๐ ็ธฝ็ฎ้ ๏ฝ ๐ ่ฑๆๅๆ๏ผๆฌ็ฏ๏ผ ๏ฝ ๐ ๅฎๆด็ฟป่ญฏ ๏ฝ โญ ็ฒพ่ฏ็ญ่จ
Tip Stitch Step-by-Step
Tip Stitch Step-by-Step
a. The flap is brought into place using buried sutures, allowing the tip to rest with
only minimal tension in its desired position. b. The needle is inserted into the distal edge of the distal nonflap section of skin at 90
degrees with a trajectory running toward the planned entry point in the tip. c. The needle is then grasped with the surgical pickups and simultaneously released
by the hand holding the needle driver. As the needle is freed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to place the next throw. d. The needle is inserted into the distal portion of the tip at the level of the superficial
dermis, which should be the same depth at which it exited in the prior step. Keeping the needle running horizontally, parallel with the skin surface, it is rotated through the dermis of the tip, exiting on the proximal side of the tip at the same depth. e. The needle is then reloaded in a backhand fashion and inserted into the dermis of
the proximal nontip section of skin, exiting, parallel to its initial entry point. f. The suture material is then gently pulled taught and tied utilizing an instrument tie.
Care should be taken to minimize tension on this suture to mitigate the risk of flap tip necrosis.
The tip stitch is very useful when bringing the tip of a flap into place, and is used frequently in this situation.30โ32 Importantly, this technique is designed to gently approximate the tissues so that the flap is properly inset in the surrounding skin. While it bears a technical resemblance to the half-buried horizontal mattress, it is important to appreciate that the tip stitch is not designed to work under significant tension, as tension across the suture may lead to necrosis of the delicate and lightly vascularized tip of the flap.
Flap tip necrosis is the greatest risk with this technique, since suture material traverses the dermis containing the tipโs vascular supply. This risk may be mitigated by tying the suture relatively loosely so that the tip is not overly constricted when the knot is tied. Additionally, if the bites of dermis are sufficiently set back from the wound edge, a small bite comprising less than half of the dermis in the tip could be taken. This would allow blood supply to the tip even in the context of a relatively tight loop running through the distal flap.
There is sometimes a tendency for the tip to sit deeper than the surrounding tissues. This may be related to the relative upward pull on the nontip sections of skin by the transepidermal sutures.
Finally, while flap tip necrosis is a risk, studies have suggested that the tip stitch provides less vascular constriction than other options, such as placing two vertically oriented sutures at the edges of the tip or a suture directly through the tip itself.31