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492 Reprinted from Australian Family Physician Vol. 35, No. 7, July 2006 ‘Will the surgery leave a scar?’ is one of the mostfrequently asked questions that surgeons face. Whileoperating on deeper structures may present more of achallenge for surgeons, patients often judge the skillsof a surgeon by the cosmetic appearance and scarringresulting from surgery. With appropriate expertise andtechnique, a well placed fine line scar should be a goalthat all surgeons aim to deliver to their patients. Everysurgicalortraumaticwoundhealswithascar.Thefinalappearanceofanyscarisdependenton: ãpatientfactorsãwoundfactors,andãtechnicalfactors. Patientfactorsincludethepatient’sgeneralhealthandcomorbidconditions,age,ethnicity,hereditarypredisposition,skintype,andmedications.Whilethesefactorsareoftenoutsidethecontrolofasurgeon,everyeffortshouldbemadetooptimiseanycorrectableproblems.Apasthistoryofkeloidorhypertrophicscarshouldalsoalertthepatientandthesurgeonthatclosefollowupandearlyinterventionmaybeneeded.Woundfactorsincludethenatureofthewound(eg.traumaticvs.elective),thelocationandorientationofthewound,thevascularityandqualityoflocaltissues,theelasticityandtensionofadjacentsofttissues,andthedegreeofcontaminationbybacteriaanddirt.Exceptforthelocationoftraumaticwounds,surgeonscanofteninfluencethefinalresultbyimprovingsomeofthewoundfactors.Thetechnicalfactorsarecompletelywithinthecontrolofthesurgeonandincludetheplanningofincisions,careoftissuehandling,adequacyofdebridement,suturesused,methodandtensionofwoundrepair,theperiodoftimethatsuturesareleftinsitu,andpostoperativescarmanagement. BACKGROUND Although meticulous technique cannot guarantee a superior cosmetic result when repairing skin wounds or excisingskin lesions, a well planned and executed repair reduces the risk of unsatisfactory scarring. OBJECTIVE This article discusses sound plastic surgery principles that every doctor operating on the skin can apply. Common suture techniques and simple flap techniques and their indications are also discussed. DISCUSSION Principles of effective wound repair include: good lighting and equipment, atraumatic tissue handling, early repairof traumatic wounds, thorough wound debridement and lavage, avoiding healing by secondary intention, judiciousantibiotic prophylaxis, appropriate planning of incisions, carefully executed incisions, avoiding wound repair under tension, layered wound repair, use of appropriate suture size and needle, everted wound edges, use of adjuncts such asskin tapes and soft tissue adhesives, and early suture removal. Useful suture techniques include deep dermal sutureswith buried knots, simple interrupted sutures, vertical mattress, horizontal mattress, subcuticular sutures, continuousover-and-over sutures and far-near near-far pulley sutures. Rotation, transposition, advancement and island flaps can beuseful to close defects in situations where skin grafting is not possible or desirable. Plastic surgerymade easy Simple techniques for closing skin defectsand improving cosmetic results Terry Wu MBBS, FRACS, is a plasticsurgeon, Waverley PrivateHospital, Epworth EasternMedical Centre, CothamPrivate Hospital, PeterMacCallum Cancer Institute,Dandenong and Box HillHospitals, and the Skin andCancer Foundation, Melbourne,Victoria.
