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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 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? • 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?
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: 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 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
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
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.
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 • 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 • 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 • 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 • 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 • 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