3Suture 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.
4What 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?
6How Dermatologic Surgeons Sew Prospective survey of members of AADS in 2003.60% response rateIndicative of high levels of uniformity in technique.
7How 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.
8How 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).
9How 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.
10Subcuticular Sutures: Are They Better or Just Different?
11Subcuticular Sutures: Trunk and Extremities New data indicates many benefitsLess erythema at 1-12 weeksLess risk of “track marks.”Lower risk of dehiscence or scar spread if sutures are left in for a while.“Looks nicer” to patients
13Subcuticular 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.
14Running Sutures: Trunk and Extremities Running superficials tend to leave “track marks” on high tension areas of the trunk and extremities.
15Subcuticular Sutures: Trunk and Extremities …And a few caveatsNeed to learn and master new techniqueMay 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 occurProlene stronger than VicrylBut Prolene left in indefinitely can be a long-term problem
16Subcuticular Sutures: Trunk and Extremities Subcuticular running Prolene placed too high, with subsequent central spitting and ulceration
17Subcuticular Sutures: Trunk and Extremities Location of Subcuticular Running KnotsInside the suture line, pressed inBenefit: do not need to be removedRisk: can cause opening of suture line as knots interfere with flush closure.5 to 1 cm beyond the edges of the suture lineBenefit: do not interfere with close appositionKnots may need to be snipped at 2-3 week follow-up to prevent tract formation
18Subcuticular Sutures: Trunk and Extremities Number of Deep Sutures PlacedSmall number, about 1 per cmBenefit: quick, do not result in epidermal distortionRisk: can dehisce, place strain on subcuticulars, and risky in pediatric patients and at high tension areasLarge number, about 1 per 0.5 cmBenefit: reduce risk of dehiscence, especially in high risk patients and at high risk areasRisk: time consuming, can result in suture line asymmetry and epidermal distortion, with greater risk of spitting
19Subcuticular Sutures: Trunk and Extremities How Long Subcuticular Left In2-3 weeksBenefit: low risk of spitting, sinus tracts or suture irritation.Risk: can dehisce when removedIndefinitelyBenefit: reduced risk of dehiscence, especially in high risk patients and at high risk areasRisk: greater risk of spitting and sinus tracts, plus persistent erythema
20Subcuticular 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
22Subcuticular 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
23Subcuticular Sutures: Face Initial studies indicate that subcuticular sutures may also have same advantages on face as elsewhere.No visible sutures to frighten patientsMinimal redness of suture line that takes months to resolveBUT, there are disadvantages:Temporarily may result in slightly lumpy appearanceMay be inappropriate if there is tension on the wound
25Do 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.
26Keloid Prevention with Running Subcuticular Sutures and Adhesive INDICATION: To close defects at risk for keloids or hypertrophic scars so as to minimize this riskMETHODS: 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:
27Keloid Prevention with Running Subcuticular Sutures and Adhesive
28Artificial 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 followedREFERENCE: Jeschke MG, Rose C, Angele P, et al. Plast Reconstr Surg 2004;113:
29Artificial Skin with Fibrin Glue and Negative Pressure
30PROBLEMS AFTER MOHS SURGERY: AVOIDABLE WITH BETTER SURGICAL TECHNIQUE
31Bleeding or HematomaAfter epinephrine wears off, some bleeding will occur: pressure dressing for 48 hoursBruising in some areas is expected (periocular, due to shearing trauma on poorly anchored vessels)—inform patientsPatient-induced traumaPatient susceptibility: anticoagulants, alcohol, malnourishment
32Management of Bleeding Patient-directed15 minutes of pressureApply to smallest possible area to avoid diffusion of pressurePersistent bleeding: Return to officeOpen woundControl bleedingImmediately resuture or heal by granulationResuture before day 4 can be done without freshening edges with minimal risk of infection or disruption of the healing process
33InfectionInfrequent since cutaneous surgery is clean (e.g., compared to bowel surgery)ManagementAvoid heavy colonization during surgeryRemove sutures as soon as possibleObtain culture; initiate antibioticsReinforce wound with other methodsTopical ointment to clear Candida
34Acute Tissue Reactions Chondritis of the pinnaIf exposed cartilageTetracycline, vinegar soaks, analgesicsInflamed tissue: overtight sutureMay be with slight prurulenceEnsure no infectionRelease some suturesConsider antibiotics and antiinflammatories (naproxen)
35Contact Dermatitis To antibacterial ointment Allergic tape reaction Pruritus, erythema, rare bullous reactionTreat by:Substituting petrolatumHigh-potency steroid ointment for 3-5 daysAllergic tape reactionSharply demarcatedDiscontinue tape use if possible; consider cloth dressings
36Dehiscence Causes Avoidance Management Pressure on sutures Weakening of wound by trauma, infection, bleeding, edemaPremature removal of suturesAvoidanceVertical mattress sutures may be strongerAvoid deep sutures on scalp (abscess)ManagementIf edges trimmed, closure will take longerUse wound closure tape concurrentlyScar revision
38Tissue Necrosis Causes: poor blood supply Manifestations Tension on vesselsTransection of vessels during surgeryPoor tissue handlingInadequate local blood supplyManifestationsSuperficial blisteringDusky appearance, soon demarcatedManagement: debride
39Hypergranulation Occasionally in wounds healing by secondary intent Bright red spongy tissue that rises above wound bed“Proud flesh”: delays or impede healingManagementCurettage/aluminum chlorideSilver nitrate sticks (may stain)May need to repeat treatments
40Pain Intraoperative Postoperative Light pain can be corrected by further anesthesia% Lidocaine with epinephrine and bicarbonatePostoperativeTylenol q4 routinely after surgeryIce packs prnTylenol #3 if necessary; substitute if allergic
41Immediate Nerve Damage Usually on face or scalpExamine patient preoperatively and document in chartKnow anatomyBlunt dissection and gentle techniqueMinimize incisions and their sizeAvoid critical areas during reconstruction
42Edema Usually minimal in cutaneous wounds Suture stretch and tissue necrosis is possiblePotential sitesPeriorbital on malar eminenceUsually temporary – few weeksSwelling of eyelids may be significantOther areas where lymphatic flow interrupted by surgery
43Surgical Technique: General Principles Keep surgery cleanHandle tissue gentlyKeep removals of tissues and repairs as small as possibleMinimize scar length and visibilityMake sure patient can reach you with problems early, before they become big