10

Chapter
Basic excisional surgery 131

well approximated and everted wound edge with

minimal tension, thereby resulting in a cosmeti-
cally elegant scar. The nature of the surrounding
skin, and the size and depth of the wound, will
determine which suture material and closure
technique is appropriate (see Chapter 12: Suture
materials).
In general, excision of full-thickness lesions
necessitates a layered closure, which consists of a
buried inverted layer of absorbable ­ intradermal/
subcutaneous sutures and a percutaneous layer
of suture, tissue adhesive or adhesive tapes
Figure 10-16 “Figure of 8” technique of suture ligation (Fig. 10-17). The intradermal/subcutaneous su-
tures provide the support following removal of
the percutaneous sutures, when the wound has
to the isolated vessel (Fig. 10-15). This minimizes only achieved 5% of its final tensile strength. A
­extensive tissue destruction in the surrounding layered closure (see Chapter 11: Suture tech-
area, as well as optimizing the ability of the elec- niques) achieves the following:
trode to coagulate in a drier wound bed.
Be meticulous but do not be overzealous in • Allows elimination of any potential dead
coagulating the bleeding, especially that seen space, thereby minimizing the risk of
along the epidermal/dermal wound edge (resulting hematoma or seroma formation, which can
from visible telangiectasias), as this may increase serve as a nidus for infection
the risk infection and prolonged healing, and • Approximates the wound edges with proper
adversely affect the resultant appearance of the eversion
scar. Even larger bleeding vessels, especially vis- • Reduces the tension along the wound edges,
ible arteries, are more reliably treated with ­suture thereby resulting in a well healed scar.
ligation, using the figure-of-eight technique
(Fig. 10-16). Using an absorbable suture, such as
chromic, the vessel is visualized and isolated with
Dog ear repair
a fine-tipped hemostat, and the suture is passed Burrow’s triangles, standing cone deformity, and
in and across the vessel in a diagonal and out, “dog ears” – all refer to redundant skin that is
and again, from the opposite side, in and across formed from wounds with apical angles greater
the vessel in a diagonal and out, and tied off as the than 30°, or those with unequal lengths at the
hemostat is removed. This effectively clamps the time of closure. In general, this tissue redundancy
actively bleeding vessel. is located at the apices of the ellipse, but may
occur along the length of the longer wound edge.
The repair is performed by pulling the
Closing the surgical wound redundant tissue perpendicular to the direction
Once meticulous hemostasis is achieved, and wide of closure, incising one half of the tissue until
undermining is performed, the wound is ready another apex is reached. This incised flap is
for closure. The goal of closure is to ­ produce a draped over the incision, and the other half of

a b

Figure 10-17 Layered closure of the excision

132 Dermatologic Surgery

Figure 10-18 Management of dog ear deformity

 10

Chapter
Basic excisional surgery 133

Figure 10-18, cont’d.

the redundant tissue excised. Undermining this thin lax skin, for ­example the periorbit, is also more
newly formed apex will minimize pseudo-dog prone to edema. As such, elevation of the limb or
ear formation. The wound is then closed accord- head is often ­recommended. Excisions around and
ingly (Fig. 10-18). Dog ear deformity may also be over joints often require special immobilization
repaired using the M-plasty technique described to give the wound the time to strengthen, and to
above (see Fig. 10-11). minimize the risk of wound dehiscence.
Patient education is the key to avoiding post-
Postoperative course and care operative complications (see Chapter 17: Surgical
complications). The patient should understand
Patients should receive written and verbal post- that some edema, ecchymosis, ­erythema, and ten-
operative instructions relating to the excisional derness is normal and should be expected. These
surgery just performed. When the patients are expected sequelae of surgery may be alarming if
properly educated about postoperative expec- the patient has not been forewarned. Patients who
tations, instructions for care and potential com- are anticoagulated should be cautioned regarding
plications, their anxieties are tempered and the difference between exaggerated bruising ver-
the risks for complications are minimized. Al- sus an expanding hematoma. All patients should
though considered a relatively minor procedure, be provided with a 24-h contact telephone
­patients should be prepared to experience some number and instructed to contact their surgeon
­limitations in their daily activities, at least for with any concerns. All information should be
the first 24–48 h. This is especially stressed with explained verbally to the patient and any family
regard to strenuous activities, including heavy member who may be accompanying them. These
lifting and vigorous exercise. Further restric- same instructions should be provided in written
tions on physical activity are individually tailored form for ready reference at home.
according to the patient’s age, preoperative level
of activity, and extent, location, and depth of the
wound.
Wound care
Certain situations warrant special attention dur- Most excisions require a simple pressure dressing
ing the postoperative period. Surgery performed that should remain intact for 24 h. Basically, this
on dependent areas, such as the hand, wrist, or leg, is prepared as follows: a thin layer of ointment
are more likely to result in edema. Surgery around (­petrolatum ointment, Aquaphor®, or antibiotic
134 Dermatologic Surgery

a b

c d

Figure 10-19 Postoperative dressing

ointment), a nonadherent gauze (such as Telfa®, Table 10-3 Suture removal recommendations
cut to fit the dimensions of the suture line), an ab-
sorbent layer of gauze, and secured with an outer Location No. of days
layer of surgical tape (e.g. Mefix®, Micropore™). Eyelid 2–4
Oftentimes a liquid adhesive (tincture of benzoin
Face 4–7
or Mastisol®) is used to secure the surgical tape in
place (Fig. 10-19). Neck 5–7
Patients are instructed to remove the pres- Scalp 7–10
sure dressing in 24–48 h. The wound surface is
Trunk 7–12
cleansed with soap and water. Hydrogen perox-
ide may be used sparingly to remove any dried Extremities 10–14
blood or crust. Occlusive ointment is reapplied,
and, depending on location and level of activity,
a light dressing or strip bandage may be required. provide further support to the wound edges after
This wound care is repeated two to three times the percutaneous sutures have been removed.
daily until the sutures are removed. These typically stay on for about 5–7 days. Pa-
tients are instructed to leave these alone, and
allow them to fall out on their own. Table 10-�3
Suture removal outlines general recommendations on suture
The timing of removal of the percutane- ­removal.
ous sutures is of utmost importance. Sutures
should be left long enough to permit complete Complications
­epithelialization across the wound margins, but
early enough to avoid suture tracking. Obviously, Although relatively infrequent, patients need to
there is ­ individual variability in wound healing. be informed about the potential complications of
For example, sutures may be removed a little skin surgery at the time of informed consent, and
earlier for young, healthy, nonsmoking individu- be educated about how these may be manifested
als, compared to older, smoking, diabetic patients, immediately after surgery. When they do occur, the
because of problem with delayed wound healing. surgeon should be able to recognize and ­manage
Occasionally, wound closure tapes are used to them appropriately. The four most frequently
 10

Chapter
Basic excisional surgery 135

encountered complications (see Chapter 17: leave permanent scars (Fig. 10-20). When the
Surgical complications) are: middle finger is placed between the tongs of the
forceps about half way down, the forceps are
• Hematoma formation held open and one side can be used in place of
• Infection a skin hook.
• Wound dehiscence •W
 hen placing sutures, both intradermally and
• Necrosis. percutaneously, the square knot can be secured
by drawing one end of the suture toward you,
while keeping steady tension on the other end
PEARLS
of the suture. This will avoid slippage of the
•H
 andle the skin with great care. This will be knot and separation of the wound edges
evident in the final scar that results. To minimize (Fig. 10-21).
trauma to the wound edges, use of a skin •A
 s much as possible, try to use your
hook is quite helpful. If not, with the toothed instruments to help you perform the procedure
forceps, grasp the relatively acellular dermis or in an efficient manner. When performing a
fascia, rather than the epidermis, which may running percutaneous suture, try to minimize

