A thoracodorsal axial pattern flap has been tubed and applied over an elbow wound.

BASIC SKIN FLAP

GENERAL INFORMATION

• When using “walking” sutures, place perpendicular to the incision line to omit interruption of the blood supply.
• When suturing skin flaps, focus efforts to minimize tension, especially at the base of the flap.
• Avoid placing sutures under the flap to optimize vascular integrity.
• Techniques to manage dead space: drains, SQ closure, walking sutures, quilled sutures.
• Subcuticular sutures should be placed at flap periphery followed by simple interrupted skin sutures.

 

MOST COMMON COMPLICATIONS AND DIFFICULTY

• Inadequate undermining with resulting tension.
• Damage of blood supply with walking sutures.
• Patient discomfort caused by walking sutures.
• Lack of drain placement.
• Lack of adequate hair clip and surgical prep.
• Seroma formation under the flap or graft may result in its death.
• With flaps, the edges of the flap may die if there is insufficient vascularity to the pedicle.
• With grafts, the subcutaneous tissues must be removed to allow the graft to receive adequate nutrition from the host bed or the graft will die.

"EXPERTS' ADVICE"

• Dissection to minimize tension on primary incision must be balanced against need to preserve blood supply and tissue viability.
• Perform flaps, rather than grafts, whenever possible as they are more likely to survive.
• Avoid walking sutures whenever possible. They can damage blood supply and they may anchor the skin in an unnatural position when the patient is in a more normal, standing position. Skin is meant to slide over the subcutaneous fascia for function and comfort. Instead, avoid tension by proper undermining and flap selection/creation and place appropriate drain systems.
• Closed suction drain systems are often advisable over passive drainage, especially for large skin flaps.

 

Skin flaps often have a fair amount of tension placed upon them and therefore one should consider using sutures with good tensile strength. Reconstructive procedures around the face and eyelids should utilize fine suture material and smaller needles to achieve good cosmetic results.


BASIC SKIN FLAP:
SUTURE AND NEEDLE OPTIONS

	Brand		Needle Type	Needle Reference
	Main Choice	Also Possible		Main Choice	Also Possible
COSMETIC	MONOCRYL*		Taper Point Reverse Cut	RB-1 P-3	G-6, P-1, C-3
SKIN CLOSURE	ETHILON* PROLENE*	Silk	Reverse Cut	FS-2, FS-1, FS	FSL, CP-2, CP-1, KS

	Cat/Small Dog (20 lbs or less)	Medium Dog (20-45 lbs or less)	Large Dogs (50 to 75 lbs)	Giant Dog (75 lbs +)
COSMETIC	5-0 or 4-0	5-0 or 4-0	5-0 or 4-0	4-0
SKIN CLOSURE	4-0	4-0 or 3-0 or 2-0	3-0 or 2-0	2-0

 

Use the suture selection tool for specific product code recommendations.