[email protected] THEME Wounds Reprinted from Australian Family Physician Vol. 35, No. 7, July 2006 493 Althoughmeticuloustechniquecannotguaranteeafinelinescar,awellplannedandexecutedwoundrepairreducesthepossibilityofunfavourablescarring. Basic principles of wound repair Good lighting and equipment Itcannotbeemphasisedenoughthatgoodlightingandequipmentareparamountforagoodsurgicalresult.Appropriatelysizedtoothedforcepsandneedleholdersareimportant,whilegoodcuttingscissorsneedtobepartofeverysuturekit.Aselectionofscalpelsizesshouldalsobeavailable,althoughthemostfrequentlyusedisthesize15scalpel. Atraumatic soft tissue handling Tissueischaemiaanddesiccationresultinnecrosisandpoorscarring.Itisvitallyimportanttoavoidroughtissuehandlingandcrushinginstruments.Skinhooks,cat’spawsandtoothedforcepsfacilitateatraumatictissuehandling.Frequenttissuewettingwithnormalsalinepreventstissuedesiccation.Judiciouscauterycanpreventbleedingandimprovewoundhealing. Early repair of traumatic wounds Bacterialinoculationofthewoundmaybeincreasedwhenthewoundrepairissignificantlydelayed.Traumaticwoundsshouldberepairedassoonaspossible.However,whenanearlyrepairisnotpossible,appropriatedressingstoreducetissuedesiccationandcontaminationmayallowthesurgeontoclosethewoundupto24–48hourslater. Thorough wound debridement and lavage Debridementinvolvestheremovalofalldevitalisedandcontaminatedtissueswithmaximalpreservationofcriticalanatomicalstructures.Copiousirrigationorpulsatilejetlavageshouldalsobeusedtoremoveresidualcontaminants.Oftenwhentheborderbetweenviableanddevitalisedtissuesisnotclear,itisimportanttodressthewoundappropriatelytopreventdesiccationandreturnforasubsequentdebridement24–48hourslater.Morereconstructionsaftertraumafailbecauseofinadequatedebridementthanbecauseoffailedreconstructivetechnique. Avoid healing by secondary intention Healingbysecondaryintentionshouldbeavoidedasitisprolongedandoftenproduceshypertrophicscarring. Judicious antibiotic prophylaxis Asingleprophylacticantibioticdosageadministeredjustbeforeskinincisionmayreducetheincidenceofwoundinfection. Appropriate planning of incisions Inexcisingalesioninanellipticalfashion,thelongaxisshouldbefourtimesthelengthoftheshortaxis.Whentheellipseistooshort,oronesideoftheellipseisshorterthantheother,‘dogears’formattheendsoftherepairedwound( Figure 1 ).Although‘dogears’mayflattenovertime,preventionorprimarycorrectiongivesthebestresult.Thefinalorientationofanellipticalincisionshouldbeparalleltothe‘relaxedskintensionlines’(RSTL).Theselinescorrespondtoskinwrinklelinesandlieperpendiculartothelongaxisofunderlyingmuscles.Theyrepresentlinesofminimalskintension.MaximalscarcontractionoccurswhenascarcrossesRSTLatarightangleandmaybeveryobvious.ScarsarebestconcealedwhentheyareplacedalongRSTLandnaturalbordersbetweenanatomicalregions( Figure 1 ).Examplesincludeplacingthescarsalongforeheadwrinklesornasolabialfolds.Everyeffortshouldbemadetoavoidincisionscrossingajointcreaseatarightangleandparticularlyovertheflexorsurfaceofajoint.Theseincisionscanresultinscarandjointcontractures.Whenanexcisionisplanned,itisimportanttoavoiddistortionofadjacentanatomicallandmarkssuchastheeyelid,eyebroworearhelicalrim.Frequentlyaflapshouldbeusedtoavoiddistortionofananatomicallandmarkeventhoughdirectclosureistechnicallypossible.Wedgeexcisionsmaybeusedonlipsoreyelidswhilesteppedwedgeexcisionsmaybeusefultoavoidhelicalnotchingwhenexcisingfullthicknessearlesions( Figure 2 ). Expertly executed incisions Incisionsshouldbemadeconfidentlyandcleanly.Incisionsshouldbeperpendiculartotheskinsurfaceandshouldnotbeangled.Poorlyexecutedincisionscanimpairwoundedgeappositionandresultinpoorscarring. Avoid wound repair under tension Woundrepairundertensiongreatlyincreasestissueischaemiaandnecrosisandoftenresultsindehiscenceandpoorscarring.Whentensionfreedirectclosure Figure 1. Positioning of incisions alongRSTL and natural anatomical bordersReproduced with permission: Aston SJ,Beasley RW, Thorne CHM, editors. Grabband Smith’s plastic surgery. 