Guide to suturing and producing better scars

1. Guide to suturing, achieving better scars
& flaps for skin cancers
Dr Charles Cope
MBBS(Hons), BSc(Med), FRACS
Cosmetic Plastic & Reconstructive Surgeon

2. Local anaesthetics
• Lignocaine
– 5mg/kg, 7mg/kg with adrenaline
– for 1% lignocaine 0.5mls = 5mg
– faster onset, shorter duration vs Marcain
– adrenaline takes 7mins or more to work
– never use adrenaline in extremities (digits/penis)
• Marcain
– 2mg/kg (with/without adrenaline)
– more cardiac toxicity (Naropin better)
• Emla (topical cream)
– mix 2.5% lignocaine and 2.5% prilocaine (expensive)
– increasing depth penetration up to 3-4mm at 4hrs

3. Traumatic wounds
• ?Foreign body - ?x-ray or ultrasound
• Debridement
• Washout
• ADT- tetanus
• Antibiotics

4. Skin lesion excision principles
• Incision placement
• Avoid tension
• Avoid dead space
• Intradermal (deep dermal) sutures
• Skin sutures
• Dressings
• Scar management

5. Incision
• Place incision along
Langer’s lines
• Length scar is 2.5-3.0
times length of lesion
being excised – if <2.0
then will definitely get
dog-ear

6. Incision
• pinch skin to create
Langer’s lines if no
creases present

7. Incision
• Bevel incision
outwards
– avoids incomplete
excision
– helps to achieve
eversion of wound
closure

8. Wound Closure
• Avoid tension if possible
• Avoid trauma to surrounding tissue
• Undermining the skin edges helps to ease the tension
• Leave a thin layer of fat underneath the dermis when
undermining, to preserve the subdermal blood supply
• Avoid dead space by ensuring approximation of deeper
tissues – dead space increases haematoma/seroma rate and
wound infection
• “Halving” important if wound edges of different lengths,
and helps to avoid dog-ears at the ends of the wound

9. Wound Closure (continued)
• Avoid excessive tightness of sutures in
closure – some oedema day 2-3 -
“approximation without strangulation”
• Excessive tightness of skin sutures can
lead to necrosis, infection and poor scar
(old abdominal closures)
• Lower limb in elderly – better to leave
1-2mm gap than strangulate!

10. Wound tensile strength
• In areas prone to
stretched scars eg back,
shoulder, around joints
need to provide support
to the wound for at least
3 months

11. Intradermal (deep dermal) sutures
• Use intradermal suture to take
tension off skin closure
• Helps to avoid dead space
• By reducing tension of the
superficial wound closure, allows
– smaller sutures to be used in
the skin
– skin sutures to be removed
earlier (no stitch marks)
• Provides long-term support to
wound, reducing stretching and
depression of the scar

12. Intradermal (deep dermal) sutures
• Absorbable monofilament
undyed suture eg Monocryl
(PDS on back/shoulder)
• Important to place knot on
deep surface
• Placing too superficially
increases risk infection (esp
Vicryl)
• Especially useful with
subcuticular sutures eg back
• Can be used as only skin
closure without skin sutures
NB increases firmness scar (short-term), small percentage have
late infection as suture dissolves (4-6 weeks)

13. Simple sutures
• Suture through all
epidermis and some/all of
the dermis
• Depth of dermal
placement on thickness
skin (thin skin  deeper)
• Slightly more dermis than
epidermis in bite (needle
at least at right angles to
skin surface) – everting
wound edges helps to
achieve this

14. Simple sutures
• Avoid wound inversion – this
leaves a depressed scar
• Aim for wound eversion –
scar flattens in relatively
short time

15. Treating the dog-ear
• all methods make the
scar longer
• easiest way is to make
the incision longer in a
straight line

16. Minimising scar length – serial excision
• Benign lesions in
cosmetically sensitive areas
eg alar nose or large lesions
eg congenital naevi
• 2 excisions, 2-3 months
apart
• 1st stage - excise ellipse
within lesion (removes most
of lesion)
• 2nd stage – excision all
remaining lesion

17. Subcuticular closure
• Knots at the end can
be difficult!
• Use intradermal suture
to start subcuticular
suture
• Alternatively, where
many intra-dermal
sutures present, do not
tie knots at either end
and steristip wound

18. Continuous suture (over and over)
• Advancement on underside wound
• Most rapid, but technique important!
• Must carefully adjust tension on
suture as progress along wound
• If not careful can either get excess
tension (postop swelling) leading to
stitch marks or separation wound
• Suitable for nearly any wound where
edges are equal length
• If slightly uneven edges can use
occasional mattress suture (reverse
direction)

19. Dressings/topical ointments
• Applied for haemostasis, to absorb exudate, protect
wound surface, reduce pain
• Remove initial dressing at 24-48 hrs if expecting ooze
• Topical antibiotic may assist in healing – keeps surface
moist, preventing contamination, bactericidal
• Remove dressing and apply tds eg chloromycetin
• Useful for facial wounds where some ooze expected

