Ebook Requisites in dermatology - Dermatologic surgery: Part 2

(BQ) Part 2 book Requisites in dermatology - Dermatologic surgery presents the following contents: Basic excisional surgery, suture techniques, sture materials, flaps, skin grafts, nail surgery, mohs micrographic surgery, surgical complications,...

The simple excision is the foundation of

cuta-neous surgery Though seemingly complex to a

novice, it should be mastered by any

dermatolo-gist seeking to perform this relatively simple

pro-cedure in an office-based setting Knowledge of

surgical anatomy, tumor biology, local anesthetics,

instrumentation, and suturing techniques is

cru-cial prior to performing any cutaneous surgery

In addition, a thorough preoperative evaluation

is essential to help minimize postoperative

com-plications When performed properly and

meticu-lously, a fine cosmetically acceptable scar results

Application

The simple excision is designed to remove entire

lesions for histopathologic examination, as well as

surgical cure Whether it is a benign lesion that

is troublesome (e.g cyst, lipoma, or

dermato-fibroma) or cosmetically bothersome (e.g nevus

on the chin or cheek), or a lesion of uncertain

biologic behavior (e.g clinically atypical nevus on

the back), these lesions can be excised in an

ellip-tical fashion to achieve definitive histopathologic

diagnosis, as well as complete removal On the other hand, a surgical excision can be the definitive treatment of choice for selected malig-nant lesions that have been diagnosed on a prior biopsy However, in this case, margins for cure, as well as cosmetic and functional challenges regard-ing the final scar, must be taken into considera-tion, making the excision a bit more challenging For example, a well demarcated basal cell carci-noma on the extremity can usually be excised with a 4–5-mm margin of normal appearing skin around the circumference of the lesion A super-ficial spreading melanoma on the forearm with

a Breslow level of 0.43 mm, for example, can be excised with a 10-mm margin down to the fascia See Table 10-11 for general recommendations on margins of excision

Techniques

Orienting the ellipseWhether one is working on the head and neck region, or the trunk and extremities, a work-ing knowledge of anatomic danger zones (see Chapter 1) and surface anatomy, with regard to relaxed skin tension lines, contour lines, and cos-metic units is essential (Figs 10-11 & 10-2) Plan-ning your incision lines along relaxed skin tension lines, natural skin lines, cosmetic units, and bound-aries can increase the likelihood of a cosmetically acceptable scar, by providing optimal camouflage and allowing the wound to be closed under the least amount of tension

Relaxed skin tension lines are formed by the pull of the underlying muscles at the site of their insertion on the overlying skin In general, the skin creases form in a pattern that is perpendic-ular to the direction of the underlying muscle contraction Wounds oriented parallel to the skin creases or skin tension lines close under less ten-sion, and result in well camouflaged, thin scars Although Figures 10-1 and 10-2 show these lines

Basic excisional surgery

124 Dermatologic Surgery

in general, many variations exist Therefore, one

should consider each patient individually In

elderly patients, the lines are quite evident In

younger individuals, asking them to make an

ex-aggerated facial expression or pinching the skin

and identifying the natural skin lines will aid in

determining the axis of orientation If there is

question as to optimal suture line orientation,

the lesion should first be removed in a circular

fashion, and undermined This maneuver allows

the skin’s inherent elasticity to determine along

which axis it will form an oval The surgeon can

then extend the incision along this axis to form

an ellipse

Cosmetic subunit junction lines are formed at

the borders of fixed structures on the face, and

divide the face into cosmetic units that have

simi-lar skin color, texture, sebaceous gland quantity

and quality, and hair content (see Fig 10-22)

Exci-sions should be designed and contained within a

single cosmetic unit and resultant scars planned

so that they lie within cosmetic subunit junction

lines This best maintains the normal anatomy of

the face, in particular, as well as making the scar

less conspicuous than one that crosses multiple

cosmetic units Some surgeons even enlarge their

excisions so that the resultant scar will lie along

a subunit junction line, emphasizing the

impor-tance of these boundary lines over relaxed skin

tension lines

As a general rule, the length of the ellipse

should be three to four times the width, and the

tips drawn at an angle ranging from 30° to 75°

(Fig 10-33) This ensures that the wound edges

will come together without “dog ears” or

redun-dancies at the apices of the ellipse, and that the

scar will lay down flat against the skin If

pos-sible, the length of the ellipse should be drawn

along the length of the lesion, to minimize the

length of the scar However, there are times

when a longer, well placed scar, such as one that

is oriented within a contour line or along skin

tension lines, will result in a more cosmetically

acceptable scar than a shorter, more

conspicu-ous, one

Preparing for the excisionPlanning the excision should be done with the patient upright, to minimize apparent distortion

of the relaxed skin tension lines Marking of the planned excision should be done prior to infiltrat-ing the anesthetic This minimizes distortion of the skin tension lines and avoids obscuring the lesion margins

Prior to marking, the area should be cleansed with 70% isopropyl alcohol Any hair in and around the operative site that will interfere with the surgical procedure should be secured away from the operative field or clipped with scissors Preoperative shaving creates microabrasions in the skin and should be avoided due to increased risk of wound infection

Lines of planned excision may now be drawn using a skin marking pen, fine-tipped perma-nent marker, or a wooden applicator dipped in gentian violet The surgical site is then anesthe-tized, including a sufficient margin to allow for wide undermining (Fig 10-44) The area is then prepped with an appropriate surgical scrub (e.g povidone–iodine, chlorhexidine) (see Chapter 2: Antisepsis) Chlorhexidine should be used with caution around the eye, as it can cause corneal ulceration, and avoided completely around the ear if there is chance of a tympanic membrane perforation Povidone–iodine should be avoided

in patients with known allergy to iodine sal precautions should be employed at this point, including the use of sterile gloves, masks, and eye protection for surgical personnel The surgical field is then draped with sterile towels, or dispos-able sheets, and the excision carried out under aseptic conditions

