1. Refinements in Surgical Technique
Murad Alam, MD
Chief, Section of Cutaneous & Aesthetic Surgery
Departments of Dermatology, Otolaryngology, and Surgery
Northwestern University
Chicago, IL

2. Suturing: Questions

3. Suture Technique: What Do We Know?
Very basic skill necessary for most scalpel surgery, including cutaneous oncologic surgery and cosmetic surgery.
BUT:
Surprisingly little objective data comparing techniques.
No randomized controlled trials.

4. What Do Most Surgeons Do?
What types of stitches are used most commonly?
When are bilayered closures used?
When are primary closures used, versus granulation or more complex repairs?
What can less experienced surgeons learn from their more experienced colleagues?

5. Suturing: Some Answers

6. How Dermatologic Surgeons Sew
Prospective survey of members of AADS in 2003.
60% response rate
Indicative of high levels of uniformity in technique.

7. How Dermatologic Surgeons Sew
Epidermal layers were closed most often, in descending order, by simple interrupted sutures (38-50%), simple running sutures (37-42%), and vertical mattress sutures (3-8%).
Subcuticular sutures used more often on the trunk and extremities (28%).
Most commonly used superficial sutures were nylon (51%) and polypropylene (44%), and the most common absorbable suture was polyglactin 910 (73%).
Bilayered closures, undermining, and electrocautery were used, on average, in 90% or more sutured repairs. Face was the most common site for these.

8. How Dermatologic Surgeons Sew
54% of wounds were repaired by primary closure, 20% with local flaps, and 10% with skin grafting, with the remaining 15% left to heal by second intent (10%) or referred for repair (5%).
Experience-related differences were detected in defect size and closure technique:
Defects less than 2 cm in diameter were seen by less experienced surgeons.
Defects greater than 2 cm by more experienced surgeons (Wilcoxon rank sum test: p=0.02).
But more experienced surgeons were less likely to use bilayered closures (r= -0.28, p=0.036) and undermining (r= -0.28, p=0.035).

9. How Dermatologic Surgeons Sew: Conclusions
Undermining, cautery, and bilayered closures are performed routinely on most defects prepared for closure.
Subcuticular sutures are more commonly used on the trunk or extremities, while on the head and neck, interrupted or running sutures are used.

10. Subcuticular Sutures: Are They Better or Just Different?

11. Subcuticular Sutures: Trunk and Extremities
New data indicates many benefits
Less erythema at 1-12 weeks
Less risk of “track marks.”
Lower risk of dehiscence or scar spread if sutures are left in for a while.
“Looks nicer” to patients

12. Subcuticular Sutures: Trunk and Extremities

13. Subcuticular Sutures: Trunk and Extremities
Can be placed as rapidly as or faster than superficial running sutures, with moderate precision, for superior long-term cosmetic results.

14. Running Sutures: Trunk and Extremities
Running superficials tend to leave “track marks” on high tension areas of the trunk and extremities.

15. Subcuticular Sutures: Trunk and Extremities
…And a few caveats
Need to learn and master new technique
May be less successful at high tension areas, like scapula, where subcuticular sutures may break or spread.
If nonabsorbable subcuticular sutures are used, suture granulomas and spitting may occur
Prolene stronger than Vicryl
But Prolene left in indefinitely can be a long-term problem

16. Subcuticular Sutures: Trunk and Extremities
Subcuticular running Prolene placed too high, with subsequent central spitting and ulceration

17. Subcuticular Sutures: Trunk and Extremities
Location of Subcuticular Running Knots
Inside the suture line, pressed in
Benefit: do not need to be removed
Risk: can cause opening of suture line as knots interfere with flush closure
.5 to 1 cm beyond the edges of the suture line
Benefit: do not interfere with close apposition
Knots may need to be snipped at 2-3 week follow-up to prevent tract formation

18. Subcuticular Sutures: Trunk and Extremities
Number of Deep Sutures Placed
Small number, about 1 per cm
Benefit: quick, do not result in epidermal distortion
Risk: can dehisce, place strain on subcuticulars, and risky in pediatric patients and at high tension areas
Large number, about 1 per 0.5 cm
Benefit: reduce risk of dehiscence, especially in high risk patients and at high risk areas
Risk: time consuming, can result in suture line asymmetry and epidermal distortion, with greater risk of spitting

19. Subcuticular Sutures: Trunk and Extremities
How Long Subcuticular Left In
2-3 weeks
Benefit: low risk of spitting, sinus tracts or suture irritation.
Risk: can dehisce when removed
Indefinitely
Benefit: reduced risk of dehiscence, especially in high risk patients and at high risk areas
Risk: greater risk of spitting and sinus tracts, plus persistent erythema

20. Subcuticular Sutures: Trunk and Extremities
With subcuticular vicryl left in, there is a flatter, thinner scar, than with simple running sutures removed after 14 days, which result is spreading and visible suture marks

21. But Do Subcuticular Sutures Work on the Face?

22. Subcuticular Sutures: Face
Common in plastics repairs; less common in dermatology.
Wisdom is that simple interrupted sutures provide best eversion.
Some use absorbable running superficial sutures +/- Steristrips

23. Subcuticular Sutures: Face
Initial studies indicate that subcuticular sutures may also have same advantages on face as elsewhere.
No visible sutures to frighten patients
Minimal redness of suture line that takes months to resolve
BUT, there are disadvantages:
Temporarily may result in slightly lumpy appearance
May be inappropriate if there is tension on the wound

24. Tissue Glues

25. Do Tissue Glues Have a Role In Dermatologic Surgery?
Recently introduced to ERs for rapid approximation of lacerations when there is little tissue loss.
Can also be used as an adjunct for sutured closures in routine skin surgery.

