Professional Documents
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Learning objectives
After completing this learning activity, participants should be able to describe common suturing errors that lead to unaesthetic scars and identify methods to gain hemostasis efficiently
and re-approximate skin in a layered fashion with proficiency.
Disclosures
Editors
The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with
commercial interest(s).
Authors
The authors involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).
Planners
The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved
with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).
Sound surgical technique is necessary to achieve excellent surgical outcomes. Despite the fact that
dermatologists perform more office-based cutaneous surgery than any other specialty, few dermatologists
have opportunities for practical instruction to improve surgical technique after residency and fellowship.
This 2-part continuing medical education article will address key principles of surgical technique at each
step of cutaneous reconstruction. Part II reviews the placement of deep and superficial sutures. Objective
quality control questions are proposed to provide a framework for self-assessment and continuous quality
improvement. ( J Am Acad Dermatol 2015;72:389-402.)
Key words: excise; excision; incise; skin; surgery; suture; technique; undermine.
INTRODUCTION
Part I of this continuing medical education
article reviewed surgical techniques that involve
cutting tissue: incising, excising, and undermining.
Final inspection of the wound after completing
these cutting steps should reveal cleanly incised,
vertical wound edges, a wound base with a
uniform anatomic depth, and precisely undermined skin flaps. Careful hemostasis should minimize bleeding. Strategies for effective hemostasis
have been reviewed elsewhere.1,2 Precise execution of these cutting steps prepares the wound for
accurate placement of buried and superficial
sutures.
From the Department of Dermatology,a University of Pennsylvania, Philadelphia, and Private Practice,b Austin.
Video available at http://www.jaad.org.
Funding sources: None.
Conflicts of interest: None declared.
Accepted for publication August 1, 2014.
Correspondence to: Joseph F. Sobanko, MD, Edwin & Fannie Gray
Hall Center for Human Appearance, University of Pennsylvania,
389
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Fig 1. The superficial (A) and buried vertical mattress (B) sutures each have heart-shaped
loops, but the knot is at the bottom of the loop for the buried suture.
d
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Fig 2. Countertraction with either forceps or a skin hook exposes the dermis for placement of
the deep sutures. A, Ideal placement of the retracting instrument in the papillary dermis
maximizes visibility of the dermis and orients the skin in an everted position. B, Suboptimal
placement of the retracting instrument in the reticular dermis compresses the dermis, which
minimizes visibility and orients the skin in an inverted position.
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Fig 4. The snap of the wound edge toward the center of the wound after the first bite of the
suture indicates a good path of the buried vertical mattress suture. A, The first bite of the suture
has been completed and the skin hook still applies countertraction. B, The skin hook has been
released and the skin edge snaps back toward the center of the wound.
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Fig 6. When the paths of the suture on each wound edge are not mirror images, a discrepancy
in the height of the wound edges results. A, The exit point of the suture on the left side of the
wound is in the reticular dermis, but the needle is entering in the papillary dermis on the right
side of the wound. B, The right side of the wound has been pulled down by the superficial bite.
The exposed dermis on the high side frequently bleeds.
Fig 7. The path of the buried vertical mattress suture varies depending on the thickness of the
dermis. A, Thicker dermis requires a wider bite that extends further from the incised wound
edge and has a greater difference in height between the peak and valley of the heart-shaped
loop. B, Thinner dermis requires a narrower bite with a smaller difference in height between
the peak and valley and of the heart-shaped loop.
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Fig 8. The pull test identifies wound edges that will benefit from a dermal suture. A, Pulling
the wound edges identifies a gap remaining on the right side of the wound. B, After placement
of another deep suture on the right side, the pull test no longer creates a gap, indicating that a
sufficient number of deep sutures have been placed.
Fig 9. A, After placement of the deep sutures in a location with thick dermis, a gap persists
between the wound edges. Note the absence of eversion. B, Narrow suture bites and a circular
path results in a gap after the deep sutures. The wound edges with this suture path do not snap
toward the center of the wound. C, Typical appearance of a wound 1 week postoperatively
after closure with this type of deep suture. The scar is already inverted and excessive tension
from the top sutures has caused intense inflammation and early track marks.
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Fig 10. A, Appearance of a wound after deep sutures that caused eversion and inversion. The
weak dermis could not support the upward slope of the wound edges, which collapsed and
inverted. B, Everted wound edges that collapse and invert because the dermis cannot support
the upward slope to a peak. The wound edge on the right rides over the left side like shingles
on a roof. C, Two-week postoperative appearance of a wound that was sutured with collapse
of eversion. The lower wound edge remains fixed over the upper wound edge, especially on
the left half of the wound.
Fig 11. A, Excessive wound eversion has resulted in a persistent gap between the epidermal
edges after placement of the deep sutures. B, A suture path with an excessively wide bite nearly
sutures the undersurfaces of the dermis together. C, Long-term result with scar spread,
hypertrophy, and suture marks from excessive tension of the top sutures.
Tension may prevent immediate approximation, and the exposed wound edges may bleed.
b. Troubleshooting #2A gap between wound
edges may result from failure to cinch the
buried knot. Eliminate air knots with snug but
not strangulating buried sutures.
c. Troubleshooting #3An insufficient number
of deep sutures will result in weak approximation of the dermis and potential bleeding.
Apply the pull test to the wound. If lateral
traction pulls the wound edges away and
reveals a prominent gap, additional buried
sutures may be necessary (Fig 8).
d. Troubleshooting #4A circular path of the
buried suture results in bleeding from
exposed dermis superficial to the suture
loop. A circular suture path is identified by
splayed wound edges with minimal to no
eversion and by the lack of the dimple often
seen with a heart-shaped buried vertical
mattress suture (Fig 9, A). The circular suture
path occurs most commonly as a result of
either too narrow a bite of the buried suture
or failure to retract the skin edge in an everted
position during the throw of the suture.
Because of the lack of eversion, the skin
edges fail the snap test. Troubleshooting
requires removal of the initial deep sutures
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Fig 12. Correction of wound edges with eversion and inversion phenomenon. A, Identify the
point of collapse where the wound edge begins to invert. B, Trim the excess skin beyond
the point of collapse. C, The newly trimmed wound edges will snap toward the center of the
wound to allow tension-free approximation.
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Fig 13. A, The buried vertical mattress suture has been placed with unequal bites, resulting in a
height discrepancy of the wound edges. B, To correct the height discrepancy with top sutures,
it is often easiest to bite the high side first with a shallow, narrow throw. C, After biting the high
side, the wound edge can be depressed to match the lower side, and a deeper, wider bite is
thrown on the low side. D, The completed top suture corrects the height discrepancy.
Incising
Technical error
Excising
Correction of errors
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Surgical technique
Surgical technique
Undermining
Placing deep
sutures
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Correction of errors
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Technical error
Table I. Contd
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CONCLUSION
This continuing medical education series
provided quality control questions to assess the
technical precision of each step of cutaneous
surgery: incising, excising, undermining, placing
buried sutures, and placing cuticular sutures. These
quality control questions provide a methodology for
objective self-evaluation and help to identify
common technical errors and potential solutions to
obtain reproducibly excellent surgical outcomes
(Table I).
REFERENCES
1. Howe N, Cherpelis B. Obtaining rapid and effective
hemostasis: Part I. Update and review of topical hemostatic
agents. J Am Acad Dermatol. 2013;69:659.e1-659.e17.
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