Concepts for flawless wound closures

July 1, 2007

Finessing one's surgical closures begins with avoiding complications and includes several relatively simple concepts, such as respecting facial contours, picking the best suture technique for the job and keeping closures simple, one expert says.

Key Points

Summer R. Youker, M.D., assistant professor of dermatology, St. Louis University, reviews key closure principles to remember.

Avoid complications

Danger zones here include the mandibular and temporal branches of the facial nerve and the spinal accessory nerve (CN 11), she says.

To avoid dehiscence, Dr. Youker adds, "Close wounds appropriately so that one doesn't have too much tension."

Picking the right sutures and giving patients explicit postsurgical instructions - such as "no lifting X pounds" - also help, she says.

Should dehiscence occur, Dr. Youker advises resuturing patients who present less than 24 hours postsurgery; if they present after a longer period, one should allow granulation tissue to form, debride as necessary and possibly use antibiotics.

Regarding bleeding, she says it's a myth that dermatologic surgeons can tell if patients are taking blood thinners because their wounds ooze more during surgery.

"That's been disproven by multiple well-designed studies," Dr. Youker tells Dermatology Times.

In reality, she says it makes little difference if patients are on anticoagulants during skin surgery.

Conversely, she says definitive data regarding the need for prophylactic antibiotics in skin surgery patients are lacking.

Although dermatologic surgeons traditionally have used prophylactic antibiotics in patients with large joint replacements, Dr. Youker says available literature reveals that "We actually don't have to prophylax patients with large joint replacements" that were performed longer than six months prior to the current dermatologic surgery.

"Skin surgery is very clean," she explains, "and the risk of bacteremia is incredibly low."

However, she says she does order prophylaxis for certain patients, such as those with heart valve replacements, a history of rheumatic heart disease or valve-related disease, and patients undergoing surgeries in susceptible areas such as the groin and ear.

Respect facial contours

In this area, Dr. Youker says it's helpful to hide surgical scars within wrinkles.

It's also critical to know how to suture around naturally occurring convexities and concavities such as the round helix of the ear.

Likewise, she says, "Place scars along cosmetic unit boundaries, and limit closures or scars to one cosmetic unit."

Optimize suture placement

Stacking buried sutures requires putting all the tension-bearing sutures in the center of a wound, Dr. Youker says.

"Many of us are taught to place a suture in the center of the wound where most of the tension is, then place others halfway between that one and the end of the wound. Actually, it makes sense to put all of one's tension-bearing sutures where the tension is," she says.