Chapter 1: Skin Repair and Minor Plastic Surgery

It is important to keep the following in mind:¹

1. Plan all excisions carefully.

2. Check previous scars for healing properties.

3. Aim to keep incision lines parallel to natural skin lines.

4. Take care in poor healing areas, such as backs, calves and knees; and in areas prone to hypertrophic scarring, such as over the sternum of the chest, and the shoulder.

5. Use atraumatic tissue-handling techniques.

6. Practise minimal handling of wound edges.

7. Use Steri-Strips™ after the sutures are removed.

Suturing is a fundamental and important skill for which patients may judge the performance quality of their practitioner. This skill involves the appropriate method of treating a wound. Small superficial cuts heal well if debrided and cleaned with a suitable antiseptic such as chlorhexidine, and covered with a clean adhesive dressing.

The use of Steri-Strips™ for smaller clean wounds is to be encouraged (Fig. 1.1). Children may not tolerate repair of wounds with local anaesthetic and suturing so appropriate closure with Steri-Strips™ after disinfection and drying is recommended—as is the use of their hair for scalp wounds (Chapter 15). Primary sutures should be avoided in significantly contaminated or severely contused wounds, especially if there has been a delay of 4 hours or more before repair. Such wounds should be cleaned, trimmed and a dry dressing applied. It can then undergo primary suturing on the fifth day.

Steri-Strips™

These adhesive strips are ideal for smaller clean cut wounds which should at first be disinfected and dried.

Method

1. It is usual to start in the centre of the wound.

2. Render the strip taut and straight with a finger on either side of the strip as it is placed over the wound (Fig. 1.1).

3. Lock it in place then repeat with a series of strips at appropriate intervals. The strips can be bolstered by applying a cross strip parallel to the wound.

Steri-Strips™ can also be used to supplement a sutured wound.

How long

They are usually worn until they fall off or are removed in 5 to 7 days.

Removal

Soak in water. Remove any cross strip. Then as you press down on skin, lift one end, then the opposite end and gently lift it off the wound.

• Aqueous chlorhexidine gluconate

• Alcoholic chlorhexidine gluconate

• Chlorhexidine and cetrimide

• Povidone-iodine (aqueous)

• Povidone-iodine (alcohol base)

  Rules:

• Blot dry any pools of preparation solutions.

• Alcohol-based preparations are flammable.

• Avoid alcohol on mucous membranes and on sensitive skin, e.g. eyelids, scrotum.

• Avoid chlorhexidine contact on eye or middle ear. It can cause conjunctivitis and severe corneal damage.

Mandatory safety measures

• Goggles

• Gloves

• Protective gown

Common mistakes for excisional surgery

• Skimping (inadequate margins)

• Tension on skin edges

• Knots too strongly tied

• Stitches too thick

• Too large a bite

• Stitches in too long

• Inadequate early compression

Minimising bleeding in the elderly

Stop anticoagulants (if possible) before a significant procedure. Examples:

• warfarin—3 days

• aspirin—10 days

• NSAIDs—2 to 5 days (check half life).

• NOACs—3 to 4 days

Suture material (Table 1.1)

• Monofilament nylon sutures are generally preferred for skin repair. They produce less tissue reaction than silk.

• Use the smallest calibre compatible with required strains.

• The synthetic, absorbable polyglycolic acid or polyglactin sutures (Dexon™, Vicryl^®) are stronger than catgut of the same gauge, which is uncommonly used now. The monofilament absorbable sutures (Monocryl^®, Maxon™)¹ are most suitable for subcuticular suturing.

Instruments

Examples of good-quality instruments:

• locking needle holder (e.g. Crile-Wood 12 cm)

• skin hooks

• iris scissors.

Holding the needle

The needle should be held in its middle because this will help to avoid breakage and distortion, which tends to occur if the needle is held near its end (Fig. 1.2a).

Incisions

Incisions should be made perpendicular to the skin (not angled) (Fig. 1.2b).

Dead space

Dead space should be eliminated, to reduce tension on skin sutures. Use buried absorbable sutures to approximate underlying tissue. This is done by starting suture insertion from the fat to pick up the fat/dermis interface so as to bury the knot (Fig. 1.3).

Everted wounds

Eversion is achieved by making the ‘bite’ in the dermis wider than the bite in the epidermis (skin surface) and making the suture deeper than it is wide. Shown is:

• a simple suture (Fig. 1.4a)

• a vertical mattress suture (Fig. 1.4b).

The mattress suture is the ideal way to evert a wound.

Number of sutures

Aim to use a minimum number of sutures to achieve closure without gaps, but sufficient sutures to avoid tension. Place the sutures as close to the wound edge as possible.