Univer-Performing the excisionFor the majority of basic excisional surgery, a

no 15 scalpel blade attached to a Bard Parker dle, is appropriate (see Chapter 4: Surgical instru-ments) For small, delicate excisions, the scalpel should be held vertically like a pen For larger ex-cisions, it may be preferable to hold it horizontally, like a steak knife Prior to starting the incision, traction should be placed on the wound edges by the surgeon’s nondominant hand or by a surgical assistant Next, the skin is incised at a 90° angle, starting at the distal tip of the ellipse The incision should be carried out toward the surgeon, ideally with enough pressure to incise the skin up to the subcutaneous fat The angle of the scalpel is de-creased to about 45° when incising along the cur-vature of the ellipse, with the belly of the blade in contact with the skin This is the sharpest part of the blade (Fig 10-55) Again, the angle of the blade

han-is held at 90° when approaching the other apex

of the ellipse (Fig 10-��) The incision is repeated

Table 10-1 General rules for margins of excision

Nonmelanoma skin cancer

(not an indication for Mohs

126 Dermatologic Surgery

Lateral ridge

of noseInfraorbitalcreaseNasoalarcreaseMelolabialcreaseVermillionborderLabiomentalcrease

Figure 10-3 Dimensions of the ellipse

Figure 10-4 Anesthetizing a previously marked planned

excision

a

b Figure 10-5 With the nondominant hand providing tension

opposite the side of incision, the tip of the blade is used

to incise the apex of the ellipse (a) and the belly of the blade incises the curvature of the ellipse (b)

Figure 10-5 With the nondominant hand providing tension

opposite the side of incision, the tip of the blade is used

to incise the apex of the ellipse (a) and the belly of the

blade incises the curvature of the ellipse (b)

Figure 10-6 The angle of the blade during incision

Figure 10-7 Avoid “fishtail” or “cross-hatching”

at the other side of the ellipse Care should be taken to avoid “cross-hatching” or “fishtails” at the apices of the ellipse (Fig 10-77) Try to avoid multiple shallow incisions, in order to minimize

“stair-casing” of the wound margins (Fig 10-��)

Variations of the ellipse

Crescentic excision

Sometimes also referred to as the “pregnant belly,” the crescentic excision takes advan-tage of sides of unequal length, and results in a curvilinear scar As the arc of the crescent de-termines the resultant scar, the ellipse could be oriented along curved skin tension lines or cos-metic subunit junction lines The wound should

be closed using the rule of halves, thereby mizing any resulting Burrow’s triangles from the unequal sides Areas of potential use include the cheek (along the malar eminence) and the chin, for example (Fig 10-99)

mini-S-plasty excision

Also called “lazy S,” the S-plasty excision is ful when performing an excision along a convex surface, for example the forearm, shin, or jaw This minimizes the contraction and buckling seen along the length of the scar Similarly, clos-ing the wound with the rule of halves is helpful (Fig 10-10)

Correct

Figure 10-8 “Staircasing”

128 Dermatologic Surgery

Specimen removal and undermining

Once you have incised through the full thickness of

the skin, the lesion is transected at its base, sharply,

with the blade, or bluntly with dissecting scissors,

at the level of the subcutaneous fat (Fig 10-12 &

Table 10-22) To aid removal of the specimen, a skin

hook or toothed forceps is used to pick up the

dis-tal apex of the ellipse, and the base is transected as

described Try to remove the specimen with

uni-form thickness and avoid beveling the wound edges

when making your incision, to minimize

“scoop-ing” or “boat“scoop-ing” of the specimen and wound edges,

as this will ultimately affect the proper apposition

of the wound edges (Fig 10-13)

Undermining serves a number of purposes that

result in a more cosmetically pleasing scar:

• It reduces the tension on the wound edges

• It creates a horizontal scar band that parallels

the skin surface

• It restores the contour of the skin surrounding

the excision

Figure 10-9 Crescentic excision

Figure 10-10 S-plasty excision

1

2

a

b Figure 10-11 M plasty excision (a) Design of the M plasty

and end result; (b) M plasty excision illustrating tip stitch

10

Basic excisional surgery

Undermining is performed by blunt dissection of

the surrounding wound edge, around the entire

border of the excision, including the apices of the

ellipse The level for undermining is dictated by the

anatomic location of the wound (see Table 10-22)

This may be done using a blunt-tipped dissecting

scissors (see Chapter 4: Surgical instruments),

or sharply with caution using the blade Using the scissors, the closed to open technique is used (Fig 10-14) To minimize damage to the wound edge, a skin hook is used to visualize the field and expose the level of undermining The scissors is

Figure 10-12 Sharp or blunt transection of the base of the specimen

Figure 10-13 Avoid “boating” or “scooping” the specimen

Figure 10-14 Blunt undermining of the wound edges using the closed–open technique Note the use of a skin hook to

minimize trauma to the skin edge

130 Dermatologic Surgery

c

Figure 10-15 (a) Direct touch to smaller vessels; (b) isolation of larger vessels with tissue forceps; (c) transmission of

energy by touching the electrode tip to the tissue forceps.

inserted with its tips closed, and then opened to

separate fibrous attachments aside, as well as

cut-ting the intervening fibers

The extent of undermining depends on the

lax-ity of the surrounding skin In general, the width of

undermining is the distance equal to, or up to

dou-ble the length of, the short axis of the ellipse For

example, excision of a lesion with a diameter of

1 cm would necessitate undermining 1–2 cm ally Ultimately, undermining is done to the extent that is necessary to facilitate placement of subcuta-neous/intradermal sutures with minimal tension.Obtaining hemostasis

later-Complete hemostasis should be achieved to imize the risk of hematoma formation after sur-gery One should be very meticulous, taking into consideration the effects of epinephrine during the procedure and its expected vasodilatation postoperatively This can be achieved using elec-trodessication and electrocoagulation techniques.For small bleeding vessels, a direct touch to the vessels using the handheld electrode is sufficient When larger vessels are transected, use of a tissue forceps to elevate and isolate the vessel is help-ful The electrode is then touched to the distal aspect of the forceps, which transmits the energy

min-Table 10-2 Planes of undermining

Trunk and extremities Mid to deep subcutaneous fat

above muscular fasciaHands and feet Immediately subdermal

10

Basic excisional surgery

Figure 10-16 “Figure of 8” technique of suture ligation

well approximated and everted wound edge with minimal tension, thereby resulting in a cosmeti-cally elegant scar The nature of the surrounding skin, and the size and depth of the wound, will determine which suture material and closure technique is appropriate (see Chapter 12: Suture materials)

