Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

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Chapter 12  Incision, Draining, and Exteriorization Techniques
The presence of melanin pigment has been reported in one
case.26
These lesions are frequently asymptomatic but may increase
in size and require removal. Usually they are a few millime-
ters in diameter and rarely exceed 10 mm in size. Although
these lesions can be confused with cystic basal cell carcinoma,
the surface is usually smoother, contains no telangiectasias,
and is somewhat softer in quality. Histologically this lesion
consists of a thin lining of apocrine secretory cells. Small
lesions of 1–2 mm in size can be incised and drained. Larger
lesions can be exteriorized by removing the overlying skin
and then taking a sharp delicate scissor and dissecting out the
cyst lining. Note that the cyst lining is very fragile and thin
and can be easily ruptured, releasing somewhat mucoid mate-
rial. After the cyst is dissected, the base is lightly cauterized
and topical antibiotic ointment is applied. If the lesion is near
the eye, an ophthalmic topical antibiotic should be used.
Steatocystoma
Steatocystoma is the only true ‘sebaceous’ cyst. It contains
sebaceous lobules within the thin wall of the cyst, or it may
have sebaceous ducts draining into the cyst cavity. The wall
of the cyst is generally quite thin with the contents having an
oily consistency and being made up of esters of sebum. Indi-
vidual lesions are often yellowish white in color, and usually
a few millimeters in diameter. They occur on the trunk and
proximal extremities, with the sternal area being the most
common site. Steatocystoma can be a solitary lesion but is
seen more frequently as multiple lesions, particularly on the
chest.17 They are commonly inherited as an autosomal domi-
nant condition18 and occur most frequently in adolescence or
early adult life. In contrast to epidermal cysts, the lesions of
steatocystoma usually have no overlying epidermal pore, but
may be associated with multiple surrounding open comedones.
Individual lesions can be treated by making a small linear
incision overlying the cyst and grasping and gently extracting
the underlying cyst with fine forceps19,20 or a skin hook. Care
must be taken not to rupture the thin wall of the cyst. Gentle
dissection with a small iris or Gradle scissors is occasionally
necessary. The skin hook technique utilizes a smaller incision,
which is important because, when multiple sites are treated,
there is an increased risk of hypertrophic scars, especially on
the chest. One should note that frequently the multiplicity
of lesions makes routine incision and removal of all lesions
impractical. Sato and associates have reported good success
with aspiration drainage of the cysts.21 The carbon dioxide
laser has also been used to exteriorize and destroy these cysts
with some success.22
Apocrine hidrocystoma
Apocrine hidrocystomas, which are most commonly seen in
adults, present as bluish-colored papules23,24 in the periocular
region and on the face (Fig. 12.12). The cause of the bluish
discoloration has been attributed to the Tyndall phenome-
non,23 from extravasated red blood cells,24 and lipofuscin.25
A
B
Figure 12.11  (A) Large pilar cyst shown preoperatively with overlying redundant skin. (B) Excess skin was trimmed during the
procedure after the cyst was removed to give a fine-line closure.
Figure 12.12  Apocrine hidrocystoma on the right lateral lower
eyelid. The clinical appearance can mimic a basal cell
carcinoma.

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Part 2  Essential Surgical Skills
using either a forceps or hemostat to advance the material
until the inflamed space is appropriately filled to allow for
adequate drainage (Fig. 12.15). If excess blood is noted on the
packing material, allow additional time for hemostasis and
repack. The packing material is withdrawn a small amount
each day when the dressing is changed until it is completely
removed. The wound drains and heals gradually by second
intention. If there is concern regarding possible infection, one
can prescribe an oral antibiotic. Broad-spectrum antibiotics
such as cephalosporins or erythromycins are good choices as
frequently the lesions can be polymicrobial containing Staphy-
lococcus and Streptococcus spp.28 Follow up in a few days is
appropriate to assess healing, check dressing compliance, and
correlate culture results with the antibiotic prescribed.
Inflamed and infected cysts and abscesses
Inflamed and infected cysts and abscesses are a common
problem. Incision and drainage are frequently used for their
treatment. First, carefully inspect the area and pay close atten-
tion to erythema, induration, and fluctuance (Fig. 12.13).
Gently palpate the area as it may be quite tender. If fluctuance
is appreciated, then incision and drainage may be necessary.
Sterile preparation of the area is useful because a culture of the
contents may be required for appropriate adjunct oral antibiotic
therapy. Prior to the injection of local anesthesia, a topical skin
refrigerant may be used to reduce the discomfort of injection.
Inject the anesthetic very slowly as more rapid injection causes
abrupt tissue distention, more rapid change in pH, and hence
more resultant pain. Local anesthesia is often less effective in
infected tissues because of the low pH of infected tissues.27
Once the area is adequately anesthetized, make a small stab
incision over the point of greatest fluctuance (Fig. 12.14).
Make sure you are wearing protective eyewear, mask, and
clothing as frequently the inflamed lesions are under consid-
erable pressure and decompression can result in spraying of
the contents quite widely. Shielding the area where the stab
incision is to be made with sterile gauze helps to minimize
spraying of the contents. Immediately after making the stab
incision, material should be collected for wound culture if
clinically appropriate.
Lateral compression will usually express the contents of the
cavity and retained keratinous fragments can be removed by
gently probing with a curette. The cavity is then irrigated with
saline and inspected to remove as much of the contents as
possible. A decision is then made whether packing the wound
or insertion of a drain is necessary. Packing can be performed
with Iodoform or plain gauze (usually one-quarter to one-half
inch wide). Packing material is removed from the bottle ster-
ilely with a forceps or hemostat. The wound is then packed
Figure 12.13  Abscess with erythema and induration. The area
of maximum fluctuance is identified by gentle palpation.
Figure 12.14  After identifying the area of greatest fluctuance, a
small stab incision is made to allow for drainage.
Figure 12.15  Wick of packing material extruding from the
wound after packing has been completed.
Inflamed and infected cysts and abscesses
 Assess for fluctuance.
 Apply topical skin refrigerant to lessen pain of injection.
 Local anesthesia may be less effective due to low pH of
infected tissue.
 Wear protective eyewear, mask, and clothing as contents
may be under pressure.
 Shield stab incision with sterile gauze to minimize spraying of
contents.
 Culture contents if appropriate.
 Drain cavity and pack if necessary.
 Broad-spectrum oral antibiotics to cover Staphylococcus and
Streptococcus spp.
Apocrine hidrocystoma
 May be confused with cystic basal cell carcinoma.
 Send tissue fragments for microscopic confirmation.
 Care should be taken to avoid injury to the eye when
removing periocular lesions.
 Ophthalmic antibiotic should be used for periocular lesions.