Special techniques of knot tying are necessary to achieve a secure knot. Insecure knots leading to slippage of a tie may result in catastrophic blood loss or at least revisiting the surgery. The ability to tie a secure knot should be a reflex action based on practice for the proceduralist. The friction between threads of the suture material is also a factor in avoiding slippage of the knot. The monofilament braided synthetics, particularly nylon and polyesters, are more supple and easier to handle so that knots are easier to tie securely.

Reef knot

The traditional secure knot is the reef knot, which is a firm interlocking knot. The basic element is a half-hitch and it forms the basis of the surgeon’s knot. In this knot, one thread is looped around the other and the knot is completed by a mirror image of the first throw. It is achieved by trying the first throw one way and then reversing it. The two free ends of one suture emerge from either above or below the loop created by the other suture (Fig. 1.5). It is basically two loops that pull against each other to interlock. Consider it as ‘left over right’ and then ‘right over left’.

Granny knot

A granny knot is formed when the reverse of this mirror image throw is formed; that is, the throws go the same way. The free ends emerge one above and one below each loop (Fig. 1.6). It is best to avoid this knot in surgical practice as it tends to slip and is therefore dangerous for precise surgery as the wound will open.

The surgeon’s knot

Also known as the square knot, it involves the same pattern as the reef knot, except that there are two throws on each side of the knot instead of one (Fig. 1.7). The ends of the thread should be pulled at 180º to each other.

The instrument knot

The instrument knot, which is the most common knot, uses the principle of the reef knot. Initially, the thread is wound twice around the needle holder (say in a clockwise direction) to create the double loop of a surgeon’s knot and then firmly tied (Fig. 1.8a). On the reverse side, the thread is wound around the needle holder in the opposite direction (an anti-clockwise spiral), thus creating the double loop of a surgeon’s knot. The knot is finally secured by pulling the ends at 180º to each other (Fig. 1.8b).

Ligatures on vessels

Every precaution must be undertaken to avoid the ligature slipping. The first tie should be very tight, and the second slacker than the first. For deep ties on vessels it is best to tie with the hands and keep the ties parallel to the wound. Do not pull upwards on the tie. Leave an adequate cuff of tissue past the tie (see Fig. 1.28).

The two common methods of holding a scalpel are:

• the pen grip, and

• the underhand grip.

The pen grip, which is the one most commonly used in minor surgery, is used for fine incisions or excisions and for dissection with the scalpel. Most of the movement imparted to the blade comes from the hand and fingers (Fig. 1.9). The underhand or table-knife grip (Fig. 1.10) is traditionally used for long incisions, such as in abdominal surgery. A larger handle and blade are used.

While many part-time surgeons prefer the use of disposable scalpels, it is appropriate to use firm two-piece metal scalpel holders and blades. For safe handling it is important to become deft at using forceps to insert scalpel blades onto the scalpel handle (Fig. 1.11), and also to remove the blade. In the latter the thumb can be used to facilitate unloading by steadily pressing against the forceps (haemostat clamp) in an extension movement (Fig. 1.12). Another blade unloading method is to grasp the blade with the forceps and rotate the forceps to lift the end of the blade, which is then pushed off the handle.

If grit and other foreign material such as oil is left in the wound, an unacceptable tattoo effect will occur in the healed wound. This can be avoided by meticulous exploration of the wound to remove debris and dermabrasion for superficial grit.

Continuous subcuticular (intradermal) running suture

This is ideal for the repair of episiotomy wounds with an absorbable suture after the dead space has been closed. It does have a limited place in skin repair where monofilament nylon material is best, especially for removal of the suture. With this non-absorbable suture method the meticulous placement without kinks or knots that may impede later removal is necessary. Either end is left free but the total suture can be tied over the wound (Fig. 1.13(b)) in contrast to leaving the ends free. Supplementary interrupted skin sutures or Steri-Strips™ may be necessary for accurate skin-edge apposition.

Method

This suture picks up dermis only (picking up the epidermis and fat is not acceptable), and should be inserted uniformly at the same level without gaps in the linear direction (Fig. 1.13a).

‘Over-and-over’ suture

This is a useful time saver, especially where a meticulous cosmetic result is not required. One disadvantage is the tendency to bunch the wound up. The suturing should not be too tight nor too widely spaced (Fig. 1.13c).

Blanket stitch

The blanket or ‘running lock’ stitch does not tend to bunch the wound up. A double turn at each stitch converts it into a locked suture (Fig. 1.13d).

The pulley suture, also called the ‘near–far, far–near’ suture, is a very useful technique for the closure of difficult wounds, especially those on the lower leg. It permits approximation of the wound when an extra 2–3 mm of space needs closing and the normal method falls short of adequate closure.

