RU2747360C1 - Method for suture-adhesive closure of skin wounds - Google Patents

Abstract

FIELD: medicine; surgery; traumatology.SUBSTANCE: invention relates to medicine, namely to surgery, to maxillofacial surgery, traumatology and is intended for closing a skin incision when removing skin formations and hypodermic tissue, including those one on the face, in order to form an optimal postoperative scar, as well as suturing traumatic wounds after primary surgical treatment. Operative access to the formation of the skin and hypodermic tissue is carried out by a rhomboid-shaped edging incision. Sutures are applied from the site of the greatest divergence of the edges of the wound, at the obtuse corners of the rhomboid-shaped incision, retreating from the edges of the wound by 0.4-0.5 cm. The number of sutures is always odd, with a mandatory “central” suture and tying on fast-spreading knots. The next step, on the second day of the postoperative period, the knots are untied, the surgical threads are not cut, leaving only small areas up to 0.5 cm long; medical glue is applied to the suture line in two layers. As a result, the scar is formed in the form of a thin, inconspicuous line; there are no traces of sutures on the skin in the form of “sleepers”.EFFECT: method provides a good cosmetic and functional result of the operation, is a low-traumatic, effective method of treatment, and reduces possible complications.1 cl, 1 dwg

Description

The invention relates to medicine, namely to surgery, to maxillofacial surgery, urology, in ENT practice, gynecology, traumatology and is intended to close a skin incision when removing formations of skin and subcutaneous tissue, including on the face, in order to form an optimal postoperative scar, as well as suturing of traumatic wounds after primary surgical treatment.

An important point of any operation when removing formations on the skin and in the subcutaneous tissue is to ensure good hemostasis, create conditions for the complete adaptation of the wound edges, exclude the penetration of infection into the wound and form an invisible, linear scar.

All seams, regardless of their purpose, are subject to the following requirements. The seams must:

1) precisely adapt the wound edges (precision);

2) eliminate cavities and pockets;

3) minimize trauma to the stitched tissue;

4) avoid skin tension;

5) achieve a hemostatic effect;

6) achieve a cosmetic effect;

7) be able to completely remove or biodegrade;

8) quickly superimposed and removed;

9) do not interfere with the natural drainage of the wound;

10) apply a minimum amount of suture material in the wound cavity (Kozlov, V.G. Skin suture: study guide / V.G. Kozlov, A.V. Bolshov. - Minsk: BSMU, 2016.-p. 5) ...

Known simple interrupted suture, which is the main type of circular vertical suture used in surgical practice. In this case, a needle with a thread is passed through the edges of the skin wound, including the epidermis, dermis itself, subcutaneous fat and superficial fascia. Subsequently, the edges of the wound are brought together by tension of the thread and fixed by tying a knot (Kochnev OS, Izmailov SG Wounds suturing methods. - Publishing house of Kazan University, 1992. - S. 61-85).

The disadvantage of this type of suture is the creation of pressure in the skin, directly in the area of the surgical thread. This leads to disruption of trophism in the area of direct regeneration, which, under conditions of the initial excessive tension in the skin, increases the likelihood of suture eruption, ischemia and marginal tissue necrosis.

A noticeable scar remains after surgery, which, if localized in a cosmetically significant area, can reduce the aesthetic effect of surgery.

In addition, the threads pulled out and tied into a knot on the surface of the skin leave visible suture marks in the form of sleepers, like a “railroad track” (Semenov G.M., Petrishin V.L., Kovshova M.V. Surgical suture. St. Petersburg, 2002 - S. 49-50).

Linear intradermal sutures, in contrast to circular vertical sutures, do not create pressure in the skin immediately adjacent to the edges of the wound. At the same time, the intradermal ("cosmetic") linear suture according to Halstead, having a good cosmetic effect in ordinary linear wounds, under conditions of significant divergence and tension, does not provide a full adaptation of the wound edges, suturing of cavities under the skin. As a result, hematomas may form, skin necrosis and suture divergence may occur; a keloid scar may form. In addition, the manipulations for the imposition of a "cosmetic" intradermal suture delay the time of surgery.

