refinements in surgical technique murad alam, md chief, section of cutaneous & aesthetic surgery...

Refinements in Surgical Refinements in Surgical TechniqueTechnique

Murad Alam, MDMurad Alam, MDChief, Section of Cutaneous & Aesthetic SurgeryChief, Section of Cutaneous & Aesthetic Surgery

Departments of Dermatology, Otolaryngology, and Departments of Dermatology, Otolaryngology, and SurgerySurgery

Northwestern UniversityNorthwestern UniversityChicago, ILChicago, IL

Suturing: QuestionsSuturing: Questions

Suture Technique: Suture Technique: What Do We Know?What Do We Know?

Very basic skill necessary for most Very basic skill necessary for most scalpel surgery, including cutaneous scalpel surgery, including cutaneous oncologic surgery and cosmetic oncologic surgery and cosmetic surgery.surgery.

BUT:BUT: Surprisingly little objective data Surprisingly little objective data

comparing techniques.comparing techniques. No randomized controlled trials.No randomized controlled trials.

What Do Most Surgeons Do?What Do Most Surgeons Do?

What types of stitches are used most What types of stitches are used most commonly?commonly?

When are bilayered closures used?When are bilayered closures used? When are primary closures used, versus When are primary closures used, versus

granulation or more complex repairs?granulation or more complex repairs? What can less experienced surgeons What can less experienced surgeons

learn from their more experienced learn from their more experienced colleagues?colleagues?

Suturing: Some AnswersSuturing: Some Answers

How Dermatologic Surgeons How Dermatologic Surgeons Sew Sew

Prospective survey of members of Prospective survey of members of AADS in 2003.AADS in 2003.

60% response rate60% response rate Indicative of high levels of uniformity Indicative of high levels of uniformity

in technique.in technique.


Epidermal layers were closed most often, in Epidermal layers were closed most often, in descending order, by simple interrupted sutures descending order, by simple interrupted sutures (38-50%), simple running sutures (37-42%), and (38-50%), simple running sutures (37-42%), and vertical mattress sutures (3-8%).vertical mattress sutures (3-8%).

Subcuticular sutures used more often on the trunk Subcuticular sutures used more often on the trunk and extremities (28%). and extremities (28%).

Most commonly used superficial sutures were nylon Most commonly used superficial sutures were nylon (51%) and polypropylene (44%), and the most (51%) and polypropylene (44%), and the most common absorbable suture was polyglactin 910 common absorbable suture was polyglactin 910 (73%). (73%).

Bilayered closures, undermining, and Bilayered closures, undermining, and electrocautery were used, on average, in 90% or electrocautery were used, on average, in 90% or more sutured repairs. Face was the most common more sutured repairs. Face was the most common site for these.site for these.


54% of wounds were repaired by primary closure, 54% of wounds were repaired by primary closure, 20% with local flaps, and 10% with skin grafting, 20% with local flaps, and 10% with skin grafting, with the remaining 15% left to heal by second with the remaining 15% left to heal by second intent (10%) or referred for repair (5%). intent (10%) or referred for repair (5%).

Experience-related differences were detected in Experience-related differences were detected in defect size and closure technique: defect size and closure technique: Defects less than 2 cm in diameter were seen by less Defects less than 2 cm in diameter were seen by less

experienced surgeons.experienced surgeons. Defects greater than 2 cm by more experienced Defects greater than 2 cm by more experienced

surgeons (Wilcoxon rank sum test: p=0.02). surgeons (Wilcoxon rank sum test: p=0.02). But more experienced surgeons were less likely to use But more experienced surgeons were less likely to use

bilayered closures (r= -0.28, p=0.036) and undermining bilayered closures (r= -0.28, p=0.036) and undermining (r= -0.28, p=0.035). (r= -0.28, p=0.035).

How Dermatologic Surgeons How Dermatologic Surgeons Sew:Sew:

ConclusionsConclusions Undermining, cautery, and bilayered Undermining, cautery, and bilayered

closures are performed routinely on closures are performed routinely on most defects prepared for closure.most defects prepared for closure.

Subcuticular sutures are more Subcuticular sutures are more commonly used on the trunk or commonly used on the trunk or extremities, while on the head and extremities, while on the head and neck, interrupted or running sutures neck, interrupted or running sutures are used.are used.