Method

1. Introduce the needle 3–4 mm from the edge of the wound.

2. Let the needle emerge about 8–10 mm from the wound edge on the opposite side.

3. Reintroduce the needle at 8–10 mm on the original side.

4. Finally, let the needle emerge at 3–4 mm on the opposite side (Fig. 1.13e).

After the suture is in place, normal interrupted sutures can close the wound. However, the pulley suture may create too much tension and, if it does, it should be removed and replaced with a simple suture.

The cross-stitch, which is a type of pulley suture, is an excellent method for closing difficult wounds where there is likely to be some tension across the wound.

The cross-stitch is ideal for small circular wounds left after a 3–5 mm punch biopsy. It will shorten the scar and avoid the placement of two sutures. It gives a neater result than the vertical mattress or the horizontal mattress. Circular wounds up to 10 mm in diameter in areas of thicker skin can be closed with one such figure-of-eight suture.

Method

Consider a punch biopsy wound of 5 mm in diameter. Using a 5/0 or 6/0 nylon atraumatic suture insert the needle from right of centre across the wound to left of centre, then from left of centre to right of centre on the next pass (or the other way, i.e. from left to right and back). Thus four strands cross the wound and when tied create a pulley effect (Fig. 1.14).

It is important to select optimal sites for elliptical excisions of tumours of the face. As a rule, it is best for incisions to follow wrinkle lines and the direction of hair follicles in the beard area. Therefore, follow the natural wrinkles in the glabella area, the ‘crows feet’ around the eye, and the nasolabial folds (Fig. 1.15). To determine non-obvious wrinkles, gently compress the relaxed skin in different directions to demonstrate the lines.

For tumours of the forehead, make horizontal incisions, although vertical incisions may be used for large tumours of the forehead. Ensure that you keep your incisions in the temporal area quite superficial, as the frontal branch of the facial nerve is easily cut.

Small lesions are best excised as an ellipse. Generally, the long axis of the ellipse should be along the skin tension lines identified by natural wrinkles.

The intended ellipse should be drawn on the skin (Fig. 1.16). The placement will depend on such factors as the size and shape of the lesion, the margin required (usually 2–3 mm) and the skin tension lines.

Note: The scalpel should be held at right angles to the skin.

Excision margin rules

• 1–2 mm: moles and benign lesions

• 3–4 mm: BCCs

• 4–10 mm: SCCs

General points

• The length of the ellipse should be 3 times the width (usually for head and neck).

• This length should be increased (say, to 4 times) in areas with little subcutaneous tissue (dorsum of hand) and high skin tension (upper back).

• Incisions should meet, rather than overlap, at the ends of the ellipse.

• A good rule is to obtain an angle at the end of 30° or less.

• These rules should achieve closure without ‘dog ears’.

‘Dog ears’ are best avoided by using a long axis (at least 3 to 1) for an elliptical excision.

The fish-tail cut

However, if this axis turns out too short after excision, performing a fish-tail cut (Fig. 1.17a) will avoid the necessity of later correction.

Correction of ‘dog ear’

If a ‘dog ear’ results in the suture line after elliptical defect closure, it can be dealt with by limited further excision and closure.

Method

1. Place a hook in the end of the wound, which is elevated; this defines the extent of the ‘dog ear’ (Fig. 1.17b).

2. Incise the skin around the base (1).

3. Stretch the resultant flap across the wound so that excess skin is defined and removed (2).

4. Complete the suturing of the wound, which will have a slight curve (3).

In wounds with a triangular flap component, it is often difficult to place the apex of the flap accurately. The three-point suture is the best way to achieve this while minimising the chance of strangulation necrosis at the tip of the flap.

Method

1. Pass the needle through the skin of the non-flap side of the wound.

2. Pass it then through the subcuticular layer of the flap tip at exactly the same level as the reception side.

3. Finally, pass the needle back through the reception side so that it emerges well back from the V flap (Fig. 1.18).

This method of repair of the perineum is suitable either for an episiotomy or a simple tear, and uses a technique of inverted vertical mattress sutures.

It is a simple method that provides a sound and comfortable repair. Because it is an interrupted suture wound, drainage is not sacrificed for the sake of comfort.

Method

1. Suture the vaginal tissue with a normal, continuous absorbable suture tied subcutaneously.

2. If the wound is very deep, a second internal layer of sutures should be inserted initially.

3. Close the perineal skin with the inverted mattress sutures (Fig. 1.19) using an absorbable suture. It is preferable to commence anteriorly, as this provides accurate opposition of the skin edges.

