Lower Extremity Soft Tissue & Cutaneous Plastic Surgery, 2e

Chapter
Basic instruments and tissue handling
43
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Figure 5.50  Blunt retractor. The hand is positioned with several fingers
simulating a rake, creating the retracting motion.
Figure 5.51  Straight periosteal elevator. A single straight finger extended
toward the instrument passer is the standard sign. A prearranged type of
elevator makes this signal easy to recognize.
FURTHER READING
Bernstein, G., 1995. Choosing the correct
surgical instruments. Adv Dermatol 10,
245–283.
Bogle, M.A., Joseph, A.K., 2005. Instruments
and materials. In: Robinson, J.K., Hanke,
C.W., Sengelmann, R.D., et al. (Eds.),
Surgery of the Skin. Elsevier Mosby,
Philadelphia, pp. 59–66.
Dockery, G.L., 1980. Hand signals in surgery.
J Am Podiatr Assoc 70 (1), 47–49.
Dockery, G.L., 1992. Principles of forefoot
plastic surgery. In: Butterworth, R., Dockery,
G.L. (Eds.), Color Atlas and Text of Forefoot
Surgery. Mosby – Year Book, St Louis,
pp. 7–34.
Drake, L.A., Ceilly, R.I., Cornelison, R.L., et al.,
1995. Guidelines of care for office surgical
facilities. Part 2. Self-assessment checklist.
J Am Acad Dermatol 33, 265–270.
Eedy, D.J., Breathnach, S.M., Walker, N.P.
(Eds.), 1996. Equipping the Theatre. In:
Surgical dermatology. Wiley-Blackwell,
London, pp. 1–18.
Fulchiero, G.J., Vujevich, J.J., Goldberg, L.H.,
2009. Nonverbal hand signals: a tool
for increasing patient comfort during
dermatologic surgery. Dermatol Surg
35 (5), 856–857.
Iavazzo, C., Gkegkes, I.D., Vouloumanou, E.K.,
et al, 2011. Sutures versus staples for
the management of surgical wounds: a
meta-analysis of randomized controlled
trials. Am Surg 77 (9), 1206–1221.
Lynch, W.S., 1994. Surgical equipment and
instrumentation. In: Wheeland, R.G. (Ed.),
Cutaneous Surgery. WB Saunders,
Philadelphia, pp. 91–101.
Malay, D.S., 2001. Instrumentation. In: Banks,
A.S., Downey, M.S., Martin, D.E., et al.
(Eds.), McGlamry’s Comprehensive
Textbook of Foot and Ankle Surgery,
third ed. Lippincott Williams & Wilkins,
Philadelphia, pp. 3–15.
Maloney, M.E., 1991. The dermatologic
surgical suite. Design and materials.
Churchill Livingstone, New York.
Mamelak, A.J., Vuyevich, J.J., Golderg, L.H.,
et al., 2008. The use of a surgical hook
for alignment in the closure of elliptical
excisions. J Drugs Dermatol 7 (11),
1082–1083.
Nealon, T.F., 1979. Fundamental skills in
surgery, third ed. WB Saunders,
Philadelphia, pp. 12–14.
Pezzella, A.T., 1996. Hand signals in surgery.
AORN J 63 (4), 769–771.
Rutherford, C.J., 2005. Differentiating
surgical instruments. FA Davis Co,
Philadelphia.
Tollafield, D.R., Merriman, L.M., 1997.
Operative techniques. In: Tollafield, D.R.,
Merriman, L.M. (Eds.), Clinical Skills in
Treating the Foot. Churchill Livingstone,
London, pp. 81–104.
Weber, L.A., 1998. The surgical tray. Dermatol
Clin 16 (1), 17–24.

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CHAPTER CONTENTS
Introduction
45
Local anesthetics
45
Anesthetic techniques
46
Topical anesthesia
46
Nerve blocks and infiltration
46
Intravenous sedation
48
Regional nerve block
49
Conclusion
50
INTRODUCTION
Surgery of the foot and ankle is often effectively performed with the
administration of local or regional anesthesia to the area, thereby
avoiding the risk and complications associated with general anesthe­
sia. Certainly there are circumstances that necessitate the use of a
general anesthetic, but because of the superficial attitude of many of
the distal peripheral nerves, local anesthetic infiltration will frequently
provide adequate anesthesia to the surgical area. There are complica­
tions, however, that can occur with any form of anesthesia and a
plethora of anesthetic agents to consider before determining the most
appropriate type for each patient.
LOCAL ANESTHETICS
The most direct and simplest method of anesthesia is the administra­
tion of local anesthetic directly to the area upon which surgery is to
be performed. Any agent capable of preventing conduction in a nerve
when applied to nerve tissue can be considered a local anesthetic.
Ideally, the local anesthetic would have complete reversibility, low
systemic toxicity, rapid onset but duration sufficient for the procedure,
sterilizability and primary action on the nerve tissue with minimal
irritability. The most commonly employed local anesthetics are either
aminoamides or aminoesters. Both of these agents affect nerve func­
tion in a similar fashion with the greatest affect on transmission of
pain sensation.
Pain is carried on small non-myelinated neurons, which can easily
be blocked by the local anesthetic. Temperature, touch and proprio­
ception are then blocked in descending order. The impulses for pain
and temperature are, therefore, easily lost, while motor function and
sense of pressure or touch is usually preserved.
The two classes of local anesthetic agents differ greatly in their
pharmacology. Aminoesters undergo hydrolysis in the plasma by
pseudocholinesterase, while aminoamides are metabolized in the
liver. Esters are unstable in solution and have a greater potential to
elicit an allergic reaction, while amides are stable in solution and have
a greater potential to elicit a toxic reaction. Commonly utilized ami­
noesters include procaine, chloroprocaine, tetracaine and cocaine. The
aminoamides are more frequently employed due to decreased risk of
allergic reaction and greater stability in solution. Some of the more
common agents include lidocaine, mepivacaine, prilocaine, bupi­
vacaine and etidocaine.
Determining which local anesthetic to utilize should be based on
the individual profile of each anesthetic. All anesthetics have a pKa
between 7.6 and 9.2, enabling them to function best in a neutral or
slightly alkaline environment. When acidic tissue is present, such as
in inflammation and infection, the efficacy of the anesthetic is
decreased. The potency, onset of action and duration are diverse even
in similar classes of anesthetics. The potency is based on degree of
lipid solubility, as well as the amount of vasodilatation resulting from
the anesthetic. All local anesthetics, except for cocaine, result in some
degree of vasodilatation. The greater the degree of vasodilatation, the
greater the amount of systemic absorption and the lesser amount that
is absorbed at the nerve cell. This will greatly affect the duration of
the local anesthetic at the surgical site.
To enhance the effect of the local anesthetic, epinephrine in
concentration of 1 : 200 000 is frequently employed. The epinephrine
shortens the onset of anesthesia and prolongs its effects. Other
benefits seen with epinephrine include local vasoconstriction, which
minimizes bleeding and diminishes the need for a tourniquet, and a
decreased volume of anesthetic is required to achieve anesthesia,
thereby reducing potential for toxic reactions.
©2012 Elsevier Ltd.
Anesthesia
Mary E. Crawford
Chapter
6

46
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
The allergic reaction to a local anesthetic, usually an aminoester,
responds to discontinuation of the drug and the application of a
tourniquet, while assisting respiration as needed.
ANESTHETIC TECHNIQUES
Topical anesthesia
There are three methods for anesthetizing the lower limb: percutane­
ous (topical), nerve block or infiltration of anesthetic. Percutaneous
application is utilized for desensitizing the skin and very superficial
tissues. Emla® (AstraZeneca, LP, Wilmington, DE 19850), a topical
anesthetic compound, is composed of 25 mg of lidocaine 2.5% and
50 mg of prilocaine 2.5% in an emulsion cream. It is applied topically
under occlusion 45–60 min prior to a procedure to diminish cutane­
ous sensation. Adverse reactions may occur, such as contact dermatitis,
blanching followed by erythema and methemoglobinemia, but the
incidence of an adverse reaction with a topical anesthetic is very rare.
Other topical anesthetics available include combinations of agents
such as TAC (tetracaine, adrenaline or epinephrine, and cocaine); LET
(lidocaine, epinephrine and tetracaine) and two newer agents: prilo­
phen (prilocaine and phenylephrine) and bupivaphen (bupivacaine
and phenylephrine). Emla is by far the most commonly employed,
especially in the pediatric population. There is now also a transdermal
patch consisting of lidocaine that can be utilized to diminish sensa­
tion along an area that is hyperanalgesic from surgery or injury.
Nerve blocks and infiltration
Nerve blocks and infiltration techniques are by far the most common
methods for achieving anesthesia to the lower extremity. The superfi­
ciality of the nerve trunks facilitates the process of attaining anesthesia
to an area and often the nerves may be palpated directly. Some of the
most common nerve blocks performed in foot and ankle surgery
include the common peroneal nerve, the tibial nerve, the sural nerve,
the deep and superficial peroneal nerves and the saphenous nerve.
The common peroneal nerve is one of the branches of the sciatic
nerve and is best accessed as the nerve passes behind the fibular
head and courses posterolateral to the side of the neck of the fibula
(Fig. 6.1). This nerve block delivers sensory anesthesia to the lateral
leg and dorsum foot, and a motor blockade of the anterior and lateral
muscle compartments. In some surgical cases, it may be desirable to
block the branches of the common peroneal nerve, the superficial and
deep peroneal nerves.
The superficial peroneal nerve is the most variable in its path as it
descends the leg. It supplies the muscles of the lateral compartment
It has been perpetuated in historic, anecdotal legend that the use
of epinephrine in digital surgery is contraindicated. There are many
studies, surveys and authors that contradict this age-old myth, in view
of the fact that epinephrine results in only temporary vasoconstriction
that lasts for only 20–60 min, and even then, circulation is not com­
pletely occluded to the digit.
Nonetheless, there are some contraindications for the use of
epinephrine, such as thyrotoxicosis, coronary artery disease, severe
peripheral vascular disease, vasospastic conditions and tricyclic anti­
depressants, such as monoamine oxidase inhibitors, that may augment
the effect of the epinephrine. More commonly, the serious detrimental
outcomes following the use of epinephrine are a result of poor tissue
handling, poor vascular assessment, poor injection technique or
excessive volume of anesthetic into one area.
Complications from the administration of local anesthetic agents
can occur and are usually related to toxicity or allergic reaction to the
agent. Allergic reaction may present very rapidly and exhibit urticaria
or skin reaction, bronchospasm or respiratory compromise, edema
and anaphylactic shock. Toxicity can be seen by injection of an exces­
sive dose based on mg/kg of body weight, inadvertent intravascular
injection or rapid absorption from a highly vascular area. Toxic sys­
temic reaction manifests as convulsions, anxiety, restlessness, respira­
tory and cardiac depression, hypotension and cardiac arrhythmia and
eventual cardiac arrest. The toxic dose of commonly utilized local
anesthetics is based on the agent selected and the weight of the patient
(Table 6.1).
Most surgeons will become familiar with a few of the local anesthet­
ics that they commonly use and memorize the toxic dose to avoid
such complications. In foot and ankle surgery, lidocaine and bupi­
vacaine are regularly employed. The toxic dose for the average sized
adult is 300 mg for lidocaine and 175 mg for bupivacaine. When
epinephrine is added to the local anesthetic, the toxic dose increases
due to the decreased vascular absorption and is reported as 500 mg
for lidocaine with epinephrine and 225 mg for bupivacaine with
epinephrine. The treatments of toxic and allergic reactions differ due
to the distinct symptoms that exist. For toxic reactions, the convul­
sions are best treated with hyperventilation with Ambu bag and 100%
oxygen by facemask. Of special note, bupivacaine particularly tightly
binds to adipose tissue when compared with other local anesthetic
agents. Systemic toxicity of bupivacaine can result in fatal cardiac
arrhythmias. A fairly recently discovered antidote to local anesthetic
toxicity is Intralipid 20% (a 20% intravenous fat emulsion). This pure
lipid drug administered intravenously rapidly binds to systemic local
anesthetics and allows patients to be stabilized. The seizure compo­
nent of a toxic reaction can be effectively treated with diazepam at
0.1 mg/kg and the hypotension treated with intravenous fluids and
peripheral vasoconstrictor agents, along with the Trendelenburg
position.
Table 6.1  Toxic doses of commonly employed local anesthetic agents
Anesthetic agent
Classification
Maximum safe dose
Maximum dose with epinephrine
70 kg adult (mg)
mg/kg body weight
70 kg adult (mg)
mg/kg body weight
Lidocaine (Xylocaine)
Amide
300
4.5
500
7.0
Bupivacaine (Marcaine)
Amide
175
2.5
225
3.5
Mepivacaine (Carbocaine)
Amide
300
5
500
7.0
Prilocaine (Citanest)
Amide
400
600
Procaine (Novocaine)
Ester
500
600

Chapter
Anesthesia
47
| 6 |
easier to achieve a full anesthetic block. The deep peroneal nerve
descends in the anterior muscle compartment and becomes superficial
with the anterior tibial artery in front of the ankle. The nerve is com­
monly found between the extensor hallucis longus and extensor digi­
torum longus tendon, above the flexure lines of the ankle and medial
to the anterior tibial artery (Fig. 6.3). A local anesthetic block in this
area will provide anesthesia to the first web space.
The tibial nerve, or more commonly referred to as the posterior
tibial nerve, is the other branch of the sciatic nerve and is in direct
vertical continuity of the sciatic. As the nerve bisects the popliteal
fossa, it descends the leg between the deep and superficial posterior
muscle groups until reaching the inferior one-third of the leg, where
the nerve becomes superficial on the medial side of the ankle midway
between the medial malleolus and the Achilles tendon. The nerve lies
immediately lateral and posterior to the posterior tibial artery. The
tibial nerve divides within the tibiotalocalcaneal canal into its two
terminal branches, the medial and lateral plantar nerves.
Because of the broad distribution of cutaneous innervation to the
plantar foot, the posterior tibial nerve is probably the most common
local nerve block performed in foot surgery. Although the location of
the nerve within the tibiotalocalcaneal canal is reasonably consistent,
it can be one of the more frustrating nerve blocks to perform effec­
tively. There are three techniques utilized, that, with some practice,
offer the physician the most reproducible results. The first is to have
the patient prone with the foot draped over the edge. The needle is
then inserted immediately above the medial malleolus medial to the
Achilles tendon. The needle is advanced until paraesthesia is obtained
or the tibial border is encountered. The needle is then withdrawn
1 inch and the local anesthetic is infiltrated after aspiration.
A second, more popular, method is when the patient is supine and
the leg is externally rotated and the foot internally rotated. The needle
is inserted directly above the nerve at the tibiotalocalcaneal canal,
which lies just posterior to the arterial pulse, and the local anesthetic
is infiltrated once paraesthesia is obtained. Aspiration in this area
is also critical, to avoid intravascular injection of the anesthetic
(Fig. 6.4).
and then pierces the fascia between the peroneus brevis and extensor
digitorum longus and descends into the foot. It divides into the ter­
minal branches of the medial and intermediate dorsocutaneous
nerves, which then innervate the dorsal foot. The superficial peroneal
nerve is difficult to isolate for a local anesthetic block due to its vari­
ability in where it pierces the fascia, but on occasion, it can be found
with plantarflexion and inversion of the ankle and palpation in the
distal one-third of the anterolateral leg (Fig. 6.2).
A successful local anesthetic block in this area will obtain anesthesia
to the dorsal foot, along with a saphenous and sural nerve block. The
deep peroneal nerve is fairly consistent in its location and is often
Figure 6.1  Topographical anatomic location of the common peroneal
nerve and placement of the local anesthetic infiltrate (at large dot)
posterolateral to the side of the neck of the fibula.
Figure 6.2  Topographical anatomic location of the superficial lateral
peroneal nerve (dotted line) and placement of the local anesthetic
infiltrate (at large dot). This nerve distribution is slightly more variable
than other foot and ankle nerve distributions.
Figure 6.3  Topographical anatomic location of the deep peroneal nerve
(solid line) and placement of the local anesthetic infiltrate (at large dot)
at the ankle joint as part of an ankle block.

48
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
nerve receives an anastomotic branch from the peroneal communicat­
ing nerve, which is a branch of the common peroneal nerve, to form
the sural nerve. The sural nerve courses distally along the lateral border
of the Achilles tendon and is anterolateral to the lesser saphenous
vein. The sural nerve consistently runs between 1 and 1.5 cm behind
the tip of the lateral malleolus (Fig. 6.5). A local anesthetic block in
this location will provide anesthesia to the lateral, dorsolateral and
plantar lateral foot.
The saphenous nerve is the terminal sensory branch of the femoral
nerve. It innervates the medial aspect of the leg and foot to the level
of the medial hallux, and is joined by the medial branch of the super­
ficial peroneal nerve. In cases where an anesthesiologist has performed
a regional sciatic nerve block, the saphenous nerve is not affected and
must be blocked separately in order to fully anesthetize the foot. The
saphenous nerve is easily identified just above the medial malleolus.
The foot is dorsiflexed creating a sulcus between the tibialis anterior
tendon and the medial malleolus. In the center of this sulcus are the
greater saphenous vein and the corresponding saphenous nerve.
Because of the close proximity of the saphenous nerve and the greater
saphenous vein, aspiration prior to injection of local anesthetic is
recommended (Fig. 6.6).
INTRAVENOUS SEDATION
Although many surgical procedures of the foot and ankle can be per­
formed with local anesthetic infiltration to the nerves above, the
anxiety provoked by the sound and vibration of the surgery and the
discomfort from the local infiltration frequently necessitates some
degree of sedation be provided for patient comfort. An anesthesiolo­
gist or nurse anesthetist usually administers this unless the surgeon is
specifically trained in the administration of intravenous sedation.
Administering a combination of an amnestic, analgesic and sedative
pharmacologic agents usually produces intravenous or conscious
sedation.
A final method to achieve a posterior tibial nerve block is less effec­
tive than the others and requires greater volume of local anesthetic,
as it indirectly blocks the tibial nerve by infiltrating the entire neurov­
ascular tunnel. The leg is externally rotated and the knee is bent in
order to lay the lateral foot on the supporting surface. At two finger
breadths above the medial malleolus, a line is drawn perpendicular
to the long axis of the tibia. The needle is inserted tangential to the
medial border of the Achilles and advanced until touching the tibia.
The needle is then withdrawn a few millimeters and 7–10 mL of
anesthetic is injected. If successful with any of these methods, the
majority of the plantar aspect of the foot is now fully anesthetized for
surgical intervention.
The final nerve to take its root from branches of the sciatic nerve is
the sural nerve. The sural nerve begins as the medial sural nerve, which
is a branch off the tibial nerve in the popliteal fossa. The medial sural
Figure 6.4  Two variations of the posterior tibial nerve local anesthetic
infiltrate. (A) Patient supine and left leg externally rotated, foot internally
rotated. Infiltration (at large dot) directly over posterior tibial nerve (solid
line) in the tarsal canal. (B) Patient prone and anesthetic is administered
(at large dot) just above the right medial malleolus (outlined), medial to
Achilles tendon.
A
B
Figure 6.5  Topographical anatomic location of the sural nerve 1–1.5 cm
behind the lateral malleolus (outlined) and placement of the local
anesthetic infiltrate (at large dot).