Medical glue (BF-6, fibrin glue, as well as glue based on cyanoacrylates - MK-2, MK-7, sulfacrylate) is used to create the possibility of “seamless” wound closure, improve the aesthetic effect and abandon general anesthesia in traumatic skin injuries in children. ). One of the popular types of medical glue for seamless joining of skin wounds is ETHICON DERMABOND surgical skin glue, which is made on the basis of 2-octylcyancrylate. Dermabond skin glue, in combination with an intradermal suture, is indicated for closing skin wounds in general surgery, cardiovascular, thoracic surgery, as well as in obstetrics and gynecology. The use of DERMABOND dermal glue gives a noticeable improvement in the cosmetic effect of the sutured wound. In this regard, the glue is especially indicated for use in plastic surgery, as well as in pediatrics (Description and instructions for use. - Medichome.ru. Official representative of MEDTRONIC (COVIDIEN). - ETHICON JOHNSON & JOHNSON in Russia).

At the same time, the use of Dermabond medical glue and other types of medical adhesives independently, without suturing, is possible only with small superficial wounds, without pronounced diastasis of the wound edges, mainly in pediatric practice, in children. For deeper, subcutaneous lesions and formations, where there is a noticeable divergence of the edges of the wound, preliminary suturing is required in one way or another, and the glue is applied from above, on the skin sutures, to seal the postoperative suture line, creating a film impermeable to bacteria and, as a result , refusal of dressings. In the future, it is necessary to remove the suture superimposed under it from a non-absorbable suture material, or to wait for the complete resorption of the suture material, which requires prolonged observation by a specialist doctor.

An operation for an inguinal hernia was taken as a prototype, in which, after hernia repair in children, the wound is sutured using a suture-glue method by the method of hernioadhesion: ... "the postoperative wound was closed by

layer-by-layer suturing of the superficial fascia and skin. 2-3 rare converging sutures were applied to the skin incision, cyanoacrylate glue was applied over the sutures, which, after polymerization, formed a thin transparent film above the suture line, hermetically closing the postoperative wound (Yu.A. Kravtsov "Surgical treatment of inguinal hernias in children using cyanoacrylate glue" - Diss. For the degree of Candidate of Medical Sciences, - M., 1986.- p.91.)

The method protects the postoperative wound from maceration and infection, which is especially important in childhood after inguinal hernia repair.

The prototype has the following disadvantages. The presence of postoperative nodal sutures causes swelling and compression of tissues until they are absorbed or removed, which requires the use of anesthetic drugs and limits the ability to self-service. Rare sutures on the skin may not provide proper hemostasis, therefore tissue bleeding leads to postoperative edema. On the skin there are traces of sutures like "sleepers", the postoperative scar is noticeable to others. If the situation requires drainage of the wound with a rubber graduate (for example, there is an extended channel in which blood and tissue fluid can accumulate), drainage will have to be applied through an additional skin puncture (counterperture) so as not to violate the integrity of the adhesive film; all this worsens the conditions for wound healing and creates an additional scar.

The objective of the invention is to create a universal, easily reproducible method of closing skin wounds after removing skin and subcutaneous formations, which eliminates the disadvantages of known methods of operations, first of all, the risk of inflammatory complications, hematoma formation, creates a good aesthetic effect of the operation, reduces the time of surgery and anesthesia.

The technical result of the invention is the simplicity and ease of execution of the method, the presence of clear cutaneous landmarks for the incision, the acceleration of the operative access time; at the same time, simultaneous surgical intervention is possible on a variety of formations, including on the face.

The proposed method provides a smooth course of the postoperative period, the possibility of imposing cosmetically beneficial types of closure of the postoperative wound.

The task is achieved by the fact that in the inventive method, prompt access to the formation of skin and subcutaneous tissue is carried out by a rhomboid bordering incision. In the future, the resulting defect is sutured with an interrupted suture superimposed in the center of the incision, connecting the obtuse corners of the rhombus and turning it into a linear wound. The suture is applied with an absorbable suture through the entire layer of the skin and subcutaneous tissue, to the bottom of the incision, tied to a three-loop quick-release knot. On the second day of the postoperative period, a dressing is performed, in which the surgical threads are untied, the sutures are not removed, their excess is cut off, and Dermabond skin medical glue is applied to the suture line. Further, dressings are not needed, the wound heals under the adhesive film, which later peels off on its own.