Skin grafting may be performed in the general practice setting to treat small areas of skin loss following accidents such as flap wounds on the lower leg and the tips of fingers (the most common reason). If the defect on the finger tip is small, grafting is not necessary since healing is usually good. There are two possible grafts:

• full thickness: a small area of skin is carefully taken with a sharp knife; all fat is debrided until only the dermis remains

• split skin: usually 0.25–0.5 mm thick using a silver razor dermatome (e.g. Aesculap^®).

The skin is then placed on paraffin gauge correctly orientated. The surface of the graft is then applied to the defect site after trimming the unit to fit the site. Then apply a firm Kaltostat^® (or similar) dressing.

The basic types of flaps are:

• advancement

• rotation

• transposition.

Triangular flap wounds below the knee are a common injury and are often treated incorrectly. Similar wounds in the upper limb heal rapidly when sutured properly, but lower limb injury usually will not heal by first intention unless the apex of the flap is excised and a small donor graft implanted. Also think twice about suturing a pretibial laceration in an elderly person.

Proximally based flap

A fall through a gap in flooring boards will produce a proximally based flap; a heavy object (such as the tailboard of a trailer) striking the shin will result in a distally based flap.

Usually the apex of the flap is crushed and poorly vascularised; it will not survive to heal after suture.

Treatment method

1. Infiltrate a wide area around the wound with LA.

2. Excise the apex of the skin flap back to healthy tissue.

3. Loosely suture the angles at the base of the flap.

4. With a no. 24 scalpel, shave a small, split-thickness graft from the anaesthetised area proximal to the wound; place it on the raw area (Fig. 1.20).

5. Cover both the wound and donor site with petroleum jelly gauze, a non-stick dressing and a combine pad; strap firmly with a crêpe bandage.

The patient should rest with the leg elevated for 3 days. Re-dress the wound on the fourth day.

Alternative (preferred) method

It may be possible to save the distal avascular flap, especially in younger patients, by scraping away the subcutaneous tissue on the flap and using it as a full-thickness graft.

Distally based flap

This flap, which is quite avascular, has a poorer prognosis. The same methods as for the proximally based flap can be used (Fig. 1.21).

General practitioners, in both city and country, not uncommonly excise small skin tumours under local anaesthesia using an elliptical incision. Where the skin is tight, as on the trunk or thigh, suture of an elliptical wound creates tension at the centre. A split skin graft or Wolfe graft will solve the problem but all too often leaves a depressed, unsightly scar. A rotation flap will cover the deficiency nicely but requires the undermining of a large area of skin and time-consuming suturing. However, flaps are essentially the domain of the skin specialist, especially the plastic surgeon who should not be asked to cope with a ‘failed’ repair due to an inexperienced operator.

Double Y on V advancement flap method⁴

Tumours up to 2.5 cm in diameter can be excised and the deficiency repaired without tension by means of a double advancement flap fashioned from the ‘wings’ of the ellipse after the lesion has been excised. As the viability of the flaps relies on a blood supply from the subcutaneous tissue, do not undermine the flaps. Incise the skin and subcutaneous tissue vertically to the fascia. The elasticity of the subcutaneous tissues will permit the flaps to be advanced to the midline to be united by sutures (Fig. 1.22).

Alternative flap technique

More flexibility of the flaps can be obtained by undermining the flaps above and below the incision lines (Fig. 1.23). Viability of the flaps is not a problem.

The Y on V (or Island) advancement flap

This flap, which maintains a good blood supply, is ideal to close the end of an amputated finger tip in a child, or to use as an excision procedure on the face in the area of the nasolabial fold and lip where it conforms to skin creases.

Method

1. Mark the excision lines carefully before excising (Fig. 1.24a).

2. Excise the lesion as a square or rectangle.

3. Fashion the flap as a triangle about 2 to 2½ times the length of the defect. Carefully free the flap so that the skin remains on its subcutaneous tissue pedicle. This flap is referred to as an ‘island’.

4. Using skin hooks, advance the base of the flap to the far edge of the defect with the help of blunt dissection and avoiding excessive tension (Fig. 1.24b).

5. Use three-point sutures at the two edges and at the apex.

6. Suture the sides of the wound (Fig. 1.24c).

Thus the V ‘island’ is converted to a Y-shaped scar.

H double advancement flap⁴

Like the double Y on V flap this is suitable for areas with a good pad of subcutaneous tissue (e.g. re-excision of a melanoma on the arm). It is useful in places such as the forehead where the scars conform to skin creases. It is used where skin closure is impossible for a large ellipse. It can be tested, aborted or grafted.

