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Hand

Hand Approaches -

As long as certain principles are observed, skin incisions can be made anywhere on the hand: 

  1. Sterile skin marker - Incisions should be outlined on the skin, especially if multiple incisions are needed. They may then be made without hesitation, thus saving time after the tourniquet is inflated.
  2. Curved Incisions - Rarely should an incision be made in a straight line. If gently curved, the scar is less noticeable and usually conforms better to natural lines. A curved incision can also later be extended with freer choice of direction. Exposure is usually better on the concave side of a semicircular incision; an S-shaped incision provides even more exposure.
  3. Deep Creases - Incisions within deep creases should be avoided. Here subcutaneous fat is thin, and moisture tends to accumulate, macerating the skin edges. 
  4. Do not cross a crease at or near a right angle, since the resulting scar, being in the line of tension created by motion, will hypertrophy. The plane of motion of a part is approximately perpendicular to the long axis of skin creases. Scars may limit motion, since a mature scar will not stretch like skin. Contractures in the hand create significant impairment to function.
  5. Excessive stretching - An incision should be long enough to expose the deep structures without excessive stretching of the skin edges; greater exposure is possible if the skin and subcutaneous fat are dissected from the underlying fascia. The tissue beneath the skin incision is usually converted into a mobile oval or elliptic opening. 
  6. Parallel incisions that are too close together or too long should be avoided, because healing may be slow or skin necrosis may even develop because of impairment of the blood supply. 
  7. Incision Position - The placement of an incision applies only to the skin; entries into deeper structures are made according to their anatomy and may be opposite in direction to those made in the skin. For example, while the skin incision over the radial surface of the wrist in de Quervain's disease may be transverse, the underlying incision in the stenosed sheath is longitudinal.
  8. Offset Incisions - Scars that adhere to the underlying structures, especially bone, should be avoided if possible. The offset incision is helpful: the first incision is carried through the skin and subcutaneous fat, and after a flap is undermined on one side, the deep approach is made through the fascia and muscle parallel with but offset from the skin incision.
  9. Shorter incisions may suffice on the dorsum of the hand because here the skin is more mobile. 


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