The inventive method is carried out as follows. Prompt access to the formation of skin and subcutaneous tissue is carried out by a rhomboid bordering incision. The long axis of the rhombus-shaped bordering cut is located along the Langer lines. The length of the section corresponds to the diameter of the formation. With small sizes of education (up to 0.5 cm in diameter), the incisions are made by 4 injections with a lance-shaped scalpel along the contour of the formation, repeating the contours of the rhombus. In the presence of subcutaneous formations, the subcutaneous fascia is sutured with the first row of absorbable sutures. If a linear incision is sutured with an extended surgical approach, for example, after a hernia repair, the stage of skin suturing begins in the middle of the postoperative wound. After the stage of removal of the formation, hemostasis of the bleeding vessels of the subcutaneous tissue is carried out, an interrupted vertical suture is applied to the skin and subcutaneous tissue with an absorbable suture, with stitching to the bottom of the wound. The first suture is applied at the place of the greatest divergence of the edges of the wound, at the obtuse corners of the diamond-shaped incision, departing from the edges of the wound by 0.4-0.5 cm. With small sizes of the formation (up to 0.5 cm in diameter), one suture is enough; if the divergence of the wound edges persists, they are additionally applied along the suture to the right and left of the central suture. The number of sutures can be greater, with large wound sizes, but always odd, with a mandatory "central" suture. The suture thread should be strong, braided, absorbable, not monofilament, with good ability to tie in 3 loops. An important point in tightening the thread and bringing the edges of the wound closer is tying it to a fast-opening knot. As such a knot, the well-known double reef knot, sometimes called a byte knot, is used, in which the ends of the surgical suture are tied folded in half. Thus, the tying of the surgical suture after suturing the tissues begins with the imposition of an “analogue” of the surgical knot, when the first loop makes two turns; after tightening it and transferring it to one side, a second loop is tied - a simple untie knot that can be untied by pulling on the working end of the thread. The third loop is also a simple untie knot. As a result of tightening and tying the knot loops, a triple quick-release knot is formed in the center of the wound, suturing all its layers vertically. The diamond-shaped form of the wound becomes linear, the diastasis of the edges is eliminated. Pulling on the central knot, they straighten and bring the edges of the wound closer together, applying additional knots to the right and left of the central knot and tying them according to the same technique, with a three-loop quick-disconnect bow knot. If necessary, a drainage strip made of glove rubber is inserted between the nodes to drain the sacral contents of the subcutaneous cavity. The number of nodes can reach 5.7, and more, but always odd, due to the central node and paired nodes on the sides of the central one. The distance between the nodes is from 0.5 to 0.7 cm, depending on the age and constitution of the patient, and should ensure tight adaptation of the wound edges and reliable hemostasis. After treatment of the seam with an antiseptic solution, the wound is sealed with a bandage of the "Cosmopor" type, or closed with a napkin and glued with strips of sticky plaster.

The next stage, on the second day of the postoperative period, is dressing under aseptic conditions, in the dressing room; during the dressing, the postoperative sticker is removed, the knots are gradually untied, starting at the periphery, while forming a fold of skin around the wound to prevent divergence of the wound edges. The untied surgical sutures are not pulled out, cut off, leaving only small sections up to 0.5 cm long, while the ends of the cut suture are laid in opposite directions; medical glue (Dermabond, Ethycon) is applied to the seam line, holding the wound edges for the time of glue polymerization - about 1 min. The glue is applied with streak movements parallel to the scar, clockwise around the wound, at a distance of up to 1.0 cm from the edges of the wound, with the obligatory involvement of the ends of the cut surgical sutures into the adhesive film, laying them parallel to the scar line. After polymerization and hardening of the first layer, a second layer of Dermabond glue is applied, distributing it more widely from the edges of the wound, at a distance of up to 1.5 cm. At the same time, the ends of the cut threads are filled with an adhesive film and remain fixed, holding the edges of the wound. After the final hardening of the adhesive film, the wound is covered with a sterile aseptic adhesive, if the seams are under clothing, to protect against mechanical damage. On open areas of the body (face, neck), the adhesive film can be left open. In the future, there is a gradual peeling of the adhesive film on the 8-10th day of the postoperative period. In the process of caring for the wound, the skin around it can be washed with water from the shower, without mechanical impact; the skin around is wiped with solutions of water antiseptics (for example, chlorhexidine).

In the case of a traumatic origin of a wound of the skin and subcutaneous tissue, the use of a stitched, up to 2 days postoperative period, "seamless" adhesive joint allows you to transfer any skin wound sutured with interrupted sutures into a cosmetically advantageous healing option, when on the second day of the postoperative period, transversely applied skin sutures are cut at the node ; the sutures are not removed, the knot remains in place, and the free end of the ligature is laid along the wound, parallel to the future scar and fixed with Dermabond glue covering the scar line

As a result of early removal or untiing of sutures, the scar is formed in the form of a thin, inconspicuous line; there are no traces of seams on the skin in the form of "sleepers".