Method

1. Excise the tumour with a square excision.

2. Extend the excision lines to about 1½ times the length of the defect (Fig. 1.25a).

3. Excise the skin and subcutaneous tissue with care vertically to the fascia.

4. Dissect the skin flaps from the subcutaneous tissue and advance them towards each other (preferably with skin hooks) to meet in the middle (Fig. 1.25b).

5. Use three-point sutures to anchor the corners of the flaps and then suture the wound as shown in Figure 1.25c.

Before excising a small tumour, such as a dermatofibroma, skin tag or similar benign tumour, a primary suture can be inserted.

The advantages include better initial haemostasis and ability to operate singlehandedly.

Method

1. Infiltrate around the lesion with local anaesthetic.

2. Insert an appropriate suture (you may choose to insert more than one) to straddle the tumour (Fig. 1.26).

3. Excise the tumour. (Take care not to cut the suture.)

4. Secure the suture.

5. Add more sutures if necessary.

Lacerations in a cosmetically important place, such as the face, that have ragged edges or multiple components should be trimmed and/or excised (Fig. 1.27). This will provide vertical edges and an organised wound, which can then be sutured meticulously. For the face, use 6/0 nylon. Sacrifice of small amounts of facial skin is justified in the interest of a linear and less obvious scar. Sometimes Z-plasty is required.

Avoid using adhesive tapes on friable skin or dehydrated skin. Instead, use a cohesive bandage such as Easifix^® or Tubigrip™.

When a flap moves laterally into the primary defect it is called a transposition flap, and when rotated into the defect it is called a rotation flap. With these flaps, be careful to avoid a vascular disaster.

It is imperative to pay close attention to safe ligation of any bleeding vessels in the wound by clamping and using a properly placed ligature. A ligature applied too close to the cut end may subsequently slip and cause unexpected bleeding (Fig. 1.28).

In the transposition flap, the flap moves sideways into the primary defect. The flap has a donor site that usually runs radial to the defect. The flap crosses over intervening normal skin to slot into the defect. The point at the base of the flap opposite the defect does not move, and this is the pivot point that is marked with an asterisk in Figure 1.29. The distance from the pivot point to the top of the flap should be the same as the distance from the pivot point to the far side of the defect. The donor site is closed directly. The transposition flap has widespread use, especially on the face and scalp.

The local rotation flap is a most useful procedure in general practice for the excision of skin lesions such as basal cell carcinomas (BCCs). The excision is semicircular and the pivot point is at the end of the releasing incision. The larger the flap, the more skin becomes available. This method is favoured for the excision of BCCs greater than 12 to 20 mm and other tumours, especially on shoulders and backs.

Method

1. Excise the tumour using a triangular excision, which, ideally, should be equilateral. Extend the excision beyond subcutaneous fat to the deep fascia-covering muscle (Fig. 1.30a).

2. Extend the excision in a curve to a length about 3 times that of the length of a side of the original triangular excision.

3. Now undercut the skin flap to the line AD (Fig. 1.30b).

4. Rotate this flap so that AC corresponds to AB without excessive tension.

5. Use simple sutures to close the wound (Fig. 1.30c).

Note: Blood is supplied to the skin on the back by the lateral cutaneous branch of each posterior intercostal artery and hence follows the line of the ribs. Make sure that the extended incision allows a blood supply to the flap—that is, that AD faces medially and not laterally.

The rhomboid flap is very useful for repairing defects that are difficult to suture directly or where the tension is in the wrong direction. It is most useful for removing lesions on the forehead, temple and scalp.

Method

1. Draw out the rhomboid and the relief extensions, making sure that the angles, lengths and directions are correct. The short diagonal of the rhomboid equals the length of the sides, giving the appearance of two equilateral triangles placed side by side. The direction of the relief extensions (theoretically four options) depends on the availability of skin.

2. Extend the diagonal for an equal distance in the desired direction and then draw a back line parallel to one of the sides of the rhomboid (Fig. 1.31a).

3. Remove the lesion and free the flaps by back-cutting.

4. Ensure that the ‘x’ lengths are equal.

5. Rotate the flap so that A moves to A1, B to B1 and C to B. This should fill the defect perfectly (Fig. 1.31b).

6. Care is required in suturing the corners—especially A and B, where subcutaneous three-point sutures are appropriate (Fig. 1.31c).

7. The resultant tension from the example illustrated is transverse (←→). This contrasts with longitudinal tension if sutured directly.

When the standard elliptical skin excision is unworkable or inappropriate, a crown-shaped excision provides an excellent alternative. This applies particularly to skin lesions adjacent to key facial structures such as the nose, lips, ears and eyes. The shape of the crown excision can vary—it does not always have to be curved.

Method

(Using a basal cell carcinoma adjacent to the nose as an example.)

