Blunt and penetrating trauma can lead to a myriad of soft tissue
injuries. The management of the majority of these injuries is discussed
elsewhere in this text. Some soft tissue injuries require detailed
explanations for their repair. These injuries are discussed below.
Wounds of unequal thickness are not suited for repair with simple
interrupted sutures. Unequal tissue loss on each edge of a wound
creates a thick edge–thin edge wound. The
depressed edge must be elevated to the level of the nondepressed
edge in order to attain proper wound apposition and cosmesis.
There are two techniques to repair wounds with edges of unequal
thickness. One technique utilizes a half-buried horizontal mattress
suture (Figure 80-1).1 Place the suture through the thick
edge of the wound, across the wound and buried into the subcutaneous
tissue of the thin edge, and back out the skin of the thick edge
(Figure 80-1A). Apply traction to the
suture and tie it to approximate the wound (Figure 80-1B). Apply an ointment-based compressive
Closing a wound with edges of unequal thickness using
half-buried horizontal mattress sutures.
The second technique requires undermining both wound edges at
the same depth in the subcutaneous tissue plane (Figure 80-2).2 Make
an incision in the subcutaneous tissues of both wound edges and
at the same level (Figure 80-2A). Undermine
the area to free the tissue flaps (Figure 80-2B).
Grasp the subcutaneous tissue flap from the thicker side and insert
it under the thinner side beneath the undermined area (Figures 80-2B and C).
Place a buried horizontal mattress suture to maintain the flaps
in position. This “flap” elevates the depressed
wound edge and facilitates appropriate wound approximation (Figure
80-2).2 Place interrupted sutures to approximate the wound
edges (Figure 80-2C).
An alternative technique to close a wound with edges
of unequal thickness. A. Make an incision
in the subcutaneous tissue of both wound edges. B. Undermine
the edges. Transpose the subcutaneous tissue of the thicker side
into the undermined area of the thinner side (arrow). C. Approximate the wound edges using
Tangential flap lacerations over thin skin, such as the dorsum
of the hand or the pretibial area, where there is very little subcutaneous
tissue can be approximated with a specially placed simple interrupted
suture. Insert the needle through the tip of the thin edge, across
the wound, into the dermis of the thick edge, and out the skin of
the thick edge. Apply traction to the suture to pull the thick edge
up to meet the thin edge, producing good ...