Chapter
Anesthesia
49
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comprehensive block of all the nerves in the corresponding area and
usually only one injection is required.
The benefit of peripheral nerve blocks is well documented. Periph­
eral nerve injury that occurs during surgical procedures triggers a state
of neuronal excitation centrally that is termed ‘central facilitation’, or
‘wind up’. This can result in significant hyperesthesia and allodynia
after surgery, even chronic regional pain syndrome (CRPS). When
preoperative administration of anesthetic occurs, the ‘wind up’
is prevented. Anesthetic administered only postoperatively does not
prevent central facilitation from occurring. Therefore, the attention to
the preoperative blockade of pain transmission is important for long-
term postoperative pain management and reduction of possible post­
operative complications resulting in chronic pain. Other benefits of
regional blockade preoperatively include improved pulmonary func­
tion and cardiovascular stability, which is attributed to the reduction
in the use of postoperative narcotics as well as reduced post-injury
physiologic stress from reduced pain. There is also a reduction of
thromboembolic events due to reduced physiologic stress and
improved mobility due to decreased pain.
The sciatic nerve is the largest nerve of the body. It consists of two
distinct nerve trunks, the tibial nerve and the common peroneal nerve
that together innervate the posterior, lateral, anterior leg and dorsal
and plantar foot. From their origin to the popliteal fossa, these two
nerves share a common epineural sheath. Just above the popliteal
fossa, the nerves diverge, the tibial continuing in a linear fashion into
the posterior calf and the common peroneal nerve proceeding laterally
to the fibular neck (see prior section on local anesthetic blocks).
Administration of local anesthetic to the sciatic nerve effectively pro­
vides prolonged anesthesia rapidly and effectively to all areas of the
foot and ankle except along the innervation of the saphenous nerve
medially, which can be blocked separately as previously described.
The regional anesthetic block of the sciatic nerve can be performed in
a multitude of ways, depending on patient position and desired
outcome. A sciatic block, performed in the area just above the pop­
liteal fossa, is often referred to as a popliteal or low sciatic block. This
provides anesthesia to both the tibial and common peroneal nerves
and often can be accomplished with one injection performed either
laterally or posteriorly just above the popliteal fossa at the location
of the common epineural sheath (Fig. 6.7). Identification of the
accurate location for the administration of the anesthetic is often
facilitated with the use of peripheral electrical stimulator connected
to an insulated needle that can properly stimulate the nerves to
achieve the proper muscular contraction (Fig. 6.8). Plantarflexion of
the foot and ankle as a motor response was more accurate in predict­
ing a complete sciatic block than eversion of the foot, yielding a higher
success rate for the block. Once the common epineural sheath is
located, injection of high dose bolus anesthetic may be administered
or an indwelling catheter may be placed for continuous infusion
postoperatively.
The epidural block is a regional anesthesia in which the spinal
nerves are blocked as they pass through the epidural space of the
vertebral canal. The epidural provides some advantages over the spinal
anesthesia, in that there is less incidence of post-anesthetic headache
and a continuous indwelling catheter can be placed for prolonged
cases or postoperative pain control. The epidural block, however,
is often times more difficult to place to achieve complete anesthesia
and has a longer induction period before the anesthetic takes
full effect.
The spinal block is often preferred by surgeons and anesthesiolo­
gists because of the rapid induction time and decreased incidence of
nausea and vomiting with the spinal anesthetic compared with general
anesthesia. The local anesthetic is injected into the subarachnoid
space and is able to achieve full sensory, motor and autonomic block­
ade. There is an increased risk, however, of post-anesthetic headache,
REGIONAL NERVE BLOCK
Regional anesthesia involves anesthetizing regional areas in the body,
including single extremities, multiple extremities, the torso, the face
or the jaw. A regional nerve block usually involves administration of
anesthetic to the large proximal nerve of an extremity, with electrical
needle stimulation guidance or a spinal or epidural anesthetic admin­
istered by the anesthesiologist or nurse anesthetist. In foot and ankle
surgery, the regional blockade of the sciatic may offer the patient a
greater degree of comfort for extended duration owing to the more
Figure 6.6  Topographical anatomic location of the saphenous nerve
(dotted line) just anterior to the medial malleolus and placement of the
local anesthetic infiltrate (circle of dots) just medial to the tibialis anterior
tendon and anterior to the medial malleolus.
Figure 6.7  Topographical anatomic location of the low sciatic nerve just
above the popliteal fossa. Note the anatomy of the tendons in this area
to guide the location of the injection.

50
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
of anesthetic administered is lidocaine 3 mg/kg of body weight. Lido­
caine is usually the agent of choice due to decreased risk of methemo­
globinemia and thrombophlebitis. There are some inherent risks
associated with the infiltration of the local anesthetic intravenously.
The greatest risk is loss of tourniquet inflation resulting in a sudden
release of a large volume of anesthetic intravascularly, which could
result in cardiac arrest. A dual bladder control tourniquet is frequently
employed to decrease the likelihood of this occurrence. A rapid influx
of a large volume of anesthetic could also occur, or a toxic reaction
could occur, if the case was too short to allow for a slow resorption
of the anesthetic and the tourniquet was released resulting in a rapid
inflow of blood to the area. Minor toxic reactions may also occur
resulting in ringing in the ears or syncope due to drop in blood
pressure.
A major toxic reaction can occur, however, that could result in severe
hypotension, convulsions, respiratory depression or even death. Indi­
cations for a Bier block may include a patient in whom a general
anesthetic poses too great a risk; a spinal or epidural is not possible
due to spinal arthritis or laminectomy or specific local nerve blocks
are not possible. Contraindications would include any patient with a
history of anaphylaxis to local anesthetics, previous history of throm­
bophlebitis or deep vein thrombosis, or localized infection. Therefore,
a Bier block is not as commonly utilized as other regional blocks, such
as the epidural or spinal anesthesia or sciatic block.
CONCLUSION
In the end, the choice of anesthetic agent and the method of admin­
istration both involve consideration of several variables. The age and
health status of the patient; the past history of prior anesthetic experi­
ences; the capability of the surgeon to deliver adequate anesthesia
locally; the expertise of the anesthesiologist to provide regional
anesthesia and the desires of the patient, must all be contemplated.
The risk and benefit of each anesthetic type must be weighed against
the convenience of certain methods to determine the most appropri­
ate form for each individual case, providing the safest, most effective
environment for the patient.
especially in young adults, and also a risk of profound hypotension,
urinary retention, infection, direct needle injury or scar tissue. These
risks are very rare and are often outweighed by the benefits of the
spinal anesthetic to deliver complete anesthesia to the surgical site.
There are indisputable contraindications to a spinal anesthetic that
should not be disregarded, such as bleeding disorders that may result
in hemorrhage, shock or hypovolemia, severe cardiac disease, spinal
deformities and any neurologic condition that may be exacerbated by
increased intracranial pressures.
A more localized regional block can also be performed and is
known as an intravenous regional anesthesia or Bier block, first
described in 1908. This involves the administration of local anesthetic
into an intravenous line in the lower extremity while under a proximal
inflated calf tourniquet. The local anesthetic perfuses into the sur­
rounding tissues distal to the tourniquet. The usual agent and dosage
Figure 6.8  Electronic nerve stimulator with insulated needle to accurately
identify location of sciatic nerve within the common epineural sheath
above the popliteal fossa.
FURTHER READING
Arcioni, R., Palmisani, S., Rocca, M., et al.,
2007. Lateral popliteal sciatic nerve block: a
single injection targeting the tibial branch
of the sciatic nerve is as effective as a
double-injection technique. Acta
Anaesthesiol Scand 51, 115–121.
Bern, S., Akpa, B.S., Kuo, I., et al, 2011. Lipid
resuscitation: a life-saving antidote for local
anesthetic toxicity. Curr Pharm Biotechnol
12 (2), 313–319.
Bier, A., 1908. A new method for local
anesthesia of the extremities. Ann Surg 48,
780.
Borghi, B., D’Addabbo, M., White, P.F., et al.,
2010. The use of prolonged peripheral
neural blockade after lower extremity
amputation: the effect on symptoms
associated with phantom limb syndrome.
Anesth Analg 111 (5), 1308–1315.
Braid, D.P., Scott, D.B., 1965. The systemic
absorption of local anaesthetic drugs. Br J
Anaesth 37, 394.
Butterworth, R., 1992. Local anaesthetics. In:
Butterworth, R., Dockery, G.L. (Eds.), A
Colour Atlas and Text of Forefoot Surgery.
Wolfe, Aylesbury, pp. 35–63.
Cavaliere, R.G., Pappas, E., 2001. Anesthesia.
In: Banks, A.S., Downey, M.S., Martin, D.E.,
et al. (Eds.), McGlamry’s Comprehensive
Textbook of Foot and Ankle Surgery, vol 1,
third ed. Lippincott Williams & Wilkins,
Philadelphia, pp. 177–200.
Chung, D., Laur, A., 1997. Essentials of
anesthesiology. WB Saunders,
Philadelphia.
Cobbold, A., Money, T., 2010. Regional
anaesthesia: back to basics.
J Perioper Pract 20 (8): 288–293.
Corman, S.L., Skledar, S.J., 2007. Use of
lipid emulsion to reverse local-anesthetic-
induced toxicity. Ann Pharmacother
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CHAPTER CONTENTS
Introduction
53
Definition of asepsis
53
Definition of antisepsis
54
Definition of sterility
54
Surgical infections
54
Types of surgical incision infections and their
classification
54
Prevention of contamination
54
Preoperative
54
Intraoperative
55
Postoperative
55
Contamination risk factors
55
Systemic factors
55
Surgical incision factors
56
The operative procedure factors
56
Type of operation factors
56
Postoperative incision management
56
Surgical instrument and equipment sterilization
57
Autoclaves (steam under pressure)
57
Instrument disinfection
57
Low-temperature steam
57
Dry heat
57
Chemical disinfectants
57
Operating room attire
57
Scrub suits
57
Head cover
57
Facemask
57
Eye cover or protection
58
Foot covers
58
Asepsis
58
Preoperative preparation
59
Hand scrubbing
59
Surgical gowning
60
Sterile gloving
60
Removing sterile gloves
61
Patient’s skin scrub
61
Preparation of the surgical site
62
Skin disinfection and scrubbing
62
Draping of the operation site
63
Intraoperative preparation
65
Postoperative preparation
65
Summary
65
INTRODUCTION
Once an incision is made into the skin, the body’s major protective
defence barrier against infection is broken. During surgery, the inner
surfaces of the body are exposed to the environment and, potentially,
to contamination and infection. Every effort must then be made to
avoid microorganisms from entering the incision (asepsis) and to
eliminate microorganisms if they have already entered (antisepsis). In
lower extremity plastic and dermatological procedures, the surgeons
perform a wide range of techniques in several types of settings such
as the clinic, surgery center or hospital. Procedures range from simple
techniques using non-sterile gloves and alcohol prep of the skin for
biopsies, to complete surgical care with sterile gowns, gloves, masks
and strict asepsis for more complex procedures. The following infor­
mation delineates the most important information about aseptic tech­
niques and their relevance to plastic and dermatological surgery.
Definition of asepsis
Asepsis is a condition in which no living disease-causing microorgan­
isms are present. Asepsis covers all those procedures designed to
reduce the risk of bacterial, fungal or viral contamination, using sterile
instruments, sterile draping and the gloved ‘no touch’ technique. They
also include all of the prophylactic methods, working processes and
behavioral forms by which microorganisms can be kept away from
the patient’s body and the surgical incision. The goal of asepsis is to
prevent contamination, which can be ensured by the use of sterile
©2012 Elsevier Ltd.
Aseptic techniques
G. Dock Dockery
Chapter
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54
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
The infection of surgical skin incisions is one of the main expres­
sions of nosocomial infections. As nosocomial infections are a source
of great cost to the patient, the surgeon and to the health care system,
an understanding of the etiology and pathomechanism is of the
utmost importance. The main cause of postoperative skin incision
infections is Staphylococci and Streptococci. In direct incision infection,
the process is started by residual skin flora, dermal infection, the
surgeon’s hands or a contaminated device or bandage, or it can be
transmitted from drains and intravenous catheters. Air-borne infec­
tions originate from the skin and clothing of operating room person­
nel, other patients or the hospital or clinic staff and from the airflow
in the hospital room or operating room.
Types of surgical incision infections
and their classification
The Center for Disease Control defines a surgical site infection (SSI)
as any surgical incision that produces pus within 30 days of the surgi­
cal procedure, even in the absence of a positive culture. An exception
to this definition is the suture abscess, which may drain or appear to
have pus, but resolves with the removal of the suture. Inflammation
is frequently associated with incision infection but in the absence of
pus, it is not classified as an infection (Box 7.1).
PREVENTION OF CONTAMINATION
Examination of the sources of infection in the immediate peri­
operative period reveals the following origins of possible causative
agents to be: patients waiting for their operation; members of the
operating team; the operating room itself (e.g. circulating air, air con­
ditioning, water, dirty floors, etc.); devices for the operation (e.g.
drapes, instruments, sutures, bandages, etc.) or contamination of
dressings post­operatively. The rules of asepsis must be kept in connec­
tion with all of the above factors, as this is the only way to decrease
incision infections.
Preoperative
A vigilant surgical scrub and preparation of the operative site (cleans­
ing of the skin and rarely, removal of hair) is necessary. Preoperative
shaving of the surgical site the night before an operation is associated
with a significantly higher SSI risk than either the use of depilatory
agents or no hair removal. The increased SSI risk associated with
shaving has been attributed to microscopic cuts in the skin that later
serve as foci for microorganism multiplication. Shaving immediately
before the operation compared with shaving within 24 h preopera­
tively was associated with decreased SSI rates (3.1% vs 7.1%); if
shaving was performed >24 h prior to operation, the SSI rate exceeded
20%. Clipping hair immediately before an operation also has been
associated with a lower risk of SSI than shaving or clipping the night
before an operation (SSI rates immediately before = 1.8% vs night
before = 4.0%). Although the use of depilatories has been associated
with a lower SSI risk than shaving or clipping, depilatories sometimes
produce hypersensitivity reactions. Other studies have shown that
preoperative hair removal by any means was associated with increased
SSI rates and suggested that no hair be removed. The one exception
might be when the hair was directly interfering with the ability to
make a surgical incision. If this is the case, then the hair should be
judiciously clipped at the incision site with scissors or electric clippers
immediately prior the preoperative skin scrub.
While the risk of surgical site infections is generally low in patients
undergoing dermatological surgery, antibacterial prophylaxis is advo­
cated in patients who are undergoing certain procedures with a high
devices, materials and instruments and by creating an environment
that is low in microbe volume.
Definition of antisepsis
Antisepsis relates to the removal, or elimination, of transient micro­
organisms from the skin and a reduction in the resident flora. The
resident flora help protect the patient from infection by competing
with pathogens for substrate and tissue receptors. The most common
resident organisms of the skin are the coagulase-negative staphyloco­
cci, with Staphylococcus epidermidis accounting for more than 90% of
resident aerobes.
Techniques may be applied to eliminate contamination (bacterial,
viral, fungal and others) present on objects and the skin by means of
sterilization and disinfection. Living surfaces, the skin, the operating
field and the surgeon’s hands cannot be considered sterile. Therefore,
the goal of preoperative skin cleansing is to dramatically decrease the
resident skin flora to its lowest potential level, realizing that it cannot
be totally eliminated.
In a broader sense, asepsis concerns an idyllic state, in which the
instruments, the skin and the surgical incision are free from patho­
genic organisms and transient flora, while antisepsis includes all those
prophylactic procedures designed to promote surgical asepsis. Asepsis
is what is primarily important. Antisepsis is the primary prevention.
Transient flora is acquired through contact with people, objects or
the environment. The majority of postoperative infections are due to
transient microorganisms that contaminate the incision or wound
during or immediately after surgery. Most pathogens are transmitted
via one of four fundamental pathways: direct or indirect contact, air-
borne, vehicle or vector. The contact and the air-borne pathways are
the most likely means of contamination of surgical incisions. Contact
transmission may be indirect where microorganisms are transferred
by fomites or inanimate objects capable of carrying microorganisms,
such as suture material or dressings, or direct contact such as when
contaminated skin touches the open incision or deep wound. The
air-borne method may occur when microorganisms from desqua­
mated skin cells, aerosolized water droplets or dust particles con­
taminate gloves, gowns, surgical linens or instruments. Vehicle
contamination may occur with infected blood or water. Vector con­
tamination (such as the transmission of disease-causing microorgan­
isms from one infected person to another, such as via a mosquito) is
the least likely form of post-surgical incision infection.
Definition of sterility
Sterility is a microbiologically germ-free state of all surgical materials
and items. This means that they are free from all kinds of pathogenic
and non-pathogenic microorganisms.
SURGICAL INFECTIONS
Problems appearing during medical care (e.g. wrong limb or wrong
surgery) or caused by medication (e.g. allergic reactions or incorrect
medications) are referred to as iatrogenic disorders. There are also
conditions of iatrogenic infections caused by the doctor, medical staff
or facility. Nosocomial infections, ones that originate or occur in a
hospital, are iatrogenic and may manifest in different forms. Some of
these infections are well-defined and originate from a single micro­
biological cause. However, in most cases, a pattern of infection evolves,
which is caused by many different pathogens. Skin surgery is mainly
affected by this problem, with many different pathogens capable of
infecting the skin.