In general, excision of full-thickness lesions necessitates a layered closure, which consists of a buried inverted layer of absorbable intradermal/subcutaneous sutures and a percutaneous layer

of suture, tissue adhesive or adhesive tapes (Fig 10-17) The intradermal/subcutaneous su-tures provide the support following removal of the percutaneous sutures, when the wound has only achieved 5% of its final tensile strength A layered closure (see Chapter 11: Suture tech-niques) achieves the following:

• Allows elimination of any potential dead space, thereby minimizing the risk of hematoma or seroma formation, which can serve as a nidus for infection

eversion

• Reduces the tension along the wound edges, thereby resulting in a well healed scar

Dog ear repairBurrow’s triangles, standing cone deformity, and

“dog ears” – all refer to redundant skin that is formed from wounds with apical angles greater than 30°, or those with unequal lengths at the time of closure In general, this tissue redundancy

is located at the apices of the ellipse, but may occur along the length of the longer wound edge.The repair is performed by pulling the redundant tissue perpendicular to the direction

of closure, incising one half of the tissue until another apex is reached This incised flap is draped over the incision, and the other half of

to the isolated vessel (Fig 10-15) This minimizes

extensive tissue destruction in the surrounding

area, as well as optimizing the ability of the

elec-trode to coagulate in a drier wound bed

Be meticulous but do not be overzealous in

coagulating the bleeding, especially that seen

along the epidermal/dermal wound edge (resulting

from visible telangiectasias), as this may increase

the risk infection and prolonged healing, and

adversely affect the resultant appearance of the

scar Even larger bleeding vessels, especially

vis-ible arteries, are more reliably treated with suture

ligation, using the figure-of-eight technique

(Fig 10-1�) Using an absorbable suture, such as

chromic, the vessel is visualized and isolated with

a fine-tipped hemostat, and the suture is passed

in and across the vessel in a diagonal and out,

and again, from the opposite side, in and across

the vessel in a diagonal and out, and tied off as the

hemostat is removed This effectively clamps the

actively bleeding vessel

Closing the surgical wound

Once meticulous hemostasis is achieved, and wide

undermining is performed, the wound is ready

for closure The goal of closure is to produce a

Figure 10-17 Layered closure of the excision

the redundant tissue excised Undermining this

newly formed apex will minimize pseudo-dog

ear formation The wound is then closed

accord-ingly (Fig 10-1�) Dog ear deformity may also be

repaired using the M-plasty technique described

above (see Fig 10-11)

Postoperative course and care

Patients should receive written and verbal

post-operative instructions relating to the excisional

surgery just performed When the patients are

properly educated about postoperative

expec-tations, instructions for care and potential

com-plications, their anxieties are tempered and

the risks for complications are minimized

Al-though considered a relatively minor procedure,

patients should be prepared to experience some

limitations in their daily activities, at least for

the first 24–4� h This is especially stressed with

regard to strenuous activities, including heavy

lifting and vigorous exercise Further

restric-tions on physical activity are individually tailored

according to the patient’s age, preoperative level

of activity, and extent, location, and depth of the

wound

Certain situations warrant special attention

dur-ing the postoperative period Surgery performed

on dependent areas, such as the hand, wrist, or leg,

are more likely to result in edema Surgery around

thin lax skin, for example the periorbit, is also more prone to edema As such, elevation of the limb or head is often recommended Excisions around and over joints often require special immobilization

to give the wound the time to strengthen, and to minimize the risk of wound dehiscence

Patient education is the key to avoiding operative complications (see Chapter 17: Surgical complications) The patient should understand that some edema, ecchymosis, erythema, and ten-derness is normal and should be expected These expected sequelae of surgery may be alarming if the patient has not been forewarned Patients who are anticoagulated should be cautioned regarding the difference between exaggerated bruising ver-sus an expanding hematoma All patients should

post-be provided with a 24-h contact telephone number and instructed to contact their surgeon with any concerns All information should be explained verbally to the patient and any family member who may be accompanying them These same instructions should be provided in written form for ready reference at home

Wound careMost excisions require a simple pressure dressing that should remain intact for 24 h Basically, this

is prepared as follows: a thin layer of ointment (petrolatum ointment, Aquaphor®, or antibiotic

134 Dermatologic Surgery

Figure 10-19 Postoperative dressing

ointment), a nonadherent gauze (such as Telfa®,

cut to fit the dimensions of the suture line), an

ab-sorbent layer of gauze, and secured with an outer

layer of surgical tape (e.g Mefix®, Micropore™)

Oftentimes a liquid adhesive (tincture of benzoin

or Mastisol®) is used to secure the surgical tape in

place (Fig 10-19)

Patients are instructed to remove the

pres-sure dressing in 24–4� h The wound surface is

cleansed with soap and water Hydrogen

perox-ide may be used sparingly to remove any dried

blood or crust Occlusive ointment is reapplied,

and, depending on location and level of activity,

a light dressing or strip bandage may be required

This wound care is repeated two to three times

daily until the sutures are removed

Suture removal

The timing of removal of the

percutane-ous sutures is of utmost importance Sutures

should be left long enough to permit complete

epithelialization across the wound margins, but

early enough to avoid suture tracking Obviously,

there is individual variability in wound healing

For example, sutures may be removed a little

earlier for young, healthy, nonsmoking

individu-als, compared to older, smoking, diabetic patients,

because of problem with delayed wound healing

Occasionally, wound closure tapes are used to

provide further support to the wound edges after the percutaneous sutures have been removed These typically stay on for about 5–7 days Pa-tients are instructed to leave these alone, and allow them to fall out on their own Table 10-33 outlines general recommendations on suture removal

Complications

Although relatively infrequent, patients need to

be informed about the potential complications of skin surgery at the time of informed consent, and

be educated about how these may be manifested immediately after surgery When they do occur, the surgeon should be able to recognize and manage them appropriately The four most frequently

Table 10-3 Suture removal recommendations

• Handle the skin with great care This will be

evident in the final scar that results To minimize

trauma to the wound edges, use of a skin

hook is quite helpful If not, with the toothed

forceps, grasp the relatively acellular dermis or

fascia, rather than the epidermis, which may

leave permanent scars (Fig 10-20) When the middle finger is placed between the tongs of the forceps about half way down, the forceps are held open and one side can be used in place of