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

Subcuticular Sutures: Trunk Subcuticular Sutures: Trunk and Extremitiesand Extremities

New data indicates many benefitsNew data indicates many benefits Less erythema at 1-12 weeksLess erythema at 1-12 weeks Less risk of “track marks.”Less risk of “track marks.” Lower risk of dehiscence or scar spread Lower risk of dehiscence or scar spread

if sutures are left in for a while.if sutures are left in for a while. ““Looks nicer” to patientsLooks nicer” to patients


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 Running Sutures: Trunk and ExtremitiesExtremities

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


……And a few caveatsAnd a few caveats Need to learn and master new techniqueNeed to learn and master new technique May be less successful at high tension areas, May be less successful at high tension areas,

like scapula, where subcuticular sutures may like scapula, where subcuticular sutures may break or spread.break or spread.

If nonabsorbable subcuticular sutures are used, If nonabsorbable subcuticular sutures are used, suture granulomas and spitting may occursuture granulomas and spitting may occur

Prolene stronger than VicrylProlene stronger than Vicryl But Prolene left in indefinitely can be a long-term But Prolene left in indefinitely can be a long-term

problemproblem


Subcuticular running Prolene placed too high, with subsequent central spitting and ulceration


Location of Subcuticular Running KnotsLocation of Subcuticular Running Knots Inside the suture line, pressed inInside the suture line, pressed in

Benefit: do not need to be removedBenefit: do not need to be removed Risk: can cause opening of suture line as knots Risk: can cause opening of suture line as knots

interfere with flush closureinterfere with flush closure .5 to 1 cm beyond the edges of the suture line.5 to 1 cm beyond the edges of the suture line

Benefit: do not interfere with close appositionBenefit: do not interfere with close apposition Knots may need to be snipped at 2-3 week follow-up Knots may need to be snipped at 2-3 week follow-up

to prevent tract formationto prevent tract formation


Number of Deep Sutures PlacedNumber of Deep Sutures Placed Small number, about 1 per cmSmall number, about 1 per cm

Benefit: quick, do not result in epidermal distortionBenefit: quick, do not result in epidermal distortion Risk: can dehisce, place strain on subcuticulars, and Risk: can dehisce, place strain on subcuticulars, and

risky in pediatric patients and at high tension areasrisky in pediatric patients and at high tension areas Large number, about 1 per 0.5 cmLarge number, about 1 per 0.5 cm

Benefit: reduce risk of dehiscence, especially in high Benefit: reduce risk of dehiscence, especially in high risk patients and at high risk areasrisk patients and at high risk areas

Risk: time consuming, can result in suture line Risk: time consuming, can result in suture line asymmetry and epidermal distortion, with greater asymmetry and epidermal distortion, with greater risk of spittingrisk of spitting


How Long Subcuticular Left InHow Long Subcuticular Left In 2-3 weeks2-3 weeks

Benefit: low risk of spitting, sinus tracts or Benefit: low risk of spitting, sinus tracts or suture irritation.suture irritation.

Risk: can dehisce when removedRisk: can dehisce when removed IndefinitelyIndefinitely

Benefit: reduced risk of dehiscence, especially Benefit: reduced risk of dehiscence, especially in high risk patients and at high risk areasin high risk patients and at high risk areas

Risk: greater risk of spitting and sinus tracts, Risk: greater risk of spitting and sinus tracts, plus persistent erythemaplus persistent erythema


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 But Do Subcuticular Sutures Work on the Face?Work on the Face?

Subcuticular Sutures: Face Subcuticular Sutures: Face

Common in plastics repairs; less Common in plastics repairs; less common in dermatology.common in dermatology.

Wisdom is that simple interrupted Wisdom is that simple interrupted sutures provide best eversion.sutures provide best eversion.

Some use absorbable running Some use absorbable running superficial sutures +/- Steristripssuperficial sutures +/- Steristrips

Subcuticular Sutures: Face Subcuticular Sutures: Face

Initial studies indicate that subcuticular sutures Initial studies indicate that subcuticular sutures may also have same advantages on face as may also have same advantages on face as elsewhere.elsewhere. No visible sutures to frighten patientsNo visible sutures to frighten patients Minimal redness of suture line that takes months to Minimal redness of suture line that takes months to

resolveresolve BUT, there are disadvantages:BUT, there are disadvantages:

Temporarily may result in slightly lumpy appearanceTemporarily may result in slightly lumpy appearance May be inappropriate if there is tension on the May be inappropriate if there is tension on the

woundwound

Tissue GluesTissue Glues

Do Tissue Glues Have a Role In Do Tissue Glues Have a Role In Dermatologic Surgery?Dermatologic Surgery?

Recently introduced to ERs for rapid Recently introduced to ERs for rapid approximation of lacerations when approximation of lacerations when there is little tissue loss.there is little tissue loss.

Can also be used as an adjunct for Can also be used as an adjunct for sutured closures in routine skin sutured closures in routine skin surgery.surgery.