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Box 7.1  Criteria for defining a surgical site infection (SSI)
Superficial incision SSI
Infection occurs within 30 days after the operation and infection
involves only skin or subcutaneous tissue of the incision and at least
one of the following:
1. Purulent drainage, with or without laboratory confirmation, from
the superficial incision
2. Organisms isolated from an aseptically obtained culture of fluid or
tissue from the superficial incision
3. At least one of the following signs or symptoms of infection: pain
or tenderness, localized swelling, redness, heat and a superficial
incision deliberately opened by surgeon, unless the incision is
culture-negative.
Diagnosis of superficial incision SSI by the surgeon
or attending physician
Exclusions: Do not report the following conditions as SSI:
1. Stitch abscess (minimal inflammation and discharge confined to the
points of suture penetration)
2. Localized stab wound infection
3. Infected burn wound
4. Incisional SSI that extends into the fascial and muscle layers (see
deep incisional SSI)
5. Cellulitis, by itself, does not meet the criteria for superficial incision
SSI.
Deep incision SSI
Infection occurs within 30 days after the operation if no implant is left
in place or within 1 year if implanta is in place and the infection
appears to be related to the operation and infection involves deep soft
tissues (e.g. fascial and muscle layers) of the incision and at least one
of the following:
1. Purulent drainage from the deep incision but not from the organ/
space component of the surgical site
2. A deep incision spontaneously dehisces or is deliberately opened by
a surgeon when the patient has at least one of the following signs
or symptoms: fever (>38°C/>100°F), localized pain, or tenderness,
unless site is culture-negative
3. An abscess or other evidence of infection involving the deep
incision is found on direct examination, during reoperation, or by
histopathological or radiological examination
4. Diagnosis of a deep incisional SSI by a surgeon or attending
physician.
Notes:
a. Report infection that involves both superficial and deep incision
sites as deep incisional SSI.
b. Report an organ/space SSI that drains through the incision as a
deep incisional SSI.
Organ/space SSI
Infection occurs within 30 days after the operation if no implant is
left in place or within 1 year if implant is in place and the infection
appears to be related to the operation and infection involves any part
of the anatomy (e.g. organs or spaces), other than the incision, which
was opened or manipulated during an operation and at least one of
the following:
1. Purulent drainage from a drain that is placed through a stab
wound into the organ/space
2. Organisms isolated from an aseptically obtained culture of fluid or
tissue in the organ/space
3. An abscess or other evidence of infection involving the organ/
space that is found on direct examination, during reoperation, or
by histopathological or radiological examination
4. Diagnosis of an organ/space SSI by a surgeon or attending
physician.
Source: Horan, T.C., Gaynes, R.P., Martone, W.J., et al., 1992. CDC definitions
of nosocomial surgical site infections, 1992: a modification of CDC definitions
of surgical wound infections. Infect Control Hosp Epidemiol 13 (10), 606–608.
aImplant: material or tissue (non-human derived object) that is permanently
placed in a patient during an operative procedure and is not routinely
manipulated for diagnostic or therapeutic purposes. Examples: metal rods,
mesh, wires, screws, metal plates, cements, joint replacements and other
devices.
risk of infection, or who have a high risk of bacterial endocarditis or
prosthetic infection.
Intraoperative
Appropriate surgical techniques must be applied (careful tissue prepa­
ration, strict management of bleeding vessels, gentle handling of
tissues and skin, minimal use of absorbable sutures, etc.). The surgical
site and anatomical body parts involved are usually covered with
sterile drapes to protect the area from microorganisms present on the
surrounding non-sterile areas. For very small isolated surgical sites,
such as the toes, the sterile drapes may be small themselves. When a
much larger area is involved (e.g. the entire lower leg), then much
more sophisticated sterile draping may be necessary. Finally, during
surgery, if there is a concern or evidence of glove breakage, it is wise
to rescrub the hands if soiled and change gloves.
Postoperative
Surgical site infections evolve shortly after contamination, usually
within 2 h. Hand-washing is mandatory and the use of sterile gloves
is compulsory while handling incision dressings and changing
bandages during the early postoperative period. It is almost univer­
sally advised that the surgical dressings be kept dry immediately fol­
lowing surgery to reduce contamination of the incision. This is based
upon the concept that the wet bandages may ‘wick’ adjacent skin
microorganisms into the surgical field. This can be especially harmful
when water from outside the dressing, such as during bathing, con­
taminates the dressing.
CONTAMINATION RISK FACTORS
Systemic factors
These include undernourishment, obesity, hypovolemia, smoking,
impaired tissue perfusion, age (the elderly or very young children)
and steroid therapy. Medical conditions associated with altered
immune responses such as diabetes mellitus, cirrhoses, uremia and
immunosuppressed states are all risk factors. In the majority of these
cases, the surgical intervention should be performed exclusively under

56
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Type of operation factors
The risk factor for incision contamination may be increased with the
type of operation itself, as certain operations have a higher than
average risk of incision contamination. For example, a very long surgi­
cal procedure in which a great deal of sharp instrumentation, such as
K-wires and external fixators, are used may increase the potential for
contamination.
Surgical wounds can be categorized according to the level of
incision contamination as: clean (Class I); clean–contaminated
(Class II); contaminated (Class III) and dirty–infected groups (Class
IV) (Box 7.3).
POSTOPERATIVE INCISION MANAGEMENT
The crucial factor in postoperative incision management is the meticu­
lous preservation of the rules of asepsis: the primarily closed incision
is covered with a sterile covering bandage for 48 h; hygienic hand-
washing before and after the incision management is mandatory; and
a sterile technique must be practiced during any change of the post­
operative bandages for the first 6–7 days.
aseptic circumstances in the sterile operating room. These patients
must usually be treated with strict adherence to the rules of asepsis
and incision management should be performed in the surgery
center or hospital, rather than in the treatment rooms or clinic rooms
(Box 7.2).
Surgical incision factors
The factors related to the surgical wound include dead or devitalized
tissue left in the incision, a hematoma or seroma, foreign bodies such
as drains or sutures, dead space, improper skin scrubbing, inadequate
disinfection and shaving, or a previously existing infection (locally or
distant to the incision).
The operative procedure factors
These include performing an incorrect surgical technique, inadequate
handling of bleeding vessels, long surgical times (>2 h); intraoperative
infections, non-sterile operating room personnel, non-sterile instru­
ments, improper air-exchange in the operating room, hypothermia,
and a long preoperative or postoperative hospital stay.
Box 7.2  Characteristics that may influence the risk of
development of surgical site infection
Patient
• Age
• Nutritional status
• Diabetes
• Smoking
• Obesity
• Coexistent infections at a remote body site
• Colonization with microorganisms
• Altered immune response
• Length of preoperative stay
Operation
• Duration of surgical scrub
• Skin antisepsis
• Preoperative shaving
• Preoperative skin prep
• Duration of operation
• Antimicrobial prophylaxis
• Operating room ventilation
• Inadequate sterilization of instruments
• Foreign material in the surgical site
• Surgical drains
• Surgical technique:
– Poor hemostasis during procedure
– Failure to obliterate dead space(s)
– Tissue trauma
Adapted from: Cruse, P.J., 1992. Surgical wound infection. In: Wonsiewicz, M.J.
(ed.), Infectious diseases, Philadelphia: WB Saunders, pp. 758–764.
Box 7.3  Surgical wound classification
Class I/Clean
An uninfected operative incision or wound is defined as clean if it is
elective, non-traumatic, non-emergent and carried out on non-
inflamed tissues under strict aseptic technique. In addition, clean
wounds are primarily closed and, if necessary, drained with closed
drainage. Operative incisional wounds that follow non-penetrating
(blunt) trauma should be included in this category if they meet the
criteria.
Class II/Clean–contaminated
A clean–contaminated incision or wound is defined by minor breaks
in aseptic technique or entry into contaminated areas. Urgent or
emergency case that is otherwise clean. Specifically, operations
involving the respiratory, gastrointestinal, biliary or genitourinary tract
with minimal spillage are included in this category, provided no
evidence of infection or major break in technique is encountered.
Class III/Contaminated
Contaminated wounds or incision include those where major breaks
in aseptic technique have occurred, or there is inflammation, but no
frank pus encountered. These include open, fresh, accidental wounds
and penetrating traumatic wounds open <4 h. They include chronic
open wounds to be grafted or covered.
Class IV/Dirty–infected
Old traumatic wounds with retained devitalized tissue and those
that involve existing clinical infection or purulent fluid, such as in
an abscess. This also includes penetrating traumatic wounds open
for >4 h. This definition suggests that the organisms causing
postoperative infection were present in the operative field before the
operation.
Modified from: Berard, F., Gandon, J., 1964. Postoperative wound infections:
the influence of ultraviolet irradiation of the operating room and of various
other factors. Ann Surg 160 (Suppl. 1), 1–192; and Garner, J.S., 1993. The
CDC Hospital Infection Control Practices Advisory Committee. Am J Infect
Control 21, 160–162.

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Mycobacterium species are very resistant. Slow viruses are highly resist­
ant. This cold disinfectant is the least effective method of preparing
surgical instruments for plastic and dermatological surgery and is
generally not recommended.
OPERATING ROOM ATTIRE
Scrub suits
Surgical attire can be either non-sterile or sterile. The non-sterile scrub
suits are designed to reduce microbial shedding from surgical person­
nel. These items of surgical clothing are referred to as ‘greens’ or ‘blues’
due to the most common colors of the material (Fig. 7.1). They are
permeable to moisture and should be changed immediately if they
should become wet with blood or other body fluids. They should
never be worn from the outside of the hospital to the inside of the
operating room and should be changed upon entry to the operating
theater. There is little clinical evidence that wearing scrub suits offer
significant microbiological advantage, and may, after a few hours,
shed as much bacteria as normal clothing; they do, however, prevent
contamination of normal clothes with blood and other fluids, and for
this reason should be worn in the surgical setting.
Head cover
The surface of hair of the head and face carries bacteria, which may
be shed during surgery and contaminate the surgical field. The head
cover should cover the hair completely. Those with short hair may use
the surgical cap style of head cover (Fig. 7.2), while those with longer
hair may use the bouffant-style head cover (Fig. 7.3). Men with facial
hair should utilize the head cover with an extended flap to cover the
face (Fig. 7.4).
Facemask
Masks should cover the nose and mouth, fitting snugly across the
bridge of the nose, at the edge of the cheeks and under the chin. The
nose portion should be crimped to fit the contour of the nose and
then the mask should be tied firmly at the back of the head (Fig. 7.5).
It is generally thought to be inappropriate to have the nose exposed
SURGICAL INSTRUMENT AND
EQUIPMENT STERILIZATION
This process involves the removal of viable microorganisms (patho­
genic and non-pathogenic microorganisms, including latent and
resting forms such as spores), which can be achieved by different
physical and chemical methods or by their combined effects, in killing
or inactivating all living microorganisms and their latent and resting
forms.
Autoclaves (steam under pressure)
Autoclaves are highly effective and inexpensive tools of sterilization.
Their effectiveness is based on the fact that the temperature of steam
under pressure exceeds 100°C. At 108 kilopascals (kPa), the steam is
121°C (a vacuum has to be created). When the pressure is 206 kPa,
the temperature of steam is 134°C. The time needed for sterilization
at 121°C is 20 min and at 134°C is 10 min. To be effective against
viruses and spore-forming bacteria, the steam must be in direct contact
with the materials. The effectiveness can be checked via the color
change of the indicator tape placed on the packing. The disadvantage
of autoclaves is that they are unsuitable for heat-sensitive objects and
repeated exposure to high humidity and heat may dull sharp, fine
cutting instruments, particularly high-grade carbon steel edges of scis­
sors and scalpel blades.
INSTRUMENT DISINFECTION
This involves the reduction of the number of viable microorganisms
by destroying or inactivating them on living or inanimate (non-living)
surfaces. It can be achieved low-temperature steam, dry heat and with
chemicals (disinfectants).
Low-temperature steam
Most bacteria and viruses are killed by exposure to moist heat. This is
usually achieved with saturated steam at 73°C, applied for >10 min
(usually 15–30 min), depending on the density of the surgical
package. This procedure is effective, reliable and suitable for instru­
ments with a lumen but it is unsuitable for heat-sensitive items.
Dry heat
Dry heat (121–201°C) is suitable for instruments that can withstand
prolonged exposure to heat without humidity. This method does not
dull sharp surgical instrument edges, as does the low-temperature
steam heat.
Chemical disinfectants
These are suitable for heat-sensitive items, but are less effective than
heat. Some of these disinfectants are sporicidal, but they should gener­
ally not be used for sterilization because most items need a very long
time (≥10 h) of soaking in order to render them sterile. Agents include
glutaraldehyde, aqueous formaldehyde or quaternary detergents,
which may be used as ‘cold disinfectants’. Instruments must be
immersed for 6–12 h. The goal is to destroy microorganisms by
chemical or physicochemical means. Different organisms vary in
their sensitivity to them: Gram-positive bacteria are highly sensitive
and Gram-negative bacteria are relatively resistant. Clostridial and
Figure 7.1  Surgical scrub suits.

58
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Eye cover or protection
Eye contamination from splashed fluids or blood during surgical
procedures places the surgeon at risk for communicable diseases
such as human immunodeficiency virus (HIV) and hepatitis B and C.
There is need to enforce universal precautions during surgery to
protect the eyes of surgeons from blood or other body fluids from the
patient being operated upon. Various types of eye protection to
prevent eye contamination include: (1) modern prescription glasses;
(2) standard surgical telescopic loupes; (3) hard plastic contoured
glasses; (4) disposable plastic glasses and (5) a combination facemask
and plastic lens eye shield. Readily available and disposable plastic
glasses are associated with the lowest rate of conjunctival contamina­
tion and are an effective means with which to protect the foot
and ankle surgeon from communicable diseases by conjunctival
contamination.
Foot covers
The foot covers worn during surgery should be fluid resistant and have
non-slip soles. Paper booties, with elastic at the ankles, are the most
common form of shoe protection and are worn over street shoes
(Fig. 7.8). These disposable shoe covers protect the surgeon’s shoes
from exposure to blood-borne pathogens and add to the overall
hygiene of the operating room. Shoe covers should be removed at the
end of the surgery before leaving the operating room if they become
heavily contaminated with irrigation fluids or blood. There is limited
evidence that the use of foot covers directly affects wound infection
rates but it is standard practice in most clinical and surgical operating
rooms.
ASEPSIS
In surgery, asepsis has developed into an entirely sophisticated proce­
dure practiced every day and on every case. The rules of asepsis must
be maintained as it concerns the patient, the operating room person­
nel, the operating room, the operating room devices, the tools and
the surgical instruments. Surgical asepsis stresses rigid precautions,
while working in a sterile field assumes the understanding
that breach of the technical rules may cause serious complications
or infections.
Figure 7.2  Short surgeon cap.
Figure 7.3  Bouffant-style head cover, for longer hair.
Figure 7.4  Full-head gear, for facial hair cover.
Figure 7.5  Mask with eye protection in proper position.
during time spent in the operating area (Fig. 7.6). If it becomes neces­
sary to cough or sneeze during a procedure, it is best to step away from
the surgical site and face the surgical field rather than turning to one
side. Intraoperative talking should be kept to a minimum. Masks
should be changed between cases or when they become wet (usually
from breath). They should never be worn dangling around the neck
(Fig. 7.7).

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Hand scrubbing
The surgical hand scrub serves to remove the transient flora from
the fingernails, hands and forearms. The surgical hand and arm
scrub procedure must be performed in the scrub suite before entry
into the surgical suite/operating room (Fig. 7.9). The efficacy of
the hand scrub depends upon the antiseptic agent being used and
its method of application. The antiseptic of choice should be a broad-
spectrum, non-irritating, fast-acting agent that provides a continued
antimicrobial action even when covered with a surgeon’s glove. It is
widely held that hand scrubbing with an aqueous antiseptic solution
under a stream of running water provides sufficient disinfection for
Figure 7.6  (A) Mask on incorrectly with nose exposed. (B) Mask below nose and tied loosely.
A
B
Figure 7.7  Mask hanging from neck. Note the poor hair cover by cap.
Figure 7.8  Shoes covers.
PREOPERATIVE PREPARATION
Discernibly, the two most important areas where a decrease in skin
flora is crucial are on the surgeon’s hands and on the patient’s skin
immediately adjacent to and at the location of the surgery.

