Você está na página 1de 5

CHAPTER 3

Anatomy of Wound
Repair
Key Practice Points
nn The

most important layer of skin for wound closure is the tough dermis.
It is the anchor for sutures.
nn Proper and careful apposition of the wounded dermis will bring the
lacerated outer layer of skin, the thin epidermis, together for the best
cosmetic result.
nn The superficial fascia, or subcutaneous fatty tissue, lies just below the
dermis. Because nerve fibers travel in the subcutaneous layer below
and into the dermis, this fatty layer is the preferred site for delivery of
local anesthetics.
nn Dbridement of dermis should be judicious and limited, whereas for
subcutaneous fat it can be liberal.
nn Lacerations and incisions parallel to skin tension lines leave thinner
and less visible scars than those that cross these lines.
nn Age and use of corticosteroids weaken skin and make it thinner.
Repairing lacerations and wounds to this skin is a challenge.

The primary anatomic focus in surface wound care is the skin. Underlying the skin are two
equally important structures, the superficial (subcutaneous) fascia and the deep fascia. The
fasciae not only act as a supportive base to the skin but also carry nerves and vessels that
eventually branch into the fasciae. All the layers of the skin and fascia are present in every
body site, but they vary considerably in thickness. Most skin is 1 to 2 mm thick, but thickness can increase to 4 mm over the back. This variability often dictates the choice of suture
needles. Larger, stronger needles are required to penetrate the skin on the palms of the hands
and the soles of the feet. Small, delicate needles should be used on the thin skin of the eyelids.

ANATOMY OF THE SKIN AND FASCIA


Although the skin and fascia comprise a complex system of organs and anatomic features,
it is the layer arrangement that is most important for wound closure (Fig. 3-1). These layers
include the epidermis, dermis, superficial fascia (commonly referred to as the subcutaneous or subcuticular layer), and deep fascia. These layers should be thought of as planes that
need to be carefully and accurately reapproximated when disrupted by trauma. Each one
has its own set of characteristics that are important to proper wound closure and healing.

Epidermis and Dermis (Skin or Cutaneous Layer)

The epidermis is the outermost layer of the skin. The epidermis consists entirely of
squamous epithelial cells and contains no organs, nerve endings, or vessels. Its primary
function is to provide protection against the ingress of bacteria and toxic chemicals and
10
Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

CHAPTER 3 Anatomy of Wound Repair

Epidermis

Stratum corneum
Stratum germinativum
Blood vessels and nerves

Dermis
Duct of sweat gland
Body of sweat gland
Hair follicle
Subcutaneous fat

Superficial fascia
(subcutaneous fascia)
Deep fascia
Blood vessels and nerves
Muscle group
Blood vessels

Figure 3-1. Anatomy of the skin illustrating structures pertinent to wound repair.

the inappropriate egress of water and electrolytes. This is the outermost, visible layer
and gives skin its final cosmetic appearance.
Although the epidermis is an anatomically separate layer, it is only a few cell layers
thick. During wound repair, it cannot be seen by the naked eye as separate from the dermis. Correct approximation of the epidermis naturally results from careful apposition
of the lacerated edges of the dermis.
The dermis lies immediately beneath the epidermis. It is much thicker than the epidermis and is composed primarily of connective tissue. The main cell type in the dermis
is the fibroblast, which elaborates collagen, the basic structural component of skin. The
deeper dermis contains the bulk of adnexal structures of the skin. These include the
hair follicles and vascular plexus. Nerve fibers branch and differentiate into specialized
nerve endings that reside in the dermis.
The dermis is the key layer for achieving proper wound repair. It is easily identifiable
and provides the anchoring site for percutaneous and deep sutures (Fig. 3-2). Every
effort is made to cleanse, remove debris, and accurately approximate the dermal edges
to allow for optimal wound healing with minimal scar formation. If dermis is devitalized or severely damaged, sharp dbridement often is necessary to remove it. Tissue
excision and trimming must include only that which is truly unsalvageable, however.
Because dermal defects are replaced by scar tissue, any unnecessary dermis removal
increases the size and prominence of that scar.