1. Mark out the lines of excision around the lesion in a circle.

2. Extend the axis of the excision in the free skin (Fig. 1.32a).

3. On the ‘obstacle’ side, excise two small curved flaps as illustrated.

4. Suture the defect so that a Y-shaped wound is eventually produced (Fig. 1.32b).

The Z-plasty is a procedure that redistributes wound tension by transposing two interdigitating triangular flaps. It brings in tissue from the sides to lengthen the wound and break up the tension across it. All arms of the Z are equal in length.⁵

Method (scheme for a longitudinal contracture)

1. Mark out the Z so that the angles are 60° and the arms are of equal length.

2. Incise along the lines to produce two flaps and free the flaps by dissection.

3. Transpose the flaps and suture (Fig. 1.33).

Indications

• Treatment of contractures (to lengthen).

• Facial scars (to change direction).

While small lacerations of the buccal mucosa of the lip can be left safely, more extensive cuts require careful repair. Local anaesthetic infiltration may be adequate, although a mental nerve block is ideal for larger lacerations of the lower lip.

For wounds that cross the vermilion border, meticulous alignment is essential. It may be advisable to premark the vermilion border with gentian violet or a marker pen. It is desirable to have an assistant.

Method

1. Close the deeper muscular layer of the wound using 4/0 absorbable suture. The first suture should carefully appose the mucosal area of the lip, followed by one or two sutures in the remaining layer (Fig. 1.34).

2. Next, insert a 6/0 monofilament nylon suture to bring both ends of the vermilion border together. The slightest step is unacceptable.

3. Close the inner buccal mucosa with interrupted 4/0 absorbable sutures.

4. Close the outer skin of the lip (above and below the vermilion border) with interrupted nylon sutures.

Post-repair

1. Apply a moisturising lotion along the lines of the wound.

2. Remove nylon sutures in 3 to 4 days (in a young person) and 5 to 6 days (in an older person).

Indications

Small, invasive squamous cell carcinomas leading to a defect on less than one-third of the lip. Alternative procedures are required for larger defects and for tumours close to the angles of the mouth.

An assistant is necessary to help achieve haemostasis, due to the copious bleeding from the inferior labial artery in the posterior third of the lip.

Method

1. Provide anaesthesia with a mental nerve block.

2. Carefully mark the excision outline, with special attention to the vermilion border (allow a 2–3 mm margin from the lesion). A small marker ‘nick’ or a stay suture at the border can be used as a guide.

3. Have the assistant hold the lip firmly on either side of the excision lines with gauze for a good grip, and slightly evert the lip.

4. Excise a clean, full-thickness wedge, with the apex extending almost to the mental fold (Fig. 1.35a).

5. Identify the labial arteries and either use diathermy or clamp and tie these bleeders.

6. Close the dead space of the muscular layer with interrupted 4/0 absorbable sutures, starting with accurate apposition of the main lip area (Fig. 1.35b).

7. Insert a 6/0 nylon suture precisely at the vermilion border (the slightest step is unacceptable) and one at the apex of the wound.

8. Close the buccal mucosa with interrupted absorbable sutures.

9. Finally, insert nylon sutures to the vermilion border and skin.

This procedure is ideal for small tumours on the superior surface of the helix. The requirements are the same as for wedge excision of the lip.

Method

1. Provide LA by infiltrating subcutaneously around the appropriate margin of the ear. The area for infiltration (to cover all the ear) is shown in Figure 1.36a. This V infiltration method is the simplest way to block the ear completely. Specific nerve blocks are outlined in Chapter 2.

2. Cleanse with antiseptic.

3. Mark an outline of the area of excision with the back of the scalpel and, with a marker, the margins for the first suture (e.g. the rim of the helix).

4. With tension applied by the assistant, excise a wedge, cutting cleanly through the skin and cartilage (Fig. 1.36b). The anterior skin is incised with a scalpel and then surgical scissors or the scalpel cuts through the cartilage and posterior ear skin so that the posterior and anterior aspects of the wedge are an exact match.

5. Brisk bleeding should soon cease with direct pressure.

6. Place the first suture to achieve meticulous alignment. Place a non-absorbable mattress suture to ensure hypereversion.

7. Suture the skin on the anterior surface with 6/0 nylon.

8. When the assistant folds the ear over, place and bury a few interrupted absorbable sutures in the cartilage (Fig. 1.36c). This step is optional, as granuloma formation may complicate buried sutures.

9. Suture the skin of the posterior surface with nylon.

The dressing

A single layer of paraffin gauze is used, then a double layer of gauze folded around the ear, so that it sits back in its normal position. The dressing is firmly fastened with tape.

The dressing is changed in 3 days and the sutures removed in 6 days.

