advanced suturing - dr. laravia
TRANSCRIPT
Advanced Suturing
Dennis LaRavia, MD, DiplomateABFM; Fellow AAFPProfessor, LSUHSC-NO School of Medicine, Dept. of Family MedicineResidency Director, LSU Rural Family Medicine Program, Bogalusa, LA
BASIC SUTURING: A REVIEW
Cleansing and IrrigationAnesthetic ChoicesSuture SelectionHealing ConsiderationsSuture Removal ConsiderationsPost-op Discussion
Basic Closure: Review
Thorough Debridement and CleansingAppropriate AnesthesiaProper Selection of SutureGood closure techniques:
Approximation, not strangulationMild eversion, no inversion Suture not too close to skin edge
Basic Closure: Continued
FollowupSuture Removal TimingLong-term skin careWound Healing:
0-5 Days= Initial Lag Phase5-14 Days= Initial Healing Phase14-365 Days= Complete Healing
Initial Goals: Advanced RepairEvaluate Lesion/Lesions for possible excision/RepairUnderstand Patient’s Expectations
Discuss options and choose correct optionInformed Consent ProcessPerform the procedure correctlyPost-op Instructions and Follow-up
Evaluate Lesion/Lesions
History>Diabetes Mellitus>Immune Problem>Keloid Former>Prior Repairs: how did they heal?
Evaluate Lesion/Lesions(cont)
Physical>Review any prior excisions/scars>How compliant is skin?>What type of complexion and skin
color does patient have?>Circulatory/cardiac status?
Evaluate Lesion/Lesions(cont)
Cogitate on Options:BiopsyExcisionSurveillanceRepair
Understand Patient Expectations
Patient Education> Basic Healing Explanation> Options for Patient to consider
Patient Expectations> Make sure communication is
occurring!
Discuss Options/Choose Option
Develop options for treatment with the patientDevelop Best Plan with patient’s agreementDiscuss details of approachDiscuss, in general, post-op and healing expectations
Informed Consent Process
Informed consentPhoto consentPhotograph the lesion(s): Preferably digital*All documentation into EMR or Paper RecordReaffirm Allergies/Sensitivities
Perform the “Right” Procedure Correctly
Review anatomy of regionUnderlying structures
Preparation of the WoundType of anesthesia Type of suture
Take care to place the right suture in the right place (set a high standard)
Perform the Procedure Correctly-Review Anatomy
Facial AreasNeck AreasWrist and HandOther areas with significant deep structures to the wound or lesion
Perform the Procedure Correctly-Preparation of Wound
Antiseptic/Aseptic PrepBetadineAlcoholSoap CleanserOther Prep
Site and individual Dependent
Perform the Procedure Correctly-Preparation of Wound (cont)
AnesthesiaWho-is the patient?What-is the procedure?Where-is the site we are reviewing?How- long will the procedure take?
Conscious Sedation: should it be considered?
Perform the Procedure Correctly-Preparation of Wound(cont)
AnestheticBlockLocalBuffered Solution: Why?
1:8 to 1:10 Dilution of Sodium Bicarbonate to AnestheticChoice of materials
LidocaineMepivacaineWith or without epinephrine
Anesthetic Concentrations:EquivalentConcentration Local Anesthetic Onset Duration
1% Lidocaine 1 min 45-60 minutes
1% Lidocaine w/epi 1 min 2 – 6 hours
1% Mepivacaine 3-5 mins 45-90 minutes
.25% Bupivacaine (Marcaine) 5 mins 2-4 hours
.25% Bupivacaine w/epi 5 mins 3-7 hours
Perform the Procedure Correctly- Suture Selection
Non-ResorbableMonofilament
Resorbable (Absorbable)MonofilamentBraidedCatgut
PlainChromic
Healing Time
Sutures
Suture/Types Tissue Reaction Absorption RateAbsorbable Sutures:Gut/Plain Moderate 70 daysGut/Chromic Moderate 90 daysPolyglycolic/Mono (Dexon) Mild 40% 7 daysPolyglactic/Braided (Vicryl) Mild 60-90 days
Needles
Cutting/Reverse Cutting
Suture: How will I decide?
What is the extent of the wound or proposed lesion excision?Where is the lesion/wound?How long do I want the sutures to remain?What likelihood is there of infection?What about the individual patient?
