed. Free skin grafts, tubed and pedicle flaps can be used to reconstruct large deep defects of the perineum, pubis, and groin. Such flaps provide satisfactory coverage for exposed testicles and large vessels or other important structures. Rotation flaps and Z-plasty have certain disadvantages. When the axillary defect is long and wide, the arms of the Z may have to extend and disfigure the anterior chest.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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