General points

• Ensure that the tear duct is not involved.

• Preserve as much tissue as possible.

• Do not shave the eyebrow.

• Do not invert hair-bearing skin into the wound.

• Ensure precise alignment of the wound margins.

• Tie suture knots away from the eyeball.

Method

1. Place an intermarginal suture behind the eyelashes if the margin is involved (Fig. 1.37a).

2. Repair conjunctiva and tarsus with 6/0 absorbable sutures (Fig. 1.37b).

3. Then repair the skin and muscle (orbicularis oculi) with 6/0 nylon (Fig. 1.37c).

Wherever possible, it is best to avoid repair to wounds of the tongue because these heal rapidly. However, large flap wounds to the tongue on the dorsum or the lateral border may require suturing. The best method is to use buried absorbable sutures.

Method

1. Infiltrate with 1% lidocaine LA and leave for 5 to 10 minutes. (Sucking ice may provide adequate analgesia.)

2. Use 4/0 or 3/0 absorbable sutures to suture the flap to its bed, and bury the sutures (Fig. 1.38).

It should not be necessary to use surface sutures. If it is, 4/0 silk sutures will suffice.

The patient should be instructed to rinse the mouth regularly with salt water until healing is satisfactory.

A bloodless field in the anaesthetised digit (after a digital block) can be achieved by using a rubber band as a simple tourniquet.

Method

1. Elevate the hand vertically (or the leg) for 2 minutes and wrap tape from the tip of the digit to its base.

2. Wrap a rubber band around the base of the digit to block circulation, and unwrap the tape.

3. Now place the limb on the table and complete the procedure (e.g. removing a foreign body or repairing a wound).

4. When completed, apply a dressing and snip the rubber band with a scalpel or scissors.

Indication

Profuse sweating of axillary hyperhydrosis, especially with body odour, unresponsive to antiperspirants.

Method⁶

1. Shave the axilla.

2. Apply iodine starch powder to the axilla. This produces a dark blue/purple response in the area of highest sweat production.

3. Mark the area requiring wedge resection, which is usually elliptical.

4. Swab with antiseptic and infiltrate with local anaesthetic.

5. Perform a wedge resection to remove the sweat glands, which lie in the layer immediately below the dermis. Clearing the undersurface of the flap of subcutaneous fat will remove these sweat glands.

6. Close the wound, which may be sutured directly or by employing a flap if extensive.

Suture marks are related to the time of retention of the suture, its tension and position. The objective is to remove the sutures as early as possible, as soon as their purpose is achieved. The timing of removal is based on commonsense and individual cases. Nylon sutures are less reactive and can be left for longer periods. After suture removal it is advisable to support the wound with Micropore™ skin tape (e.g. Steri-Strips™) for 1 to 2 weeks, especially in areas of skin tension.

Method

1. Use good light and have the patient lying comfortably.

2. Use fine, sharp scissors that cut to the point or the tip of a scalpel blade, and a pair of fine, non-toothed dissecting forceps that grip firmly.

3. Cut the suture close to the skin below the knot with scissors or a scalpel tip (Fig. 1.39a).

4. Gently pull the suture out towards the side on which it was divided—that is, always towards the wound (Fig. 1.39b).

Note: In children, cut all sutures before removal.

There are several anatomical pitfalls awaiting surgical excision. The following summarises potential or real problem areas.

• The face—for cosmetic reasons.

• The face—for potential nerve damage, e.g. temporal branch of facial nerve (Fig. 1.40).

• The lips and helix of the ear—because of malignant potential.

• The eyelids.

• The inner-canthus of the eye with close proximity to the nasolacrimal duct.

• Mid-sternomastoid muscle areas where the accessory nerve is superficial.

• Fingers where functional impairment may be a concern.

• Lower limb below the knee where healing, especially in the elderly, will be a problem.

Referral to a specialist

Referral should be considered when one or more of the following is involved:

• uncertainty of diagnosis

• any doubts about appropriate treatment

• tumours larger than 1 cm

• multiple tumours

• recurrent tumours, despite treatment

• incompletely excised tumours, especially when complete excision may be difficult

• recommended treatment beyond the skills of the practitioner

• anticipation of difficulty with technique or anatomy where an appropriate specialist should be consulted

• squamous cell carcinomas on the lips and ears

• infiltrating or scar-like morphoeic BCCs—particularly those on the nose or around the nasal labial fold, as there may be a problem in determining the tumour’s extent and depth

• cosmetic concerns such as lesions of the upper chest and upper arms where keloid scarring is a potential problem

• areas where palpable regional lymph nodes suggestive of metastatic spread of squamous cell carcinoma exist, namely head and neck, axilla and groin.