Comparative analysis of the proposed method with the prototype shows that

in the claimed method, the skin incision is reduced to a minimum, it is performed along the skin Langer's lines, the edges of the incision are easily adapted, which facilitates the application of an adhesive cosmetic "suture". Additional dissection of the wound edges during surgery is not required. The claimed invention makes it possible to effectively perform the excision of multiple formations, to carry out the prevention of inflammatory disorders. The postoperative scar on the skin becomes almost invisible. All of the above generally increases the cosmetic effect of the operation, improves the conditions for wound healing, therefore, the proposed method provides an increase in the cosmetic effect of the operation without prejudice to the radical nature of the intervention. In addition, the claimed surgical technique allows to speed up the process of treatment and recovery of patients with pathology of the skin and subcutaneous tissue, to increase the radicality of surgery, excising the damaged edges of the wound in traumatic injuries during primary surgical treatment, and helps to reduce the number of complications of the postoperative period. The use of a "seamless" adhesive joint, stitched up to 2 days, makes it possible to transfer any skin wound sutured with interrupted sutures into a cosmetically advantageous healing option.

The essence of the invention is illustrated by drawings, which schematically show the stages of suturing: the first stage (wound suturing) - top view (Fig. 1, A) and sectional view (Fig. 1, B); the second stage (glue application) is a top view (Fig. 1, B) and a sectional view (Fig. 1, D).

Clinical example of the implementation of the method.

Example 1. Patient Ch., 46 years old, was admitted for surgery with a diagnosis of multiple verrucous nevi of the face. On examination, 9 formations of a rounded shape, on a broad base, spreading to the entire layer of the dermis were noted; base diameter - from 0.3 to 0.6 cm, up to 0.5 cm high, densely elastic consistency. The surface is pink with brownish patches at the top. The formations were located chaotically on the face, in the buccal, chin, parotid-chewing, zygomatic regions on the right and left. Surgery was performed to excision each formation under local infiltration anesthesia with 0.1% lidocaine solution. Surgical intervention consisted in excision of each formation within the healthy skin with a diamond-shaped incision, the long axis of which coincided with the Langer's lines. The skin was dissected with a sharp-pointed scalpel blade set to the skin surface at an angle of 90 °. A full-thickness skin flap was excised to form the subcutaneous tissue. Hemostasis was performed by point coagulation with a Colorado needle electrode, using the Surgitron apparatus. The length of the operating wounds obtained as a result of excision of skin lesions ranged from 0.5 to 1.2 cm. Diastasis of the wound edges before suturing was 0.4 - 0.8 cm. Additional unsealing of the wound edges was not performed. Suturing of wounds was carried out according to the proposed method with an atraumatic thread - Vikril 3/0. The suture was started at the place of the greatest divergence of the edges of the wound in the buccal region on the left, at the obtuse corners of the diamond-shaped incision; the needle was injected, retreating from the edges of the wound in the area of the lateral corners of the diamond-shaped wound by 0.4 cm The wound was stitched with one "central" suture through all layers of the dermis, with the capture of the bottom of the wound and an injection into the opposite edge of the skin, retreating from the edge also by 0.5 cm The ligature was tied to a quick-disconnecting three-loop knot: first, the thread of the first loop was tightened by two turns, with a different direction of the thread overflow; after tightening it and transferring it to one side, they tied the second - a simple untied bow loop. The third loop of the knot was also a simple bow, and as a result, the wound was sutured with an untied knot. The diamond shape of the wound became linear. The suture was treated with a solution of liquid betadine, a small postoperative sticker made of a sticky plaster "Cosmopor" was applied. The same operation was performed with excision of 6 more formations in other areas on the face on the right and left. In two cases, after excision of the formations in the zygomatic and chin regions, one suture was not enough; additional sutures were placed to the right and left of the central suture; pulling on the central knot, straightened and brought the wound edges closer, applying additional knots to the right and left of the central knot and tying them using the same technique, with a triple quick-knot knot, thereby eliminating the diastasis of the wound edges. Each access has a separate aseptic sticker. The patient was discharged home for outpatient treatment, antibiotic therapy, cold to the wound and painkillers on demand were prescribed. There was no increase in temperature in the postoperative period. On the second day of the postoperative period, aseptic dressing was performed, postoperative stickers were removed. All wounds were observed: moderate edema of the edges of the wound, hemorrhagic narrow crusts in some areas of the wound line. Tight uniform contact of the wound edges along the entire incision line. Produced toilet wounds with 3% solution of hydrogen peroxide, treatment with 70 ° alcohol. On the wound in the zygomatic region, knots are untied, while a fold of skin around the wound is formed by the surgeon's fingers in order to prevent the divergence of the edges. The untied surgical suture was cut, leaving the ends 0.5 cm long, which were laid parallel to the scar, while the ends of the cut suture were laid in opposite directions; 0.5 ml of Dermabond medical glue was applied to the suture line clockwise around the wound, holding the edges of the wound during the polymerization of the glue for 1 min. The glue was applied with stroked movements, at a distance of up to 1.0 cm from the edges of the wound, with the obligatory involvement of the ends of the cut surgical sutures into the adhesive film, placing them parallel to the scar line. After polymerization and hardening of the first layer, a second layer of 0.5 ml of Dermabond glue was applied, spreading it more widely from the edges of the wound, at a distance of up to 1.5 cm. After the final hardening of the glue film, the wound was not closed, left open. The same procedure was carried out on the remaining 8 postoperative wounds. The patient was allowed to go home, where she took care of the wounds by rubbing the skin around the adhesive film with a chlorhexidine solution.

