Repair of large and difficult-to-close wounds

Large defects may at first appear to be too big to close in a side-to-side fashion. Certain wounds and situations may call for healing with second intent. Undermining and pulley sutures are very helpful in bringing together wound edges of certain large openings. Partial closures may decrease the tendency to exert unwanted tension against a free margin, decrease the size of the wound allowed to heal with second intent, shorten the duration of healing, and keep scars within one cosmetic unit. Buried sutures should be placed and laid beside the wound without tying the knot until the surface stitches or the external device approximates the wound edges. In this way, one can be certain that the buried stitch will provide adequate support to the infrastructure of the wound. Intraoperative skin expansion may help close wounds that could not be closed by any other technique except for skin grafting.