26. Keloid Prevention with Running Subcuticular Sutures and Adhesive
INDICATION: To close defects at risk for keloids or hypertrophic scars so as to minimize this risk
METHODS: Vicryl to close subcutis, Maxon or PDS to close dermis, and then subcuticular running nylon suture covered with Dermabond and, sometimes, Proxi-Strip skin closure tape.
REFERENCE: Hyakusoku H, Ogawa R. Plast Reconst Surg 2004;113:

27. Keloid Prevention with Running Subcuticular Sutures and Adhesive

28. Artificial Skin with Fibrin Glue and Negative Pressure
INDICATION: For closure of large acute or chronic wounds in areas (often limbs) where coverage is more vital than cosmesis.
METHODS: Attachment of Integra collagen template, median area grafted 250 sq. cm., using fibrin glue sprayed onto the wound, pressure, staples, and negative pressure of 150 mmHg. Skin grafting followed
REFERENCE: Jeschke MG, Rose C, Angele P, et al. Plast Reconstr Surg 2004;113:

29. Artificial Skin with Fibrin Glue and Negative Pressure

30. PROBLEMS AFTER MOHS SURGERY: AVOIDABLE WITH BETTER SURGICAL TECHNIQUE

31. Bleeding or Hematoma
After epinephrine wears off, some bleeding will occur: pressure dressing for 48 hours
Bruising in some areas is expected (periocular, due to shearing trauma on poorly anchored vessels)—inform patients
Patient-induced trauma
Patient susceptibility: anticoagulants, alcohol, malnourishment

32. Management of Bleeding
Patient-directed
15 minutes of pressure
Apply to smallest possible area to avoid diffusion of pressure
Persistent bleeding: Return to office
Open wound
Control bleeding
Immediately resuture or heal by granulation
Resuture before day 4 can be done without freshening edges with minimal risk of infection or disruption of the healing process

33. Infection
Infrequent since cutaneous surgery is clean (e.g., compared to bowel surgery)
Management
Avoid heavy colonization during surgery
Remove sutures as soon as possible
Obtain culture; initiate antibiotics
Reinforce wound with other methods
Topical ointment to clear Candida

34. Acute Tissue Reactions
Chondritis of the pinna
If exposed cartilage
Tetracycline, vinegar soaks, analgesics
Inflamed tissue: overtight suture
May be with slight prurulence
Ensure no infection
Release some sutures
Consider antibiotics and antiinflammatories (naproxen)

35. Contact Dermatitis To antibacterial ointment Allergic tape reaction
Pruritus, erythema, rare bullous reaction
Treat by:
Substituting petrolatum
High-potency steroid ointment for 3-5 days
Allergic tape reaction
Sharply demarcated
Discontinue tape use if possible; consider cloth dressings

36. Dehiscence Causes Avoidance Management Pressure on sutures
Weakening of wound by trauma, infection, bleeding, edema
Premature removal of sutures
Avoidance
Vertical mattress sutures may be stronger
Avoid deep sutures on scalp (abscess)
Management
If edges trimmed, closure will take longer
Use wound closure tape concurrently
Scar revision

37. Delayed Wound Healing Causes Management Infection Nutrition/metabolic
Poor vascular supply (esp. LE)
Management
Treat underlying problem
Prolong suture time
Use concurrent antibiotics and antiinflammatories to reduce risk

38. Tissue Necrosis Causes: poor blood supply Manifestations
Tension on vessels
Transection of vessels during surgery
Poor tissue handling
Inadequate local blood supply
Manifestations
Superficial blistering
Dusky appearance, soon demarcated
Management: debride

39. Hypergranulation Occasionally in wounds healing by secondary intent
Bright red spongy tissue that rises above wound bed
“Proud flesh”: delays or impede healing
Management
Curettage/aluminum chloride
Silver nitrate sticks (may stain)
May need to repeat treatments

40. Pain Intraoperative Postoperative
Light pain can be corrected by further anesthesia
% Lidocaine with epinephrine and bicarbonate
Postoperative
Tylenol q4 routinely after surgery
Ice packs prn
Tylenol #3 if necessary; substitute if allergic

41. Immediate Nerve Damage
Usually on face or scalp
Examine patient preoperatively and document in chart
Know anatomy
Blunt dissection and gentle technique
Minimize incisions and their size
Avoid critical areas during reconstruction

42. Edema Usually minimal in cutaneous wounds
Suture stretch and tissue necrosis is possible
Potential sites
Periorbital on malar eminence
Usually temporary – few weeks
Swelling of eyelids may be significant
Other areas where lymphatic flow interrupted by surgery

43. Surgical Technique: General Principles
Keep surgery clean
Handle tissue gently
Keep removals of tissues and repairs as small as possible
Minimize scar length and visibility
Make sure patient can reach you with problems early, before they become big