Figure 10-20 Grasp the dermis, rather than the epidermis, to minimize trauma to the surface that might potentially leave
a permanent scar

Figure 10-21 Securing square knots

136 Dermatologic Surgery

a
d

Figure 10-22 Use instruments to aid closure of the wound in an efficient manner. (a) Secure the exit point on the skin with
a skin hook. (b) Grasp the needle while maintaining tension on the needle’s exit point. (c) Grab the needle at the body,
ready to place the next bite. (d) Pick up the suture and provide sufficient tension to help placement of the next bites
 10

Chapter
Basic excisional surgery 137

• Closure on atrophic skin: use of the strip

suture technique: The use of Steri-Strips™ along
the wound edges, or perpendicular to
the incision, will aid the application of
percutaneous sutures along the wound edges
that would have otherwise pulled through
(Fig. 10-23).

Further reading
Bennett RG. Fundamentals of Cutaneous Surgery.
St Louis: CV Mosby, 1988:353–444.
Dunlavey E, Leshin B. The simple excision. In:
McGillis ST, ed. Dermatologic Clinics, Excision
and Repair. Philadelphia: WB Saunders, 1998:
49–64.
Figure 10-23 Closure using strip suture method for thin
atrophic skin Leshin B. Proper planning and execution of surgical
excisions. In: Wheeland R, ed. Cutaneous Surgery.
Philadelphia: WB Saunders, 1994:171–177.
Jackson IT. Local Flaps in Head and Neck
your movements by using your forceps to Reconstruction. St Louis: CV Mosby, 1985.
stabilize your exit point, and push the needle Olbricht S. Biopsy techniques and basic excisions. In:
through with your needle-holder. This movement Bolognia J, Jorizzo J, Rapini R, eds. Dermatology.
will allow you to grasp and lock the needle at London: Mosby, 2003:2269–2286.
the intended body of the needle, ready to take
Paolo B, Stefania R, Massimiliano C, et al. Modified
the next bite. You or your assistant can also hold S-plasty: an alternative to the elliptical excision
onto the suture, providing just enough tension to reduce the length of suture. Dermatol Surg
along the already sutured wound edge; this 2003;29:394–398.
provides tension along the wound edge
Perry AW, McShane RH. Fine tuning of the skin
that you are about to place the needle in
edges in the closure of surgical wounds. J Dermatol
(Fig. 10-22).
Surg Oncol 1981;7:471–476.
•M
 anagement of cysts: For noninflamed cysts, Robinson JK, Hanke CW, Sengelmann RD, Siegel
mark the margin of the cyst, but perform a DM, eds. Surgery of the Skin: Procedural
punch biopsy or elliptical excision within the Dermatology. Philadelphia: Elsevier Mosby, 2005.
margins, carefully dissect around the well Sadick N, D’Amelio DL, Weinstein C. The modified
demarcated cyst, and perform a layered closure. buried vertical mattress suture. J Dermatol Surg
This minimizes the resulting scar. Oncol 1994;20:735–739.
•M
 anagement of lipomas: Similarly, carefully Salasche SJ, Bernstein G, Senkarik M. Surgical
palpate the lesion to assess the depth and size Anatomy of the Skin. Norwalk: Appleton & Lange,
of the lipoma, and mark the presumed size. 1988:13–35.
Plan for an incision well within the margins of Zalla MJ, Padilla RS. Excision. In: Roenigk RK, Ratz
the lesion, or a punch biopsy. A lipoma can be JL, Roenigk HH, eds. Roenigk’s Dermatologic
delivered through a very small opening when Surgery: Current Techniques in Procedural
pressure is placed on both sides. Carefully Dermatology, 3rd edn. New York: Informa
dissect the lesion out. When involving the Healthcare, 2007:131–139.
forehead, attempt to dissect the frontalis muscle Zitelli JA. Tips for a better ellipse. J Am Acad
bundles in a vertical orientation, and repair the Dermatol 1990;22:101–103.
muscle and fascial planes if necessary.
A layered closure will minimize the risk of
seroma or hematoma formation.
 11

Chapter
Suture techniques
Brittany Wilson, Andrea Willey,
and Ken K. Lee

Key Points
• Suturing is one of the mainstays of cutaneous General guidelines for suture
surgery. placement
• Closing a wound by first intention helps achieve
hemostasis, decreases the risk of infection, and Typically, the needle should penetrate the skin at
closes dead space. a 90° or greater angle. This helps facilitate wound
• The primary goals of suturing include eversion and minimizes trauma to tissue. Simi-
achieving wound eversion, decreasing tension larly, the needle should exit perpendicular to the
on the wound, and approximating wound
skin surface. It may be helpful to use forceps to
edges.
• Wound eversion helps to decrease the risk of a grasp the needle as it exits the tissue. This can help
spreading or depressed scar. stabilize the needle and minimize the chance of
• Various suture techniques can be selected loosing the needle in the soft tissue. Needle safety
based upon anatomical location, tension on the is paramount when suturing. The following steps
wound, tissue quality, and wound depth. are important in preventing needle sticks:

1. Always use the needle holder or

forceps initially to grasp and stabilize
Loading the needle the needle.
2. When handling the base of needle with
Correct placement of the needle is important in your thumb and index finger, always apply
gaining appropriate angle of entry into the tissue the forceps or needle holder between your
and avoiding a bent needle. Grasp the needle with fingers and the needle tip.
the needle holder in the mid to distal portion of
the needle, approximately one half to three quar-
ters of the distance from the tip of the needle
(Fig. 11-�
1).

Grasping the needle holder Swag

Point
There is more than one proper way to hold the
needle holder. Some surgeons prefer to hold it in
the palm of the hand without placing fingers in Body
the loops. This method offers maximum dexte­
rity. Alternatively, the needle holder is grasped by
placing the thumb and the fourth finger in the
loops and placing the index finger at the fulcrum.
This method offers maximum stability.

