1. Problem Wounds, Flaps and Grafts

2. Wound care priorities 4 Discover and treat injuries to critical deep structures 4 Cover critical deep structures with skin 4 Prevent infection, suture only when necessary 4 Maintain function unhindered by contracture 4 Cosmesis is a distant fifth priority

3. Problem Closures 4 Important tissues deep to wound must be explored 4 Wound contaminated or skin nonviable 4 Closure under tension or inadequate skin to close 4 Edges uneven or complex shapes

4. Extend wound for exploration, parallel to important deep structures

5. Problem Closures 4 Important tissues deep to wound must be explored 4 Wound contaminated or skin nonviable 4 Closure under tension or inadequate skin to close 4 Edges uneven or complex shapes

6. Debride contaminated sub Q fat and nonviable skin

7. Debride and undermine to give everted closure

8. Defatting flaps improves viability

9. Apical stitch salvages viability

10. V-Y closure for nonviable edge

11. Closing a nonviable flap

12. Problem Closures 4 Important tissues deep to wound must be explored 4 Wound contaminated or skin nonviable 4 Closure under tension or inadequate skin to close 4 Edges uneven or complex shapes

13. Undermining first choice to relieve tension, but leaves dead space

14. Closing dead space prevents fluid collection but adds foreign body

15. Cotton pledgets may help when you must close under tension

16. Closing circular defect

17. V-Y double advancement flap

18. Curvilinear flap

19. Z-plasty changes direction of wound to align with skin tension; use 60 degree angles

20. Donor sites for full thickness grafts

21. Measure site and prepare graft

22. Hold the graft down to the bed

23. Preferred method to bolster graft in place

24. Problem Closures 4 Important tissues deep to wound must be explored 4 Wound contaminated or skin nonviable 4 Closure under tension or inadequate skin to close 4 Edges uneven or complex shapes

25. Avulsion closure: larger bite on flap side prevents override

26. Use apical stitches first on geographic lacerations

27. Apical first for stellate lacerations too

28. Half buried horizontal for edges of differing thickness

29. Fixing Bowser

30. Closing parallel lacerations; where ample skin, could also simply excise island

31. Dermal suture to close laceration within abrasion

32. Moist occlusive dressing leads to more rapid healing of open wounds