60
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
their hands with liquid soap and water after the gloves have been
removed.
Traditionally, when a hand scrub is utilized, it is performed as a
2-phase scrub. This consists of a mechanical cleansing phase and a
disinfectant phase. The mechanical cleansing phase begins by
washing the hands and then the forearms for up to 2 min with a
detergent solution and brush to remove superficial and visible soil.
The majority of problematic hand flora is found under and around
the fingernails, therefore a disposable orange stick or plastic nail stick
may be used to remove subungual debris (Fig. 7.12). Wash the hands
and forearms thoroughly with liquid or foam soap. Rub each side of
each finger, between the fingers, and the back and palm of the hands
with soap. After the hands have been scrubbed, the arms are scrubbed.
Rub the soap on each side of the forearm from the wrist to the elbow
to at least two fingerbreadths below the elbow, keeping the hand
higher than the arm at all times. This prevents contaminated soap
and water from recontaminating the hands. If at any time the hand
touches anything non-sterile, the scrub must be lengthened by 1 min
for the area that has been contaminated. Then, after a careful cleans­
ing, the second phase or disinfectant portion is begun by rinsing the
hands and forearms with water, followed by the application of a
disinfectant hand scrub agent (typically a foam) with rubbing for
up to 2 additional minutes (Fig. 7.13). It is usually not necessary
to scrub for more than 4 min unless contamination of the hands
has occurred during the washing process. Commonly, a disposable
sterile combined brush and sponge is available with an impregnated
antiseptic agent of chlorhexidine gluconate or povidone–iodine
solution.
Surgical gowning
The scrubbed persons enter the operating room immediately after
the hand/arm scrub. The washed hands are continued to be held
above the elbows, in front of the chest, allowing any fluids to drip
from the elbow. The hands are carefully dried with a sterile towel
either picked up carefully from the sterile back table or handed by
the surgical scrub room assistant (Fig. 7.14). If you are starting the
sterile gowning process yourself, grasp the gown firmly and bring
it away from the wrapper or sterile back table. Never touch the
outer surface of the gown at any time. Holding the gown by the inside
at the neckline, allow it to unfold gently, ensuring that the gown
does not come into contact with anything that is not sterile. If you
are being assisted by a sterile assistant or scrub technician, then wait
until the gown has been opened for you and then insert both arms
into the armholes, keeping your arms extended as you do so (Fig.
7.15). Wait for the non-sterile operating room nurse to assist you
by pulling the gown up over the shoulders and tying it in the back
of the neck. The nurse stands at the back and grasps the inner
surface of the gown at each shoulder. The gown is pulled over the
shoulders and the sleeves up over the wrist. The nurse assists you by
fastening the gown at the back. Meanwhile the cuffs of the gown can
be adjusted.
Sterile gloving
Most surgeons prefer to glove the right hand first but it is not univer­
sal. The sterile scrub assistant holds the right hand glove open with
her fingers beneath the cuff so that her glove does not come in contact
with your skin. The palm of the glove faces you (Fig. 7.16A). Slip your
right hand into the glove so that the glove cuff covers the sleeve cuff.
When you put on the left hand glove, place the fingers of your gloved
the hands. The most common antiseptic agents include povidone–
iodine 10% aqueous solution and chlorhexidine gluconate 4%
aqueous solution, with or without alcohol, and other alcohol-based
preparations.
The povidone–iodine agent is a potent broad-spectrum antimicro­
bial that works within minutes but must be left on the skin to have a
persistent effect. It is quickly inactivated when rinsed with water so it
may be at its best when it is applied and not washed off prior to
gloving. There is a minor potential risk for skin reactions and tissue
irritation when povidone–iodine is applied to broken skin or repeat­
edly used by the surgeon as a hand scrub. This solution may also stain
sterile drapes or corrode metal equipment.
Chlorhexidine is also effective against a wide variety of microorgan­
isms. It has a lower incidence of irritation and allergy when compared
to povidone–iodine. Chlorhexidine binds to proteins in the stratum
corneum, leaving a persistent residue of the antiseptic on the skin in
excess of 6 h, which is not subject to removal with alcohol and there­
fore, may be more effective than povidone–iodine.
Alcohol solutions are becoming more popular for hand scrubs but
since they do not contain detergents to remove soil and dirt they
should only be applied to clean skin and fingernails, such as during
a second scrubbing or between cases. While 70% alcohol in aqueous
solution may destroy up to 90% of bacteria when applied for a con­
tinuous 2-min period, the usual single wipe with alcohol probably
reduces skin flora by no more than 75% and, once evaporated, it does
not have significant residual activity. Alcohol-containing products are
highly flammable and may ignite in the presence of cautery or the
electrical spark from a hyfrecator, with consequent risk of burns to the
patient. Frequently, alcohol-based preparations are combined with a
second antiseptic agent, such as chlorhexidine gluconate, for a much
greater sustained effect.
For minor or fast procedures such as biopsies and small excisional
procedures, the literature does not support the need for a formal surgi­
cal hand scrub, but it is recommended before operations that are more
extensive or for procedures lasting for an extended period of time. All
jewelry on the fingers and wrists should be removed. For minor or
very short procedures, the application of sterile gloves without hand-
washing may be all that is necessary (Fig. 7.10). After the procedure,
the gloves are carefully removed by folding them inside-out and must
be disposed of as clinical waste (Fig. 7.11). The wearers should wash
Figure 7.9  Surgical scrub sinks.

Chapter
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glove and pull it down to the middle of the palm so that it hangs
down from your finger in inside-out mode, and then repeat the
process with the other one. Now you can take off both gloves one at
a time without touching the dirty outer surfaces. As described earlier,
surgical gloves must be disposed of as clinical waste and the wearer
should wash their hands with liquid soap and water after the gloves
have been removed.
Patient’s skin scrub
The skin harbors resident flora, e.g. Staphylococcus epidermidis (micro­
organisms that cause no harm unless drawn into the body through a
break in the skin) and transient flora (acquired from a contaminated
source and includes any type of bacterium that can live on the skin).
right hand under the awaiting glove cuff to widen the opening and
thrust your hand into the glove (Fig. 7.16B). You may now adjust your
gloves so that they fit comfortably on both hands (Fig. 7.16C). The
gown’s waist tie paper tag may be now passed to the non-sterile oper­
ating room assistant to pass behind the surgeon and return to the
surgeon the tie, while removing the paper tag to tie the waste of the
gown (Fig. 7.16D). The surgeon is now fully dressed and may enter
the sterile field (Fig. 7.17).
Removing sterile gloves
When removing the gloves, you should touch only their outer surface.
In this way, you can retain the cleanness of your hands if you change
gloves during an operation. Grasp the cuff of your dirty left-hand
A
B
Figure 7.10  (A) Sterile gloves are cautiously opened so as to not contaminate them. (B) Carefully applying the first glove without touching the sterile
areas. (C) The gloved fingers slip under the cuff of the second glove and it is lifted to allow the second hand to slip in. (D) The second glove is applied.
(E) With both gloves in place, the fingertips may then be adjusted for proper fit.
C
D
E

62
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
povidone–iodine and also had greater residual activity after a single
application. Further, chlorhexidine gluconate is not inactivated by
blood or serum proteins. Povidone–iodine solutions may be inacti­
vated by water, blood or serum proteins, but exert a bacteriostatic
effect as long as they are present on the skin. This skin preparation is
performed immediately before the operation.
The surgical disinfectants can also be grouped according to color
(e.g. povidone–iodine) or colorless (e.g. chlorhexidine, alcohol). The
advantage of color is that the prepared area of the skin is visible, while
colorless compounds are used when observation of the skin’s own
color is important (e.g. discerning the differences between infected or
necrotic and viable tissues).
Skin disinfection and scrubbing
All supplies used (towels, gauze sponges, sponge forceps and gloves)
must be sterile. Scrubbing is performed outward from the incision site
and concentrically. The skin prep must be performed in accordance
with the accepted and generally applied rules of the operating room.
The prepped area must be large enough for the lengthening of the
incision or insertion of a drain. The classical method: (1) removal of
the fat from the skin surface with alcohol (twice); (2) antiseptic paint
(1–5% iodine tincture) is applied twice immediately following the
application of alcohol. Currently, only antiseptic paint is applied
(usually povidone–iodine) at least twice (but usually three times),
although alcoholic solutions could be used in the case of sensitive
skin, applied with sterile sponges (gauze balls) mounted in a sponge-
holding clamp.
In aseptic surgical interventions, the procedure starts in the line of
the planned incision. Washing with antiseptics is begun at the exact
location where the incision will be made, moving outward in a circu­
lar motion. A ‘no touch’ technique is used in which an area already
washed is not returned to with the same sponge. In septic, infected
operations, it starts from the periphery towards the planned area of
the operation. The disinfectant collections in body folds must be
sponged up after the skin-scrubbing procedure, in order to avoid skin
inflammation and burns.
It is not clear that preoperative bathing lowers the germ count of the
skin, but as it pertains to elective surgery, preoperative antiseptic
showers/baths are usually recommended. Special attention is paid to
cleansing the operative area. This area should be bathed with antisep­
tic soap (such as chlorhexidine) on the morning of the operation.
Preparation of the surgical site
Preoperative shaving may make the surgery, the suturing and the
dressing removal easier, if it is in the site of surgery. It must be done
immediately prior to the operation and with the least amount of skin
injury possible. In most cases of reconstructive or corrective foot and
ankle surgery, the skin does not need to be shaved at all.
The same antiseptic agents used for hand scrubbing are available
for preoperative preparation of skin at the incision site. The iodophors
(e.g. povidone–iodine or Betadine), alcohol-containing products and
chlorhexidine gluconate (Hibiclens) are the most commonly used
agents. Both chlorhexidine gluconate and povidone–iodine solutions
have broad spectra of antimicrobial activity. In some comparisons of
the two antiseptics when used as preoperative hand scrubs, chlorhexi­
dine gluconate achieved greater reductions in skin microflora than did
A
Figure 7.11  (A) One glove is pulled to turn it inside out. (B) The second
glove is then removed in a similar manner covering the first glove. They
may then be disposed of properly.
B
Figure 7.12  Cleaning the area below and around the fingernails. A
disposable orange stick or plastic nail stick may be used to remove
subungual debris prior to washing the hands.

Chapter
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A
B
C
D
E
F
Figure 7.13  (A) The hands and forearms are first wetted. (B) Cleansing soap is applied to the hands. (C) The fingers and hands are washed. (D) The
forearms are washed. (E) Both hands and arms are then rinsed, letting the water run towards the elbows. (F) The second phase is begun with washing
the fingers and hands again with a foaming disinfectant (in this case, chlorhexidine gluconate foam).
Draping of the operation site
After the skin preparation, the disinfected operating area must be
isolated from the non-disinfected skin surfaces and body areas by the
application of a sterile linen textile or by disposable sterile waterproof
paper (non-woven) drapes and other sterile accessories/supplements.
The segregation draping prevents contamination originating from the
patient’s skin. For small or short-duration procedures, disposable
fenestrated paper drapes may be used. Draping is typically performed
by the surgeon after the surgeon is fully donned of gown and gloves.
The draping may also be done by the sterile surgical scrub technician
or surgical residents. Some surgeons prefer to apply two layers of
sterile gloves for the draping and then remove the outer layer once
final draping is performed or they may maintain two layers of sterile
gloves throughout the case to lessen the risk of contamination should
a glove become damaged.
The use of sterile self-attaching synthetic adhesives (affixed to the
disinfected operating area) is questionable, because these can help
residual microorganisms come to the surface, due to the increased
perspiration and warmth during the operation. As the deeper
layers of the disinfected skin always contain residual microorganisms,
this covered skin should not be touched either by instruments or
by hand.
Non-disposable, permeable linen textiles may be fixed with small
towel clips; usually four clips fix the sheets adequately. In the draping
routine, four towels are placed around the immediate surgical site: this
is the ‘squaring-off’ (isolation) of the site. The isolated area is always
smaller than the scrubbed area. After being placed on the patient,

64
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
(G) The disinfectant portion of the wash is continued from the hands to the forearms. (H) Final rinsing of both hands and
arms.
G
H
Figure 7.14  (A) Hand drying after the hand/arm scrub. The sterile towel is placed over one hand and the towel is not allowed to touch any other
items in the room. (B) The opposite hand is thoroughly dried with the sterile towel. (C) The sterile towel is then used to dry the opposite hand and
arm and it is then dropped onto the floor of the surgery room or handed to an operating room staff.
A
B
C
Figure 7.13, Continued

Chapter
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Spectacles and eyewear must not be touched; a non-sterile assistant
must be asked to adjust them, if necessary. Sterile gloved-hands must
be kept within the sterile boundary of the gown. Sterile hands must
not touch the cap, the mask or the non-sterile parts of the gown.
Operating personnel should use only sterile instruments and touch
only sterile surfaces (e.g. the patient and the table covered with sterile
sheets). Contact between sterile devices and objects of unknown steril­
ity potentiates the risk of contamination. You must not stretch out
your hand in an attempt to catch falling instruments and you are not
allowed to pick them up. Do not take any instrument from the instru­
ment stand; ask the scrub assistant to pass it to you. This rule obvi­
ously does not apply when the surgeon is doing minor procedures
without an assistant.
If the sterility of an item or a person is questionable, this item or
person is considered contaminated. Sterile tables are sterile at table
height only. Sterile objects and surfaces in the air become unavoidably
contaminated after a while. Humid sterile surfaces become contami­
nated because of capillary activity (e.g. sterile package and sheets
become humid). This is called strike-through contamination. The edges
of boxes and pots cannot be considered sterile. This means that the
edge of any container that holds sterile supplies is not sterile. Finally,
potentially or known contaminated instruments must be removed
from the sterile field at once (e.g. scalpels used to debride ulcer
borders) and must be replaced by new, sterile instruments.
Immediately following closure of the surgical incision, the closed
wound should be prepared and dressed sterilely. If necessary, splinting
or casting may be used over the sterile dressings.
POSTOPERATIVE PREPARATION
The patient should be told to prevent getting the dressings wet and
instructed to notify the doctor if there is blood seepage through the
bandages. The postoperative bandages should be changed only when
this is indicated. Bandages on aseptic patients are changed first when
possible if patients with infection or open wounds also require dress­
ing changes. Dressings in aseptic patients should be changed with
sterile techniques and instruments when possible. Before and after
bandage change, hand-washing is mandatory with antiseptic soap and
new sterile gloves should be used for every case.
SUMMARY
It is commonly considered that most surgical site infections are due
to contamination that occurs during or immediately after surgery.
Common sources of contamination include the surgical environ­ment,
instruments and the normal flora of the patient and surgical person­
nel. The key to considering any of these sources of infection is the
nature of the microorganisms, including how easily they are spread
from one location to another and their ability to flourish in the
surgical incision site. Undeniably, the finding that preoperative
shaving is linked with a greater infection rate than leaving the hair
unshaven obviously shows how our knowledge continues to expand.
As the diversity and intricacy of the procedures performed by foot
and ankle surgeons expands, so will the need to recognize aseptic
measures appropriate to each procedure’s risk for wound infection.
This will range from minimal procedures, such as the use of gloves
and alcohol skin wipes for a biopsy, to full surgical preparation
and strict asepsis for major reconstructive procedures of the lower
extremities.
Figure 7.15  Sterile gowning by a scrub assistant. Once the gown has
been opened, the arms are inserted into the armholes, keeping the arms
extended. The non-sterile operating room assistant can then secure the
gown in the back and at the neckline.
sheets cannot be moved toward the operating area, but only toward
the periphery because pathogens can be transferred from the non-
disinfected parts to the surgical area. A special full sheet may be
applied, too. This is positioned so that a hole incorporated in it lies
over the operative site.
The isolation can be performed with disposable sterile sheets, which
are attached to each other where they cross by self-attaching surfaces.
A common lower extremity disposable drape is one that is fenestrated
for the foot and leg region (Fig. 7.18A). Once the sterilely prepped
foot and ankle is passed through the aperture and positioned properly,
the final protective sterile barrier is brought up over the patient (Fig.
7.18B). Finally, the bottom portion of the protective sterile barrier is
used to cover the remainder of the surgical table (Fig. 7.18C). This
provides a complete isolation of all but the anatomical site scheduled
for surgery.
INTRAOPERATIVE PREPARATION
The sterile operating room personnel should remain well within the
sterile area. Operating team members should move about the suite as
little as possible. Unnecessary movement leads to dust and air currents
with the potential for spread of bacteria. Sterile personnel should
strive to face each other and also face the sterile field during the entire
procedure. Their backs should never be turned toward the sterile field
(it must be remembered that the back of the gown is considered non-
sterile). Additionally, other parts of the gown cannot be regarded
as sterile, such as the armpits; the areas lateral to the armpits; below
the waistline; the sleeves above the elbow and 10 cm from the
shoulders.

66
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
C
D
A
B
Figure 7.16  (A) The scrub assistant holds the surgeon’s hand glove open with their fingers beneath the cuff so that their glove does not come in
contact with the surgeon’s skin. The palm of the glove is facing the surgeon and the glove is donned. (B) The surgeon then thrusts the other hand
into the other glove while placing the gloved hand under the glove cuff to widen the opening and assisting the hand into the glove completely.
(C) The surgeon may then adjust the fingers of the each glove to a snug fit. (D) The gown’s waist tie paper tag may now be passed to the non-sterile
operating room assistant to pass behind the surgeon and return the tie to the surgeon while removing the paper tag, to allow the gown to be tied
sterilely in the front.

Chapter
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67
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Figure 7.17  The fully clothed surgeon with double gloves for draping.
Figure 7.18  (A) Once the patient’s foot and lower leg have been prepped, it is placed through a sterile disposable aperture extremity drape. (B) The
upper layer of the drape is extended up over the patient’s chest area. (C) The bottom layer of the drape is brought over the remainder of the table
under the extremity. This completes the full isolation sterile draping of the extremity and the patient is ready for surgery.
A
B
C

