Modified corner stitch flap has better result

May 1, 2008

A modified Gillies suture modeled by Bechara can help an aesthetic surgeon achieve far better cosmetic outcomes when fixaing flaps over skin defects in reconstructive surgery without increasing the risk of necrosis of the flap.

Key Points

Bochum, Germany - According to one expert, the modification of an old, but commonly used, suture for the fixation of skin flaps following reconstructive surgery after tumor excision can achieve a much better aesthetic without increasing the risk of necrosis of the flap tip.

Following the excision of a skin cancer, which often occurs on sun-exposed areas such as the face, the dermatologic surgeon's two major priorities are to restore functionality of the operated area and to achieve a favorable aesthetic result. Here, flaps are commonly used to cover skin defects, and a Gillies suture is frequently used.

"I have used the Gillies suture for years and have not seen any problems in the microcirculation of the flaps, which explains why necrosis is so rarely seen.

In order to raise the tip and have the wound edges on one plane, Dr. Bechara uses an additional suture, and places it just a bit more superficially above the Gillies suture.

This additional suture should, optimally, be placed at the upper dermis, as opposed to the Gillies suture, which is placed deep in the dermis, slightly higher than the dermal-fat junction.

After the surgeon places this second suture and closes the wound gently by applying slight but steady tension, the wound edges automatically elevate. Dr. Bechara says this modified Gillies suture is a very simple procedure, however, cosmetically, a very effective one.

Reconstructive surgeons often use special local flaps or other closure techniques, Dr. Bechara tells Dermatology Times. When repositioning these often triangularly shaped flaps into the defect to be closed, many surgeons simply apply one suture through the entire epidermis and dermis of the flap tip and fixate it on the defect wound edge.

"This technique increases the amount of tension on all the sides of the wound, especially on the tip itself, regardless of the generous undermining performed. The problem is that the tension you create can likely cause a decreased microcirculation, at least theoretically, and this will lead to a necrosis, usually seen at the flap tip," Dr. Bechara says.

Theoretical disadvantage

Dr. Bechara says the theoretical disadvantage of his modified Gillies suture is that if one adds an additional suture to the delicate wound area, one adds an additional trauma to the dermis of the flap tip, which means there is an additional trauma to the microcirculation, which has already been traumatized from the scalpel.

"This risk, however, in my opinion, remains only a theoretical risk, because in clinical routine, I have not witnessed any increase in adverse events as a result of this modified suture procedure in terms of necrosis at the tip of the flap," Dr. Bechara says.

Dr. Bechara stresses that it is important that the surgeon take his or her time to perform this second suture, as it is of paramount importance that it be placed very high up in the dermis. The precision of the placement of this second suture will dictate the degree of aesthetic success, post-operatively.

Furthermore, the surgeon should use small skin hooks instead of forceps when handling the skin flap, as forceps can be brutal and unforgiving to the delicate tissues in the operating field.

According to Dr. Bechara, this second suture in his modified Gillies technique can help the surgeon reduce or avoid the risk of a depressed scar.

"The most unsightly scars are the depressed scars, especially in the face. If you have a slightly elevated scar, they often resolve in the weeks to months following the surgery, or they can be aesthetically corrected with a laser.

"However, a depressed scar creates a shadow, and the altered light within the depression makes this type of scar one of the most feared by surgeons. This depressed scar cannot be so easily corrected with lasers, and must, unfortunately, be excised to achieve a better aesthetic result.

"My modified technique can help avoid this cosmetic corrective surgery," Dr. Bechara says.