• As much as possible, try to use your instruments to help you perform the procedure

in an efficient manner When performing a running percutaneous suture, try to minimize

Figure 10-20 Grasp the dermis, rather than the epidermis, to minimize trauma to the surface that might potentially leave

a permanent scar

Figure 10-21 Securing square knots

Figure 10-22 Use instruments to aid closure of the wound in an efficient manner (a) Secure the exit point on the skin with

a skin hook (b) Grasp the needle while maintaining tension on the needle’s exit point (c) Grab the needle at the body, ready to place the next bite (d) Pick up the suture and provide sufficient tension to help placement of the next bites

10

Basic excisional surgery

your movements by using your forceps to

stabilize your exit point, and push the needle

through with your needle-holder This movement

will allow you to grasp and lock the needle at

the intended body of the needle, ready to take

the next bite You or your assistant can also hold

onto the suture, providing just enough tension

along the already sutured wound edge; this

provides tension along the wound edge

that you are about to place the needle in

(Fig 10-22)

• Management of cysts: For noninflamed cysts,

mark the margin of the cyst, but perform a

punch biopsy or elliptical excision within the

margins, carefully dissect around the well

demarcated cyst, and perform a layered closure

This minimizes the resulting scar

• Management of lipomas: Similarly, carefully

palpate the lesion to assess the depth and size

of the lipoma, and mark the presumed size

Plan for an incision well within the margins of

the lesion, or a punch biopsy A lipoma can be

delivered through a very small opening when

pressure is placed on both sides Carefully

dissect the lesion out When involving the

forehead, attempt to dissect the frontalis muscle

bundles in a vertical orientation, and repair the

muscle and fascial planes if necessary

A layered closure will minimize the risk of

seroma or hematoma formation

• Closure on atrophic skin: use of the strip suture technique: The use of Steri-Strips™ along the wound edges, or perpendicular to

the incision, will aid the application of percutaneous sutures along the wound edges that would have otherwise pulled through (Fig 10-23)

Further reading

Bennett RG Fundamentals of Cutaneous Surgery

St Louis: CV Mosby, 19��:353–444

Dunlavey E, Leshin B The simple excision In:

McGillis ST, ed Dermatologic Clinics, Excision and Repair Philadelphia: WB Saunders, 199�:

49–�4

Leshin B Proper planning and execution of surgical excisions In: Wheeland R, ed Cutaneous Surgery Philadelphia: WB Saunders, 1994:171–177

Jackson IT Local Flaps in Head and Neck Reconstruction St Louis: CV Mosby, 19�5

Olbricht S Biopsy techniques and basic excisions In: Bolognia J, Jorizzo J, Rapini R, eds Dermatology London: Mosby, 2003:22�9–22��

Paolo B, Stefania R, Massimiliano C, et al Modified S-plasty: an alternative to the elliptical excision

to reduce the length of suture Dermatol Surg 2003;29:394–39�

Perry AW, McShane RH Fine tuning of the skin edges in the closure of surgical wounds J Dermatol Surg Oncol 19�1;7:471–47�

Robinson JK, Hanke CW, Sengelmann RD, Siegel

DM, eds Surgery of the Skin: Procedural Dermatology Philadelphia: Elsevier Mosby, 2005.Sadick N, D’Amelio DL, Weinstein C The modified buried vertical mattress suture J Dermatol Surg Oncol 1994;20:735–739

Salasche SJ, Bernstein G, Senkarik M Surgical Anatomy of the Skin Norwalk: Appleton & Lange, 19��:13–35

Zalla MJ, Padilla RS Excision In: Roenigk RK, Ratz

JL, Roenigk HH, eds Roenigk’s Dermatologic Surgery: Current Techniques in Procedural Dermatology, 3rd edn New York: Informa Healthcare, 2007:131–139

Zitelli JA Tips for a better ellipse J Am Acad Dermatol 1990;22:101–103

Figure 10-23 Closure using strip suture method for thin

atrophic skin

Loading the needle

Correct placement of the needle is important in

gaining appropriate angle of entry into the tissue

and avoiding a bent needle Grasp the needle with

the needle holder in the mid to distal portion of

the needle, approximately one half to three

quar-ters of the distance from the tip of the needle

(Fig 11-11)

Grasping the needle holder

There is more than one proper way to hold the

needle holder Some surgeons prefer to hold it in

the palm of the hand without placing fingers in

the loops This method offers maximum

dexte-rity Alternatively, the needle holder is grasped by

placing the thumb and the fourth finger in the

loops and placing the index finger at the fulcrum

This method offers maximum stability

Tissue stabilization

Tissue stabilization aids in proper suture

place-ment Depending on the setting, tissue may be

stabilized using the hands, forceps, or skin hooks

Tissue should always be handled delicately to

avoid excessive trauma

General guidelines for suture placement

Typically, the needle should penetrate the skin at

a 90° or greater angle This helps facilitate wound eversion and minimizes trauma to tissue Simi-larly, the needle should exit perpendicular to the skin surface It may be helpful to use forceps to grasp the needle as it exits the tissue This can help stabilize the needle and minimize the chance of loosing the needle in the soft tissue Needle safety

is paramount when suturing The following steps are important in preventing needle sticks:

1 Always use the needle holder or forceps initially to grasp and stabilize the needle

2 When handling the base of needle with your thumb and index finger, always apply the forceps or needle holder between your fingers and the needle tip

Suture techniques

Brittany Wilson, Andrea Willey,

and Ken K Lee

11 Chapter

Swag

BodyPoint

3 Use your third, fourth, and fifth fingers

to shorten any extra slack in the suture

One technique is to “figure 8” the

slack between the third and fifth fingers

(Fig 11-22)

Instrument tie

The square knot is the basic surgical knot and is

the primary knot used in cutaneous surgery

Tying a square knot ( Fig 11-�� )

1 Place the suture using the desired technique

and leave approximately 4–5 cm of suture

on the short (cut) end Grasp the base of the

needle between the index finger and thumb of

your nondominant hand (as described above)