68
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
FURTHER READING
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et al., 2010. Prevention of surgical-site
infections. N Engl J Med 362, 1540–1541.
Association of Operating Room Nurses, 1998.
Recommended practices for surgical attire.
Association of Operating Room Nurses.
AORN J 68, 1048–1052.
Berard, F., Gandon, J., 1964. Postoperative
wound infections: the influence of
ultraviolet irradiation of the operating
room and of various other factors. Ann
Surg 160 (Suppl. 1), 1–192.
Boyce, J.M., Pittet, D., 2002. Guideline for
hand hygiene in healthcare settings:
Recommendations of the healthcare
infection control practices advisory
committee and the HICPAC/SHEA/APIC/
IDSA hand hygiene task force. CDC MMWR
51, 1–45.
Crowe, M.J., Cooke, E.M., 1998. Review of
case definitions for nosocomial infection-
towards a consensus. J Hosp Infect 39 (5),
3–11.
Cruse, P.J., 1992. Surgical wound infection. In:
Wonsiewicz, M.J. (Ed.), Infectious Diseases.
WB Saunders, Philadelphia, pp. 758–764.
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2010. Chlorhexidine-alcohol versus
povidone-iodine for surgical-site antisepsis.
N Engl J Med 362, 18–26.
Edwards, P., Lipp, A., Holmes, A., 2004.
Preoperative skin antiseptics for preventing
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surgery. Cochrane Database Syst Rev (3),
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Control Practices Advisory Committee. Am
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Gray, M., Doughty, D., 2001. Clean versus
sterile technique when changing wound
dressings. J Wound Ostomy Continence
Nurs 28, 125–128.
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surgical site infections, 1992: a
modification of CDC definitions of surgical
wound infections. Infect Control Hosp
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CHAPTER CONTENTS
Introduction
69
Laboratory testing
69
Hemostatic agents
70
Mechanical methods
70
Thermal methods
71
Chemical methods
72
Medicinal leeches
74
Conclusion
74
INTRODUCTION
The safe and satisfactory control of bleeding is paramount to a suc­
cessful outcome in cutaneous and plastic surgery. The hemostatic
mechanism involves a complex interaction of at least five compo­
nents, which includes the blood vessels, the plasma coagulation pro­
teins, physiologic protease inhibitors, platelets and the fibrinolytic
system. This elaborate interaction has two primary functions, one is
to confine the circulating blood to the vascular bed and the other is
to halt bleeding at the site of an injured vessel.
When injury to a vessel does occur, either from trauma or surgery,
the hemostatic primary response begins with the interaction between
the blood vessel and the circulating platelets in the formation of a
platelet plug. The coagulation proteins then interact in the secondary
response to ultimately result in the generation of cross-linked fibrin,
which stabilizes the platelet plug. This entire process relies on the
presence of a variety of factors found in the blood that results in a
cascade of events, eventually concluding with coagulation and hemos­
tasis. The entire clotting cascade is a complex interaction of multiple
proteins, calcium and blood factors and can be partitioned into the
intrinsic and extrinsic pathways, which ultimately join for the end
result of fibrin clot formation.
The intrinsic pathway begins with factor XII, which, once activated,
activates factor XI, which then activates factor IX. Along with factor
VIIIa and calcium ions, factor IX now activates factor X. This is the
convergence point between the intrinsic and extrinsic pathways. Both
pathways activate factor X to factor Xa, albeit by different mechanisms.
Factor Xa, along with factor Va and calcium, converts prothrombin to
thrombin, which then converts fibrinogen to fibrin, and this, along
with factor XIII, solidifies the clot.
Our current concept of the extrinsic pathway begins with the forma­
tion of a complex interaction between tissue factor (TF), which is
exposed as a result of a vessel wall injury, and activated factor VII
(FVIIa) that is normally present in circulating blood. The TF–FVIIa
complex converts factor X into factor Xa. As stated above, factor Xa
then activates prothrombin to thrombin. Thrombin then activates
factors VIII, V, and XI and platelets. Thrombin-activated platelets
change shape and create the perfect template for full thrombin
generation involving factors VIII and IX. Full thrombin generation is
necessary for complete activation of factor XIII and fibrinolytic inhibi­
tor, and for the formation of the fibrin structure of the hemostatic
plug (Fig. 8.1). Any alteration of this cascade of events will have a
detrimental effect on the formation of clot and thereby, increase the
incidence of bleeding and complications. There may be a systemic
basis for abnormal clotting to occur, such as both qualitative and
quantitative platelet abnormalities, vascular abnormalities and von
Willebrand’s disease.
Many medications can also lead to abnormal hemostasis as com­
monly seen with aspirin therapy, chlorpromazine hydrochloride, pro­
cainamide, penicillin and anticoagulant therapy with warfarin. It is
vital for the surgeon to obtain a complete history from the patient of
any prior surgeries, any postoperative complications, any current
medications, both over-the-counter and prescription and any known
abnormal bleeding or clotting deficiencies.
LABORATORY TESTING
Besides a thorough history and physical examination, there are labora­
tory tests that can help the surgeon evaluate the patient in more detail.
Platelet count, bleeding time, prothrombin time, INR (International
normalized ratio), activated partial thromboplastin time and thrombin
time may provide much needed additional information of any inter­
nal deficiencies that may have a detrimental affect on the final surgical
©2012 Elsevier Ltd.
Hemostatic techniques
Mary E. Crawford
Chapter
8

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
therapy where the desired range is 1.5–2.5 times longer than the upper
level of normal range. If a patient has abnormal APTT, but normal
PTT, the patient probably has a deficiency of one of the factors of the
intrinsic pathway, factors VIII, IX, X, XI, XII. A normal range for PTT
is 27–38 s.
A final laboratory test that may be helpful in evaluating a surgical
patient is thrombin time. Thrombin time may be abnormal when the
plasma level of fibrinogen is decreased or when there are circulating
anticoagulants, fibrin-degradation products or paraproteins. The
normal value for thrombin time may range from 10 to 14 s.
HEMOSTATIC AGENTS
Understanding the clotting cascade and the intricate mechanism by
which bleeding is controlled, the surgeon can then examine the
various agents that are available for obtaining hemostasis during sur­
gical procedures to provide the best possible outcome with the fewest
complications. While there is no ideal method available, certain char­
acteristics of hemostatic methods or materials are desirable, such as
minimal tissue damage, convenience of use, low cost, and biodegrad­
ability. When hemostasis becomes necessary, a surgeon can determine
the best product for each surgical circumstance based on the patient
and the procedure being performed. Hemostatic methods can be
grouped into mechanical, thermal or chemical techniques based on
the manner in which the hemostasis is achieved.
MECHANICAL METHODS
Mechanical methods of hemostasis work by tamponade and have no
hemostatic property of their own. These include application of direct
pressure, ligation of bleeding vessels, bone wax, tourniquet applica­
tion, compressive dressings and use of acrylates. Direct pressure
occludes the bleeding vessel temporarily and allows for platelet aggre­
gation and plug formation, and the release of mediators that initiate
fibrin-clot formation, as discussed earlier. In some cases, the bleeding
vessel may be too large to form an adequate clot rapidly and the vessel
should be ligated.
A general rule is, if the vessel is large enough to be identified, it
should be clamped and tied off. Usually, the vessel alone is isolated
and tied off. However, in some instances, the vessel cannot be isolated
from the surrounding tissue and a stick-tie, which includes a small
amount of the adjacent tissue, or a purse string, which is a larger
amount of adjacent tissue, is incorporated with the vessel and tied off.
The use of a tourniquet is the most common method of mechanical
hemostasis among surgeons of the lower extremity. The tourniquet
can be applied to the thigh, calf, or ankle depending on the duration
of the surgery, the location of the surgical procedures performed, and
the concern of vessel damage from the applied cuff.
The ankle tourniquet just above the malleoli is thought to result in
greater neurovascular damage due to the lack of adequate adipose
tissue and muscle in the distal leg to avoid direct harm to the smaller
vessels. It is, therefore, recommended that the ankle tourniquet be
applied for less duration and with less pressure than the thigh tour­
niquet, and should be well padded to protect the underlying vascular
structures. The thigh tourniquet, in theory, results in less neurovascu­
lar damage owing to greater soft tissue interposition, but increased
ischemic muscle damage beneath and distal to the tourniquet. The
vascular tissues are deeper at the thigh and, therefore, the cuff pressure
must be greater to achieve adequate hemostasis. The pressure over the
nerve is highest toward the edge of the cuff, as there is a sharp gradient
outcome. Platelet count is highly variable, with a broad range of
150 000–450 000 µL. There is inconsistency among surgeons as to the
absolute number required before proceeding with surgery, but the
general accepted value is a platelet count not less than 150 000.
Thrombocytopenia, defined as a below normal number of platelets,
can occur in patients whose bone-marrow production of platelets is
decreased or the peripheral destruction of platelets is increased. As
platelet function and aggregation is critical in the coagulation scheme,
insufficient numbers may result in excessive bleeding. Bleeding time
is the single best procedure for evaluating primary hemostasis and
platelet dysfunction. Patients with abnormal bleeding time but
normal platelet count require further testing with platelet aggregation
tests, quantification of various components of factor VIII complex and
platelet retention procedures. The normal bleeding time is <10 min.
Prothrombin time evaluates the extrinsic system and can be pro­
longed by congenital or acquired deficiencies of factors V, VII, X,
prothrombin and fibrinogen. The normal range is 11.5–13.5 s. It is
also used to closely monitor efficacy of anticoagulation therapy
with warfarin, as this directly affects factor VII. INR is now more com­
monly utilized to monitor anticoagulation therapy. A patient on oral
warfarin should maintain a range of 2–2.5 normal values if properly
anticoagulated.
Activated, partial thromboplastin time (APTT) monitors the intrin­
sic pathway of coagulation and is closely evaluated during heparin
Figure 8.1  Cascade of events leading to clot formation and hemostasis.
Intrinsic Pathway
Extrinsic Pathway
HMW Kininogen
XII
XIIa
IIa
Prekallikrein
XI
XIa
Thromboplastin
(tissue factor)
VIII
VIIIa
VIIa
VII
XIII
XIIIa
Ca++
Ca++
Ca++
Ca++
Ca++
Tissue factor
Phospholipid
IX
IXa
X
Xa
IIa
Prothrombin
Thrombin
Fibrinogen
Fibrin
monomer
Fibrin
polymer
Cross-linked fibrin
Va
V
Ca++
Phospholipid

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Hemostatic techniques
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problems that may make them susceptible to bleeding. Adding bulky
loose gauze, cotton balls, dental rolls or gauze pads to the postopera­
tive dressing creates a compressive dressing. Surgeons should exercise
caution to avoid excessive compression, especially over a flap or graft,
as the blood supply to the area could be occluded and the tissue
compromised.
One of the more recently promoted methods for attaining rapid
hemostasis is the application of acrylates, a rapidly polymerizing
plastic found in super glues. Acrylates adhere to the tissue and provide
a rapid mechanical blockage of hemorrhage. A different material that
can assist in hemostasis of bleeding bone is bone wax (Fig. 8.2). Bone
wax is a very common commercially available product that provides
a mechanical tamponade of the bleeding vessels following a bone
procedure and has the benefit of low cost, easy preparation and han­
dling. However, bone wax has been shown to inhibit bone healing
and may develop a foreign body granuloma.
THERMAL METHODS
Thermal agents all utilize heat to seal and occlude the bleeding vessel.
The heat is produced most commonly by an electrical current that
passes through the tissue and produces heat as a result of the resist­
ance of the tissue to the flow of the current. By varying the electrode,
the intensity and the current, different effects on tissue are achieved.
Electrocoagulation is usually achieved with a monopolar electrode,
which delivers direct current to the vessel and a grounding pad
grounds the patient (Fig. 8.3). A bipolar forceps is also available that
results in a much narrower area of tissue damage, as the current goes
only between the tips of the forceps (Fig. 8.4). The bleeding vessel is
grasped and coagulated directly by the two active electrodes.
Electrocoagulation is frequently erroneously referred to as electro­
cautery. Electrocautery uses electricity to heat only a filament tip and
does not apply electricity directly to a patient (Fig. 8.5). The heated
filament can be used on non-conductive tissue such as nail, cartilage
and bone when needed. This results in much less surrounding tissue
damage, as there is no electrical current to the tissues, and can even
be used in patients with pacemakers. A more recent technology known
as electrosection utilizes a cutting current that is capable of excision
with instant coagulation of small to medium-sized blood vessels. The
electrosurgical cutting current utilizes a much focused heat that rup­
tures the tissue. However, there is an increased risk of delayed wound
at the cuff edge. The greater pressures required for the thigh tourniquet
can result in pain as a result of skeletal muscle acidosis, which is
usually proportionate to the duration of ischemia. The thigh tourni­
quet inflation is, therefore, limited to approximately 90–120 min
intervals to diminish the possible risk of permanent muscle damage.
The question of permanent nerve damage has been debated and is
still considered by some to be a concern. It has been shown that pres­
sures of up to 350 mmHg resulted in reversible ischemia to the nerve.
This was also shown to be reversible by electrophysiologic changes
that initially revealed slowing of nerve conduction underneath and
distal to the tourniquet, but were all reversible within 30 min of
release of the tourniquet. However, the controversy goes on, as many
surgeons prefer the bloodless field in which to operate, while others
do not feel the risks outweigh the benefits. The complications that can
occur with tourniquet use include effects associated with ischemia,
pressure, constriction and local skin effects.
The most common complications are those associated with the
constrictive effect of the tourniquet. Paralysis can occur resulting in
motor loss and various sensory changes to the extremity. Although
these effects may be temporary, the changes appear to be due to the
metabolic acidosis and hypoxia that occurs during the tourniquet
inflation. This may increase the risk of postoperative hematoma for­
mation and enhanced postoperative swelling. Other surgeons prefer
to perform lower-extremity surgery without the use of a tourniquet
for the practical advantage of identifying and controlling the bleeding
vessels during the dissection and surgical procedure rather than at the
completion of the surgery when the bleeding vessel may no longer be
accessible. This decreases the need for the use of a drain and decreases
the likelihood of a postoperative hematoma that could lead to
increased risk of infection. There is general consensus, however, on
the contraindication to the use of a tourniquet on a dysvascular
limb that could result in further ischemia to the area, even if only
temporary.
Most amputations should be performed without the use of a tour­
niquet in order to visualize viable skin margins. This is also the
concern regarding the use of a tourniquet during the creation of
various skin flaps. The need to assess the blood supply from the
pedicle of the flap is paramount to the success of the flap transfer. If
the vascularity to the skin margins or the body of the flap cannot be
well discerned, there is the possibility of vascular compromise to the
flap and flap loss. Therefore, many of the cutaneous flaps are per­
formed without the use of a tourniquet to more accurately assess the
flap perfusion.
The inflation pressure and duration of the tourniquet also varies
and should be customized to the patient. A general rule is an ankle
tourniquet pressure set approximately 100 mmHg higher than the
systolic blood pressure; however, newer research would indicate that
arterial occlusion might be achieved with much lower pressures. Ankle
tourniquet pressure rarely should exceed 250 mmHg for an adult or
150 mmHg for a child. Thigh tourniquets may be elevated in adults
to 300–350 mmHg because of the greater soft tissue coverage and
larger girth of the limb in this area. The effects of the tourniquet are
based not only on the inflation pressure, but also on the duration of
inflation. After approximately 90 min of ischemia, many surgeons will
release the tourniquet and allow intermittent perfusion to the limb
for approximately 10 min to reduce the degree of ischemic cell injury
if the tourniquet must be reinflated.
The surgeon may continue to protect the patient from the postop­
erative complication of excessive bleeding that may result in a
hematoma or other tissue compromise by utilizing a compressive
dressing. Compressive dressings are often used after surgery on
patients who require any medication postoperatively that may inter­
fere with clotting, on any surgical wounds created in vascular areas,
on excision of vascular lesions or on any patient with internal medical
Figure 8.2  Bone wax is supplied in a sealed foil pouch and is utilized for
tamponade of bone bleeding.

72
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
enhanced clotting mechanism with a physiologic agent. Caustic agents
such as aluminium chloride hexahydrate 20%, Monsel’s solution,
silver nitrate, phenol and dichloroacetic acid or trichloroacetic acid
have all been utilized with varying degrees of success and complica­
tions. They all denature and agglutinate protein and damage the sur­
rounding tissue to some degree.
Aluminium chloride hexahydrate is most often used following
superficial shave biopsies or curettage to provide hemostasis to the
site (Fig. 8.6). This caustic agent results in protein precipitation by the
Figure 8.4  (A) Bipolar forceps. It is also used for blood vessel
coagulation with much narrower focus of tissue damage only at vessel
site. (B) Different interchangeable lengths and sizes may be used.
A
B
Figure 8.5  Portable battery-powered electrocautery unit. (A) The
handheld unit. (B) Close-up of the heated filament tip. This unit is
especially useful in nonconductive tissue such as nail, bone and cartilage.
A
B
Figure 8.6  Aluminium chloride hexahydrate 20% solution as a chemical
hemostatic agent that may be used following shave biopsy or other
superficial procedures.
Figure 8.3  Monopolar electrode cautery unit. It may be applied to
vessels for coagulation and hemostasis.
healing, excessive scar formation and damage to wound edges due to
the lateral spread of the heat into surrounding normal tissue. In all of
these examples of thermal methods of hemostasis, there is more
damage to the surrounding tissues due to the use of heat to achieve
the hemostasis as compared with ligation or other mechanical
methods.
CHEMICAL METHODS
The most common hemostatic method involves the application of a
chemical substrate to the bleeding area that results in improved
hemostasis by either direct tissue damage with a caustic agent or

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aluminium ion and acidic solution and, therefore, should not be
used in deeper wounds due to tissue damage and possible delayed
healing. The caustic hemostatic agent, Monsel’s solution, is 20% ferric
subsulfate. It is less commonly utilized than aluminium chloride
due to an increased risk of tissue tattooing and greater postoperative
discomfort. A common household product that can also be utilized
as a chemical hemostatic agent is hydrogen peroxide. Hydrogen per­
oxide has a mild hemostatic effect while having the advantage of being
non-toxic, non-allergenic and inexpensive compared with other
caustic chemicals. The tissue catalase present in the wound quickly
degrades the hydrogen peroxide to oxygen and water, so tissue damage
is minimized.
The most preferred method to achieve hemostasis with the least
amount of tissue damage is through the use of physiologic agents that
affect the clotting mechanism rather than denature the tissues. Epine­
phrine added to a local anesthetic infiltrate is the most common of
all the agents available and the least costly. Epinephrine also prolongs
the effects of the anesthetic and decreases systemic absorption, thereby
reducing the risk of systemic anesthetic toxicity. Although rare, toxicity
can occur if injected too rapidly into a vascular area or if accidental
intravascular injection occurs. The toxic side-effects seen include
nausea, tachycardia, hypertension, tremors, anxiety, palpitations,
headache and arrhythmia. The vasoconstrictive properties of epine­
phrine are achieved approximately 10 min after infiltration and allow
for vasoconstriction of the skin, mucosa and the smaller vessels in the
deeper tissues. Although there is anecdotal information cautioning
against the use of epinephrine in digital blocks, the author finds only
rare contraindications and these are primarily in patients with vasos­
pastic or severe arterial disease.
The usual commercially available preparation of epinephrine is
1 : 100 000 or 1 : 200 000, although the solution can be diluted with
additional local anesthetic agent up to 1 : 400 000 or 1 : 500 000 with­
out much loss of vasoconstrictive property. In some specific cases, a
preparation of 1 : 1000 or 1 : 10 000 is used on the skin-graft donor site.
One novel use is to combine a new 50 g tube of K-Y jelly (Johnson
and Johnson, Arlington, TX) with a 1 mL ampule of 1 : 1000 epine­
phrine to make a 1 : 50 000 epinephrine concentration that would be
used in place of mineral oil at the dermatome skin graft interface. This
provides for both the proper lubrication as well as hemostasis at the
graft site with significant reduction of bleeding at the graft site and
simple cleaning of the dermatome as the K-Y jelly is water soluble and
easily rinses from the blade.
Other more expensive physiologic hemostatic agents include
absorbable gelatin sponges, oxidized agents made from cellulose,
bovine collagen microfibrillar hemostat, topical thrombin and fibrin
sealant and glue. These agents are much more expensive than epine­
phrine, but with less perceived possible complications. The absorba­
ble gelatin sponges provide a physical meshwork to facilitate blood
clotting. Gelfoam is a non-antigenic, pliable surgical sponge that is
porous and capable of absorbing many times its weight in blood
(Fig. 8.7). This absorbable gelatin is also available in a powder form.
It can be implanted either dry or soaked in saline or thrombin and is
completely absorbed in 4–6 weeks. It may increase the rate of infec­
tion due to possible foreign body effect. Oxycel or Surgicel is also an
absorbable material, but is made from cellulose that is oxidized by
nitrous oxide (Fig. 8.8). It absorbs uncoagulated blood and is also
acidic, a fact that may play a role in its hemostatic and mildly bacte­
riocidal properties.
The bovine collagen microfibrillar hemostat Avitene is fibrous water
insoluble partial hydrochloric acid salt of bovine corium. Avitene
tenaciously adheres to blood-soaked surfaces and attracts platelets
that adhere to fibrils in the interstices of its fibrous mass. Its effect on
platelet adherence is not affected by heparin. One of its advantages
over other topical agents is, that it does not appear to interfere with
Figure 8.7  Absorbable gelatin hemostatic agents. (A) Surgifoam sponge.
(B) Surgifoam powder. Both are highly absorbent and non-antigenic.
A
B
Figure 8.8  Oxidized cellulose material Surgicel is mildly bacteriocidal due
to its acidic properties.