Tissue stabilization
Tissue stabilization aids in proper suture place-
ment. Depending on the setting, tissue may be
stabilized using the hands, forceps, or skin hooks.
Tissue should always be handled delicately to
avoid excessive trauma.
140 Dermatologic Surgery

3. Use your third, fourth, and fifth fingers 3. Open the needle holder and grasp the short
to shorten any extra slack in the suture. (cut) end of the suture.
One technique is to “figure 8” the 4. Gently pull the loops off the needle holder
slack between the third and fifth fingers and reverse your hands. This knot should be
(Fig. 11-�
2). slightly looser than the final desired tension
of the wound (the second knot will tighten
Instrument tie the tie).
5. Bring the needle holder across the wound
The square knot is the basic surgical knot and is again and make a single loop (in the opposite
the primary knot used in cutaneous surgery. direction of the first knot) with the long
(needle) end of the suture.
Tying a square knot (Fig. 11-�
3) 6. Open the needle holder and grasp the short
1. Place the suture using the desired technique (cut) end of the suture.
and leave approximately 4–5 cm of suture 7. Gently pull the loops off the needle holder,
on the short (cut) end. Grasp the base of the reverse your hands and tighten.
needle between the index finger and thumb of 8. Repeat steps 5–7 again. The important point
your nondominant hand (as described above). is to reverse the direction of the loop and
2. Bring the needle holder across the wound the direction in which the needle holder is
and loop the suture twice around the tip of pulled across the wound.
the holder.
Simple interrupted suture
The simple interrupted suture (Box 11-1) is the
fundamental suture in cutaneous surgery:

• Place the suture by entering with the needle

at least perpendicular to the skin surface
(Fig. 11-�4).
• To obtain wound eversion, the suture should
be placed in a flask shape with the wide end
inferiorly (Fig. 11-�
5). Sutures that do not
follow the flask shape can lead to an inverted
suture line.
• Wounds of uneven height can be closed by
placing the suture deep on the low side and
shallow on the high side (Fig. 11-�6).
• Larger wounds or thicker skin may require
larger bites, perhaps necessitating reloading of
a
the needle from the center of the wound.

Box 11-2 lists the disadvantages of simple inter-

rupted sutures.

Vertical mattress suture

A properly placed vertical mattress suture can evert
skin edges better than any other suturing tech-
nique. Additionally, vertical mattress sutures pro-
vide eversion with less tension than other suturing
techniques. The vertical mattress is a strong suture
that can provide support to a wound under stress.

Placing the vertical mattress suture

(Fig. 11-�
7)
1. Place the deep suture first by entering the
epidermis approximately 5 mm from the
b wound edge and exiting from a similar
distance on the opposite skin edge with the
Figure 11-2 (a, b) Suture technique needle coursing deeper in the wound.
 11

Chapter
Suture techniques 141

Pull gently

Pull gently

Figure 11-3 (a, b) Instrument tie

Continued
142 Dermatologic Surgery

Pull gently

Pull gently

Figure 11-3 (a, b) Instrument tie

 11

Chapter
Suture techniques 143

B ox 1 1 - 1
Simple interrupted sutures

These are useful for:

• Closing small low-tension wounds, including punch biopsy
sites
• Top suture for layered repairs
• Correcting wound edges of unequal heights (“step off”)

Figure 11-6 Simple interrupted suture for wounds of

uneven height

B ox 1 1 - 2
Disadvantages of simple interrupted sutures

• Potential for “railroad track” scarring

• Inadvertent inversion of the wound edges
• Uneven tension on the wound
• More time consuming than other methods

Figure 11-4 Simple interrupted suture

Figure 11-5 Simple interrupted suture Figure 11-7 Vertical mattress

2. Place the second, shallower, bite by entering Advantages and disadvantages of vertical mattress
and exiting in the opposite direction from sutures are shown in Boxes 11-�
3 & 11-4.
the first pass, approximately 1–3 mm from
the wound edge.
Half-buried vertical mattress suture
3. The distance of the sutures from the wound A vertical mattress suture in which one side of
edge will vary depending on tension on the the suture remains subcuticular is called a half-
wound and the amount of dead space to be buried vertical mattress suture (Fig. 11-�8). This
closed. suture can be useful to close dead space ­without
144 Dermatologic Surgery

B ox 1 1 - 3 bite that exits far from the wound (Fig. 11-� 9).
This suture is useful in elevating the deep tissue
Advantages of vertical mattress sutures in which it is placed, for example when closing
the orbicularis oris muscle in a lip wedge.
• Excellent wound eversion
• Decreased wound tension
Pulley suture
• Provide added support to defects under stress
The pulley suture can be very helpful when ­closing
• Useful for closing dead space
wounds under tension. The critical feature of the
pulley suture is multiple passes through the ­tissue,
creating significant resistance and making the ­suture
B ox 1 1 - 4 unlikely to slip. Although variations exist, the ­suture
is typically initiated by entering the epidermis dis-
Disadvantages of vertical mattress sutures tant to the defect, traveling across the defect and
exiting nearby. The needle is then redirected to en-
• Potential for railroad tracking
ter the epidermis near the wound, traveling across
• More time consuming than some other methods the defect and finally exi­ting far from the wound
• Tissue strangulation may occur if tied too tight (Fig. 11-10). The suture may be left in place after
wound closure, or used to decrease tension while
placing additional sutures and then removed.

Horizontal mattress sutures

The horizontal mattress suture is an invalu-
able “stay” suture, and can be helpful to achieve
­hemostasis. Used by itself, it reduces wound
­tension, everts wound edges, and closes dead space.
It is also often used in conjunction with a second,
more superficial, interrupted suture placed closer
to the wound edges. Some surgeons remove this
suture once suturing is complete. Others wait
days to weeks to remove the suture. If the latter is
the case, consider placing a bolster to prevent the
­suture from cutting into the skin and lea­ving “rail-
road track” scarring. Owing to the risk of decreased
wound edge perfusion, this suture is generally not
used on poorly vascularized wounds or flaps.

Placing the horizontal mattress

suture (Fig. 11-11)
1. Place the initial suture in same fashion as the
simple interrupted suture.
Figure 11-8 Half-buried vertical mattress
2. Without tying, travel approximately 2 mm
parallel to the wound edge and place a
leaving track marks on the subcuticular side of second suture entering on the same side and
the wound. It is valuable when closing wounds traveling to the opposite side. Gently tie the
near hair-bearing skin where one side of the clo- knot lateral to the wound edge, with care not
sure can be hidden. It does not provide as much to strangulate the tissue.
tension as the classic vertical mattress ­suture.
Advantages and disadvantages of horizontal mat-
Near–far adaptation of the vertical tress sutures are shown in Boxes 11-�
5 & 11-6.
mattress suture Canal suture
The near–far adaptation of the vertical mattress The canal suture is a horizontal mattress suture
suture is employed by beginning the suture near placed in the reverse direction (Fig. 11-12). It
the wound with a small epicuticular bite, then can be used intentionally to invert the wound
re-entering deep and exiting far from the wound. edge into which it is placed, and everts the deep
Next, the direction of the needle is reversed, and a edge of the wound. For example, this suture can
near epicuticular bite is taken, followed by a deep be placed on the outside (cutaneous side) of a
 11

Chapter
Suture techniques 145

Figure 11-9 Near–far adaptation of vertical mattress suture

Figure 11-10 Pulley stitch

wound to evert the underlying mucosal surface of closed (Fig. 11-13). An overly tight or improperly
full-thickness mucosal defects. placed corner suture can lead to tissue necrosis.
Three-point corner (tip) suture Four-point corner (tip) suture
This important variation on the horizontal mat- Another variation on the horizontal mattress su-
tress suture can be employed when closing acute ture can be employed when closing two acute tis-
tissue angles. This suture involves passing the sue angles. This suture involves passing the needle
­needle subcuticularly through the “tip” to be subcuticularly through the two “tips” to be closed
146 Dermatologic Surgery

Figure 11-11 Horizontal mattress

Running locked suture

B ox 1 1 - 5
A running locked suture is useful for achieving
Advantages of the horizontal hemostasis in wounds with a high potential for
mattress suture bleeding. However, if placed too tightly, tissue
• Hemostasis necrosis may occur. To place a running locked
­suture, pass the needle through the loop created
• Helpful as a “stay” or anchor suture by each previous stitch (Fig. 11-16).
• Decreases and redistributes tension
Running horizontal mattress suture
• Eversion of wound edges
The running horizontal mattress suture is a
• Closes dead space time-efficient suture that provides good wound
eversion. The technique is similar to the stand-
ard horizontal mattress suture described above,
­except that it is run continuously until the end
B ox 1 1 - 6 of the incision (Fig. 11-17).
Disadvantages of the horizontal
mattress suture Combination running simple
and vertical mattress suture
• “Railroad track” scarring
The use of alternating vertical mattress sutures
• Overly tight horizontal mattress sutures can result in tissue
hypoxia and poor wound healing with simple running sutures also produces good
wound eversion in a time efficient manner. Simple
• Time consuming when compared to other methods cutaneous sutures are followed by vertical mat­t­
ress sutures in an alternating pattern (Fig. 11-18).