20. Wounds where some ooze expected
• Chloromycetin/betadine ointment
• Jelonet & gauze
• Occlusive Tegaderm
• Instruction to remove dressing if excessive ooze or
seal broken and dressing wet

21. Steristrips/micropore
• Useful where minimal ooze expected (small
lesion, not on aspirin etc)
• Opsite spray helps to stick
• Patient can shower – simply pat dry
• Often stays on until suture removal

22. Suture removal
• Be careful if removing sutures
at 4-5 days!
• Technique is more important
• Grasp suture near knot and
cut between knot and skin
• Pull the suture towards and
over the incision
• Steristrip wound

23. What I use for wound closure
Site Intradermal Skin suture Suture Dressing
suture removal
Face 5/0 Monocryl 5/0 or 6/0 4-5 days Steristips or
ointment
Scalp 4/0 4/0 or 5/0 7 -10 days Ointment
Arm, chest, 3/0 to 5/0 Subcuticular 7-10 days Steristips or
back, abdo ?PDS or 5/0 Occlusive
Leg 3/0 to 5/0 4/0 10-14 days Steristips or
Occlusive

24. Postoperative scar management
• Important on face/neck/sternum/back/previous
hypertrophic scars
• Alternatives
– Micropore tape applied along scar
– Massage (firm)
– Hyperfix/Fixomull
• Start at day 10-14
• Continue for minimum 3 months postoperatively
• Other scar management EARLY if scar becoming
raised

25. Corticosteroids
• Used alone variable response rate (50-100%)
• Most effective EARLY
• Soften and flattens scar
• Kenacort A10 4 weeks apart until no further
regression (A40 if no reponse from A10)
• Side effects – hypopigmentation, fat atrophy,
telangiectasias, necrosis – inject into scar only
(see blanching)

26. Silicone gel sheeting
• Has to be on all the time! – better tolerated than
pressure garments
• May need to be supervised by physiotherapists
• Need to hold silicone sheet to scar in many areas
eg around joints (difficult on face) eg Hyperfix
• Treatment may need to be for > 6 months
• Preventative following excision if history of
hypertrophic scars

27. Laser therapy
• Vascular specific laser (585nm) or Fraxel®
• Scars softer, less erythematous, pruritic and
hypertrophic
• 80% response after 2 treatments
• Most effective early (1st 2-3 months)

28. Fraxel laser – surgical scar

29. Pressure therapy (Jobst garment)
• Action secondary to tissue ischaemia
• Poorly tolerated by patients
• Increases success to 90-100%

30. Treatment hypertrophic scars - ?scar revision
• If there was a problem with the original wound
healing eg infection, wound breakdown, then scar
revision more likely to improve the appearance of
the scar
• Surgical excision best treatment for small-moderate
sized hypertrophic scars
• Always use other modalities (steroids, silicone etc)
as well – high recurrence (50-80%) with surgery
alone
• Sometimes use z-plasty or w-plasty to reorientate
contraction forces

31. Z-plasty and W-plasty
• Redistributes line
of tension across
the wound

32. W-plasty & laser

33. Summary of skin lesion excision
principles
• Use intradermal sutures to avoid tension
and dead space
• Take out skin sutures early
• Prophylactic treatment scar
• Treat or refer problem scars EARLY
(within 6-8 weeks)

34. Skin flaps
• Better cosmetic result than
skin grafts
• Useful when:
– cannot close wound primarily
– primary closure would distort
surrounding important
structures eg nose, eyelid
• But
– take longer to settle (often
swelling for months)
– some need revision
• Need better haemostasis

35. Skin flaps for skin cancers
• Principle = distribute tension over larger area to
achieve closure (but results in bigger scar)
• General principle – larger flap = better blood
supply, less tension on closure
• Nearly all have prolonged swelling requiring
massage (months to settle)
• The same flap does not work all the time in the
same position esp. on nose!

36. Useful flaps
• Hatchet
– preauricular, temple, forehead
– legs (1 or 2) caution!
• V-Y advancement
– cheeks, nose
• Keystone
– lower leg, forearm, torso
– hand/foot (caution)

37. Hatchet flaps - Emmett

38. V-Y advancement flaps
• Useful on cheek, nose &
sometimes eyelid
• leaves subcutaneous pedicle
• undermine leading edge (20-25%)
• mobilise remainder with blunt
dissection using spreading scissors
to maintain blood supply

39. V-Y advancement flaps

40. V-Y advancement flaps

41. Keystone flap – Felix Behan 2003
• Often has larger blood
vessels/perforators going into
the flap
• Useful to avoid grafting
• Lower leg, forearm, trunk
• Hand & foot (caution)

42. Keystone flap

44. Keystone flap
• Useful to avoid grafting
• Lower leg, forearm, torso
• Hand & foot (caution)

45. • Questions?
• Practical suturing session
– use of intradermal sutures