Primary linear closure

May 1, 2007

While side-to-side closures require basic technique, certain areas are notorious for causing trouble with this method, such as the nose and lips, and broad and deep defects. One specialist speaks about his experience using this closure on these areas and offers sound advice.

Key Points

Iowa City, Iowa - Dermatologic surgery's advancements over the years include complicated flaps, grafts and various innovative suturing techniques.

Primary closures are still the mainstay among surgical repair options, according to one expert, who says they usually can get the job done with good results. He offers his long years of experience and insight on primary linear closures in potential surgical "hot" spots.

Christopher J. Arpey, M.D., professor, department of dermatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, says, "All dermatologic surgeons know how to do side-to-side closures. Yet surgical areas such as the nose, the lips, as well as broad and deep defects may require a shade more surgical finesse and know-how to close properly."

Dr. Arpey says that because all noses are different, some will have more laxity than others.

The upper nasal sidewall and central nasal root are classic locations in which to do a primary linear closure. According to Dr. Arpey, midline lower noses (supratip) are sometimes suitable for a vertical repair if lax enough and sometimes suitable for horizontal repair if the tip of the nose is ptotic enough.

"It is crucial to always watch the nasal valve and nostrils. Vertical closures may narrow the nostrils and horizontal closures may flare the nostrils or yield a pug nose. Central or near central defects work best, as they involve less of the dynamics of the nostrils," he tells Dermatology Times.

Broad defects

Dr. Arpey says that when approaching a broad defect, it is paramount to accurately assess the size and extent of the defect and to possibly opt for other closure techniques, such as a flap or graft closure.

"If primary closure is chosen for a broad defect, it may close easier if made deeper. You should think in 3-D instead of 2-D. Remember, tension and distortion are your enemies, and an overzealous primary closure may come back to haunt you and the patient," Dr. Arpey says.

He adds that sometimes patients with multiple lesions or cancers need the less fancy repair to avoid potential complications postoperatively (i.e., Gorlin Syndrome, underlying health problems). The surgeon could opt to subdivide the broad defect into smaller defects and perform primary closure on the most critical areas first.

Deep defects

When approaching a deep defect, Dr. Arpey says it is critical for the surgeon to think in layers and suture "like tissue" to "like tissue" - muscle to muscle, fascia to fascia and dermis to dermis.

He uses a larger-caliber suture at the deepest layer for a stronger foundation and sometimes uses a splint or crutch postoperatively in order to reduce overuse.

"When closing deeper defects, I do not worry immediately about the surface. If tension lines are variable, I orient the closure to avoid side-to-side stress when the patient moves or bends," he says.

With lips, aim for smooth contour

Dr. Arpey says that with lips, often more muscle must be removed from the base of the defect to achieve a smoother contour.

He says that removing approximately one-third of the lower lip or one-fourth of the upper lip increases the risk of long-term deformity, with or without dysfunction.

"When performing primary closure on the lips, the alignment of the vermilion is absolutely crucial. Here, I pay close attention to the circumference of the two sides to be apposed, especially when not in the mid-line," Dr. Arpey says.

At the vermilion of the lower lip, Dr. Arpey creates an inverted "house" (pentagon) with the apex close to the mental crease. On the upper lip, he fashions a triangle with a 30-degree angle at the apex. Here, he advises to avoid the nasal sill and frenulum. Then, after marking the vermilion carefully with ink, he sutures the apices first and works from the mucosal side to the skin surface, fine-tuning the vermilion last.