74
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
costly. FloSeal is a product which combines bovine gelatin and
thrombin, which allows the product to firmly attach to the wound
while the thrombin converts the fibrinogen to fibrin forming the
clot. Some newer products with recombinant human thrombin are
becoming available due to the possible antigenicity of the bovine
proteins.
Fibrin sealant and glues, such as Tisseal, are the combination
of fibrinogen and thrombin sprayed onto a wound to make a thin
sealant or film. The fibrinogen and thrombin are supplied in two
separate double-barrel syringes that are sprayed simultaneously
onto the wound to form a fibrin seal. The process is completely
autologous as it is prepared from platelet-rich plasma separated from
the patient’s blood prior to the operation. The fibrinogen and the
thrombin are then separated out of the platelet-rich plasma. This is a
very effective and powerful hemostatic method, but is also the most
expensive.
MEDICINAL LEECHES
Any chapter discussing the hemostatic techniques utilized in cutane­
ous surgery would be remiss without the inclusion of medicinal
leeches and their role in the survival of skin flaps (Fig. 8.10). The
medicinal leech, Hirudo medicinalis, can serve two functions to salvage
a failing skin flap. The first function of the medicinal leech may be
seen in a flap compromised by underlying hematoma formation. The
leech will remove the excess blood from the flap, thereby allowing for
the flap to adhere to the underlying vascular bed. Another function
of the leech is as an antithrombotic. The leech saliva has been shown
to inhibit human platelet aggregation and has also been shown to be
a potent inhibitor of coagulation factor Xa. In some cases, a flap may
be compromised due to postphlebitic syndrome and peripheral arte­
rial disease limiting the blood supply available to the flap. The small
protein, hirudin, found in the leech saliva, is the most potent natural
inhibitor of thrombin known and is now available in recombinant
and synthesized forms.
CONCLUSION
The vast number of methods and materials available to achieve ade­
quate hemostasis for cutaneous surgery provides the surgeon with
many options that may be tailored to suit each individual patient and
procedure. The surgeon must be knowledgeable regarding the differ­
ent properties of the hemostatic techniques to choose the best agent
for the best possible outcome. The simplest method or least expensive
may not always be the optimal selection, but should be taken into
consideration in lieu of more expensive alternatives that are not neces­
sarily superior in some cases. The common use of dilutions of epine­
phrine along with vigilant dissection and electrocoagulation
techniques and judicious tourniquet use will often result in excellent
hemostasis in cutaneous surgical procedures.
bone healing, as the oxidized cellulose does. It has also been shown
in some animal models to have little to no effect on the surrounding
peripheral nerves. The material is absorbed in approximately 3 months
with minimal tissue reaction and relatively non-antigenic. Bovine
collagen is supplied in collagen hemostatic sponges or cylindrical
plugs.
Topical thrombin is a very expensive physiologic hemostatic agent
that is a product of the activation of bovine prothrombin (Fig. 8.9).
As discussed earlier, thrombin activates fibrinogen to form a fibrin clot
that results in instantaneous coagulation. Topical thrombin is prob­
ably the most effective hemostatic agent, but also one of the most
Figure 8.9  Topical thrombin powder is mixed with 5 mL of sodium
chloride 0.9%. This is an excellent physiologic hemostatic agent that
activates fibrinogen to form a fibrin clot.
Figure 8.10  Hirudo medicinalis. The application of medicinal leeches on
skin flaps may be used to prevent hematoma formation.
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CHAPTER CONTENTS
Introduction
77
Physiological factors
77
Incision placement and planning
78
Wound closure materials
78
Sutures
78
Characteristics of suture material
78
Absorbable sutures
78
Non-absorbable sutures
79
Suture classification
80
Needles
80
Characteristics of surgical needles
80
Needle coding system
81
Alternatives to suturing
81
Adhesive tape strips
81
Skin staples
82
Indications/techniques
83
Staple removal
83
Tissue adhesives
83
Tension assisted wound closure
85
Tension assisted wound closure devices for the lower
extremity
85
Rapid intraoperative tissue expansion
85
Continuous external tissue expansion
85
Skin incisions
86
Mobilization and retention suture techniques
86
Basic suture technique
86
Retention sutures
86
Special suturing techniques
88
Tendon sutures
88
Internal suture techniques
89
Buried sutures
89
Deep suture retention techniques
89
One-half buried horizontal mattress sutures
91
Apical sutures
91
Cosmetic closure
91
Intradermal suture (continuous subcuticular)
91
Dog-ear repair
92
Conclusion
93
INTRODUCTION
This chapter includes an overview of commonly used wound closure
materials as well as wound closure techniques and special suture
techniques. The basic terminology and characteristics of needles and
sutures, skin staples, closure tapes and skin adhesives are also pre­
sented. The discussion of wound closure techniques is provided with
emphasis on proper tissue handling and suture techniques, as these
factors directly affect the functional and cosmetic results of lower
extremity plastic surgery (LEPS). A variety of methods are demon­
strated as they apply to specific clinical situations in foot and ankle
surgery.
PHYSIOLOGICAL FACTORS
The physiological argument for proper tissue handling has been well
documented.1 Mechanical tissue damage by any means leads to dis­
ruption of the microcirculation and local tissue hypoxia. Niinikoski2
and Hunt and Pai3 have independently confirmed that the rate of
wound healing, as evidenced by net collagen accumulation, is signifi­
cantly decreased with hypoxia. In addition, there is a correlation of
increased rate of infection in ischemic tissues, and it has been theo­
rized that bacteria, phagocytes and fibroblasts compete for what little
oxygen is available in the wound to accomplish their specific func­
tions. The effectiveness of the phagocytic system is oxygen dependent
so that as bacteria further depletes the oxygen supply, intracellular
©2012 Elsevier Ltd.
Suture materials and techniques
Dennis N. Gusman
Chapter
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78
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
contamination/infection. The characteristics of good knot security,
optimal handling and workability are related to suture memory, elas­
ticity and plasticity.
Suture memory refers to the tendency for a suture material to return
to its original physical configuration during suturing. Thus, sutures
with high memory are more difficult to tie and the knot is less secure,
as the suture tends to untie to regain its former shape. Nylon sutures
have a high memory, whereas braided polyester is a suture material
with a low memory.
A suture’s inherent tendency to regain its original form and length
after stretching is referred to as elasticity, while plasticity refers to the
tendency of a stretched suture material to remain at its new length.
Elasticity and plasticity become important where there is swelling of
a wound. A suture with a high degree of plasticity will stretch and will
not tend to cut through the swollen tissue. However, it will retain its
stretched size after the wound swelling subsides, leading to a loose
suture. The workability or handling characteristics of sutures are there­
fore variable, based on the factors of tensile strength, elasticity, plastic­
ity and the coefficient of friction.
The tissue reactivity to sutures is influenced by the characteristics of
the material and the individual immune response. Tissue reactivity
may also be related to technical and mechanical factors. The number
of knots and location of the suture material within the tissue are
factors to consider near tissue plane interfaces and in highly mobile
areas (tendon and joint repair). Relative motion in the area of repair
(cast pressure/friction) can serve as a mechanical irritant, thus increas­
ing the tissue reactivity of any given suture.
Within several days after suture placement, there is typically infiltra­
tion of polymorphonuclear leukocytes and lymphocytes surrounding
the (foreign body) suture. Later in the proliferative phase of wound
healing, fibroblastic activity is relatively high and chronic inflamma­
tion can contribute to abundant fibrous tissue deposition. Multiple
knots and heavier suture, particularly braided sutures are more
problematic.
In addition to its role in tissue reactivity, the surface area of suture
material affects capillarity. Capillarity reflects the ability of fluid to
move along the axis of a suture and is increased with multifilament
sutures. This increases the potential for bacterial contaminants. Mono­
filament sutures are therefore less problematic in this regard.
Absorbable sutures
Commonly used absorbable synthetic sutures, polyglactin 910
(Vicryl®) and polyglycolic acid (Dexon®) are braided (Table 9.1).
Both sutures are coated to ease passage and facilitate knot tying.
Polyglactin is made as a copolymer of lactide and glycolide and it
is the water repelling properties of lactide that slows degradative
hydrolysis, which eventually reduces the tensile strength of the suture.
There are slight differences in the characteristics of the braided absorb­
able sutures, both of which are absorbed by hydrolysis. Polyglactin
910 loses approximately 40% of its tensile strength in 14 days and
70–80% in 21 days. There is thought to be minimal contribution to
wound strength at 40 days and reported complete hydrolysis at
between 60 and 90 days, whereas polyglycolic acid reportedly loses
approximately 33% of its breaking strength or tensile strength at 30
days. Complete absorption is somewhat longer in the 90–120-day
period.6
Polydioxanone (PDS) and glycolic acid and trimethylene carbonate
(Maxon®) are synthetic monofilament absorbable sutures, which may
have benefits in their lesser tendency to harbor bacterial contami­
nants. Polydioxanone can be safely used in infected wounds. These
sutures can be used for skin closure, deep tissue closure and in tendon
repair procedures. The elasticity or memory of polydioxanone is
greater than that of either polyglactin 910 or polyglycolic acid and as
killing is impaired.4 This creates both a direct and indirect inhibitory
effect on the fibroblasts.
The inflammatory phase of wound healing is an integral part of the
healing process. In the coagulation phase, the platelet factors that
mediate fibroblast migration and proliferation are released as the
thrombus forms. The small vessel dilatation caused by the inflamma­
tory response allows increased capillary permeability and migration
of monocytes and neutrophils. This process, which allows phagocyto­
sis of bacteria and debris, is now known to be influenced significantly
by prostaglandins. Leibovich and Ross5 have shown that macrophages
not only help to control infection, but also play a role in stimulating
collagen synthesis. Attempting to minimize the inflammatory response
to surgical injury by the use of injected cortisone or non-steroidal
antiinflammatory drugs may, therefore, not be in the best interest of
wound healing.
In the proliferative phase of healing, collagen strength is the criti­
cal factor for integrity of the repair. The strength of collagen is
directly related to the cross-linking of collagen molecules. Since the
production of collagen is oxygen dependent, decreased wound
strength is to be expected in situations of localized tissue hypoxia.
Collagen production in the dead space of wounds decreases with
hypoxia and increases with hyperoxia, with a peak strength of 70%
PO2.2 Hunt and Pai3 in demonstrating that infection rates are higher
in ischemic wounds concluded that the phagocytic system varies in
its effectiveness with oxygen tension. The bottom line for the surgeon
is that minimal disruption of adjacent tissues, microcirculation, and
achieving the normal inflammatory response is the goal of any oper­
ation. Proper hemostasis and the avoidance of significant dead space
areas help to normalize the internal milieu. Understanding wound
physiology provides the basis for discussion and illustration of
proper tissue handling techniques as applied to lower extremity
plastic surgery.
INCISION PLACEMENT AND PLANNING
The basic concepts of incision placement in foot and ankle surgery
with regard to relaxed skin tension lines, lines of maximum extensibil­
ity and correct performance have already been covered in Chapter 4.
It is emphasized here, that thorough familiarity with skin characteris­
tics in various zones of the foot is important in understanding what
is possible and appropriate with regard to mobilization of skin and
skin closure under acceptable wound tension. Many common wound
complications can be minimized with appropriate incision planning.
Regardless of the expertise with which a wound is closed, wound
closure techniques cannot fully compensate for poor tissue handling
such as aggressive retraction or excessive dissection, resulting in
increased local tissue hypoxia or thermal injury (aggressive use of
electrocautery). Every surgical resident learns quickly that one is left
to repair the tissue layers created with the initial dissection technique
for better or worse.
WOUND CLOSURE MATERIALS
Sutures
Characteristics of suture material
The ideal characteristics of suture material include: (1) good tensile
strength; (2) good knot security; (3) minimal tissue reactivity; (4)
optimal handling and workability; (5) ability to resist bacterial

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absorbable suture. Knot tying is more difficult than with braided
absorbable sutures.
Non-absorbable sutures
The vast majority of lower extremity flaps and grafts and some
surgical incisions are closed with non-absorbable synthetic mono­
filament sutures such as nylon, polypropylene and polybutester
(Table 9.2). Other available non-absorbable sutures include silk,
which has the disadvantage of high tissue reactivity, and stainless
steel, which has low tissue reactivity but the handling characteristics
are troublesome. Nylon sutures in general are relatively high memory
sutures and knot slippage is an issue; the advantage is good tensile
strength and minimal tissue reaction. Monofilament synthetic
sutures in general have the characteristic of low drag, which is thought
to help decrease bacterial entrapment and promote easy of suture
removal.
Polypropylene is a more flexible monofilament suture with a fairly
high tensile strength, although slightly less than nylon. The handling
it is somewhat stiffer than the rated synthetic sutures, it is therefore
a little more difficult to tie. The main advantage is that as a monofila­
ment, the breaking strength is retained for a longer period of time,
estimated at 50–60% tensile strength at 4 weeks.6 Glycolic acid
retained 55% of its tensile strength at 2 weeks. Clinically, polydiox­
anone has very good tensile strength, however shear strength is a
potential problem, particularly if the suture is clamped or grasped
with needle drivers creating a relative weak point, where, with shear
force, the suture is more easily broken. Absorption of polydioxanone
is reported at approximately 180 days and this suture is typically used
in more dense and less vascularized tissue, where wound strength or
approximation for longer periods is more important.
Poliglecaprone 25 (Monocryl®) is also a monofilament synthetic
absorbable suture comprised of glycolide and caprolactone. Poliglec­
aprone has a high initial tensile strength but it tends to lose the tensile
strength more rapidly than polydioxanone; its tensile strength is
reportedly reduced to 50% at approximately 7 days by hydrolysis.6,7
The advantage is that the suture is noticeably softer and more pliable
with greater elasticity and less tissue drag, compared with a braided
Table 9.1  Absorbable sutures
Name
Type
Brand
name
Tissue
reactivity
Knot
security
Handling
Uses
Glycolic acid
Mono-filament
Maxon
Minimal
Good
Good
Subcutaneous high tension closure
Vessel ligation
Polyglactin 910
Braided
Vicryl
Minimal
Fair
Good
Subcutaneous high tension closure
Vessel ligation
Polyglycolic acid
Braided
Dexon
Minimal
Fair
Good
Subcutaneous high tension closure
Vessel ligation
Polydioxanone
Mono-filament
PDS II
Minimal
Good
Good
High tension subcutaneous
contaminated tissue
Poliglecaprone 25
Mono-filament
Monocryl
Minimal
Good
Excellent
Subcuticular/skin closure
Table 9.2  Non-absorbable sutures
Suture name
Type
Brand name
Tissue reactivity
Knot security
Handling
Uses
Nylon
Braided
Nurolon
Low
Fair–good
Good
Ligament/skin
Monofilament
Ethilon
Skin
Braided
Dermalon
Skin
Braided
polyester
Braided
Ethibond
Moderate (if coating
sheds)
Poor
Good
Skin
Mersilene
Ligament
Stainless steel
wire
Monofilament
–
Practically none
Excellent
Poor
Skin
Braided
Tendon
Twisted
Polypropylene
Monofilament
Prolene
Minimal
Good
Good
Skin
Surgilene
Polybutester
Monofilament
Novafil
Low
Good
Good
Skin

80
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
characteristics are quite good and the suture has very little drag, pro­
moting ease of removal. Among the non-absorbables, polypropylene
and nylon sutures are preferred for continuous intradermal or running
stitch closure. The disadvantages of polypropylene include lower knot
security and, due to its high plasticity, wound edge apposition can be
compromised with initial wound edema as sutures can loosen when
the swelling resolves.
Polybutester suture is composed of polyglycol terephthate and poly­
butylene terephthate and has very good handling characteristics and
low tissue reactivity. Cosmetically superior scars in wound closures
have been reported.
Suture classification
Suture classification as per the United States Pharmacopeia (USP) is
based on the diameter of any given suture material necessary to
produce a certain tensile strength. In general, the higher suture number
indicates a lower cross-sectional diameter of the suture, however
because the USP grading system is based on suture strength, as
opposed to suture diameter, two 4–0 rated sutures from different
materials may have a different cross-sectional diameter. In any case,
since the USP baseline rating for suture is ‘0’, as suture diameter
decreases, ‘0’s or numbers followed by ‘0’s are added, i.e. 4–0 is of
lesser diameter than 2–0. Suture strength ratings above ‘0’ increase in
numeric order, i.e. 1 < 2 < 3, etc. The most commonly used skin
sutures for lower extremity surgery includes 3–0 for thicker skin areas
such as the ball of the foot and heel or in high tension areas or trau­
matic wounds and 4–0 and 5–0 sutures for thin skin areas and more
cosmetic closures.
Needles
Characteristics of surgical needles
The basic terminology of needle design for cutaneous use defines
three sections of the surgical needle: the point, the body and the
swage. The swage area is the broadest portion and is where the needle
is clamped to the suture. The body is the section used for gripping
and driving the needle with needle holders (also referred to as needle
drivers).
There are a variety of needle types available to the lower extremity
surgeon. The characteristics are important in needle selection with
regard to tissue density, needle contour, strength and ease of passage
of the needles. Common curved needle configurations include
three-eighths circle, one-half circle and five-eighths circle. Suture
needles are made of a pliable stainless steel and can be altered to some
degree for particular techniques and can also be deformed if the selec­
tion of a needle or technique of passage is inappropriate. Unfortu­
nately, there appears to be no standardization among the various
suture manufacturers with regard to needle identification. Packaging
labels indicate the diameter, radius, length and cutting points of the
various needles (Fig. 9.1). Needle selection is based primarily on the
nature of the tissue in terms of its density, vascularity and expected
tension. Common needle types include cutting, reverse cutting,
taper, diamond point and blunt needles. In addition, there are spatula-
and lancet-shaped needles as well as hand-honed reverse cutting
needles (Fig. 9.2).
Basic needle points are blunt, tapered, triangular or diamond.
Needle chord length is an important consideration in needle selection
and refers to the horizontal distance between the swage and needle
point. This feature combined with the arc of the needle ranging
from one-quarter circle to five-eighths is important to match with its
application to minimize tissue trauma such as inadvertent tearing
or cutting through tissues and to allow easy retrieval of the passed
needle. The tapered needle is commonly used in lower extremity
Figure 9.1  Suture packaging label indicates the diameter, radius, length
and cutting point of the enclosed needle.
Figure 9.2  Diagrammatic representation of the geometric configuration
of some of the more commonly used types of needle points.
Hand honed cutting
Reverse cutting
Spatula
Blunt
Lancet
Conventional cutting
Diamond point
Taper
A
Needle body
Needle
radius
Needle
diameter
Needle chord length
Needle length
1/4 Circle
2/3 Circle
1/2 Circle
Swage
Needle
point
B