Keloid Prevention with Running Keloid Prevention with Running Subcuticular Sutures and Subcuticular Sutures and

AdhesiveAdhesive INDICATION:INDICATION: To close defects at risk for To close defects at risk for

keloids or hypertrophic scars so as to keloids or hypertrophic scars so as to minimize this riskminimize this risk

METHODS:METHODS: Vicryl to close subcutis, Maxon or Vicryl to close subcutis, Maxon or PDS to close dermis, and then subcuticular PDS to close dermis, and then subcuticular running nylon suture covered with running nylon suture covered with Dermabond and, sometimes, Proxi-Strip skin Dermabond and, sometimes, Proxi-Strip skin closure tape.closure tape.

REFERENCE:REFERENCE: Hyakusoku H, Ogawa R. Plast Hyakusoku H, Ogawa R. Plast Reconst Surg 2004;113:1526-1527. Reconst Surg 2004;113:1526-1527.

Keloid Prevention with Running Keloid Prevention with Running Subcuticular Sutures and Subcuticular Sutures and

AdhesiveAdhesive

Artificial Skin with Fibrin Glue Artificial Skin with Fibrin Glue and Negative Pressureand Negative Pressure

INDICATION:INDICATION: For closure of large acute or For closure of large acute or chronic wounds in areas (often limbs) where chronic wounds in areas (often limbs) where coverage is more vital than cosmesis.coverage is more vital than cosmesis.

METHODS:METHODS: Attachment of Integra collagen Attachment of Integra collagen template, median area grafted 250 sq. cm., template, median area grafted 250 sq. cm., using fibrin glue sprayed onto the wound, using fibrin glue sprayed onto the wound, pressure, staples, and negative pressure of pressure, staples, and negative pressure of 150 mmHg. Skin grafting followed150 mmHg. Skin grafting followed

REFERENCE:REFERENCE: Jeschke MG, Rose C, Angele P, Jeschke MG, Rose C, Angele P, et al. Plast Reconstr Surg 2004;113:525-530.et al. Plast Reconstr Surg 2004;113:525-530.

Artificial Skin with Fibrin Glue Artificial Skin with Fibrin Glue and Negative Pressureand Negative Pressure

PROBLEMS AFTER MOHS PROBLEMS AFTER MOHS SURGERY:SURGERY:

AVOIDABLE WITH BETTER AVOIDABLE WITH BETTER SURGICAL TECHNIQUESURGICAL TECHNIQUE

Bleeding or HematomaBleeding or Hematoma

After epinephrine wears off, some bleeding After epinephrine wears off, some bleeding will occur: pressure dressing for 48 hourswill occur: pressure dressing for 48 hours

Bruising in some areas is expected Bruising in some areas is expected (periocular, due to shearing trauma on (periocular, due to shearing trauma on poorly anchored vessels)—inform patientspoorly anchored vessels)—inform patients

Patient-induced traumaPatient-induced trauma Patient susceptibility: anticoagulants, Patient susceptibility: anticoagulants,

alcohol, malnourishmentalcohol, malnourishment

Management of BleedingManagement of Bleeding

Patient-directedPatient-directed 15 minutes of pressure15 minutes of pressure Apply to smallest possible area to avoid diffusion Apply to smallest possible area to avoid diffusion

of pressureof pressure Persistent bleeding: Return to officePersistent bleeding: Return to office

Open woundOpen wound Control bleedingControl bleeding Immediately resuture or heal by granulationImmediately resuture or heal by granulation Resuture before day 4 can be done without Resuture before day 4 can be done without

freshening edges with minimal risk of infection freshening edges with minimal risk of infection or disruption of the healing processor disruption of the healing process

InfectionInfection

Infrequent since cutaneous surgery is Infrequent since cutaneous surgery is clean (e.g., compared to bowel clean (e.g., compared to bowel surgery)surgery)

ManagementManagement Avoid heavy colonization during surgeryAvoid heavy colonization during surgery Remove sutures as soon as possibleRemove sutures as soon as possible Obtain culture; initiate antibioticsObtain culture; initiate antibiotics Reinforce wound with other methodsReinforce wound with other methods Topical ointment to clear CandidaTopical ointment to clear Candida

Acute Tissue ReactionsAcute Tissue Reactions

Chondritis of the pinnaChondritis of the pinna If exposed cartilageIf exposed cartilage Tetracycline, vinegar soaks, analgesicsTetracycline, vinegar soaks, analgesics

Inflamed tissue: overtight sutureInflamed tissue: overtight suture May be with slight prurulenceMay be with slight prurulence Ensure no infectionEnsure no infection Release some suturesRelease some sutures Consider antibiotics and Consider antibiotics and

antiinflammatories (naproxen)antiinflammatories (naproxen)

