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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?.

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refinements in surgical technique

Refinements in Surgical Technique

Murad Alam, MD

Chief, Section of Cutaneous & Aesthetic Surgery

Departments of Dermatology, Otolaryngology, and Surgery

Northwestern University

Chicago, IL

suture technique what do we know
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 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?
how dermatologic surgeons sew
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 sew7
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 sew8
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
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 trunk and extremities
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 extremities13
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 Sutures: Trunk and Extremities

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

subcuticular sutures trunk and extremities15
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 extremities16
Subcuticular Sutures: Trunk and Extremities

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

subcuticular sutures trunk and extremities17
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 extremities18
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 extremities19
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 extremities20
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

subcuticular sutures 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 face23
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
do tissue glues have a role in dermatologic surgery
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
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.
artificial skin with fibrin glue and negative pressure
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.
bleeding or hematoma
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
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
  • 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
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
Contact Dermatitis
  • To antibacterial ointment
    • 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
  • Causes
    • 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
Delayed Wound Healing
  • Causes
    • 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
Tissue Necrosis
  • Causes: poor blood supply
    • Tension on vessels
    • Transection of vessels during surgery
    • Poor tissue handling
    • Inadequate local blood supply
  • Manifestations
    • Superficial blistering
    • Dusky appearance, soon demarcated
  • Management: debride
  • 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
  • Intraoperative
    • 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
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
  • 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
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