title: Reducing Wound Tension with Undermining or Imbrication-Do They Work?
abstract: BACKGROUND
  For the noncolonized wound, achieving tension-free, primary wound closure is ideal. Some surgeons advocate imbrication of deeper tissues rather than undermining, posing that imbrication preserves more dermal perfusion while still reducing tension at the wound edge. We sought to determine which technique most reliably reduced wound tension while preserving dermal wound perfusion.
  
  
  METHODS
  A total of 5 standardized, symmetrical pairs of full thickness wounds were created on Duroc swine. Wound tension was measured with a Tyrolean tensiometer before and after either method of closure, whereas a speckle contrast imager was used to assess dermal edge perfusion. Skin tension and dermal perfusion were evaluated for statistical significance via paired t tests and a multivariate analysis of variance.
  
  
  RESULTS
  There was a significant reduction in wound tension with undermining and imbrication relative to the raw wound tension (5 and 5.9 vs 7.1 N; P < 0.05) yet no significant difference between methods of closure (P > 0.05). There was a significant reduction in dermal perfusion between unwounded skin and the imbricated wound (222 perfusion units [PU] vs 48 PU; P < 0.05) and between the unwounded skin and the undermined wound (205 vs 63 PU; P < 0.05).
  
  
  CONCLUSIONS
  We found no significant difference in wound tension between wound undermining or imbrication and a significant decrease in dermal perfusion after imbrication and undermining although the relative decrease in perfusion was greater with imbrication. Wound undermining reduces skin tension with greater relative dermal perfusion to the skin and should be selected over wound imbrication in standard primary wound closure.
authors.affiliation: Departments of Plastic Surgery and Surgery, Medstar Georgetown University Hospital, Wash.; DAVinci Plastic Surgery, Wash.; and Department of Surgery, Medstar Washington Hospital Center and Firefighters' Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, D.C.
authors.forename: Naveen M
authors.initials: NM
authors.lastname: Krishnan
authors.affiliation: Departments of Plastic Surgery and Surgery, Medstar Georgetown University Hospital, Wash.; DAVinci Plastic Surgery, Wash.; and Department of Surgery, Medstar Washington Hospital Center and Firefighters' Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, D.C.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Brown
authors.affiliation: Departments of Plastic Surgery and Surgery, Medstar Georgetown University Hospital, Wash.; DAVinci Plastic Surgery, Wash.; and Department of Surgery, Medstar Washington Hospital Center and Firefighters' Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, D.C.
authors.forename: Steven P
authors.initials: SP
authors.lastname: Davison
authors.affiliation: Departments of Plastic Surgery and Surgery, Medstar Georgetown University Hospital, Wash.; DAVinci Plastic Surgery, Wash.; and Department of Surgery, Medstar Washington Hospital Center and Firefighters' Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, D.C.
authors.forename: Neil
authors.initials: N
authors.lastname: Mauskar
authors.affiliation: Departments of Plastic Surgery and Surgery, Medstar Georgetown University Hospital, Wash.; DAVinci Plastic Surgery, Wash.; and Department of Surgery, Medstar Washington Hospital Center and Firefighters' Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, D.C.
authors.forename: Matthew
authors.initials: M
authors.lastname: Mino
authors.affiliation: Departments of Plastic Surgery and Surgery, Medstar Georgetown University Hospital, Wash.; DAVinci Plastic Surgery, Wash.; and Department of Surgery, Medstar Washington Hospital Center and Firefighters' Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, D.C.
authors.forename: Marion H
authors.initials: MH
authors.lastname: Jordan
authors.affiliation: Departments of Plastic Surgery and Surgery, Medstar Georgetown University Hospital, Wash.; DAVinci Plastic Surgery, Wash.; and Department of Surgery, Medstar Washington Hospital Center and Firefighters' Burn and Surgical Research Laboratory, Medstar Health Research Institute, Washington, D.C.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Shupp