Chapter
Suture materials and techniques
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2 cm on each side of the wound. The tape strips should be placed
individually. Secure one side of the incision initially and apply
traction toward and perpendicular to the wound edge before adhering
to the opposite side of the wound (Fig. 9.3). Spacing of the strips
varies depending on wound tension but in general is 5 mm
to 1 cm (Fig. 9.4). Adhesive tape strips may be left in place as long
as they hold skin tension but can cause traction blistering if postopera­
tive swelling is substantial. For this reason, tape strips are often
replaced at the first or second postoperative visit.
surgery. The geometric configuration is that of a sharp circular
point gradually tapering to a round or ovoid body. Tapered needles
are ideal for passage through more friable tissue because of the low
potential for cutting or tearing through tissue (ex. tendon repair).
Cutting needles are essentially triangular needles with the apex of the
triangle at the internal arch of the needle. This assists in tissue penetra­
tion and is useful for thick, dense tissue; however, with translational
stress or tilting of the needle, this needle type will more easily cut
through tissue and is therefore often avoided simply because of the
inefficiency of use. More advantageous is the reverse cutting needle,
which combines the tissue penetrating characteristics of cutting
needles. The reverse cutting needle is essentially a triangular needle
with apex of the triangle on the outer curvature of the needle, leaving
a flat surface on the internal arc where there is less potential for cutting
through or tearing through tissue. This needle is quite effective in
re-apposition of dense connective tissue such as ligaments, tendons
and joint capsule.
Specialty needles, such as the tapered cut, which includes a reverse
cutting type configuration at the point and a round needle shaft or
oval body is helpful in penetration of dense tissues and is more
durable if the arc of the needle is altered. This needle type is also
occasionally used, although not promoted, for penetration of thin
cortical and cancellous bone for ligament imbrication procedures.
Precision point and hand-honed reverse cutting needles referred to as
plastics needles or cuticular needles are designed to allow a smooth
effortless needle passage with minimal diameter needle path. These
needles are typically used in thin skin areas and in areas where cos­
metic closure is desired. Because of the needle’s configuration, the
plastic needle can be easily deformed or broken with inappropriate
use and is best used for simple interrupted or continuous intradermal
stitches, as opposed to retention stitches or buttress stitches. These
needles are relatively expensive.
Needle coding system
In general, the various manufacturers of needles use an alpha or alpha
numeric code, which is individualized; there appears to be no stand­
ardization in the various manufacturers’ labelling.
The suture label will include material gauge as determined by
the USP and the metric equivalent, the material length, needle des­
cription and shape. The material type and description is included
as well as the date of manufacture and the expiration date of
the suture.
Alternatives to suturing
Other techniques can be employed to approximate incised or lacer­
ated skin aside from sutures. This includes adhesive-tape strips, skin
staples and tissue adhesives. These closure techniques may have
certain benefits and may be more appropriate in some situations than
standard sutures.
Adhesive tape strips
Adhesive tape strips can be used to reapproximate low tension wound
edges but are more commonly used intraoperatively to augment con­
tinuous intradermal skin sutures. Tape strips are also commonly used
for additional protection after early suture removal or to protect a
slower healing wound as sutures are removed for more favorable
cosmetic results. Higher tension wound closures can be improved by
dispersion of the distracting forces over a broader area of skin by the
use of appropriately spaced adhesive strips. After thorough cleansing
and drying of the surrounding skin, the wound edges are gently held
together. The tape strips can be shortened but should span at least
Figure 9.3  Application of Steri-Strips. The strips are placed individually
from the low side to the high side to equalize both sides.
Figure 9.4  Steri-Strips. Equal placement and distance applies even
tension on the incision.

82
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
3 inch sizes and (3) ‘wound closure system’(3M™), which includes
Steri-Strip® adhesive tape and a non-porous adhesive wound covering
(Tegaderm®) (Fig. 9.7).
Skin staples
Surgical staples are used reluctantly in lower extremity plastic surgery.
They are useful for rapid wound closure when operating time is of
concern and when cosmetic closure is not an important issue. The
potential benefits of surgical staples is that they may facilitate wound
healing by everting the wound edges but in general, are poorly toler­
ated and require staple removal instruments and tend to leave railroad
track scars. Staples are frequently used for securing split thickness skin
grafts and, in this case, are superior to sutures.
Staple appliers are medical devices that place the two prongs of
the staple through the epidermis and dermis into the subdermal
layers and then bend the staple prongs inward, grasping and securing
the skin edges (Fig. 9.8). The design of the stapler varies by
manufacturer.
Surgimate® staplers
The staplers are available in pistol grip or lever action design. These
staplers feature automatic advancement of the next staple and place
ultra-sharp, high-leg staples made of tubular surgical steel. The high-
leg staple provides better clear space between the staple and the
wound edges. The slightly curved design allows good visualization at
the staple application site.
Staple configuration
Surgimate® pistol grip staples come in three quantities: Sm-010w,
Sm-025w, Sm-035w containing 10, 25 and 35 wide-size staples,
respectively. Surgimate® lever action staples come in two quantities:
Sm 125, Sm 135 containing 25 and 35 regular width staples.
Figure 9.5  Steri-Strips. A variety of sizes are available.
(Courtesy of 3M Health Care, St Paul, MN.)
Figure 9.6  Steri-Strips. Reinforced strips of microporous material.
(Courtesy of 3M Health Care, St Paul, MN.)
Figure 9.7  Steri-Strips with a non-porous adhesive wound covering of
Tegaderm.
(Courtesy of 3M Health Care, St Paul, MN.)
Commonly available adhesive tape strips (Fig. 9.5) include: (1)
‘elastic skin closures’ (3M™ Steri-Strips®), which are ideal for body
contours and areas of musculoskeletal movement; (2) ‘Steri-Strip®
reinforced skin closures’ (3M™), which are standard reinforced
strips of microporous material (Fig. 9.6) available in 12 and 14 inch by

Chapter
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3M™ staplers
These are available in three different models.
•
3M Precise™ Disposable skin stapler
•
3M Precise™ PGX Disposable skin stapler
•
3M Precise™ Vista Disposable skin stapler (Fig. 9.9).
INDICATIONS/TECHNIQUES
The main advantage of staples over sutures is that skin closure time is
reduced. There is little argument that a well-sutured wound provides
a superior cosmetic result but staples are appropriate for situations
when faster wound closure is desirable. There are potential technical
disadvantages with stapled skin closure. As with any wound, the
dermis needs to be approximated and therefore the skin edges must
be everted during staple insertion. This is usually accomplished by
having the assistant evert the skin with forceps. Staples generally have
a centre mark or arrow to allow equal distance placement of the staple
legs across the incision (Fig. 9.10). The trigger is gently pressed with
the staple tips against the skin. As the trigger continues to be pressed,
the staple is closed, locking it into final position (Fig. 9.11). The
stapler is then repositioned at approximately 1 cm increments until
the wound is closed. Once the staple is applied, the skin position is
fixed. If the skin edges are misaligned vertically, horizontally or
improperly everted, the deformity will be maintained through the
healing process and can lead to unsightly scarring, or more impor­
tantly, compromise the wound integrity, thereby increasing the risk of
infection or wound dehiscence.
Staple removal
To remove surgical staples, a staple remover device is necessary (Fig.
9.12). To remove staples, place the side arms (jaws) of the remover
beneath the staple and compress the device (Fig. 9.13). This moves
the central arm downward effectively everting and lifting the staple.
Other, perhaps more creative, methods have been employed to remove
staples on occasion and usually to the dismay of the patient. Staple
removal can be painful enough when done properly and the use of
forceps, pick-ups, clamps, etc. are discouraged.
Tissue adhesives
The efficacy of ‘skin glue’ or tissue adhesives (TA) was initially evalu­
ated for management of low tension, highly vascularized areas (facial
and head lacerations). Farion et al.8 conducted a systematic review of
previous randomized controlled trials comparing TA to standard
wound closure methods (sutures, staples and adhesive strips), and
comparing the effectiveness of two tissue adhesives. Evaluation param­
eters included, cosmesis, pain of the procedure, procedure time, ease
of use and complications.
The TA vs standard wound closure (SWC) results in eight studies
showed no difference in cosmesis at any point in time. The pain scores
and procedure time significantly favored TA. Small but statistically
significant differences were found for wound dehiscence (favoring
SWC) and for erythema (favoring TAs).
Only one study8 compared octylcyanoacrylate to butylcyanoacr­
ylate. In this randomized clinical trial, 47 pediatric patients with
<4 cm facial lacerations were studied. Of primary concern was the
three month cosmetic result (after which no significant detrimental
changes are likely to occur).9 Secondary outcomes included time of
procedure, patient perceived pain and physician perceived difficulty.
Overall there were no differences in the primary or secondary
Figure 9.8  Staples applied to a surgical wound.
Figure 9.9  3M Precise™ Vista disposable skin stapler.
(Courtesy of 3M Health Care, St Paul, MN.)
Figure 9.10  Close-up of stapler tip showing the central line for
alignment of the staples.

84
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 9.12  Staple-remover device. This tool may be sterilized and kept
in the postoperative treatment room.
A
B
Figure 9.13  Staple removal. (A) The remover device is positioned on the
staple. (B) Pressure on the handle of the remover device bends the staple
and effectively opens it again. (C) The opened staple can then be
removed from the incision and discarded.
C
Figure 9.11  Staple closure. (A) The staple tips are placed against the skin
in the open position. (B) As the trigger of the staple gun is applied, the
staple will close securing the incision line.
A
B

Chapter
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85
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expansion is based on the observation that living tissues respond
dynamically to the mechanical stresses placed upon them. The concept
of ‘mechanical creep’ is attributed to the collagen fibers’ ability to
uncoil, align and compact more closely in response to a sustained
applied load.
The next progression of the concept was a series of clinical and
experimental investigations testing the effectiveness of more rapid
means of tissue expansion. Liang et al.15 reported approximately 40%
decrease in wound tension by holding sutured intact skin folds for a
period of several hours. Hirshowitz et al.16 reported effectively stretch­
ing intact skin by tensioning in a cyclic fashion over a period of
minutes. The obvious concern with the use of either soft tissue expan­
sion via implant or more rapid advancement with low grade constant
tension or cyclic tension methods is that complication rates have
been higher in the lower extremities. This higher complication rate
has been attributed to weight-bearing demands and use in high
mobility areas.17
Further experimentation revealed that rapid intraoperative tissue
expansion (RITE) was an effective method that prevents ischemia and
significantly reduces necrosis. Subsequently, Zhu et al.18 identified
genes which are specifically induced by RITE. The lone interspersed
nucleotide element (LINE1 or L1), along with myotubulin and
insulin1 were found to be responsive to rapid hemispherical and not
linear stretch. Other causes such as vascular compromise have been
considered. Tonseth and Hokland19 published their results of an
experimental investigation using laser Doppler to compare the effects
on microcirculation between tension wound closure (without expan­
sion) to undermining of the skin in the classic fashion. They found
that the deleterious effects of undermining were more compromising
than increased wound tension. It became obvious over time that it
was desirable to have an easily applied external device with precise
and adjustable features that could be employed in the pre-, intra- and
postoperative setting, allowing the use of constant or cycled wound
tension. The advantage of TAWC, in addition to the obvious preferred
rapid closure of wounds with full thickness skin, extends to the issue
of cost containment.20 In the proper situation, TAWC can reduce the
need for chronic wound care or more additional surgical and anes­
thetic exposure for skin grafts or flaps.
Tension assisted wound closure devices
for the lower extremity
Rapid intraoperative tissue expansion
One of the early skin stretching devices includes the Sure-Closure Skin
Stretching Device (Zimmer Inc, Warsaw, IN, USA). This device consists
of intradermal needles placed in parallel fashion approximately 5 mm
from wound margins under general or local anesthesia.21–23 Following
the placement of the needles, ‘U’ arms are positioned, engaging the
intradermal needles. The edges of the wound are manually reduced
and the device is locked into place once resistance is encountered.
Once locked, the tension knob is turned in a clockwise direction to
allow tensioning of skin edges with force up to 2.5 kg. Above 2.5 kg
an automatic clutch disengages further tensioning. Most studies
describe a short application period consisting of 20–30 min intraop­
eratively, to achieve skin closure, although longer application times
have been described.21
Continuous external tissue expansion
Proxiderm™ external tissue expander is a proprietary wound closure
device (Progressive Surgical Products Inc, New York, USA) designed
for the closure of wound edges by relatively short-term advancement.
This product provides an alternative to advancement flaps and full
outcomes and it was concluded that physician preference and cost
would dictate use.
In a study comparing 2-octylcyanoacrylate (Dermabond®, Ethicon,
Inc, Somerville NJ) with a running subcuticular closure using Monoc­
ryl, Ethicon, Inc for inguinal herniorrhaphy, Switzer et al.10 found that
closure times were quicker for the TA group than with subcuticular
closure (SCC); n = 46 (mean time of 15 vs 286 s; p < 0.001). However,
wound complications were higher in the TA group (p = 0.045),
and cosmesis (via blinded evaluation using 4 weeks post-procedure
photographs slightly favored the SCC group (4.2 vs 3.88). Interest­
ingly, in a similar study, Ong et al.11 found no time advantage to tissue
adhesives.
The predominant use of TAs has been on low tension simple
lacerations or surgical incisions. Saxena and Willital12 conducted
a 10-month, 32 pediatric-patient study of laceration repair in high-
tension extremity lacerations (hands, feet and over joints). The affected
areas were subsequently immobilized, yielding excellent cosmetic
results with the reported advantages of patient preference and
cost-effectiveness.
The use of TAs is becoming increasingly popular for skin closure of
surgical and simple skin lacerations, especially in the pediatric age
range. TAs have gained favor due to their reported quicker and painless
closure of skin wounds. 2-octylcyanoacrylate and monomeric N-
butyl-2-cyanoacrylate, new generation, medical grade tissue adhesives
have been studied extensively over the last several years. Technical
dis­advantages and concerns include inadvertent contact with
surgical instruments, gloves, clothes, sutures, etc. The adhesive must
be applied avoiding exposure to the subepidermal layers of the
wound, which may prevent wound healing. Additionally, tissue
adhesives do not provide the potential for eversion of the skin. Tissue
adhesives are colored so that the surgeon can see the sites of applica­
tion. It is necessary to approximate the wound edges for approxi­
mately 1 min to allow the adhesive to dry. Tissue adhesives can be
useful as an alternative to suture and the need for local anesthetic
block for non-contaminated lacerations, thus avoiding the need for
suture removal. The use of tissue adhesive is not advised on wounds
where significant wound tension is anticipated, except if properly
immobilized.
TENSION ASSISTED WOUND CLOSURE
Achieving closure of integument can be challenging in many instances
in foot and ankle surgery. The size of the skin and underlying soft
tissue deficit influences the surgeons’ choice of wound closure. Tension
assisted wound closure (TAWC) is often useful in large residual
wounds in the diabetic or trauma patient population. In the diabetic
or poly trauma patient, co-morbidities often shift the surgeon’s
preference to pursue non-surgical options for large wound closure.
(Vacuum assisted wound closure (VAC) methods are discussed in
Chapter 29).
External tissue expansion devices utilize the principles of TAWC
to rapidly close wound defects with full thickness skin and subcutane­
ous tissue. Based on observations of natural physiological tissue
expansion such as the gravid abdomen or pubescent or gestational
breast enlargement, Charles Neuman reported the first clinical trial of
tissue expansion via air-filled subcutaneous implants in 1957.13 His
work was largely forgotten until a similar application using subcutane­
ous silicone bags (over a period of several weeks) was reported by
Chedomir Radovan in 1979.14 The expanded skin was then used for
advancement or transposition flaps of adjacent defects. It was noted
that the expanded skin showed no thinning and in fact, there was
evidence of increased numbers of skin cells. The concept of tissue

