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

Suturing: Questions

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.

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?

Suturing: Some Answers

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

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.

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).

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.

Subcuticular Sutures: Are They Better or Just Different?

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

Subcuticular Sutures: Trunk and Extremities

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.

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

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

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

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

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

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

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

But Do Subcuticular Sutures Work on the Face?

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

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

Tissue Glues

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.

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;113:1526-1527.

Keloid Prevention with Running Subcuticular Sutures and Adhesive

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;113:525-530.

Artificial Skin with Fibrin Glue and Negative Pressure

PROBLEMS AFTER MOHS SURGERY: AVOIDABLE WITH BETTER SURGICAL TECHNIQUE

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

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

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

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)

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

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

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

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

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

Pain Intraoperative Postoperative Light pain can be corrected by further anesthesia 0.5-2.0% Lidocaine with epinephrine and bicarbonate Postoperative Tylenol q4 routinely after surgery Ice packs prn Tylenol #3 if necessary; substitute if allergic

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

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

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