(Fig. 11-14). Again, an overly tight or improperly Buried sutures

placed corner suture can lead to tissue necrosis.
Interrupted buried sutures
Buried sutures are typically used to reduce ten-
Running sutures sion and evert the wound edges. They can be
placed to reapproximate deep structures (muscle
Simple running cuticular sutures
and fascia), the dermis, or both.
The running superficial suture is a fast, efficient
Placing the interrupted buried suture
way to close wound edges under little or no
­tension. Appropriate sites for this suture include (Fig. 11-19)
eyelids, neck, scrotum, and any tissue under little 1. Enter deep and exit on the same side of the
tension where dead space has been closed pre- wound superficially, typically at the level of
viously. When beginning a running subcuticular the mid dermis.
suture, it is important to place one end perpen- 2. Continuing in the same direction, enter the
dicular to the suture line. To anchor the loose opposing side of the wound edge and travel
ends of the suture, tie them back on themselves to the deep aspect, opposite the initial entry
(Fig. 11-15). point. This results in the knot being buried in
Boxes 11-� 7 & 11-8 show the advantages and the deep aspect of the wound and minimizes
disadvantages of running subcuticular sutures. its extrusion.
 11

Chapter
Suture techniques 147

Figure 11-12 Canal stitch

Figure 11-13 Three-point corner (tip) stitch

Advantages and pitfalls on buried sutures are flap repair. The modified version is performed
shown in Boxes 11-�
9 & 11-10. by entering the wound edge deep and exiting
through the epidermis lateral to the wound. The
needle is then redirected to enter back through
Buried vertical mattress suture the same hole and to exit within the mid dermis.
This is a modification of the simple buried suture The suture is repeated on the opposite side by
that further optimizes wound eversion. To initi- entering the contralateral mid dermis and exiting
ate the suture, place a deep suture by entering through the epidermis. Again the needle re-enters
the undersurface of the dermis and traveling with the same hole, but exits deep (Fig. 11-21). The
the needle in a superficial direction almost to the modified heart-shaped suture path yields superior
level of the epidermis. Then travel back down to eversion. Care must be taken to ensure that the
exit at the level of the mid dermis. On the oppos- suture is placed sufficiently in the mid dermis to
ing side of the wound, again enter at mid dermis, prevent “pull through.”
travel superficially, then dive down and exit deep.
Running subcuticular suture
The path of the suture creates a heart shape when
complete (Fig. 11-20). When used properly, the running subcuticular
­suture can yield superior cosmetic results because
Modified buried vertical it leaves no suture exit and entrance marks along
the edge of the suture line (Fig. 11-22). This ­suture
mattress suture should be used only when the wound is well
The buried vertical mattress suture can be modi- ­approximated, the edges are everted, and wound
fied to produce similar wound eversion in areas tension is minimal. If a deep space is present, it
too small to perform a standard buried mattress should be closed with a separate ­ buried suture.
suture, such as a small punch biopsy defect or If using a nonabsorbable suture that will need
148 Dermatologic Surgery

Figure 11-14 Four-point corner (tip) stitch

 11

Chapter
Suture techniques 149

Figure 11-15 Running cuticular stitch

B ox 1 1 - 8
B ox 1 1 - 7
Disadvantages of the running
Advantages of the running subcuticular suture
subcuticular suture
• Cannot be used on wound under tension due to tissue
• Efficient use of time ­strangulation
• Applies equal tension to wound edges • Does not close dead space
• Can allow for excellent wound eversion • Can leave “track lines”
150 Dermatologic Surgery

to be removed, the suture should have an exit

point ­ every 2–3 cm for ease of removal. When
­using absorbable suture material, the technique
is ­modified.

1. The running subcuticular is initiated with a

simple dermal interrupted suture. Cut only
the short end after tying the knot.
2. After completing the running subcuticular,
the suture end is tied off with another
dermal interrupted suture. Cut only the
short end.
3. The needle end is then passed through the
end of the incision and exited distal to the
incision. The needle is pulled with tension.
This pulls the knot deeper into the wound.
The suture is then cut at the skin surface.

Purse-string suture
The purse-string suture is a variation on the
­buried dermal or simple continuous suture that
is useful for fully or partially reducing wound
­diameter or closing dead space. Circumferentially
placed intradermal or epidermal sutures can be
applied to redistribute tension equally around the
wound. In some cases the purse-string suture is
used to close a defect entirely. Alternatively, it can
be used to decrease the defect size and optimize
secondary intention. Multiple bites are oriented
horizontally around the wound edge and pulled
taught (Fig. 11-23).

Suture removal
Proper suture removal technique is often under-
appreciated. The suture should be cut and the
freed knot should be pulled across the suture line.
This allows the suture to be pulled out in the di-
rection in which it was placed and avoids placing­
tension opposite the axis of closure. Improper
Figure 11-16 Running locked stitch ­suture removal can place tension on the suture
line and put the wound at risk of dehiscence.
 11

Chapter
Suture techniques 151

Figure 11-17 Running horizontal mattress

152 Dermatologic Surgery

Figure 11-18 Running combination simple and vertical mattress

 11

Chapter
Suture techniques 153

Figure 11-19 Interrupted buried stitch

B ox 1 1 - 9
Advantages of the buried suture

• Closes dead space

• Provides wound stability and reduces tension
• Helps to evert wound edges

B ox 1 1 - 1 0
Pitfalls of the buried suture

• A suture that is pulled too tightly can result in tissue necrosis.

• A buried suture placed only in the fat can pull through. If
­possible, try to include a portion of the dermis or fascia
with the suture.
• If placed too superficially, a subcutaneous suture can pucker
the wound and may extrude or “spit” through the final wound.