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Skin incisions
Skin incisions should always be made perpendicular to the skin
surface. This is more difficult over soft tissue or bone prominences
and with curvilinear, circular or ovoid incisions. The incision should
be made completely through the dermis in an even stroke. The extent
of dermal damage at final wound closure, along with reapproximation
of the dermal layer, determines the thickness of the scar. Biased
transdermal incisions produce wider scars and tend to facilitate
improper apposition of the skin edges on closure (Fig. 9.18). This
same concept of a vertical scalpel blade during incisions is used when
excising a soft tissue mass (Fig. 9.19). The scalpel can be held in a
more vertical orientation for the initiation and termination of the
incision and the belly of the blade used to incise the main portion of
the skin (Fig. 9.20). Blade selection is based on the type of incision
and the location of the incision. As an example, circular or oval inci­
sions that are commonly used for rotational flaps are more precisely
made with a No. 15 blade because of its smaller radial arc. The No.
15 blade is also easier to control over small bone prominences on the
digits. A No. 10 blade is more often used in linear or curvilinear inci­
sions on relatively flat areas or in areas of uniform subcutaneous tissue
thickness.28
Mobilization and retention
suture techniques
Unfortunately, there are unavoidable circumstances in which
skin must be approximated under greater than optimal tension. In
these cases, several options may be used by the surgeon to help
prevent wound gaping and minimize additional trauma to the inci­
sional area from pull-through sutures. In a more ideal situation, reten­
tion sutures are used to normalize tension in a wound or incision
where non-retention sutures are inadequate. The final apposition is
aided by proper undermining at the subcutaneous tissue layer or
superficial or deep fascial layers. Undermining is performed with
both blunt and sharp dissection using dissection scissors or blunt
instruments in a radial fashion away from the highest area of tension
(Fig. 9.21).
BASIC SUTURE TECHNIQUE
One of the first principles of proper suturing is to place the needle
through the skin at the correct angle. It is common for novice sur­
geons to place the needle to the skin at a biased angle and allow the
needle to penetrate at a shallow level. It is preferable to place the tip
of the needle at 90° to the skin and allow the needle to complete its
arc of rotation through the skin (Fig. 9.22). This creates a complete
suture pattern that will properly approximate the skin edges
(Fig. 9.23).
Retention sutures
The standard techniques of vertical mattress sutures (Fig. 9.24) or
horizontal mattress sutures (Fig. 9.25) can be combined with anti-
pull-through pads, allowing dispersion of the necessary retention
forces. Common materials used for this purpose include: (1) sections
of small suction drains; (2) pediatric intravenous tubing; (3) intrave­
nous T-tube extensions and (4) French (No. 10) catheter.
In terms of strength of repair, it has been shown that skin healing
under tension yields a repair of high tensile strength.29 However, this
fact has little application in elective surgery because of the associated
widened scarring. The concept of minimizing tension in healing
wounds is often important to the overall cosmetic result.30
thickness skin grafting for closure of large wounds. The procedure
recruits adjacent normal skin for rapid advancement. The principle is
similar to the previously discussed tissue expansion methods. Funda­
mentally, soft tissue tension over time allows substantial mobilization
of the skin and subcutaneous tissues without vascular compromise.
The rate of wound edge reapproximation under tension can be con­
siderably accelerated with proper technique.
Each Proxiderm™ device has two opposing tissue hooks, which are
separated on tension and inserted ~1 cm away from the wound edges
at 2 cm intervals along the wound. The device applies a specific
amount of tension on the tissue (460 g), which causes steady expan­
sion of the tissue without pressure necrosis. Typically, the Proxiderms™
are left in place for 2–3 days. During this time, there remains access
for appropriate wound care and cleansing. This can be a multi-stage
procedure depending on the wound gap and new Proxiderms™
are applied as needed over time. The sustained low-grade tension
has been shown to induce angiogenesis. A minimal amount of under­
mining is necessary and should be done at the suprafascial
or deep subcutaneous layer to avoid compromise of the cutaneous
perforating vessels. Technically, this procedure is troublesome on
thin dorsal skin of the feet. The procedure can be done as an outpa­
tient, and it is necessary to secure each device with a suture across the
wound and tied over the top. A well-padded, bulky dressing is also
advised.
Another recent advancement in TAWC is the DermaClose® RC con­
tinuous tissue expander (Wound Care Technologies, Chanhassen,
MN, USA) (Fig. 9.14). The product is unique, allowing for radial or
linear, shoelace pattern of skin tensioning in a continuous, dynamic
fashion. Application is done under anesthesia with proper sterile
preparation of the area. The wound bed is prepped with proper
removal of fibrotic tissue. Wound margins are then undermined
approximately 0.5–1.0 cm. Angulated barbs are placed into the skin
1–1.5 cm from the edges and placed at 2–3 cm distance from each
other.20,24 Each anchor is fixated with two skin staples. A tension con­
troller with nylon line is then fitted over the hooked ends of the skin
anchors and the device is tightened (Figs 9.15, 9.16). A built-in clutch
device allows for continuous dynamic tensioning at 1.2 kg. The device
is typically left in place for 1–7 days until margins can be fully
re-approximated with suture. Intermittent or longer application times
can also be used. Studies have proven the device to be effective in
reducing wound dimensions (Fig. 9.17).25–27
Figure 9.14  DermaClose® RC continuous tissue expander.
(Courtesy of Wound Care Technologies Inc, Chanhassen, MN, USA.)

Chapter
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1
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2
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5
6
7
8
Shoelace Technique Guide
Six Anchor Technique
Step 1
Seat tension controller under tab of
home anchor (#5), loop line under
anchor tab # 1 and 3.
Eight Anchor Technique
Step 1
Seat tension controller under tab
of anchor #7 (#6 could also be used),
loop line under anchor tab #2 and 4.
Step 4
With left hand loop line under
anchor tab #6 while #8
(right hand) remains paused.
NOTE: For wounds longer than 10 cm
and/or wider than 5 cm multiple devices
may be used in series.
Step 5
Loop remaining line under tab
on anchor #3, turn blue control
knob until audible clicking is heard
(approx. 12 full rotations).
Step 2
Loop line under anchor
tab under #5 and 8.
Step 3
With left hand loop line under
anchor tab # 1 while pausing
at anchor #8 with right hand.
Step 3
Loop remaining line under tab
on anchor #2, turn blue control knob
clockwise until audible clicking
is heard (approx. 12 full rotations).
Step 2
Loop line under anchor tab #4 and 6.
A
Figure 9.15  Diagram of the Dermaclose® Anchor Technique. (A) Shoelace Six and Eight Anchor Technique. (B) Shoelace Ten Anchor and End Position
Technique.
(Courtesy of Wound Care Technologies Inc, Chanhassen, MN, USA.)

88
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
1
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Shoelace Technique Guide
Ten Anchor Technique
End Position Technique
Step 1
Step 4
Step 4
Step 5
Step 6
Step 2
Step 1
Step 2
Step 3
Step 3
Seat tension controller under
tab of home anchor (#8),
loop line under anchor tab #2 and 4.
At one end of the wound
seat tension controller under
tab of anchor #9 loop tension
line under tabs of first
opposing anchors #4 and 8.
Cross line and loop on fourth set
of opposing anchors #5 and 1 to
take up remaining slack turn
tension controller clockwise
and seat into home anchor #9.
Cross line and loop on
second set of opposing
anchors #7 and 3.
Cross line and loop on
third set of opposing
anchors #6 and 2.
Loop line under anchor
tab #6 and 10.
Loop line under anchor
tab # 1 and 5.
Loop line under anchor
tab #7 and 9.
To take up slack pull tension
controller while allowing line
to loop under anchor tab #3.
To take up remaining slack
turn tension controller clockwise
and seat into home anchor #8.
NOTE: For wounds longer than 10 cm
and/or wider than 5 cm multiple devices
may be used in series.
B
Figure 9.15, Continued.
SPECIAL SUTURING TECHNIQUES
Tendon sutures
With suture repair of tendons or in tendon transfer surgery, pull-out
strength, tissue reactivity and selection of the least constrictive or
deforming suture techniques are of primary concern. Several biome­
chanical studies have evaluated the relative strength of various suture
techniques and materials commonly used in tendon repair.
It is beyond the scope of this chapter to review the individual
studies.31–42 However, an interesting and simplistic hypothesis has
recently been presented, which suggests that given the same suture
(2 Mersilene, Ethicon, Somerville, NJ, USA), the strength of end-
to-end tendon repair is related to the number of strands crossing
the repair site as opposed to the specific technique used.31 In this
study, testing maximum break load of three common tendon suture
techniques, Sclamberg and colleagues found that all sutures failed
at the site of anastomosis without pull-through artefact. There was
no statistically significant difference noted via one way analysis
of variance (ANOVA) on maximum break load. Suture selection,
tissue handling and appropriate postoperative management are
therefore likely to be of more importance than the technique of
repair.43–45

Chapter
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89
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plantar plate), simple interrupted sutures or horizontal mattress
sutures are adequate. In certain tissues (flexor and extensor retinacu­
lae), where there is less inherent tissue strength and linearly oriented
fibers, over-and-over sutures, deep buried vertical sutures or X-sutures
may be appropriate (Fig. 9.27). For this application, the suture diam­
eter should be sufficient to allow necessary tension and hold the repair
long enough for healing of this relatively less vascularized tissue.
There are several simple methods commonly used to approximate
deep fascia, muscle and plicate or repair ligaments. A simple deep
buried knot suture (Fig. 9.28) can be modified to assist in everting
the wound edges by flaring the loop upward toward the dermis
and then downward toward the wound edge (Fig. 9.29). The over-
and-over modification (Fig. 9.30) is useful in more fragile tissue or
to reduce risk of tear through in higher tension areas. This same
suture technique may be used on superficial closures with increased
tension (Fig. 9.31). To disperse forces over a greater area of tension,
the figure-of-eight (Fig. 9.32) or running buried stitch is used
(Fig. 9.33).
One must consider the benefits of early mobilization of tendon
repairs (which would require multistrand security of the anastomosis)
vs the potential for fibrosis and adhesions associated with the
higher strength methods. Of more practical concern is the physical
deformation or constriction of the tendon which is related to the
suture method as well as the skill of the surgeon. Regardless of
the method of tendon suture, a knot should not be left outside of the
tendon. For this reason, and for the advantage of greater pullout
strength, modifications have been proposed to the traditional Kessler
and Bunnell stitches (which have only two strands of suture crossing
the repair site). Multistrand32 tendon suturing modifications are
shown in Figure 9.26.
INTERNAL SUTURE TECHNIQUES
Buried sutures
The purpose of buried sutures is to recreate the normal separation of
functional layers within the wound and to eliminate dead space. The
fundamental principle is to accomplish these goals with the least
suture possible. Excessive or inefficient buried sutures simply multiply
the risks associated with the retained foreign material and increased
tissue ischemia. It is vital that the deep tissues are appropriately, not
excessively, undermined to allow mobilization and access for accurate
reapproximation of layers. Careful analysis of wound layer tension
allows the surgeon to select the appropriate methods and materials
for functional and cosmetic closure.
DEEP SUTURE RETENTION TECHNIQUES
Imbrications of deep fascia or ligaments often require different suture
methods according to the orientation of the tissue fibers. In areas of
more or less uniform density tissue (as in the spring ligament or
Figure 9.16  Application of six anchors.
(Courtesy of Wound Care Technologies Inc, Chanhassen, MN, USA.)
Figure 9.17  (A) Almost complete wound closure using DermaClose® on
heel ulcer.
(Courtesy of Wound Care Technologies Inc, Chanhassen, MN, USA);
(B) Dramatic reduction of wound size using DermaClose® on foot ulcer.
(Courtesy of Dr Stephanie Wu.)
A
B

90
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 9.18  Skin incisions. (A) Correct angle of scalpel blade to the skin. This produces an incision that is vertical and easy to close. (B) Incorrect angle
of scalpel blade to the skin. This biased cut produces more damage to the tissues and potentially a wider scar.
A
B
Figure 9.19  Scalpel blade angle. (A) The scalpel blade is held in the
correct position, perpendicular to the skin, during the excision of a
lesion. (B) The scalpel blade is held in an incorrect angle during the
procedure.
A
B
Figure 9.20  Incision technique. The incision is started with the tip of the
scalpel blade. As the incision is advanced the belly of the scalpel blade is
used to incise the majority of the skin and the incision is terminated
using the tip of the blade once again.
Figure 9.21  Undermining. The dissecting scissors are used to undermine the skin incision edges in a radial fashion away from the highest area of
tension. In most cases, the tips of the scissors are spread apart in order to separate the tissue layers rather than being used to cut the tissues.

Chapter
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plasty. This is accomplished by proper positioning of the suture in the
dermal layer of the apex at a position that provides adequate apposi­
tion of the skin with minimal possibility of pull-through injury at the
tip. The suture is placed parallel to the dermal plexus of vessels and,
if kept superficial, it minimizes circulatory disturbance to the tip. The
needle entry and exit points are vertically placed at approximately 90°
angles to each other, at which the apex is secured by transverse place­
ment through a relatively wider area of skin. The knot is tied over the
non-apical portion of skin under sufficient tension to minimize
tension of other adjacent sutures. This technique is also known as the
‘three-point corner stitch’. This suture technique is applied commonly
to dog-ear repair, Z-plasties, double-Z rhomboid flaps, V–Y plasties
and on some types of rotational skin flaps.46 Modification of this
technique includes the ‘four-point tip stitch’, which is useful in several
flaps, including the T-shaped incisions and in some dog-ear repair
procedures (Fig. 9.38).
COSMETIC CLOSURE
The technique of skin closure can be a significant factor in the long-
term cosmetic result apart from the adherence to other basic principles
in tissue handling. The length of time sutures are left in place varies
throughout the body, ranging from 5 days on the face and scalp to 3
weeks or longer on the plantar surface of the foot. Most other foot
and ankle sutures are left in place for 10–14 days. If sutures are left
longer than necessary, epithelialization of the suture tracts can occur,
resulting in an unsightly railroad track pattern scar. A commonly used
suture technique to avoid this type of scarring is the intradermal
suture. As stated earlier, proper alignment of the dermal layer is most
critical for both strength of the approximation and to minimize the
width of the scar.
Intradermal suture
(continuous subcuticular)
This technique involves a horizontally placed serpentine continuous
suture within the dermal layer (Fig. 9.39). Apposition of the skin is
maintained by longitudinal tension of the suture along the incision.
One-half buried horizontal mattress sutures
The one-half buried mattress suture and its variations are powerful
methods to manipulate and align dissimilar and fragile tissues with
minimal trauma. The standard method is illustrated in Figure 9.34.
In symmetric wound edge reapproximation, the depth of suture
placement in the dermis is equal on both sides. In cases of dissimilar
edge thickness (myocutaneous free flaps, plantar to dorsal tissue trans­
fers, etc.) the suture depth is varied to ‘raise’ the dermal layer appro­
priately. This stitch can be used to approximate the ungual labia to
the nail bed following sharp method matrixectomies without pene­
trating the nail (Fig. 9.35). As a non-incisional option to reduce
dog-ear deformity, the half-buried horizontal mattress stitch can
be modified to a ‘deep to superficial, oblique half-buried stitch’
(Fig. 9.36).
Apical sutures
The apical stitch, corner and tip stitches are also modifications of the
one-half buried horizontal mattress stitch. The apical stitch, also
called the three-point corner stitch, can be used in a variety of skin
closures (Fig. 9.37). The purpose of this technique is to minimize
trauma and circulatory compromise to the apical portion of the skin
Figure 9.22  Suture technique. (A) Incorrect technique of placing needle in the skin at a biased angle and allowing the needle to penetrate at a
shallow level. (B) Correct technique of placing needle at 90° to the skin, which allows the needle to complete its arc of rotation through the skin.
A
B
Figure 9.23  Simple full-thickness suture.

92
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 9.25  Horizontal mattress suture. (A) Proper technique allows the suture to close the full-depth incision. (B) Buttress anti-pull through tubing
may be applied to increase strength.
A
B
•
Technique 2. This method is used for unilateral dog-ear defects.
This method is sometimes referred to as a Bürow triangle. The
redundant tissue is elevated in the centre and the primary
incision is extended along the tented surface at the end of the
incision in a J- or hockey stick-shaped secondary incision. The
redundant tissue is drawn parallel to the primary incision and
cut along the secondary incision (Fig. 9.43).
•
Technique 3. The method is used in the repair of small dog-ears.
A simple double elliptical incision is made around the
dog-ear, excising the defect in line with the primary incision
(Fig. 9.44).
•
Technique 4. This method is useful in larger dog-ear repairs when
the surgeon wishes to reduce the length of the elliptical repair
incision. The basic idea is to combine a double elliptical
incision with a V–Y incision or M-plasty excision (Fig. 9.45).
•
Technique 5. This final technique is useful for dog-ears that are
thick and more perpendicularly oriented to the primary
incision. The secondary or repair incision is simply a
perpendicularly oriented double elliptical incision around the
dog-ear made at the standard 3 : 1 ratio (length-to-width
relationship) (Fig. 9.46).
Figure 9.24  Vertical mattress suture. Proper technique allows the suture to close both the deep and superficial layers of the incision.
A
B
For longer incisions, it may be helpful to exit the dermal layer occa­
sionally and create a bridge. This will aid in suture removal by provid­
ing easy access for the suture scissors. The ends are often taped to
prevent slippage. A modification of the concept is used for horizontal
mattress sutures when both cosmesis and retention are important
(Fig. 9.40). The intradermal or running horizontal suture may also be
combined with the retention anti-pull-through tubing for even greater
strength (Fig. 9.41).
Dog-ear repair
The term dog-ear refers to a pucker of redundant skin at the end of
an incision and alternative names include: standing cone, lentoid,
pucker and tricone deformity. There are five standard methods of
repair for this condition.
•
Technique 1. The redundant tissue is elevated with a skin hook
or forceps and the incision is continued along one side of the
tented skin. When the first incision is complete to the end of
the dog-ear, the triangular flap of skin is then drawn across the
incision and a second parallel incision excising the flap is made
(Fig. 9.42).

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Figure 9.26  Modifications of tendon sutures. (A) Multistrand Krackow stitch. (B) Modified Kessler stitch. (C) Modified Bunnell stitch.
A
B
C
Figure 9.27  Specialty sutures. (A) One-half buried vertical stitch and (B) X stitch, both add reinforcement to tissues.
A
B
Figure 9.28  Simple deep buried suture. This technique is used to close
deep layers.
A newer technique that is useful for small dog-ears that occur at the
end of an excision is referred to as ‘leashing the dog’ (Fig. 9.47).47
CONCLUSION
Functional and cosmetic wound closures in lower extremity plastic
surgery can be achieved when these suture techniques are imple­
mented with proper tissue handling. Too often, a surgeon’s ‘skill’ is
assessed on speed of the procedure and the final appearance of the
incisional scar. Careful selection of materials and suturing techniques
when combined with gentle, efficient tissue handling will provide the
most consistent and cosmetic wound closures.

94
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 9.32  Figure-of-eight deep buried stitch.
Figure 9.33  Running deep buried stitch. The two ends of the suture are
tied after sliding the suture back and forth until the wound is closed.
Figure 9.29  Modified deep buried suture. This is useful in assisting in everting the wound edge in deep closures.
Figure 9.30  Modified deep over-and-over stitch. This suture technique
helps to reduce tear through in high tension areas.
Figure 9.31  Modified over-and-over retention stitch for skin.