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Delayed wound closure: Indications and techniques
SPECIAL CONTRIBUTION wounds, closure
Delayed Wound Closure: Indications and Techniques [Dimick AR: Delayed wound closure." Indications and techniques. Ann Emerg Med December 1988;17:1303-1304.] DELAYED W O U N D CLOSURE In other presentations in this symposium, there have been references regarding the need for delayed wound closure, and emergency physicians should be knowledgeable about this technique. As mentioned previously, the three phases of wound healing are the reactionary phase to wound injury; the regeneration phase, in which the defect caused by the wound is repaired; and the remodeling phase, which occurs last. The mechanisms of wound healing are first, second, and third intention. In first intention, or primary healing, wound edges are reapproximated immediately. The gap across the wound is small, so little granulation tissue forms. Epidermal continuity is restored very rapidly, within 24 to 48 hours at the most, and the reaction phase of the wound resolves very quickly. The regeneration phase is minimal, and a thin scar results with little deformity. This is ideal wound healing - - primary healing or healing by first intention. Second intention healing is more difficult and more challenging to physicians. In this situation, the wound is left open because of gross contamination or because of a defect in the soft tissues that precludes closure of the wound. The wound defect fills with the granulation tissue of the regenerative phase; contraction of the edges of the wound is more pronounced; and migration of the epithelium from the wound margin occurs in an attempt to cover the granulation tissue bed. The combination of contraction and epithelialization ultimately results in closure of the wound. The resultant scar is usually larger than in primary healing, and the deformity is greater. The use of second intention healing requires skilled management by the physician. The clinician must first achieve a normal healing response by minimizing the potential for infection or vascular compromise. Once the wound is deemed "healthy," the physician can allow the residual deformity to.be covered by epithelial migration or with flaps or skin grafts. Obviously, this is a difficult wound to manage. Third intention healing, or-delayed primary closure, occurs when the wound is intentionally left open for four to five days. The wound is not closed until edema has subsided, no infection is present, and all debris and exudate have been removed. The wound is then closed primarily as one would in first intention healing. This leaves minimal tissue defect. This technique has proven to be particularly useful in clean contaminated and contaminated wounds, achieving a more than 90% success rate if used in the appropriate patients. The final scars of wounds treated as delayed primary closure are usually identical to those incurred when the wound is treated by primary closure. Wounds c a n b e described by the degree of their contamination: a clean wound, a clean contaminated wound, or a contaminated wound. Obviously, contaminated wounds are candidates for delayed primary closure. Experimentally, incised wounds that are repaired and allowed to heal undisturbed for short periods and are then opened and immediately resutured develop strength at a significantly faster rate than wounds treated by primary closure. This may explain why wounds that dehisce and must be resutured 17:12 December 1988
Annals of Emergency Medicine
Alan R Dimick, MD Birmingham, Alabama From the Division of General Surgery, Section of Burns and Trauma, University of Alabama, Birmingham. Received for publication July 28, 1988. Accepted for publication August 31, 1988. Presented at the ACEP Winter Symposium Clinical Advances Track in San Diego, California, March 1988.
1303/77
WOUND CLOSURE Dimick
often heal just as quickly as those closed primarily with first intention healing. The dehiscence and resuturing of the wound has no detrimental effect on the rate of new collagen synthesis and deposition of that new collagen. The reaction phase in these wounds appears to have already been initiated. The regeneration phase is in progress so that when the wound is resutured, it merely continues without alteration from where it stopped before it was separated. Delayed primary closure uses these observations. This phenomenon is a local one and is not due to any circulating hormone. It is maximal at three weeks after the initial wound has occurred and disappears by six weeks. Clinically, one can take advantage of this phenomenon. If a physician must reenter a surgical incision within six weeks of its creation, he should open through the wound and not try to excise the initial scar. Beyond six weeks, it is preferable to excise the initial scar. This emphasizes the reaction and regeneration occurring inside the wound within the first six weeks. The m e t h o d s of delayed w o u n d
closure allow some leeway in the management of traumatic wounds. In the traumatic wound, questionably viable or contaminated tissue can be left in place and the areas observed over the next few days to determine if viability or infection becomes a problem. Delayed primary closure is defined as that occurring within three to four days .of the initial treatment, whereas secondary closure occurs any time after that, usually from four to seven days later. The technique of delayed p r i m a r y closure provides drainage of the wound and opportunities for easy and repeated inspection and further debridement if necessary. In delayed p r i m a r y closure, the edges of the debrided wound are usually separated by a layer of fine mesh gauze, which allows effective drainage without danger of developing pockets of infection. The wound then is covered by an occlusive dressing to prevent further bacterial contamination. If exudate, local pain, cellulitis, or fever occurs, the wound can be examined without difficulty and further debridement done as necessary. If in
three to four days there is no sign of infection or further necrotic tissue, the wound can be definitely closed with direct apposition of all layers of the tissue, including skin. This procedure does not delay wound healing, as explained earlier. The obvious advantage of this technique is that there is no delay in healing, while the complications of infection are significantly minimized.
SUMMARY Delayed wound closure should be used in wounds that are contaminated or contain devitalized tissue. The wound should be left open for three to four days for observation to determine if infection is present or if the tissues are devitalized. This m a n a g e m e n t technique allows the physician to control infection and provide surgical debridement. Leaving the wound open provides the opportunity to inspect and evaluate the wound to determine if a problem is present. The wound then can be repaired with minimal risk. It is beneficial that the wound heaiing process is not delayed using this technique of wound closure.