Examined on the 4th day - the skin surface along the seam line is clean, without signs of irritation. The glue captivity is wealthy. There is no discharge from the wounds.

7th day - the beginning of cracking of the adhesive film was noted, its fragments were tightly fixed to the seam line.

10th day - healing along the entire wound line by primary intention, the film is fragmented, began to partially exfoliate.

On the 20th day, a linear, pink scar was observed in all wounds, not protruding above the skin surface, up to 0.2 mm wide. The ends of the cut threads have been removed. There are no glue fragments.

4 months after the operation - the scars are linear, subtle, without deformation, no more than 0.1-0.2 cm wide, without signs of hypertrophy.

Example 2. Patient P., 8 years old, presented with a recently bruised wound in the chin region on the right. In the emergency room under local anesthesia, the primary surgical treatment of the wound was performed with the imposition of two non-absorbable interrupted sutures. He was sent for further treatment to a polyclinic at the place of residence. We contacted the MC "Health" for an appointment on the 2nd day of the postoperative period. The child's parents expressed dissatisfaction with the cosmetic effect of the primary surgery. The length of the wound was 2 cm, the edges were moderately edematous, slightly cyanotic and hyperemic. Discharge on the bandage is scanty, serous-hemorrhagic. The parents of the child were asked to transfer the suture made into a suture-adhesive method of closing the wound, consent was obtained. After removing the postoperative sticker, local application anesthesia was performed with EMLA cream, after which both ligatures were crossed in the region of the knot base, on the right, where the excess thread remained. After crossing the ligature, the knot remained to the left of the scar, and the free end of the ligatures was 0.4-0.5 cm. A skin fold was formed on the chin to prevent the dehiscence of the wound edges. On the scar line, 0.5 ml of tissue medical glue "Dermabond" was applied, with distribution in the longitudinal direction, parallel to the scar, with the involvement of the ligature knot and the free end of the surgical threads laid along the scar. The area of distribution of the first layer of the film was up to 1.0 cm around the scar. After the glue has polymerized and the first layer of glue film has dried, a second layer is applied, in the amount of 0.5 ml of Dermabond glue, with its distribution along the scar and in width, at a distance of up to 1.5 cm from the scar, thus overlapping the first layer of glue by 0.5 cm around the entire circumference. The bandage was not applied, the patient was given recommendations on wound care, continued antibiotic therapy, pain relief prescribed in the emergency room.

Examined on the 5th day after the operation - the skin surface along the suture line is clean, without signs of irritation. The glue captivity is wealthy. There is no discharge from the wounds.

On the 7th day - the beginning of cracking of the adhesive film was noted, it was fixed to the seam line.

10th day - healing along the entire wound line by primary intention, the film is fragmented, began to partially exfoliate. The subcutaneous part of the ligature was removed, since the material was non-absorbable.

On the 20th day, a linear, pink scar was observed in all wounds, not protruding above the skin surface, up to 0.2 mm wide. There are no glue fragments.

3 months after the operation - a scar of a linear shape, inconspicuous, without deformation, 0.2 cm wide, pale pink, without signs of hypertrophy.