2 Bring the needle holder across the wound

and loop the suture twice around the tip of

of the wound (the second knot will tighten the tie)

5 Bring the needle holder across the wound again and make a single loop (in the opposite direction of the first knot) with the long (needle) end of the suture

6 Open the needle holder and grasp the short (cut) end of the suture

7 Gently pull the loops off the needle holder, reverse your hands and tighten

8 Repeat steps 5–7 again The important point

is to reverse the direction of the loop and the direction in which the needle holder is pulled across the wound

Simple interrupted suture

The simple interrupted suture (Box 11-1) is the fundamental suture in cutaneous surgery:

• Place the suture by entering with the needle

at least perpendicular to the skin surface (Fig 11-44)

• To obtain wound eversion, the suture should

be placed in a flask shape with the wide end inferiorly (Fig 11-55) Sutures that do not follow the flask shape can lead to an inverted suture line

• Wounds of uneven height can be closed by placing the suture deep on the low side and shallow on the high side (Fig 11-66)

• Larger wounds or thicker skin may require larger bites, perhaps necessitating reloading of the needle from the center of the wound.Box 11-2 lists the disadvantages of simple inter-rupted sutures

Vertical mattress suture

A properly placed vertical mattress suture can evert skin edges better than any other suturing tech-nique Additionally, vertical mattress sutures pro-vide eversion with less tension than other suturing techniques The vertical mattress is a strong suture that can provide support to a wound under stress.Placing the vertical mattress suture ( Fig 11-�� )

1 Place the deep suture first by entering the epidermis approximately 5 mm from the wound edge and exiting from a similar distance on the opposite skin edge with the needle coursing deeper in the wound

a

b

Figure 11-2 (a, b) Suture technique

11

Suture techniques

2 Place the second, shallower, bite by entering

and exiting in the opposite direction from

the first pass, approximately 1–3 mm from

the wound edge

3 The distance of the sutures from the wound

edge will vary depending on tension on the

wound and the amount of dead space to be

Figure 11-4 Simple interrupted suture

Figure 11-5 Simple interrupted suture

B ox 1 1 - 1

Simple interrupted sutures

These are useful for:

• Closing small low-tension wounds, including punch biopsy

sites

• Top suture for layered repairs

• Correcting wound edges of unequal heights (“step off”)

Figure 11-6 Simple interrupted suture for wounds of

uneven height

B ox 1 1 - 2

Disadvantages of simple interrupted sutures

• Potential for “railroad track” scarring

• Inadvertent inversion of the wound edges

• Uneven tension on the wound

• More time consuming than other methods

Figure 11-7 Vertical mattress

leaving track marks on the subcuticular side of

the wound It is valuable when closing wounds

near hair-bearing skin where one side of the

clo-sure can be hidden It does not provide as much

tension as the classic vertical mattress suture

Near–far adaptation of the vertical

mattress suture

The near–far adaptation of the vertical mattress

suture is employed by beginning the suture near

the wound with a small epicuticular bite, then

re-entering deep and exiting far from the wound

Next, the direction of the needle is reversed, and a

near epicuticular bite is taken, followed by a deep

bite that exits far from the wound (Fig 11-99) This suture is useful in elevating the deep tissue

in which it is placed, for example when closing the orbicularis oris muscle in a lip wedge

Pulley suture

The pulley suture can be very helpful when closing wounds under tension The critical feature of the pulley suture is multiple passes through the tissue, creating significant resistance and making the suture unlikely to slip Although variations exist, the suture

is typically initiated by entering the epidermis tant to the defect, traveling across the defect and exiting nearby The needle is then redirected to en-ter the epidermis near the wound, traveling across the defect and finally exiting far from the wound (Fig 11-10) The suture may be left in place after wound closure, or used to decrease tension while placing additional sutures and then removed

dis-Horizontal mattress sutures

The horizontal mattress suture is an able “stay” suture, and can be helpful to achieve hemostasis Used by itself, it reduces wound tension, everts wound edges, and closes dead space

invalu-It is also often used in conjunction with a second, more superficial, interrupted suture placed closer

to the wound edges Some surgeons remove this suture once suturing is complete Others wait days to weeks to remove the suture If the latter is the case, consider placing a bolster to prevent the suture from cutting into the skin and leaving “rail-road track” scarring Owing to the risk of decreased wound edge perfusion, this suture is generally not used on poorly vascularized wounds or flaps.Placing the horizontal mattress suture ( Fig 11-11 )

1 Place the initial suture in same fashion as the simple interrupted suture

2 Without tying, travel approximately 2 mm parallel to the wound edge and place a second suture entering on the same side and traveling to the opposite side Gently tie the knot lateral to the wound edge, with care not

to strangulate the tissue

Advantages and disadvantages of horizontal tress sutures are shown in Boxes 11-55 & 11-6.Canal suture

mat-The canal suture is a horizontal mattress suture placed in the reverse direction (Fig 11-12) It can be used intentionally to invert the wound edge into which it is placed, and everts the deep edge of the wound For example, this suture can

be placed on the outside (cutaneous side) of a

B ox 1 1 - 3

Advantages of vertical mattress sutures

• Excellent wound eversion

• Decreased wound tension

• Provide added support to defects under stress

• Useful for closing dead space

B ox 1 1 - 4

Disadvantages of vertical mattress sutures

• Potential for railroad tracking

• More time consuming than some other methods

• Tissue strangulation may occur if tied too tight

Figure 11-8 Half-buried vertical mattress

11

Suture techniques

wound to evert the underlying mucosal surface of

full-thickness mucosal defects

Three-point corner (tip) suture

This important variation on the horizontal

mat-tress suture can be employed when closing acute

tissue angles This suture involves passing the

needle subcuticularly through the “tip” to be

closed (Fig 11-13) An overly tight or improperly placed corner suture can lead to tissue necrosis.Four-point corner (tip) suture

