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When contemplating wound closures on the lower extremities, clinicians should keep in mind that closures above the knee are fundamentally different from their below-the-knee counterparts. Thigh closures may be conceptualized as similar to closures on the upper arm—the dermis is moderate in thickness, and the area is under often-substantial tension. On the shins, however, closures are often significantly more challenging. The presence of impaired circulation and high tension mean that closures below the knee may be technically challenging to effect and are concomitantly fraught with an increased risk of infection and dehiscence when compared with closures elsewhere on the body.
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An important principle when closing wounds below the knee is to anticipate the high risk of closure failure and therefore minimize the size of the defect. Thus, concerns regarding standing cone formation should be set aside when closing most shin defects. The high tension in these areas also means that as the repair heals over time the tension across the central portion of the wound may lead to blunting of the initial valley created by the closure, and therefore the appearance of the dog ears will eventually resolve.
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As with other highly mobile areas, it is important to plan appropriately when developing an ideal axis of wound closure. Therefore, the leg should be examined preoperatively both flexed and extended, and individual closure approaches should be tailored to each patient so that a patient who spends most of the day seated at a computer or in a wheelchair may have their wound closed on a slightly different axis than a highly-active patient.
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Suture Material Choice
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Most wounds on the thighs are closed with a 3-0 absorbable suture material, though in small wounds under minimal tension a 4-0 absorbable suture may be used. Similarly, wounds on the shins are often closed with a 3-0 absorbable suture, though when an adhesive strip bolster technique is used a 3-0 nonabsorbable suture may be used as well.
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Suture Technique Choice
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The standard approach to closure would include the set-back dermal suture or the buried vertical mattress suture for most leg closures. Generally these approaches are used on the thighs, though of course with larger defects under marked tension a pulley variation of the previously mentioned techniques is possible as well. When closing wounds on the shins, however, other specific challenges may emerge. These wounds are often very narrow and the skin is often fairly inelastic, and therefore may not permit easy placement of buried vertically oriented sutures. In such cases, placing a percutaneous set-back dermal suture may be an alternative. Other approaches would also include the percutaneous buried vertical mattress technique (though the shallow portion of the bite may result in tissue tear through in the thin skin of the shins) and the percutaneous horizontal mattress suture (where the horizontal orientation allows for a ...