5th ed.Philadelphia: Lippincott-Raven, 1997Figure 2. Wedge excisions on lips, nose,eyelids and earsReproduced with permission: Aston SJ,Beasley RW, Thorne CHM, editors. Grabband Smith’s plastic surgery. 5th ed.Philadelphia: Lippincott-Raven, 1997Figure 3. Deep dermal sutures decreasewound tension and facilitate woundeversion. Skin is then closed with simpleinterrupted suturesReproduced with permission: Aston SJ,Beasley RW, Thorne CHM, editors. Grabband Smith’s plastic surgery. 5th ed.Philadelphia: Lippincott-Raven, 1997 Plastic surgery made easy – simple techniques for closing skin defects and improving cosmetic results THEME 494 Reprinted from Australian Family Physician Vol. 35, No. 7, July 2006 isnotpossible,reconstructionwitheitheraskingraftorflapwillbeneeded. Layered wound repair Deepdermalsutureswithburiedknotsprovidethestrongestskinwoundrepairandremovethetensionfromsuperficialinterruptedsutures.Theyalsoallowthesuperficialsuturestoberemovedatanearlierdateinordertopreventcrosshatching.Deepdermalsuturesalsoalignthedermisforaccuratedermisappositionandsetsthestageforsuperficialskinsutures. Use appropriate suture size and needle Byusingthesmallestpossiblesutureplacedcorrectly,woundrepairstrengthcanbemaintainedandtissueischaemiacanbeminimised.Usually5/0or6/0suturesarerequiredforthefaceandhand,while4/0or3/0suturesmaybeusedonthelimbsortrunk.Forskinrepair,acuttingorreversecuttingneedletraversesthroughtissueatraumatically. Everted wound edges Woundedgeeversionisatenetofgoodskinrepairandisachievedbybitingalargeramountofthedeeperdermiswhenintroducingtheneedlethroughtheskin.Thiscouldbeachievedbyintroducingtheneedleverticallyattheskinsurfaceandfollowthearcoftheneedlebyforearmsupination.Aftertyingtheknot,thesutureappearspearshapedincrosssection. Use of adjuncts such as skin tapes and soft tissueadhesives Correctlyappliedskintapessuchassteri-stripsormicroporetapeprovidewoundsplintingandreinforcethewoundrepair.Inchildren,theapplicationoftissueadhesivessuchasDermabondontheskinsurfaceafterdeepdermalburiedsuturescanavoidthedisadvantagesofabsorbablesuperficialsuturesortheneedtoremovenonabsorbablesuperficialsutures. Early suture removal Whensuturesareleftinfortoolong,theybecomeburiedandproducecrosshatching.Ingeneral,whenoptimalwoundhealinghasoccurredanddeepdermalburiedsuturesareused,superficialsuturesshouldberemovedfromthefaceinabout3–5days,whilesutureselsewhereonthebodyshouldberemovedinabout7–10days.Itisimportantthatthewoundsaresupportedbyskintapingaftersutureremoval. Common techniques for sutures Deep dermal sutures with buried knots UsuallyanabsorbablesuturesuchasMonocrylisused.Thisdeepsutureisvitalatfacilitatingwoundeversionandaccuratetensionfreesuperficialskinsutures( Figure 3 ). Simple interrupted sutures Simpleinterruptedsuturesarethemostcommonlyusedsutures.Theneedleshouldbeintroducedat90°intotheskininordertoincludealargeramountofthedeeperdermis.Thisallowsthewidthofthesutureatitsbaseinthedermistobewiderthantheepidermalentranceandexitpoints.Asyntheticnonabsorbablesuturesuchasnylonisoftenused. Vertical mattress Verticalmattresssuturesareusedwhenwoundeversionfailstobeachievedbysimpleinterruptedsutures.Verticalmattresssuturesleaveobviouscrosshatchingandmustberemovedearly. Figure 6. Continuous over-and-over suturesReproduced with permission: Aston SJ,Beasley RW, Thorne CHM, editors. Grabband Smith’s plastic surgery. 