Another variation on the horizontal mattress ture can be employed when closing two acute tis-sue angles This suture involves passing the needle subcuticularly through the two “tips” to be closed

su-Figure 11-9 Near–far adaptation of vertical mattress suture

Figure 11-10 Pulley stitch

(Fig 11-14) Again, an overly tight or improperly

placed corner suture can lead to tissue necrosis

Running sutures

Simple running cuticular sutures

The running superficial suture is a fast, efficient

way to close wound edges under little or no

tension Appropriate sites for this suture include

eyelids, neck, scrotum, and any tissue under little

tension where dead space has been closed

pre-viously When beginning a running subcuticular

suture, it is important to place one end

perpen-dicular to the suture line To anchor the loose

ends of the suture, tie them back on themselves

(Fig 11-15)

Boxes 11-77 & 11-8 show the advantages and

disadvantages of running subcuticular sutures

Running locked suture

A running locked suture is useful for achieving hemostasis in wounds with a high potential for bleeding However, if placed too tightly, tissue necrosis may occur To place a running locked suture, pass the needle through the loop created

by each previous stitch (Fig 11-16)

Running horizontal mattress sutureThe running horizontal mattress suture is a time-efficient suture that provides good wound eversion The technique is similar to the stand-ard horizontal mattress suture described above, except that it is run continuously until the end

of the incision (Fig 11-17)

Combination running simple and vertical mattress sutureThe use of alternating vertical mattress sutures with simple running sutures also produces good wound eversion in a time efficient manner Simple cutaneous sutures are followed by vertical matt-ress sutures in an alternating pattern (Fig 11-18)

Buried sutures

Interrupted buried suturesBuried sutures are typically used to reduce ten-sion and evert the wound edges They can be placed to reapproximate deep structures (muscle and fascia), the dermis, or both

Placing the interrupted buried suture ( Fig 11-19 )

1 Enter deep and exit on the same side of the wound superficially, typically at the level of the mid dermis

2 Continuing in the same direction, enter the opposing side of the wound edge and travel

to the deep aspect, opposite the initial entry point This results in the knot being buried in the deep aspect of the wound and minimizes its extrusion

Figure 11-11 Horizontal mattress

B ox 1 1 - 5

Advantages of the horizontal

mattress suture

• Hemostasis

• Helpful as a “stay” or anchor suture

• Decreases and redistributes tension

• Eversion of wound edges

• Closes dead space

B ox 1 1 - 6

Disadvantages of the horizontal

mattress suture

• “Railroad track” scarring

• Overly tight horizontal mattress sutures can result in tissue

hypoxia and poor wound healing

• Time consuming when compared to other methods

11

Suture techniques

Advantages and pitfalls on buried sutures are

shown in Boxes 11-99 & 11-10

Buried vertical mattress suture

This is a modification of the simple buried suture

that further optimizes wound eversion To

initi-ate the suture, place a deep suture by entering

the undersurface of the dermis and traveling with

the needle in a superficial direction almost to the

level of the epidermis Then travel back down to

exit at the level of the mid dermis On the

oppos-ing side of the wound, again enter at mid dermis,

travel superficially, then dive down and exit deep

The path of the suture creates a heart shape when

complete (Fig 11-20)

Modified buried vertical

mattress suture

The buried vertical mattress suture can be

modi-fied to produce similar wound eversion in areas

too small to perform a standard buried mattress

suture, such as a small punch biopsy defect or

flap repair The modified version is performed

by entering the wound edge deep and exiting through the epidermis lateral to the wound The needle is then redirected to enter back through the same hole and to exit within the mid dermis The suture is repeated on the opposite side by entering the contralateral mid dermis and exiting through the epidermis Again the needle re-enters the same hole, but exits deep (Fig 11-21) The modified heart-shaped suture path yields superior eversion Care must be taken to ensure that the suture is placed sufficiently in the mid dermis to prevent “pull through.”

Running subcuticular sutureWhen used properly, the running subcuticular suture can yield superior cosmetic results because

it leaves no suture exit and entrance marks along the edge of the suture line (Fig 11-22) This suture should be used only when the wound is well approximated, the edges are everted, and wound tension is minimal If a deep space is present, it should be closed with a separate buried suture

If using a nonabsorbable suture that will need

Figure 11-12 Canal stitch

Figure 11-13 Three-point corner (tip) stitch

Figure 11-14 Four-point corner (tip) stitch

• Does not close dead space

• Can leave “track lines”

B ox 1 1 - 7

Advantages of the running

subcuticular suture

• Efficient use of time

• Applies equal tension to wound edges

• Can allow for excellent wound eversion

to be removed, the suture should have an exit point every 2–3 cm for ease of removal When using absorbable suture material, the technique

is modified

1 The running subcuticular is initiated with a simple dermal interrupted suture Cut only the short end after tying the knot

2 After completing the running subcuticular, the suture end is tied off with another dermal interrupted suture Cut only the short end

3 The needle end is then passed through the end of the incision and exited distal to the incision The needle is pulled with tension This pulls the knot deeper into the wound The suture is then cut at the skin surface

be used to decrease the defect size and optimize secondary intention Multiple bites are oriented horizontally around the wound edge and pulled taught (Fig 11-23)

Suture removal

Proper suture removal technique is often appreciated The suture should be cut and the freed knot should be pulled across the suture line This allows the suture to be pulled out in the di-rection in which it was placed and avoids placing tension opposite the axis of closure Improper suture removal can place tension on the suture line and put the wound at risk of dehiscence

under-Figure 11-16 Running locked stitch

Figure 11-18 Running combination simple and vertical mattress

Advantages of the buried suture

• Closes dead space

• Provides wound stability and reduces tension

• Helps to evert wound edges

B ox 1 1 - 1 0

Pitfalls of the buried suture

• A suture that is pulled too tightly can result in tissue necrosis

• A buried suture placed only in the fat can pull through If

possible, try to include a portion of the dermis or fascia

with the suture

• If placed too superficially, a subcutaneous suture can pucker

the wound and may extrude or “spit” through the final wound

Figure 11-20 Buried vertical mattress

Figure 11-21 Modified buried vertical mattress

Figure 11-22 Running subcuticular stitch

Figure 11-23 Purse-string suture

Further reading

Adams B, Anwar J, Wrone DA, Alam M Techniques for

cutaneous sutured closures: variants and indications

Semin Cutan Med Surg 2003;22(4):306–316

Adams B, Levy R, Rademaker AE, Goldberg LH,

Alam M Frequency of use of suturing and repair

techniques preferred by dermatologic surgeons

Dermatol Surg 2006;32(5):682–689

Alam M, Goldberg LH Utility of fully buried

horizontal mattress sutures J Am Acad Dermatol

2004;50(1):73–76

Collins SC, Whalen JD Surgical pearl: percutaneous

buried vertical mattress for the closure of narrow

wounds J Am Acad Dermatol 1999;41(6):