Contact DermatitisContact Dermatitis

To antibacterial ointmentTo antibacterial ointment Pruritus, erythema, rare bullous reactionPruritus, erythema, rare bullous reaction Treat by:Treat by:

Substituting petrolatumSubstituting petrolatum High-potency steroid ointment for 3-5 daysHigh-potency steroid ointment for 3-5 days

Allergic tape reactionAllergic tape reaction Sharply demarcatedSharply demarcated Discontinue tape use if possible; consider Discontinue tape use if possible; consider

cloth dressingscloth dressings

DehiscenceDehiscence

CausesCauses Pressure on suturesPressure on sutures Weakening of wound by trauma, infection, Weakening of wound by trauma, infection,

bleeding, edemableeding, edema Premature removal of suturesPremature removal of sutures

AvoidanceAvoidance Vertical mattress sutures may be strongerVertical mattress sutures may be stronger Avoid deep sutures on scalp (abscess)Avoid deep sutures on scalp (abscess)

ManagementManagement If edges trimmed, closure will take longerIf edges trimmed, closure will take longer Use wound closure tape concurrentlyUse wound closure tape concurrently Scar revisionScar revision

Delayed Wound HealingDelayed Wound Healing

CausesCauses InfectionInfection Nutrition/metabolicNutrition/metabolic Poor vascular supply (esp. LE)Poor vascular supply (esp. LE)

ManagementManagement Treat underlying problemTreat underlying problem Prolong suture timeProlong suture time Use concurrent antibiotics and Use concurrent antibiotics and

antiinflammatories to reduce riskantiinflammatories to reduce risk

Tissue NecrosisTissue Necrosis

Causes: poor blood supplyCauses: poor blood supply Tension on vesselsTension on vessels Transection of vessels during surgeryTransection of vessels during surgery Poor tissue handlingPoor tissue handling Inadequate local blood supplyInadequate local blood supply

ManifestationsManifestations Superficial blisteringSuperficial blistering Dusky appearance, soon demarcatedDusky appearance, soon demarcated

Management: debrideManagement: debride

HypergranulationHypergranulation

Occasionally in wounds healing by Occasionally in wounds healing by secondary intentsecondary intent Bright red spongy tissue that rises Bright red spongy tissue that rises

above wound bedabove wound bed ““Proud flesh”: delays or impede healingProud flesh”: delays or impede healing

ManagementManagement Curettage/aluminum chlorideCurettage/aluminum chloride Silver nitrate sticks (may stain)Silver nitrate sticks (may stain) May need to repeat treatmentsMay need to repeat treatments

PainPain

IntraoperativeIntraoperative Light pain can be corrected by further Light pain can be corrected by further

anesthesiaanesthesia 0.5-2.0% Lidocaine with epinephrine and 0.5-2.0% Lidocaine with epinephrine and

bicarbonate bicarbonate PostoperativePostoperative

Tylenol q4 routinely after surgeryTylenol q4 routinely after surgery Ice packs prnIce packs prn Tylenol #3 if necessary; substitute if allergicTylenol #3 if necessary; substitute if allergic

Immediate Nerve DamageImmediate Nerve Damage

Usually on face or scalpUsually on face or scalp Examine patient preoperatively and Examine patient preoperatively and

document in chartdocument in chart Know anatomyKnow anatomy Blunt dissection and gentle techniqueBlunt dissection and gentle technique Minimize incisions and their sizeMinimize incisions and their size Avoid critical areas during Avoid critical areas during

reconstructionreconstruction

EdemaEdema

Usually minimal in cutaneous woundsUsually minimal in cutaneous wounds Suture stretch and tissue necrosis is Suture stretch and tissue necrosis is

possiblepossible Potential sitesPotential sites

Periorbital on malar eminencePeriorbital on malar eminence Usually temporary – few weeksUsually temporary – few weeks Swelling of eyelids may be significantSwelling of eyelids may be significant

Other areas where lymphatic flow Other areas where lymphatic flow interrupted by surgeryinterrupted by surgery

Surgical Technique: General Surgical Technique: General PrinciplesPrinciples

Keep surgery cleanKeep surgery clean Handle tissue gentlyHandle tissue gently Keep removals of tissues and repairs Keep removals of tissues and repairs

as small as possibleas small as possible Minimize scar length and visibilityMinimize scar length and visibility Make sure patient can reach you with Make sure patient can reach you with

problems early, before they become problems early, before they become bigbig

refinements in surgical technique murad alam, md chief, section of cutaneous & aesthetic surgery...

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superficial sutures

patientssubcuticular

superficial running

simple running sutures

simple interrupted sutures

vertical mattress sutures

bilayered closures r

primary closures