Over the past period, since 2018, the authors have performed surgical treatment in 23 patients with skin formations - hypertrophic scars, atheromas, nevi of the skin of various parts of the body. Excision of the formations was carried out using the proposed method of suturing wounds. The healing outcome was assessed according to the VAS pain scale, visual assessment of the forming scar, general clinical and laboratory parameters. In all cases, the formation of a thin, smooth linear scar with rapidly changing stages of swelling and compaction was observed. The normal structure of the skin was restored, there was no deformation of the epidermis, which together provided a high cosmetic effect. No toxic or allergic reactions to Dermabond glue were noted.

The analysis of the patent and scientific medical literature showed that the proposed method contains features that distinguish it not only from the prototype, but also from other options for suturing skin wounds. These differences allow us to conclude that the proposed technical solution meets the criterion of the invention “novelty”.

Comparative analysis of the proposed method and the prototype shows that the proposed method differs from the known one in that the first (central) suture is applied in the center of the wound, on the tops of the lateral obtuse corners of the rhombus formed after excision of the formation within healthy tissues, departing from the edge of the skin incision by 0 , 4-0.5 cm; subsequent seams are applied in an even amount to the right and left of the central seam; the thread in this case is tied into three loops, the first of which is a variant of the surgical tying of a knot in two turns, and the second and third are simple untied bows; As a result, the ligature is fixed with a three-loop quick-release bow knot - it is easy to dissolve it before the second, seamless stage of wound closure.

The method differs from the known ones in that the wound is closed in two stages - at the first stage, interrupted sutures are applied to the wound, which allows, when tightening the suture, to provide stable compression between the wound edges, hemostasis, prevention of seromas, hematomas; at the same time, after the subcutaneous cavity collapses on the 2nd day of the postoperative period, the need for these sutures disappears, untiing the ligature provides a good blood supply to the forming scar. The second stage of wound closure is carried out in a dressing room, does not require anesthesia and consists in suture-adhesive fixation of the edges of the postoperative wound for a long time (up to 10 days or more), during which no additional dressings are required. The novelty of ligature processing at the second stage is that the knots of the postoperative suture are untied, the ends of the threads are cut by 0.5 cm and they are laid along the wound, parallel to the scar, while the ends of the cut thread are laid in opposite directions. The application of tissue medical glue with movements along the scar, with the obligatory involvement of the cut ends of the threads, preserves the fixation of the edges of the postoperative wound, which is disturbed by untiing the ligatures; a double layer of glue, with the distribution of the first layer up to 1.0 cm from the wound, creates fixation of the ends of the cut threads. The second layer of glue is applied more widely, its distribution to the periphery up to 1.5 cm from the edges of the wound enhances the fixation of the subcutaneous part of the surgical thread and protects the first layer of adhesive film from mechanical damage and contamination. The method allows to reduce the period of rehabilitation after surgery, meets most of the criteria for a suture. The patient can take care of the developing scar at home, preventing contamination and observing hygiene measures.

The inventive method provides for the formation of a thin uniform linear scar. Thus, the proposed method allows us to conclude that it meets the criterion of the invention "inventive step".

The method constituting the claimed invention is intended for use in healthcare. This method can be used in general and pediatric surgery, maxillofacial surgery, obstetric practice and traumatology. It is possible to use the proposed method on an outpatient basis, as well as as a stage of the operation during laparoscopy to close skin punctures. The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the proposed solution meets the criterion of the invention “industrial applicability”.

Claims (1)

A method of suture-adhesive closure of skin wounds, including holding a ligature through all layers of the dermis from the opposite edges of the wound and fixing it, characterized in that the first suture is applied in the center of the wound, on the tops of the lateral obtuse corners of the rhombus formed after excision of the formation within healthy tissues ; subsequent seams are applied in an even number to the right and left of the central one; the thread is tied in three loops, starting with the imposition of a surgical knot, when the first loop makes two turns; after tightening it, the second and third loops are tied, which are a simple untied byte knot; characterized in that on the second day of the postoperative period, a dressing is performed, in which the knots of the postoperative suture are untied, the ends of the threads are cut by 0.5 cm and they are laid along the wound, parallel to the scar, in opposite directions; form a skin fold parallel to the scar and cover the scar line with tissue medical glue, applying it with movements along the scar, clockwise around the wound, at a distance of up to 1.0 cm to the sides of it, with the obligatory involvement of the cut ends of the threads; after polymerization of the glue and hardening of the first layer of adhesive film, a second layer of medical tissue glue is applied at a distance of up to 1.5 cm from the scar, thereby overlapping the zone of the first layer of adhesive film by 0.5 cm.

Images