Transcript 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
Suturing: Questions
Suture Technique:
What Do We Know?
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Very basic skill necessary for most scalpel
surgery, including cutaneous oncologic
surgery and cosmetic surgery.
BUT:
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Surprisingly little objective data comparing
techniques.
No randomized controlled trials.
What Do Most Surgeons Do?
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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?
Suturing: Some Answers
How Dermatologic Surgeons Sew
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Prospective survey of members of AADS in
2003.
60% response rate
Indicative of high levels of uniformity in
technique.
How Dermatologic Surgeons Sew
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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
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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:
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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
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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: Are They
Better or Just Different?
Subcuticular Sutures: Trunk and
Extremities
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New data indicates many benefits
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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
Subcuticular Sutures: Trunk and
Extremities
Can be placed as rapidly as or faster
than superficial running sutures, with
moderate precision, for superior longterm 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
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…And a few caveats
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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
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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
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Inside the suture line, pressed in
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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
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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
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Small number, about 1 per cm
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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
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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
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2-3 weeks
Benefit: low risk of spitting, sinus tracts or suture
irritation.
 Risk: can dehisce when removed
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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
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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
But Do Subcuticular Sutures Work
on the Face?
Subcuticular Sutures: Face
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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
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Initial studies indicate that subcuticular sutures
may also have same advantages on face as
elsewhere.
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No visible sutures to frighten patients
Minimal redness of suture line that takes months to
resolve
BUT, there are disadvantages:
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Temporarily may result in slightly lumpy appearance
May be inappropriate if there is tension on the wound
Tissue Glues
Do Tissue Glues Have a Role In
Dermatologic Surgery?
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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
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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
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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.
Artificial Skin with Fibrin Glue and
Negative Pressure
PROBLEMS AFTER MOHS SURGERY:
AVOIDABLE WITH BETTER
SURGICAL TECHNIQUE
Bleeding or Hematoma
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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
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Patient-directed
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15 minutes of pressure
Apply to smallest possible area to avoid diffusion of
pressure
Persistent bleeding: Return to office
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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
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Infrequent since cutaneous surgery is
clean (e.g., compared to bowel surgery)
Management
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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
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Chondritis of the pinna
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If exposed cartilage
Tetracycline, vinegar soaks, analgesics
Inflamed tissue: overtight suture
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May be with slight prurulence
Ensure no infection
Release some sutures
Consider antibiotics and antiinflammatories
(naproxen)
Contact Dermatitis
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To antibacterial ointment
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Pruritus, erythema, rare bullous reaction
Treat by:
Substituting petrolatum
 High-potency steroid ointment for 3-5 days
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Allergic tape reaction
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Sharply demarcated
Discontinue tape use if possible; consider
cloth dressings
Dehiscence
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Causes
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Avoidance
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Pressure on sutures
Weakening of wound by trauma, infection, bleeding,
edema
Premature removal of sutures
Vertical mattress sutures may be stronger
Avoid deep sutures on scalp (abscess)
Management
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If edges trimmed, closure will take longer
Use wound closure tape concurrently
Scar revision
Delayed Wound Healing
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Causes
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Infection
Nutrition/metabolic
Poor vascular supply (esp. LE)
Management
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Treat underlying problem
Prolong suture time
Use concurrent antibiotics and
antiinflammatories to reduce risk
Tissue Necrosis
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Causes: poor blood supply
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Manifestations
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Tension on vessels
Transection of vessels during surgery
Poor tissue handling
Inadequate local blood supply
Superficial blistering
Dusky appearance, soon demarcated
Management: debride
Hypergranulation
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Occasionally in wounds healing by
secondary intent
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Bright red spongy tissue that rises above
wound bed
“Proud flesh”: delays or impede healing
Management
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Curettage/aluminum chloride
Silver nitrate sticks (may stain)
May need to repeat treatments
Pain
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Intraoperative
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Light pain can be corrected by further
anesthesia
0.5-2.0% Lidocaine with epinephrine and
bicarbonate
Postoperative
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Tylenol q4 routinely after surgery
Ice packs prn
Tylenol #3 if necessary; substitute if allergic
Immediate Nerve Damage
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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
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Usually minimal in cutaneous wounds
Suture stretch and tissue necrosis is
possible
Potential sites
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Periorbital on malar eminence
Usually temporary – few weeks
 Swelling of eyelids may be significant
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Other areas where lymphatic flow interrupted
by surgery
Surgical Technique: General
Principles
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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