5th ed.Philadelphia: Lippincott-Raven, 1997Figure 4. Horizontal mattress suturesReproduced with permission: Aston SJ,Beasley RW, Thorne CHM, editors. Grabband Smith’s plastic surgery. 5th ed.Philadelphia: Lippincott-Raven, 1997Figure 5. Continuous subcuticular suturesReproduced with permission: Aston SJ,Beasley RW, Thorne CHM, editors. Grabband Smith’s plastic surgery. 5th ed.Philadelphia: Lippincott-Raven, 1997 Plastic surgery made easy – simple techniques for closing skin defects and improving cosmetic results THEME Reprinted from Australian Family Physician Vol. 35, No. 7, July 2006 495 Horizontal mattress Horizontalmattresssuturesmayhelpwithwoundeversion,althoughtheytheoreticallycausemorewoundischaemia( Figure 4 ). Subcuticular Continuoussubcuticularsuturesprovideanexcellentwaytoachieveaccurateskinedgeappositionwithoutexternalsuturesorcrosshatching.Theneedleisintroducedhorizontallythroughthesuperficialdermisparalleltotheskinsurfaceandthebitesneedtobemadeatthesamedepthandofthesameamounteachtimeinordertoachieveanaccurateskinedgeapproximation( Figure 5 ).EitherasyntheticabsorbablesuturesuchasMonocryl,orasyntheticnonabsorbablesuturesuchasnylon,canbeusedandremoved1–2weekslater. Continuous over-and-over sutures Continuousover-and-oversuturescanbeplacedrapidlyandprovidehaemostasisbycompressionofthewoundedges( Figure 6 ).Theymaybeusefulinscalpclosures. Far-near near-far pulley sutures Thefar-nearnear-farpulleysuturesareamodificationoftheverticalmattresssuturesandprovideapulleyeffecttoachievewoundclosureundertension.Thesuturesmaybeusedasatemporarymeasuretobringthewoundedgestogetherinorderforthedeepdermalandsuperficialinterruptedsuturestobeplaced.Thepulleysuturesmaythenberemovedtominimisecrosshatching.Thefirstloopisplacedapproximately4–6mmfromthewoundedgeonthefarsideandexitsapproximately2mmfromthewoundedgeonthenearside.Thesuturecrossesthewoundandre-enterstheskinonthefarsideat2mmfromthewoundedgeandthesutureexitstheskinonthenearside4–6mmawayfromthewound.Thiscompletesthetwoloopsthatactasapulley( Figure 7 ). Flap techniques for the treatment room Simplelocalflapscanprovidebettercolour,textureandthicknessoftissuesforthereconstruction.Flapsareparticularlyusefulwhenaskingraftisnotdesirableorpossibleduetopoorrecipientsitefactors.Themaindisadvantagesoflocalflapsincludeasteeplearningcurveandadditionalscarringintheareaofthereconstructionfromthedonorsite.Thebasicprinciplesofallflapreconstructionsareto: ãdefinethedefectfirstãfindanareawherethereareredundanttissuesanddesignawaytotransferthesetissuestorepairthedefectwhichisshortoftissues. Thismethodreliesontheskin’snaturalvisco-elasticityandisofteneasiertocarryoutintheolderpatientasthereismoreskinlaxity.Themostimportantpartoftheflapreconstructionisinitsplanning.Theflapshouldbedesigned‘inreverse’startingwithdefiningthedefectandtransferringitontoapattern.Thispatternisthenusedtocarryoutthestepsofflapreconstructioninthereverseorderuntil Figure 7. Far-near near-far pulley suturesFigure 8. Rotation flapReproduced with permission: Aston SJ,Beasley RW, Thorne CHM, editors. Grabband Smith’s plastic surgery. 5th ed.Philadelphia: Lippincott-Raven, 1997Figure 9. Transposition flapReproduced with permission: Aston SJ, Beasley RW, Thorne CHM, editors. Grabb andSmith’s plastic surgery. 5th ed. Philadelphia: Lippincott-Raven, 1997Figure 10. Clinical examples of Limberg flaps