Post-Op Care & InstructionsPatient Responsibilities:
Clean-Daily?Dry or wet-Antibiotic ointment?Covered or not
o Site Dependento Individual Dependent
Return timeCall/Come In for departures from the expected
Post-Op Care (continued)Physician Responsibilities:
Suture Removal-When?Face,Scalp, and NeckHands, Arms, and FeetTrunkLegs
Post-op evaluationIndividual careReturn Appointments
Consider……
Loss of a Flap: What are my options?Infection: How do I intervene?Other adverse results
Preparation of the Office/ED
Well trained assistantComplete set of instrumentsComplete set of supplies/Including plenty of backup sets “Ready to Go”Appropriate time set aside for procedureGood lighting (and glasses if necessary)
Preparation of the Mayo Stand What is on the stand?
Metzenbaum ScissorsSmooth forceps, tissueIris Scissors, curved or straightMosquito hemostats, curved twoHemostats, straight, twoSkin retractors, twoAllis forcepsScalpel, #15
Needle HoldersSuture Scissors4x4’s2x2’sH2O2?Sterile SalineExtra Buffered anesthetic with a small needleSuture, Varieties
Support EquipmentHot penElectrocauteryCryogun
Wound Healing ConsiderationsColor of SkinKeloid former?Child or Adult?Size of Lesion and RepairWhen to take out suturesWho to take out suturesSteri Strip Usage/BenzoinDiabetic?Immune compromisedOn blood thinnersLikelihood of infection
FarmerChild (particularly boys)
Considerations in Selecting and Planning Technique of Excision
BiopsyExcisional, ellipseKey punch
Variety of sizesSuggested size—4 mms
Considerations: other closures
Skin Glue(Dermabond)When to useWhere to use
StaplersWhen to useWhere to use
Considerations, continued
Definitive ExcisionSite/Proximity to underlying structuresAge of PatientColor of SkinElasticity of SkinPotential shortfalls of approach/complications
Plastic Repairs
Lines of Langerhans
Lines of Langerhans cont’d
Basic Closures
Interrupted
Continuous (Running) Suture
Mattress, Vertical
ShorthandRegular
Mattress, Horizontal
Corner Suture
Deep Inverted Suture
Subcuticular
Undermine?
Why undermine?How to undermineBurow’s Triangle
Other Closures Pearls
Leveling SutureApproximate—Do not StrangulateIf you are not happy with the suture, cut it out and replace with a better suture!
SUTURE, LOAD LEVELING
Keloid and other Intralesional injections
Mixture: Kenalog 10(Kenalog 10mgs/cc) and lidocaine 1:1; usually about 0.25 cc:0.25 cc.Use fine needle; 27 to 30 guage needleLuer-lock preferredInterval: usually 6-12 weeksKeloid: Do not attempt re-excision until patient has received 3 injections
Advanced Closures
Z-Plasty
Z-Plasty
Good Choice for:o Pilonidal Cyst Scar or sinuso Repair over a joint (finger)
Dog Ear Correction
Dog Ear Correction
Good Choice for:o Any repair or elective excision where you
have too much skin on one side of the repair that will immediately or ultimately result in a Dog Ear Deformity.
Single Advancement Flap
Double Advancement Flap
Single and double Advancement Flaps
Good Choice for:o Backo Thigho Abdomeno Calf, maybe
Rotation Advancement Flap
Rotation Advancement Flap
Good Choice for:NeckScalpFaceAnywhere where you have loose skin adjacent to an area that is “tight” or where there is limited skin for a flap or “good closure” without undue stress
M-Plasty
M-PlastyGood choice for:
o Scalpo Faceo Armo Leg o Footo Ankleo Almost anywhere (especially where there is limited
skin to flap)
Triple U Plasty
Triple U Continued
Triple U Continued
Triple U Conclusion
Triple U-Plasty
o Good choice for:o Noseo Necko Ear
V to Y Slide 11. Circular Defect
2. Plan triangle, using skin lines
V to Y Slide 23. Incise the triangle,
then undermine thoroughly.
4. Thin base of triangular flap to fit defect.
V to Y Slide 35. Remove triangle
6. Suture base.
V to Y Slide 47. Suture long limb.