Figure 11-20 Buried vertical mattress

154 Dermatologic Surgery

Figure 11-21 Modified buried vertical mattress

 11

Chapter
Suture techniques 155

Cut the short end of

the suture at the knot

Pull the needle through

the skin and cut at the
skin surface

Figure 11-22 Running subcuticular stitch

Figure 11-23 Purse-string suture

156 Dermatologic Surgery

Further reading Moody BR, McCarthy JE, Linder J, Hruza GJ. En-
hanced cosmetic outcome with running horizontal
Adams B, Anwar J, Wrone DA, Alam M. Techniques for mattress sutures. Dermatol Surg 2005;31:1313–
cutaneous sutured closures: ­variants and ­indications. 1316.
Semin Cutan Med Surg 2003;22(4):306–316. Odland PB, Murakami CS. Simple suturing tech-
Adams B, Levy R, Rademaker AE, Goldberg LH, niques and knot tying. In: Wheeland RG, ed.
Alam M. Frequency of use of suturing and repair Cutaneous Surgery. Philadelphia: WB Saunders,
techniques preferred by dermatologic surgeons. 1994:178–188.
Dermatol Surg 2006;32(5):682–689. Olbricht S. Biopsy techniques and basic excisions. In:
Alam M, Goldberg LH. Utility of fully buried Bolognia J, Jorizzo J, Rapini R, et al, eds. Derma-
horizontal mattress sutures. J Am Acad Dermatol tology. Philadelphia: Mosby, 2003:2269–2286.
2004;50(1):73–76. Starr J. Surgical pearl: the vertical mattress tip stitch.
Collins SC, Whalen JD. Surgical pearl: percutaneous J Am Acad Dermatol 2001;44(3):523–524.
buried vertical mattress for the closure of narrow Stasko T. Advanced suturing techniques and layered
wounds. J Am Acad Dermatol 1999;41(6): closures. In: Wheeland RG, ed. Cutaneous Surgery.
1025–1026. Philadelphia: WB Saunders, 1994:304–317.
Harrington AC, Montemarano A, Welch M, Farley M. Swanson NA. Atlas of Cutaneous Surgery. Boston:
Variations of the pursestring suture in skin cancer Little, Brown, 1987.
reconstruction. Dermatol Surg 1999;25(4): Vistnes L. Basic principles of cutaneous surgery. In:
277–281. Epstein E, Epstein E Jr, eds. Skin Surgery, 6th edn.
Krunic Al, Weitzul S, Taylor RS. Running combined Philadelphia: WB Saunders, 1987:44–55.
simple and vertical mattress suture: a rapid skin- Zelac D, Swanson N, Simpson M, Greenway H. The
everting stitch. Dermatol Surg 2005;31: history of dermatologic surgical reconstruction.
1325–1329. Dermatol Surg 2000;26(11):983–990.
 12

Chapter
Suture materials
Oliver J. Wisco and Matthew R. Ricks

Clinical overview • Sutures may tear through tissue when

tied.
The needle and suture are the foundation of 2  Triangular – reverse cutting:
wound closure. This chapter discusses the prin- • Cutting edge on the outside of the arc.
ciples of the needle and suture and how to em- • Puncture faces away from the wound
ploy their strengths and weaknesses effectively in incision.
dermatologic surgery. • Less tearing of tissue than conventional
needle.
Basic science and terminology 3 Rounded:
• Tapered rounded shape.
Key Points • Useful with fascia and delicate areas.
• Curved needles with triangular tips are typically
used in dermatology as they give the highest
precision for fine detailed closures. PEARL
• The properties of a suture determines its utility in
the closure of certain body regions and the type  riangular needles are typically preferred over
T
of closure to be used. round ­needles because they are easier to pass
through tissue.

Needles Needle nomenclature

• Curved needles with triangular tips are • There are several major suture brands,
typically used in dermatology. each using different nomenclature
• The 3/8 circle is used most commonly. (Fig. 12-3).
• The 1/2 circle is commonly used for small flaps. • Ethicon produces 80% of the surgical needles
• Other sizes include 1/4 and 5/8 circles. in North America (Table 12-1).
• The surgical needle is composed of three
parts (Fig. 12-1):
PEARLS
1 Shank – where the needle attaches, the
weakest part.  se smaller needles for areas of high cosmetic
U
2 Body – middle part (strongest part), where importance.
the needle should be held with the needle Use larger needles to close large wounds.
driver.
3 Point – sharp end extending to the largest
cross-section of the body; do not handle Suture properties
the needle in this area. • The properties of a specific type of suture
determine how it is used (Table 12-2).
• Each property influences the other
PEARL
properties.
 or finer needles, use needle holders with smaller,
F
smoother jaws.
PEARL
Types of needle (Fig. 12-2)
There is an increased rate of suture
1 Triangular – conventional cutting: absorption on mucosal surfaces and areas
• Cutting edge on the inside of the arc. of infection.
• Puncture faces the wound incision.
158 Dermatologic Surgery

Table 12-1 Ethicon needle abbreviations

Abbreviation Meaning
P Plastic
PC Precision Cosmetics
PS Plastic Surgery
FS For Skin
Tip
Adapted from Robinson et al (2005) with permission from Mosby
Grasp needle Shank
Publishing Company.
in this region

Options
Body Key Points
Figure 12-1 Curved needle. Adapted from Robinson et al • All sutures are absorbed to some degree if left in
(2005) with permission from Mosby Publishing Company long enough (except stainless steel).
• Sutures are defined as absorbable or
Conventional Reverse Round nonabsorbable according to whether the suture
loses its tensile strength by 60 days (Tables 12-3
& 12-4).
• The rate of absorption is dependent on the
suture type, the location, and the presence of
infection.

Surgical approach
Key Points
• Choose the smallest suture that can provide
adequate strength for the closure but still
minimize tissue trauma.
• For subcutaneous suturing in areas of high
tension, use sutures with longer absorption rates.
• Use sutures with minimal tissue reactivity in areas
of high cosmetic importance.

For recommendations on which suture material and

needle to use in different locations see Table 12-5.

Comparative outcomes
Figure 12-2 Different needle types. Adapted from
Key Points
Robinson et al (2005) with permission from Mosby • While suturing is typically the preferred method
Publishing Company of wound closure, staples, tissue adhesives,
and skin closure tapes can be good alternatives
P-1 PS-1 (Table 12-6).

Controversies
P-3
PS-2 Key Points
• Data on the risk of infection with braided sutures
P-4 has historically been controversial.
• It has been theorized that the braids in braided
sutures harbor microorganisms, thus increasing
PS-4 the risk of infection.
PC-1 • However, a study published in 2001 by
Gabrielli et al showed that age, sex, wound
site and length, and surgeon experience were
more important in predicting complications
PC-3 PS-6 than the choice of suture materials and suturing
techniques.
 12

Chapter
Suture materials 159

Table 12-2 Suture properties

Material Synthetic vs natural
Configuration Monofilament: single strand, low coefficient of friction allows it to slide easily, good for exterior suturing
Multifilament: braided/twisted, increased strength, easier handling but higher coefficient of friction, good for
subcutaneous suturing
Capillarity The ability to absorb and transfer fluid; it is controversial whether increased capillarity allows the suture to
harbor organisms
Tensile strength Determined by the force in pounds to snap the suture; synthetic sutures are generally stronger than natural
sutures; the greater the diameter the stronger the suture
Size Size ranks tensile strength - the thicker the suture, the greater the strength and the fewer the zeroes (3-0 is
wider and stronger than 4-0 for the same type of suture) dependent on the type of the suture
Elasticity The ability to return to the original size after being stretched; good elasticity allows for stretch with tissue
swelling, but also will recoil to maintain tissue approximation when the swelling resolves; use sutures with
good elasticity for exterior suturing
Plasticity The ability to maintain a new shape after it has been manipulated; allows for a more secure knot; good
plasticity accommodates tissue swelling without cutting tissue but does not hold tissue approximation well
when the swelling resolves
Memory A measure of a suture’s elasticity and plasticity; sutures with increased memory have a greater tendency
to return to their original configuration after being manipulated and are more difficult to handle; increased
memory causes suture knots to untie themselves, requiring extra knots
Coefficient of friction Determines how easily a suture will pull through tissue; the lower the coefficient, the easier it is for the
suture to slide through tissue, but it will also unravel more easily; sutures with a low coefficient are useful for
running subcuticular suturing
Pliability A measure of how well a suture bends; good pliability allows ease in knot tying and increased knot strength
Coating Sutures may be coated with various materials to lower the coefficient of friction or to increase the
antimicrobial properties
Tissue reactivity A measure of how much the suture will illicit a foreign body reaction; sutures with increased tissue reactivity
are natural, multifilament, absorbable, and large

