When contemplating wound closures on the lower extremities, clinicians should keep in mind that closures above the knee are fundamentally different from their below-the-knee counterparts. Thigh closures may be conceptualized as similar to closures on the upper arm—the dermis is moderate in thickness, and the area is under often-substantial tension. On the shins, however, closures are often significantly more challenging. The presence of impaired circulation and high tension mean that closures below the knee may be technically challenging to effect and are concomitantly fraught with an increased risk of infection and dehiscence when compared with closures elsewhere on the body.

An important principle when closing wounds below the knee is to anticipate the high risk of closure failure and therefore minimize the size of the defect. Thus, concerns regarding standing cone formation should be set aside when closing most shin defects. The high tension in these areas also means that as the repair heals over time the tension across the central portion of the wound may lead to blunting of the initial valley created by the closure, and therefore the appearance of the dog ears will eventually resolve.

As with other highly mobile areas, it is important to plan appropriately when developing an ideal axis of wound closure. Therefore, the leg should be examined preoperatively both flexed and extended, and individual closure approaches should be tailored to each patient so that a patient who spends most of the day seated at a computer or in a wheelchair may have their wound closed on a slightly different axis than a highly-active patient.