Superficial Fascia (Subcutaneous Layer)

Deep to the dermis is a layer of loose connective tissue that encloses a varying amount
of fat. Fat makes the superficial fascia easily recognizable in a laceration. There are several consequences of injury to this layer. Devitalized fat can promote bacterial growth
and infection.1 In contrast to dermis, the superficial fascia can be liberally dbrided so
that any devitalized portion can be excised completely. Injuries to the superficial fascia

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

11

12

CHAPTER 3 Anatomy of Wound Repair

Epidermis

Dermis

Superficial fascia

Figure 3-2. Demonstration of either percutaneous or deep suture closure. The needle is anchored in the
dermis for each suture placement.

also have the potential for creating dead space. Failure to evacuate contaminants and
clots in this space can lead to an increased risk of infection.
The sensory nerve branches to the skin travel in the superficial fascia just deep to
the dermis. When injecting a local anesthetic, the needle is directed along the plane
between the dermis and superficial fascia (see Fig. 6-1). Anesthetic spreads easily along
the floor of the dermal layer and quickly abolishes sensation from the skin.

Deep Fascia

Deep fascia is a relatively thick, dense, and discrete fibrous tissue layer. It acts as a base
for the superficial fascia and as an enclosure for muscle groups. This layer is recognized
as an off-white sheath for the underlying muscles. The main function of the deep fascia
is to support and protect muscles and other soft tissue structures. It also provides a
barrier against the spread of infection from the skin and superficial fascia into muscle compartments. Lacerations of the deep fascia are easily recognized and should be
closed, if possible, to reestablish the protective and supportive functions of this layer.
Sometimes deep fascia lacerations require too much tension to close with sutures and
can be left to heal without them.

SKIN TENSION LINES


There are two types of skin tensionstatic and dynamicthat have an important impact
on the final scar structure of healed lacerations. Because all wounds scar, knowledge of
skin tension is required when considering repair strategy or when educating the patient
about eventual healing outcome.
Because it clings tautly to the body framework, skin is under constant static tension.2
Static tension lines are commonly called Langers lines. The arrangement, orientation,

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

CHAPTER 3 Anatomy of Wound Repair

Figure 3-3. Skin tension lines of the face. Inci-

sions or lacerations parallel to these lines are less


likely to create widened scars than incisions that are
perpendicular to these lines. (Adapted from Simon
R, Brenner B: Procedures and techniques in emergency
medicine, Baltimore, 1982, Williams & Wilkins.)

and distensibility of collagen fibers cause most wounds to retract open. The degree to
which wound edge retraction, or gaping, takes place is an indicator of how wide the
resulting scar might be. Gaping of 5 mm or greater indicates significant tension and
increased risk for wide scar formation.3 In a study of poor outcomes of laceration repair,
wound width was found to be a significant factor.4 Lacerations of the lower extremity,
particularly over the anterior tibia, tend to retract under great tension and scar conspicuously. A horizontal laceration of the skin of the eyelid is under little tension with
little gaping. These lacerations become virtually unnoticeable with time.
Static skin tension plays an important role in wound edge dbridement and revision. It is tempting to excise jagged wound edges to convert an irregular laceration into
a straight one. If the wound is already gaping because of static tension, dbridement
of tissue might increase the force necessary to pull the new straight edges together.
Scar width is increased, and the purpose of the edge excision is defeated. An irregular
laceration under little tension often heals with a less noticeable scar than a straight
wound under greater tension. As a rule, a ragged wound with viable tissue edges is
repaired best by putting the puzzle pieces back together to preserve as much tissue
as possible. If the wound needs later revision, the extra tissue will be welcomed by the
plastic surgeon.
Different from static forces but equally important are dynamic forces on the skin,
illustrated by Kraissls lines in Figure 3-3.5 These forces are created by the underlying
pull of muscles in any given body area and correspond to wrinkles created by compression of the skin during muscle contraction.6 These forces are most dramatically visible
in the face during the various changes in facial expression. Lacerations that are perpendicular to these lines tend to heal with wider scars than do lacerations that are parallel.
In choosing elective incisions of the face, surgeons apply the scalpel to correspond with
these lines.