Table 12-3 Commonly used absorbable sutures

Tensile Ease of Knot Tissue Time to
Suture Configuration strength handling security reactivity absorption Uses & pearls
Surgical gut Multifilament, Low, lost in Fair Poor Moderate 70 days Rarely used
(plain) twisted 7–10 days in skin;
unpredictable
absorption
rates
Surgical gut Multifilament, Low, lost in Fair Poor Low 21–42 days Skin grafts,
(fast-absorbing) twisted 3–7 days surface
sutures
Surgical gut Multifilament, Low, lost in Poor Fair Moderate 90 days Skin grafts;
(chromic) twisted 10–21 days unpredictable
absorption
rates
Polyglycolic Multifilament, Moderate, Good Good Low 60–90 days Dexon S:
acid (Dexon®) braided 20% at uncoated
21 days Dexon II: coated
Polyglactin Multifilament, High, 75% at Good Fair Low 56–70 days Subcutaneous
(Vicryl®, braided 14 days, 50% closure, vessel
Polysorb®) at 21 days ligature, high
memory
Continued
160 Dermatologic Surgery

Table 12-3 Commonly used absorbable sutures—cont’d

Tensile Ease of Knot Tissue Time to
Suture Configuration strength handling security reactivity absorption Uses & pearls
Polydioxanone Monofilament High, 70% at Poor Poor Low 90–180 Subcutaneous
(PDS II®) 14 days, 50% days closure (high-
at 30 days, tension areas)
25% at
42 days
Polytrimethylene Monofilament Very high, Fair Good Low 60–180 Subcutaneous
carbonate 81% at days closure (high-
(Maxon®) 14 days, 59% tension areas)
at 28 days
Poliglecaprone Monofilament High, Good Good Minimal 90–120 Use when
25 (Monocryl®) 50–60% at days minimal tissue
7 days reactivity is
essential; good
for running
subcuticular
suture
Glycomer 631 Monofilament 75% at Good Poor Minimal 90–110 Subcutaneous
(Biosyn®) 14 days, 40% days closure (high-
at 21 days tension areas)
Rating scale: very low – low – poor – fair – good – moderate – intermediate – relatively high – very high – very good – highest. Adapted from Bolognia et al
(2003) and Robinson et al (2005) with permission from Mosby Publishing Company.

Table 12-4 Commonly used nonabsorbable sutures

Tensile Ease of Tissue
Suture Configuration strength handling Knot security reactivity Uses & pearls
Silk Multifilament, Low Gold standard Good High Mucosal
braided surfaces
Nylon
Ethilon® Monofilament High Good to fair Poor Low May tear
through
Dermalon® Good
delicate tissue
Surgilon® Multifilament, High Good Fair Moderate
braided
Nurolon®
Polypropylene Monofilament Moderate Good to fair Poor Low Running
(Prolene®, subcuticular
Surgilene®, suture
Surgipro®)
Polyester Multifilament, Very high Very good Very good Moderate Mucosal
(Dacron®, braided surfaces
Mersilene®)
Polyester Good Moderate Polybutylate-
(Ethibond coated
Excel®)
Polybutester Monofilament High Good to fair Good Low Exhibits
(Novafil®) elasticity
Rating scale: very low – low – poor – fair – good – moderate – intermediate – relatively high – very high – very good – highest. Adapted from Bolognia
et al (2003) and Robinson et al (2005) with permission from Mosby Publishing Company.
 12

Chapter
Suture materials 161

Table 12-5 Suture recommendations

Location Needle Suture type and size Time to removal Clinical pearls
Scalp
Deep PS-2 Vicryl, 4-0 NA Use large needle
Superficial P-3 Prolene or Ethilon, 4-0 10–14 days Can use staples
Ears
Deep Not typically used
Superficial P-3 Prolene or Ethilon, 5-0 7 days Use small needle
Other face
Deep P-3 Vicryl, 5-0 NA
Superficial P-3 Prolene or Ethilon, 7 days
5/6-0
Nose
Deep P-3 Vicryl, 5-0 NA
Superficial P-3 Prolene or Ethilon, 7 days
5/6-0
Eyelids
Deep PS-6 Vicryl, 6-0 NA Not typically used
Superficial P-3 Prolene or Ethilon, 6-0 7 days Can also use fast-
absorbing gut or silk
Lips
Deep P-3 Vicryl, 5-0 NA
Superficial P-3 Prolene or Ethilon, 6-0 7 days Can also use fast-
absorbing gut or silk
Neck
Deep P-3 Vicryl, 5-0 NA
Superficial P-3 Prolene or Ethilon, 5-0 10–14 days
Trunk
Deep P-3 Vicryl, 4-0 NA Use PDS for large
high-tension wounds
on the back
Superficial P-3 Prolene or Ethilon, 4-0 10–14 days
Arms
Deep P-3 Vicryl, 4-0 NA
Superficial P-3 Prolene or Ethilon, 4-0 10–14 days
Hands
Deep P-3 Vicryl, 5-0 NA
Superficial P-3 Prolene or Ethilon, 5-0 10–14 days Use silk for delicate
skin
Legs
Deep P-3 Vicryl, 4-0 NA
Superficial P-3 Prolene or Ethilon, 4-0 10–14 days
Feet
Deep P-3 Vicryl, 4-0 NA
Superficial P-3 Prolene or Ethilon, 4-0 10–14 days
Continued
162 Dermatologic Surgery

Table 12-5 Suture recommendations—cont’d

Location Needle Suture type and size Time to removal Clinical pearls
Penis
Deep P-3 Vicryl, 5-0 NA
Superficial P-3 Silk, 5-0 7 days
Vulva
Deep P-3 Vicryl, 5-0 NA
Superficial P-3 Silk, 5-0 7 days

Table 12-6 Closure material alternatives

Material Benefits Disadvantages Pearls
Staples Fast application; good wound Increased risk of necrosis Can be used on the scalp and
eversion; decreased risk of with flaps; painful on back, trunk; can be used to secure
infection/reactivity intertriginous areas, and over grafts
bony prominences
Tissue adhesives Fast application; no need Little eversion of wound Used for superficial/low-
(cyanoacrylate compound) for removal by a medical edges; expensive; risk of tension incisions or wounds;
professional; may have allergic reaction; can be useful for children
decreased risk of infection/ removed easily by repeated
reactivity washing
Skin closure tapes Fast application; low cost; no Little eversion of wound Used to support sutured
need for removal by a medical edges; little wound support if wounds; can be used alone
professional; may have used alone; can be removed for superficial/low-tension
decreased risk of infection/ easily incisions or wounds; not to
reactivity be used alone in cosmetically
sensitive areas