Jagged lacerations are usually best debrided with a small elliptical excision following wrinkle lines, when possible.

As a rule it is better to close a ragged wound without tension than to trim it and close it with considerable tension.

There is no rule that dictates that a laceration has to be closed as a straight line.

One procedure that debrides the sides of a ragged wound (too large for simple elliptical debridement) in a saw-toothed fashion is W-plasty. The sides of the wound have to match each other (Fig. 1.41a). With W-plasty, care should be taken to ensure that adequate blood supply is maintained. Select the pattern of debridement and, using a scalpel with a no. 15 blade, make the initial incisions through the dermis, avoiding full-length incisions, which tend to result in rolled skin edges.

Apply simple sutures using three-point sutures at the apices of the triangular components (Fig. 1.41b).

The fundamental principle of debridement is to prevent infection and facilitate healing of open wounds by the manual removal of foreign, dead and contaminated material. Comprehensive wound assessment is needed before deciding whether to debride or not. Debridement may vary from simple irrigation with saline to a major clean up under general anaesthetic.

Basic equipment will include (sterlised) scrubbing brush, saline solution, scalpel and tissue forceps, artery forceps and a 20 mL syringe for irrigation.

The principles and process are summarised in Table 1.2.

One large US study showed that frequent debridement, e.g. at least once a week, accelerates the healing process.⁷

When debriding skin in a hairy area, it is important to realise that hair shafts grow obliquely to the skin. In order to avoid creating a hairless path along the length of the scar, try to debride the skin edges at the same angle as the hair shafts (Fig. 1.42). This avoids damage to the hair follicles.

Natural lacerations (such as from a blunt blow) to hairy areas such as the eyebrow do not leave a hairless patch of scar when sutured correctly.

Removal is only necessary if hair will interfere with the incision site or if there is risk of wound contamination.

Keeping hairs out of wounds for suturing

While suturing in a hair-bearing area such as the scalp, it is important to keep hair out of the wound. This can be done by smoothing the hair down with K-Y^® gel, hair gel such as Brylcreem^® or adhesive tape.

Clearing shaved areas

An effective way to clean up a shaved area such as a scalp prior to surgical repair is to use strips of adhesive tape such as Micropore™ to pick up loose hairs.

Traumatic wounds

Primary wound closure rules

• Traditional rule—within 4 to 6 hours

• Facial wounds (uncontaminated)—within 12 to 24 hours

• Other wounds (uncontaminated)—8 to 12 hours

Delayed primary closure

• Wounds too old

• Heavy contamination

Rule: observe 3.5 days then repair if not infected.

Dressings

Table 1.3 indicates examples of the most appropriate dressing materials for the exudate level of the wound being treated.

Post-operative wound care

Useful guidelines are:

• Use non-adherent dressings over excision wounds. Leave for 24 to 48 hours. Place an occlusive dressing over this for protection and when showering.

• After removal of dressing clean daily with saline to remove crusting and to minimise infection.

• If concerned about infection use thin application of chloramphenicol (or similar ointment).

For healing by secondary intention (such as after curette or diathermy):

• Use hydrocolloidal dressings (e.g. Intrasite^®, Duoderm^®, rapid healing Band-Aids).

• Leave in situ for up to 7 days.

Healing cavities of incised cysts and abscesses

This practice tip outlines a simple method of promoting the healing of cavities resulting from drained abscesses or removed sebaceous cysts, especially infected cysts. The concept originally came from veterinary management of cysts in animals.

Method

1. For deep cavities resulting from surgical incision it is best to pack them first with sterile non-adherent gauze while the patient is anaesthetised. This controls haemostasis and maintains drainage.

2. The following day infiltrate the cavity with Intrasite^® gel.

3. Cover the wound with OpSite^® or appropriate waterproof dressing.

4. Change this every day or every second day until the wound heals.

Advantages

• The gel infuses to all recesses of the cavity that packing cannot reach.

• Patients can continue management themselves.

• More convenient for patients who have a considerable distance to travel.

• Less pain and discomfort compared with other dressings.

• Rapid healing.

For removal of sutures after non-complicated wound closure in adults, see Table 1.4.

Note: Decisions need to be individualised according to the nature of the wound and health of the patient and healing. In general, remove sutures as soon as possible. One way of achieving this is to remove alternate sutures a day or two earlier and remove the rest at the usual time. Steri-Strips™ can then be used to maintain closure and healing.

Additional aspects

In children, usually remove 1 to 2 days earlier. Allow additional time for backs and legs, especially the calf. Nylon sutures can be left longer because they are less reactive. Alternate sutures may be removed earlier (e.g. from the face in women).