Delayed Wound Closure: Indications and Techniques [Dimick AR: Delayed wound closure." Indications and techniques. Ann Emerg Med December 1988;17:1303-1304.] DELAYED W O U N D CLOSURE In other presentations in this symposium, there have been references regarding the need for delayed wound closure, and emergency physicians should be knowledgeable about this technique. As mentioned previously, the three phases of wound healing are the reactionary phase to wound injury; the regeneration phase, in which the defect caused by the wound is repaired; and the remodeling phase, which occurs last. The mechanisms of wound healing are first, second, and third intention. In first intention, or primary healing, wound edges are reapproximated immediately. The gap across the wound is small, so little granulation tissue forms. Epidermal continuity is restored very rapidly, within 24 to 48 hours at the most, and the reaction phase of the wound resolves very quickly. The regeneration phase is minimal, and a thin scar results with little deformity. This is ideal wound healing - - primary healing or healing by first intention. Second intention healing is more difficult and more challenging to physicians. In this situation, the wound is left open because of gross contamination or because of a defect in the soft tissues that precludes closure of the wound. The wound defect fills with the granulation tissue of the regenerative phase; contraction of the edges of the wound is more pronounced; and migration of the epithelium from the wound margin occurs in an attempt to cover the granulation tissue bed. The combination of contraction and epithelialization ultimately results in closure of the wound. The resultant scar is usually larger than in primary healing, and the deformity is greater. The use of second intention healing requires skilled management by the physician. The clinician must first achieve a normal healing response by minimizing the potential for infection or vascular compromise. Once the wound is deemed "healthy," the physician can allow the residual deformity to.be covered by epithelial migration or with flaps or skin grafts. Obviously, this is a difficult wound to manage. Third intention healing, or-delayed primary closure, occurs when the wound is intentionally left open for four to five days. The wound is not closed until edema has subsided, no infection is present, and all debris and exudate have been removed. The wound is then closed primarily as one would in first intention healing. This leaves minimal tissue defect. This technique has proven to be particularly useful in clean contaminated and contaminated wounds, achieving a more than 90% success rate if used in the appropriate patients. The final scars of wounds treated as delayed primary closure are usually identical to those incurred when the wound is treated by primary closure. Wounds c a n b e described by the degree of their contamination: a clean wound, a clean contaminated wound, or a contaminated wound. Obviously, contaminated wounds are candidates for delayed primary closure. Experimentally, incised wounds that are repaired and allowed to heal undisturbed for short periods and are then opened and immediately resutured develop strength at a significantly faster rate than wounds treated by primary closure. This may explain why wounds that dehisce and must be resutured 17:12 December 1988
Annals of Emergency Medicine
Alan R Dimick, MD Birmingham, Alabama From the Division of General Surgery, Section of Burns and Trauma, University of Alabama, Birmingham. Received for publication July 28, 1988. Accepted for publication August 31, 1988. Presented at the ACEP Winter Symposium Clinical Advances Track in San Diego, California, March 1988.
1303/77
WOUND CLOSURE Dimick
often heal just as quickly as those closed primarily with first intention healing. The dehiscence and resuturing of the wound has no detrimental effect on the rate of new collagen synthesis and deposition of that new collagen. The reaction phase in these wounds appears to have already been initiated. The regeneration phase is in progress so that when the wound is resutured, it merely continues without alteration from where it stopped before it was separated. Delayed primary closure uses these observations. This phenomenon is a local one and is not due to any circulating hormone. It is maximal at three weeks after the initial wound has occurred and disappears by six weeks. Clinically, one can take advantage of this phenomenon. If a physician must reenter a surgical incision within six weeks of its creation, he should open through the wound and not try to excise the initial scar. Beyond six weeks, it is preferable to excise the initial scar. This emphasizes the reaction and regeneration occurring inside the wound within the first six weeks. The m e t h o d s of delayed w o u n d
closure allow some leeway in the management of traumatic wounds. In the traumatic wound, questionably viable or contaminated tissue can be left in place and the areas observed over the next few days to determine if viability or infection becomes a problem. Delayed primary closure is defined as that occurring within three to four days .of the initial treatment, whereas secondary closure occurs any time after that, usually from four to seven days later. The technique of delayed p r i m a r y closure provides drainage of the wound and opportunities for easy and repeated inspection and further debridement if necessary. In delayed p r i m a r y closure, the edges of the debrided wound are usually separated by a layer of fine mesh gauze, which allows effective drainage without danger of developing pockets of infection. The wound then is covered by an occlusive dressing to prevent further bacterial contamination. If exudate, local pain, cellulitis, or fever occurs, the wound can be examined without difficulty and further debridement done as necessary. If in
three to four days there is no sign of infection or further necrotic tissue, the wound can be definitely closed with direct apposition of all layers of the tissue, including skin. This procedure does not delay wound healing, as explained earlier. The obvious advantage of this technique is that there is no delay in healing, while the complications of infection are significantly minimized.
SUMMARY Delayed wound closure should be used in wounds that are contaminated or contain devitalized tissue. The wound should be left open for three to four days for observation to determine if infection is present or if the tissues are devitalized. This m a n a g e m e n t technique allows the physician to control infection and provide surgical debridement. Leaving the wound open provides the opportunity to inspect and evaluate the wound to determine if a problem is present. The wound then can be repaired with minimal risk. It is beneficial that the wound heaiing process is not delayed using this technique of wound closure.