Further reading Oljoffer IH, Goldman G, Leffell DJ. Wound closure

materials and instruments. In: Bolognia JL, Jorizzo
Adams B, Levy R, Rademaker AE, Goldberg LH, JL, Rapini RP, eds. Dermatology. Edinburgh:
Alam M. Frequency of use of suturing and repair Mosby, 2003:2243–2253.
techniques preferred by dermatologic surgeons. Raza SL, Sengelmann RD. Instrumentation and
Dermatol Surg 2006;32:682–689. sutures. In: Snow SN, Mikhail GR, eds. Mohs
Bolognia JL, Jorizzo JL, Rapini RP, eds. ­Dermatology. Micrographic Surgery. Madison: Wisconsin Press,
Edinburgh: Mosby, 2003. 1999:33–42.
Coulthard P, Worthington H, Esposito M, Elst M, Robinson JK, Hanke W, Sengelmann RD, Siegel DM.
Waes OJ. Tissue adhesives for closure of surgical Surgery of the Skin: Procedural Dermatology.
incisions. Cochrane Database Syst Rev 2004; St Louis: Mosby, 2005.
(2)CD004287. Weitzul S, Taylor RS. Suturing technique and other
Eaglstein WH, Sullivan T. Cyanoacrylates for skin closure materials. In: Robinson JK, Hanke CW,
closure. Dermatol Clin 2005;23:193–198. Sengelmann RD, Siegel DM, eds. Surgery of
the Skin: Procedural Dermatology. Philadelphia:
Gabrielli F, Potenza C, Puddu P, Sera F, Masini C,
Mosby, 2005:225–243.
Abeni D. Suture materials and other factors associ-
ated with tissue reactivity, infection, and wound
dehiscence among plastic surgery outpatients. Plast
Reconstr Surg 2001;107(1):38–45.
Kanegaye JT, Vance CW, Chan L, Schonfeld N.
Comparison of skin stapling devices and standard
sutures for pediatric scalp lacerations: a rando­
mized study of cost and time benefits. J Pediatr
1997;5:808–813.
 13

Chapter
Flaps
T. Minsue Chen,
Rungsima ­Wanitphakdeedecha, and Tri H. Nguyen

Key Points a­ dvantages and limitations of each closure

• “Function before form, and form before ­method. The simplest option (fewest incisions,
cosmesis” are inviolable principles of least tissue alteration, fewest stages, etc.) is usually
reconstructive surgery. the best option provided that function and form
• The most useful flap classification schemes are are optimized – in order of simplicity: second
based on location (with respect to the defect), ­intention > primary closure > skin grafting > flap.
movement, and vascular supply. A wound closure algorithm is useful for a system-
• Most flaps in dermatologic surgery are local, atic approach (Fig. 13-1). Flaps are usually per-
being harvested from adjacent skin.
formed when other closures are less optimal due
• There are two essential local flap movements:
advancement (linear) and rotation (pivotal).
to issues with tension, function, or form. In gen-
• Transposition flaps have both a linear and a eral, flaps are ideal for reducing, redirecting, and
pivotal movement, but the flap is not directly redistributing tension from the primary defect,
contiguous with the defect. These flaps transfer and for providing bulk or thickness for deeper
tissue across an area of normal skin to reach the wounds.
defect. Flaps have a wide range of applications and
• The flap pedicle, or vascular supply, is critical to can provide excellent functional and cosmetic
tissue viability and flap survival. Pedicles may be outcomes when designed and executed precisely.
random pattern or axial based. The goals of this chapter are to discuss: (1) how
• This is especially true of flaps with axial pedicles.
flaps are classified, (2) the principles and biome-
Elasticity, restraints to movement, tension
vectors, free margins, and effects of closing the chanics of flap movement, and (3) common flap
secondary defect are all factors to consider in designs in dermatologic surgery.
flap design.
Definition
Introduction A flap is a section of partially detached tissue.
The attached portion of a flap contains its vascu-
A key tenet in reconstructive surgery is: function lar supply and is its pedicle (Fig. 13-2). All flaps
before form (contour, shape); form before cosmesis. share the following features:
A beautiful scar is worthless if nasal inspiration
is obstructed. Form is primary, because contour • The recruitment of nearby (but not
depressions and elevations are difficult to cam- necessarily contiguous) donor skin that is
ouflage. Scar quality, although important, is sec- mobile and lax.
ondary, as a wide or red scar may be hidden with • The ability to reduce, redirect, and/or
cosmetics as long as it is flush (contour) with its redistribute tension from the primary defect
surroundings. (original wound to be repaired).
Accurate wound assessment is critical to re- • The creation of a secondary defect once the
constructive planning; Box 13-1 outlines issues to flap moves into and closes the primary defect.
consider. The secondary defect is the space that the
When these details are factored, the best re- donor flap tissue occupied. The tension on
pair usually becomes evident. The surgeon should the primary defect is partially redirected and
be able to discuss with the patient the ­ inherent redistributed to the secondary defect.
164 Dermatologic Surgery

B ox 1 3 - 1 • The alteration of tension vectors (directional

movement under tension) when both primary
Wound analysis and secondary defects are closed.
Wound characteristics
How large is the defect? Classification
What tissue layers are missing – epidermis, dermis, There are numerous ways to classify flaps
subcutaneous fat, fascia, muscle? (Fig. 13-3):
Is there a need for structural support – bone, cartilage?
Is the wound located in a convex or concave region of the
• Location with respect to the surgical
body? defect – local, regional, or distant
• Movement – advancement, rotation
Are any critical structures exposed – bone, tendon, nerve, • Vascular supply – random pattern, axial, or
vessel)?
microvascular
What caused the wound – malignancy, trauma, infection? • Stage – single or multistaged
If cancer, are the margins clear? What is the risk of recurrence? • Configuration – note, rhomboid, bilobed,
Will adjuvant therapy (radiation, topical chemotherapy) be banner, etc.
necessary? • Eponym – Abbe, Reiger, Mustarde, etc.