1025–1026

Harrington AC, Montemarano A, Welch M, Farley M

Variations of the pursestring suture in skin cancer

reconstruction Dermatol Surg 1999;25(4):

277–281

Krunic Al, Weitzul S, Taylor RS Running combined

simple and vertical mattress suture: a rapid

skin-everting stitch Dermatol Surg 2005;31:

1325–1329

Moody BR, McCarthy JE, Linder J, Hruza GJ hanced cosmetic outcome with running horizontal mattress sutures Dermatol Surg 2005;31:1313–1316

En-Odland PB, Murakami CS Simple suturing niques and knot tying In: Wheeland RG, ed Cutaneous Surgery Philadelphia: WB Saunders, 1994:178–188

tech-Olbricht S Biopsy techniques and basic excisions In: Bolognia J, Jorizzo J, Rapini R, et al, eds Derma-tology Philadelphia: Mosby, 2003:2269–2286.Starr J Surgical pearl: the vertical mattress tip stitch

J Am Acad Dermatol 2001;44(3):523–524.Stasko T Advanced suturing techniques and layered closures In: Wheeland RG, ed Cutaneous Surgery Philadelphia: WB Saunders, 1994:304–317.Swanson NA Atlas of Cutaneous Surgery Boston: Little, Brown, 1987

Vistnes L Basic principles of cutaneous surgery In: Epstein E, Epstein E Jr, eds Skin Surgery, 6th edn Philadelphia: WB Saunders, 1987:44–55

Zelac D, Swanson N, Simpson M, Greenway H The history of dermatologic surgical reconstruction Dermatol Surg 2000;26(11):983–990

Clinical overview

The needle and suture are the foundation of

wound closure This chapter discusses the

prin-ciples of the needle and suture and how to

em-ploy their strengths and weaknesses effectively in

• Curved needles with triangular tips are

typically used in dermatology

• The 3/8 circle is used most commonly

• The 1/2 circle is commonly used for small flaps

• Other sizes include 1/4 and 5/8 circles

• The surgical needle is composed of three

parts (Fig 12-1):

1 Shank – where the needle attaches, the

weakest part

2 Body – middle part (strongest part), where

the needle should be held with the needle

driver

3 Point – sharp end extending to the largest

cross-section of the body; do not handle

the needle in this area

P E A R L

For finer needles, use needle holders with smaller,

smoother jaws

Types of needle ( Fig 12-2 )

1 Triangular – conventional cutting:

• Cutting edge on the inside of the arc

• Puncture faces the wound incision

• Sutures may tear through tissue when tied

2 Triangular – reverse cutting:

• Cutting edge on the outside of the arc

incision

• Less tearing of tissue than conventional needle

3 Rounded:

• Useful with fascia and delicate areas

P E A R L Triangular needles are typically preferred over round needles because they are easier to pass through tissue

Needle nomenclature

• There are several major suture brands, each using different nomenclature (Fig 12-3)

• Ethicon produces 80% of the surgical needles

in North America (Table 12-1)

P E A R L S Use smaller needles for areas of high cosmetic importance

Use larger needles to close large wounds.Suture properties

• The properties of a specific type of suture determine how it is used (Table 12-2)

• Each property influences the other properties

P E A R L There is an increased rate of suture absorption on mucosal surfaces and areas

of infection

Suture materials

Key Points

• All sutures are absorbed to some degree if left in long enough (except stainless steel)

• Sutures are defined as absorbable or nonabsorbable according to whether the suture loses its tensile strength by 60 days (Tables 12-3

& 12-4)

• The rate of absorption is dependent on the suture type, the location, and the presence of infection

Surgical approach

Key Points

• Choose the smallest suture that can provide adequate strength for the closure but still minimize tissue trauma

• For subcutaneous suturing in areas of high tension, use sutures with longer absorption rates

• Use sutures with minimal tissue reactivity in areas

of high cosmetic importance

For recommendations on which suture material and needle to use in different locations see Table 12-5

Comparative outcomes

Key Points

• While suturing is typically the preferred method

of wound closure, staples, tissue adhesives, and skin closure tapes can be good alternatives (Table 12-6)

Controversies

Key Points

• Data on the risk of infection with braided sutures has historically been controversial

• It has been theorized that the braids in braided sutures harbor microorganisms, thus increasing the risk of infection

• However, a study published in 2001 by Gabrielli et al showed that age, sex, wound site and length, and surgeon experience were more important in predicting complications than the choice of suture materials and suturing techniques

Material Synthetic vs natural

Configuration Monofilament: single strand, low coefficient of friction allows it to slide easily, good for exterior suturing

Multifilament: braided/twisted, increased strength, easier handling but higher coefficient of friction, good for subcutaneous suturing

Capillarity The ability to absorb and transfer fluid; it is controversial whether increased capillarity allows the suture to

harbor organismsTensile strength Determined by the force in pounds to snap the suture; synthetic sutures are generally stronger than natural

sutures; the greater the diameter the stronger the sutureSize Size ranks tensile strength - the thicker the suture, the greater the strength and the fewer the zeroes (3-0 is

wider and stronger than 4-0 for the same type of suture) dependent on the type of the sutureElasticity The ability to return to the original size after being stretched; good elasticity allows for stretch with tissue

swelling, but also will recoil to maintain tissue approximation when the swelling resolves; use sutures with good elasticity for exterior suturing

Plasticity The ability to maintain a new shape after it has been manipulated; allows for a more secure knot; good

plasticity accommodates tissue swelling without cutting tissue but does not hold tissue approximation well when the swelling resolves

Memory A measure of a suture’s elasticity and plasticity; sutures with increased memory have a greater tendency

to return to their original configuration after being manipulated and are more difficult to handle; increased memory causes suture knots to untie themselves, requiring extra knots