8. Close remaining incisions.
V to Y Plasty
Good choice for:o Inferior Orbital areao Pre-auricular area
Rhomboid Flap
Rhomboid Plasty
Good Choice for:o Backo Necko Thigho Abdomen
Advanced Considerations in Skin Closures
Tendon RepairsVariant SuturesRefinement of SkillsWhat to tacklePenrose DrainsConscious Sedation
Skin Grafts
Donor SitesPinchDermatome
Treatment of Donor Site
Warm SalineAntibioticTeflon cover (or Adaptic)
Tendon Repair
SutureApproachPreparationPost-Op Consideration
TENDON REPAIR
Use of Penrose Drains
When to useHow to useWhen to removeProper selection of patient and procedure is the KeyHow to secure them
Conscious Sedation
Midazolam2-10 mgs
Fentanyl25-200 mcgs
Coding & BillingCoding and billing becomes very complex for laceration repair and excisions. Important factors to list for billing personnel are:
LocationSize of lesionLength of closure or excisionSimple or intermediate repairBenign or malignant statusWhether a true skin lesion or subcutaneous tumor or deep tumor was excisedMethod of removal
Coding & Billing continuedSuture removal is included in the initial charge if the original sutures were placed by the same group of physicians. Suture removal can be billed if performed by an unassociated physician or group. Anesthetic, materials and supplies are customarily also included in the reimbursement fees. If a lesion is excised and repaired in a simple fashion (no undermining, deep sutures, flaps, or plasties), the fee for excision includes repair and suture removal.
VERTICAL MATTRESS SUTURES: VARIANTS
Far-Far/Near-NearNear-Far/Near-FarFar-Near/Near-FarNear-Far/Far-NearSpace-ObliteratingPulley or LoopHalf-Buried
Vertical Mattress: Classical, Far-Far/Near-Near
Vertical Mattress: Classical, Advantages
Everts Skin EdgesReduces Wound TensionEliminates dead spaceProvides a strong closure
Vertical Mattress: Classical, Disadvantages
Potentially StrangulatingMay compress the skin adjacent to the defect causing: scarring
focal necrosisPostoperative edemaTake a little more time
than running suture
Vertical Mattress: Near-Far/Near-Far
Near-Far/Near-Far Mattress, Vertical: Indications
Promotes Skin EversionUseful for elevating the deep tissues of a wound
Vertical Mattress: Far-Near/Near-Far
Far-Near/Near-Far Mattress, Vertical: Details
Almost identical to the Near-Far/Far-Near suture except, the knotted suture segment connects the two far points as opposed to the 2 near points.
Vertical Mattress: Near-Far/Far-Near
Near-Far/Far-Near Mattress, Vertical: Details
Described as a combination suture of traditional vertical mattress and interrupted sutureMain use where tension exists on thin skin including the eyelids and parts of the scalp.Also, creates a pulley effect which may be very helpful when significant tension exists at the time of closure
Vertical Mattress: Space-Obliterating
Space-Obliterating Mattress, Vertical: Details
Involves an additional loop within the dermisProvides a pulley effect to the closureThought to distribute tension more evenly over a larger areaGenerally work where there is considerable tension at time of closing
Vertical Mattress: Pulley or Loop
Pulley or Loop Mattress, Vertical: Details
Suture works as a PulleyProduces less tension on either of the suture strandsThus reduces pressure or impingement on the skin surfaceAlso, reckoned as a very strong closure where tension exists at time of closing
Vertical Mattress: Half-Buried
Half-Buried Mattress, Vertical: Details
Placed in a traditional far-far/near-near sequenceBut the needle does not pierce the skin surface opposite the starting pointChief Advantage: Less scarring and less likelihood of strangulationApproximates edges well, but may not relieve wound tension as wellUseful on lip, eyelid, or hairline
REVIEW SUMMARY
1. Review the Basics2. Review the options for Closure
before removal of lesion3. Make the Advanced Closure “Fit the
Site”
REVIEW SUMMARY (cont)
4. Acrostic:Corner SuturesUndermineBurow’s TrianglesExtension
5. Self-RefreshersWork on Pigs feet every 3-6 months
REVIEW SUMMARY (cont)6. Overview:
A. Vision- Visualize, in your mind, the finished product!
B. Technical- Holder yourself to ahigher standard to place every suture in the “right place”
C. Flexibility- When things don’t work out just right or look just right----make revisions then to obtain the result the best it can be.
Questions???
Dennis LaRavia, MD, F.A.A.F.P.
Professor, TAMU, COM
College Station, TX 77845
TENDON REPAIR
V to Y
Wound Healing ConsiderationsColor of SkinKeloid former?Child or Adult?Size of Lesion and RepairWhen to take out suturesWho to take out sutures
Wound Healing Considerations(cont)
Immune compromised?Diabetic?On blood thinners?Likelihood of Steri Strip Usage/Benzoin?Likelihood of infection?
FarmerChildren (particularly boys)