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

13

14

CHAPTER 3 Anatomy of Wound Repair

Ultimately, the final appearance of a scar is determined in part by static and dynamic
forces, and the patient should be counseled accordingly. The patient is advised that
it takes at least 6 months for scar contraction and collagen remodeling to diminish
and 1 year for these forces to stabilize before a wound takes on its final shape.7 During
this time, the wound undergoes many visible changes. If the scar is still worrisome to
the patient after this time elapses, tension-relieving procedures, such as W-plasty or
Z-plasty, can be applied to improve the appearance of the scar. Whenever the cosmetic
outcome is in doubt at the time of injury or the issue is raised by the patient, consultation with a plastic surgeon can be considered.

ALTERATIONS OF SKIN ANATOMY


Often, there are clinical situations in which the anatomic structure of the skin is altered
so much that it requires special wound care. The most common skin changes in this
setting are changes caused by aging and long-term corticosteroid administration.8,9
In aging, there is a flattening of the dermoepidermal junction with an accompanying decrease in the prominence of the dermal papillae. This effacement seems to result
in a reduction of vascularity and nutrient supply to the epidermis. The dermis itself
loses its thickness and becomes increasingly acellular and avascular. The net result
is that the tensile strength of the dermis decreases significantly, which makes it less
resistant to injury. More important to wound care is that the dermis does not support sutures well: They tend to tear the skin or cause ischemia, because the dermis
has a low resistance to suture tension. Although sutures can be effective in younger
patients, wound tapes are more appropriate for many lacerations that occur in older
people (see Chapter 19).
Corticosteroids have a profound effect on collagen deposition through inhibition of
collagen fiber synthesis and accelerated collagen degradation. The dermis becomes atrophic, thin, and poorly resistant to trauma. Small vessels seem to become increasingly
fragile and readily cause ecchymoses in response to even the most trivial trauma. As in
aging, the poor quality of the skin makes it less able to support sutures. Skin tapes or
simple bandages are often preferable for managing these wounds.

References

1. Haury B, Rodeheaver G, Vensko J, etal: Debridement: an essential component of traumatic wound care,
Am J Surg 135:238242, 1978.
2. Thacker IG, Iachetta FA, Allaire PE, etal: Biomechanical properties: their influence on planning surgical
excisions. In Krizek TI, Hoopes PE, editors: Symposium on basic science in plastic surgery, St Louis, 1975,
Mosby.
3. Edlich RF, Rodeheaver GT, Morgan RF, etal: Principles of emergency wound management, Ann Emerg Med
17:12841302, 1988.
4. Singer AJ, Quinn JV, Thode HC Jr: Determinants of poor outcome after laceration and surgical incision
repair, Plast Reconstr Surg 110:429435, 2002.
5. Kraissl C: The selection of lines for elective surgical incisions, Plast Reconstr Surg 8:128, 1951.
6. Borges A, Alexander J: Relaxed skin tension lines, Z-plasties on scars and fusiform excision of lesions, Br J
Plast Surg 15:242254, 1962.
7. Hollander JE, Blaski B, Singer AJ, etal: Poor correlation of short- and long-term cosmetic appearance of
repaired lacerations, Acad Emerg Med 2:983987, 1995.
8. Qun T, Shao Y, He T, etal: Reduced expression of connective tissue growth factor (CTGF/CCN2) mediates
collagen loss in chronically aged human skin, J Invest Dermatol 130:415424, 2009.
9. Gans EH, Sadiq I, Stoudemayer T, etal: Invivo determination of the skin atrophy potential of the superhigh potency topical corticosteroid fluocinonide 0.1% cream compared to clobetasol proprionate 0.05%
cream and foam, and a vehicle, J Drugs Dermatol 7:2832, 2008.

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.