Coefficient of friction Determines how easily a suture will pull through tissue; the lower the coefficient, the easier it is for the

suture to slide through tissue, but it will also unravel more easily; sutures with a low coefficient are useful for running subcuticular suturing

Pliability A measure of how well a suture bends; good pliability allows ease in knot tying and increased knot strengthCoating Sutures may be coated with various materials to lower the coefficient of friction or to increase the

antimicrobial propertiesTissue reactivity A measure of how much the suture will illicit a foreign body reaction; sutures with increased tissue reactivity

are natural, multifilament, absorbable, and large

in skin;

unpredictable absorption ratesSurgical gut

(fast-absorbing)

Multifilament,

twisted

Low, lost in 3–7 days

surface suturesSurgical gut

(chromic) Multifilament, twisted Low, lost in 10–21 days Poor Fair Moderate 90 days Skin grafts; unpredictable

absorption ratesPolyglycolic

acid (Dexon®) Multifilament, braided Moderate, 20% at

21 days

uncoated Dexon II: coatedPolyglactin

Continued

Polyester

(Dacron®,

Mersilene®)

Multifilament, braided Very high Very good Very good Moderate Mucosal surfaces

coated

Rating scale: very low – low – poor – fair – good – moderate – intermediate – relatively high – very high – very good – highest Adapted from Bolognia

et al (2003) and Robinson et al (2005) with permission from Mosby Publishing Company.

42 days

days Subcutaneous closure

days Subcutaneous closure

(high-tension areas)Poliglecaprone

(Biosyn®) Monofilament 75% at 14 days, 40%

at 21 days

days Subcutaneous closure

(high-tension areas)

Rating scale: very low – low – poor – fair – good – moderate – intermediate – relatively high – very high – very good – highest Adapted from Bolognia et al (2003) and Robinson et al (2005) with permission from Mosby Publishing Company.

fast-absorbing gut or silk

Lips

fast-absorbing gut or silkNeck

Further reading

Adams B, Levy R, Rademaker AE, Goldberg LH,

Alam M Frequency of use of suturing and repair

techniques preferred by dermatologic surgeons

Dermatol Surg 2006;32:682–689

Bolognia JL, Jorizzo JL, Rapini RP, eds Dermatology

Edinburgh: Mosby, 2003

Coulthard P, Worthington H, Esposito M, Elst M,

Waes OJ Tissue adhesives for closure of surgical

incisions Cochrane Database Syst Rev 2004;

(2)CD004287

Eaglstein WH, Sullivan T Cyanoacrylates for skin

closure Dermatol Clin 2005;23:193–198

Gabrielli F, Potenza C, Puddu P, Sera F, Masini C,

Abeni D Suture materials and other factors

associ-ated with tissue reactivity, infection, and wound

dehiscence among plastic surgery outpatients Plast

Reconstr Surg 2001;107(1):38–45

Kanegaye JT, Vance CW, Chan L, Schonfeld N

Comparison of skin stapling devices and standard

sutures for pediatric scalp lacerations: a

rando-mized study of cost and time benefits J Pediatr

Robinson JK, Hanke W, Sengelmann RD, Siegel DM Surgery of the Skin: Procedural Dermatology

St Louis: Mosby, 2005

Weitzul S, Taylor RS Suturing technique and other closure materials In: Robinson JK, Hanke CW, Sengelmann RD, Siegel DM, eds Surgery of the Skin: Procedural Dermatology Philadelphia: Mosby, 2005:225–243

eversion; decreased risk of infection/reactivity

Increased risk of necrosis with flaps; painful on back, intertriginous areas, and over bony prominences

Can be used on the scalp and trunk; can be used to secure grafts

Tissue adhesives

(cyanoacrylate compound) Fast application; no need for removal by a medical

professional; may have decreased risk of infection/

reactivity

Little eversion of wound edges; expensive; risk of allergic reaction; can be removed easily by repeated washing

Used for tension incisions or wounds; useful for children

superficial/low-Skin closure tapes Fast application; low cost; no

need for removal by a medical professional; may have decreased risk of infection/

reactivity

Little eversion of wound edges; little wound support if used alone; can be removed easily

Used to support sutured wounds; can be used alone for superficial/low-tension incisions or wounds; not to

be used alone in cosmetically sensitive areas

A key tenet in reconstructive surgery is: function

before form (contour, shape); form before cosmesis

A beautiful scar is worthless if nasal inspiration

is obstructed Form is primary, because contour

depressions and elevations are difficult to

cam-ouflage Scar quality, although important, is

sec-ondary, as a wide or red scar may be hidden with

cosmetics as long as it is flush (contour) with its

surroundings

Accurate wound assessment is critical to

re-constructive planning; Box 13-1 outlines issues to

consider

When these details are factored, the best

re-pair usually becomes evident The surgeon should

be able to discuss with the patient the inherent

advantages and limitations of each closure method The simplest option (fewest incisions, least tissue alteration, fewest stages, etc.) is usually the best option provided that function and form are optimized – in order of simplicity: second intention > primary closure > skin grafting > flap

A wound closure algorithm is useful for a

system-atic approach (Fig 13-1) Flaps are usually formed when other closures are less optimal due

per-to issues with tension, function, or form In eral, flaps are ideal for reducing, redirecting, and redistributing tension from the primary defect, and for providing bulk or thickness for deeper wounds

gen-Flaps have a wide range of applications and can provide excellent functional and cosmetic outcomes when designed and executed precisely The goals of this chapter are to discuss: (1) how flaps are classified, (2) the principles and biome-chanics of flap movement, and (3) common flap designs in dermatologic surgery

Definition

A flap is a section of partially detached tissue The attached portion of a flap contains its vascu-lar supply and is its pedicle (Fig 13-2) All flaps share the following features:

• The recruitment of nearby (but not necessarily contiguous) donor skin that is mobile and lax

• The ability to reduce, redirect, and/or redistribute tension from the primary defect (original wound to be repaired)

• The creation of a secondary defect once the flap moves into and closes the primary defect The secondary defect is the space that the donor flap tissue occupied The tension on the primary defect is partially redirected and redistributed to the secondary defect

Flaps

T Minsue Chen, Rungsima Wanitphakdeedecha, and Tri H Nguyen

13 Chapter