Cosmetic unit, boundary No single classification accounts for every design

Is the defect in an area of visual significance? or definition variation. Eponyms should generally
be avoided. Most flaps in cutaneous surgery are
Is there baseline asymmetry?
local (adjacent and contiguous skin) and regional
What cosmetic units and subunits are involved? What (nearby but not directly adjacent). Within this
proportion of the subunit is involved? If more than 50%, should context, the most useful classification scheme is
the remainder be removed and the entire subunit replaced?
based on movement and vascular supply.
What cosmetic boundaries are nearby?
Movement
Relevant anatomy There are two basic local flap movements: linear
Where are the regional relaxed skin tension lines and ­(advancement) and pivotal (rotational) (Table
rhytids? 13-1). Advancement flaps move adjacent/contigu-
Is there baseline functional compromise – nerve injury/palsy, ous skin in a linear fashion into the defect. Rota-
ectropion, nasal valve collapse, etc.? tion flaps move adjacent/contiguous tissue in an
arc or curvilinear fashion. Although these defini-
What free margins are affected – eyelids, nose, lips?
tions help in concept and classification, in practice
What neurovascular structures are at risk? many flaps involve both types of ­movement.
Is the location in an area of inherent high tension – extremity, A transposition flap may incorporate both
trunk? a pivotal and a linear movement. However,
­although a pure rotation or advancement flap
Adjacent skin moves contiguous tissue into a wound, a transpo-
Where is there lax and mobile skin – donor reservoir? sition flap transfers noncontiguous tissue across an
inte­rvening area of normal skin to close the pri-
What is the quality of the adjacent skin – Thickness? Elasticity?
mary defect (Fig. 13-4). Local transposition flaps
Sebaceousness? Compromised (actinic damage, prior scarring
or radiation)? Hair growth patterns?
are one-stage procedures (excluding revisions).
Regional transposition flaps, however, are staged
How does positional change (upright versus supine, static repairs (more than one stage for completion) and
versus dynamic) affect the defect and closure plans?
are also known as interpolation (interpolate = to
insert between parts) flaps. Interpolation flaps or
Patient-specific considerations
staged flaps, therefore, are subtypes of transposi-
What are the patient’s aesthetic expectations? tion by moving tissue across areas of unaffected
Is the patient willing to undergo a staged reconstruction? skin to reach the wound.
Wound care compliance? Vascular supply
May patient comorbidities (venous stasis, diabetes, smoking) The vascular supply or pedicle to a flap is the
affect wound healing? portion that remains attached. A pedicle may
Does the patient take any prescription and/or over-the-counter be random or axial based. Random pattern flaps
products that may complicate reconstruction – anticoagulants, include all local flaps and are nourished by der-
antineoplastic, immunomodulating medications, herbal mal and subdermal vascular plexus. Axial flaps
supplements? are regional and are based on a named artery
­(either ­ septocutaneous or musculocutaneous,
 13

Chapter
Flaps 165

No: FTSGd
Vascular
base poor?
Yes: STSGe or
allograft/xenograft
Superficial

Second intentc

Low tension: Primary closure

or delayed FTSG
Defecta

Degree of Moderate tension: Plication

tension? + primary, local flap, or
delayed FTSG
Yes: Local flapf
Deepb
High tension: Is there
adjacent tissue laxity?
No: Composite graftg,
regional flapf
No
Structural
support?
Yes: Cartilage graft Local or regional flap

Figure 13-1 Algorithm for defect closure. The algorithm is not all inclusive. Repair depends greatly on the location of
the defect; for instance, a 1-cm defect on the nose demands greater consideration and complexity than a wound of the
same size on the cheek. aSmall (<1 cm), medium (1–3 cm), large (>3 cm). Location is critical. bDefects greater than
3 mm in depth will likely heal with a contour depression (unless in concave area), especially if overlying convex surfaces
or sebaceous skin. cSmall, superficial defects in concave areas are ideal for second intention healing. Avoid second
intention if bare bone, tendon, or neurovascular structures are exposed. Large defects will also heal well if superficial.
However, anticipate significant wound contraction and its impact, if any, on free margins or function. dA full-thickness skin
graft (FTSG) may be applied to any defect that is well vascularized. Superficial defects with FTSGs will maintain contour. If
deep defects are repaired with FTSGs, contour depressions may result unless delayed (partial granulation to fill the depth)
skin grafting is performed. eSplit-thickness skin grafts (STSGs) have less metabolic demand and survive better in poorly
vascularized defects. However, significant graft contraction (with potential effect on free margins) is assured compared
with FTSGs. fCombination closures (flap + flap, flap + graft, flap + second intention) should be considered for wounds
involving multiple subunits. gComposite grafts work best for small deep wounds at free margins. Owing to their bulk and
high metabolic demand, composite grafts survive poorly if sized above 1.5 cm

e.g. ­ supratrochlear artery in a paramedian fore- outcomes, such as inadequate flap length, tissue
head flap, labial artery in a lip-switch flap) (Table ischemia, edema, and/or inability to close the sec-
13-2). All axial flaps are multistaged flaps. Not all ondary defect. The best flap designs must account
staged flaps, however, are axial in vascular supply. for and overcome a variety of tissue restraints. All
The cheek to nose staged flap, for example, is a ran- flap movement is limited by inherent, vertical,
dom pattern flap (incorporates arterial perforators and lateral restraints.
from the angular artery but the angular itself is Inherent restraint refers to the intrinsic laxity of
not in the flap pedicle), despite being a two-stage the flap tissue. For example, scalp tissue is more re-
repair. Due to a more robust and reliable vascular strained than cheek skin due to the inherent rigidi­
supply, axial designs permit flaps to reach farther ty of the galeal fascia. Similarly, the sebaceous nasal
and close more complex defects. Axial flaps can tip is more restrained than the nasal sidewall. Flap
even become free flaps if the ­vessels are divided, design must compensate for inherent tissue re-
and the flap is moved and reanastomosed with straint. A rotation flap on the scalp must be greater
microsurgical techniques at the recipient site. than the 3–4 : 1 ratio (flap diameter = 3–4 × defect
diameter) because of the scalp’s reduced mobility.
Flap biomechanics and design Vertical restraint refers to the fibrous fibers that
tether the flap to its base. Vertical restraints are
The physics mantra “for every action, there is an released by appropriate undermining. A form of
equal and opposite reaction” is applicable to flap restraint that combines both inherent and vertical
design. Poor flap design may have deleterious restraint is pivotal restraint, which is a term that
166 Dermatologic Surgery

a b

c d

Figure 13-2 Flap lexicon. (a) A = primary defect; B = pedicle, attached portion of flap; C = primary standing cone
(excises redundancy at primary defect). (b) Flap is rotated superiorly to close the defect. Note how the tension from the
primary defect is reduced, redirected, and redistributed to the secondary defect (D). (c) Length discrepancy at secondary
defect will be excised in the secondary standing cone (E), which is strategically placed at the submentum; (C) is the
primary standing cone that has been excised at the temple. (d) Outcome at 6 months

is specific to rotation flaps. It refers to the point for flap movement. Once these restraint concepts
(usually between the pedicle and the primary are understood, flap design may begin.
standing cone) on which the flap rotates into the Next to flap restraints, the secondary defect
defect. If a door is the flap, then the door hinge is closure is the most important factor to consider.
the area of pivotal restraint. Pivotal restraint teth- When designed accurately, closure of the second-
ers the flap during rotation so that the flap’s supe- ary defect can facilitate flap movement. Improp-
rior leading edge falls short of the superior border erly designed, however, untoward tension may
of the defect. Wide undermining and elongating result with subsequent complications. Closing the
the rotation flap height is required to overcome secondary defect usually involves lines of unequal
pivotal restraint (Fig. 13-5). lengths, which may be resolved by a number of
Lateral restraints are the attachments of the techniques (see below in Operative technique).
flap to its periphery (see Fig. 13-5). A cheek flap, An advancement flap is simply a method of dis-
for instance, is laterally restrained by its attach- placing a standing tissue cone from the primary
ments to the temporal and preauricular fascia. defect. The best example is the Burow’s wedge
Lateral restraints can be overcome only by prop- advancement flap (BWAF), in which one stand-
erly placed incisions. These “relaxing or releasing” ing cone is displaced laterally in a linear fashion
incisions separate peripheral anchors and allow (Fig. 13-6). Rarely used advancement flaps are