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Chapter 12  Incision, Draining, and Exteriorization Techniques
 OPTIMIZING OUTCOMES
Activity restrictions should be discussed thoroughly with
patients pre- and postoperatively. Patients with known scar-
ring problems should be followed closely so that any prob-
lems can be detected early and dealt with.
In removing lipomas, it is particularly important to spend
time in the preoperative planning stage to localize these
growths prior to removal. Remember that infiltrating lipomas
and forehead lipomas are much deeper than they appear and
are often under or between muscle.
Cysts which have been drained previously or which have
been traumatized will often have significant scar tissue associ-
ated with them. It is important to assess scar tissue preop-
eratively so that it can be removed if necessary. Infiltrating
local anesthetic in and around a cyst helps to dissect it free
from the surrounding tissue. It is important not to inject
anesthetic directly into a cyst as this may cause rupture prior
to removal. If a cyst is ruptured prior to removal, then every
effort should be made to remove all of the wall and the
keratinous debris which may be present. Cysts which have
been present over a long period of time will often have redun-
dant skin overlying them. Sometimes in the scalp area the
redundant skin will lack hair. It is important to trim the
redundant skin at the time of closure to ensure an optimum
result. Larger cysts will often require multilayered closure.
Incisional surgery for milia, apocrine hidrocystomas, and
steatocystoma multiplex cysts is relatively simple. When
incising and draining milia, the cyst wall will often be extruded
with the keratinous contents with simple pressure from a
curette or comedone extractor after a small incision is made.
Steatocystomas are somewhat more difficult to remove, but
care must be taken not to excessively traumatize the tissue as
this may result in excess scar tissue formation, especially on
the chest where many of these lesions occur. Apocrine hidro-
cystomas respond well to incision and drainage and light elec­
trodesiccation of the base will help to prevent recurrences.
When incising and draining infected or inflamed abscesses
occurring as an isolated event or in combination with hidrad-
enitis suppurativa, care must be taken to ensure a successful
outcome. With solitary inflamed cysts and abscesses, it is
important to isolate the area of maximum fluctuance care-
fully before incising and draining. This will be the area that
is most easily incised and allows access to the underlying
inflammatory debris and purulent material. When incising an
inflamed cyst, care must be taken to remove all of the kerat-
inous fragments and every attempt should be made to remove
all fragments of cyst wall. The likelihood of needing to re-
excise the lesion later is decreased substantially if all of the
cyst wall can be removed.
Hidradenitis suppurativa
Hidradenitis suppurativa (Fig. 12.16) is a chronic suppurative
inflammatory condition that involves skin with apocrine
glands and frequently results in scarring, cysts, and sinus tract
formation. It frequently involves the axillary, anogenital, and
inframammary areas. Initially, patients present with recur-
rent inflamed cysts and furuncles. Eventually, these progress
to chronic low-grade infection with abscess formation and
scarring. Fistulas may develop, especially in the anogenital
region.29,30 The histopathology of hidradenitis suppurativa
reveals inflammation resulting from rupture of follicular
infundibulum distended by keratin. Inflammation of apo-
crine, eccrine, and sebaceous glands31,32 appears to be a sec-
ondary phenomenon.
Medical treatment of hidradenitis suppurativa includes
topical and oral antibiotics. Antibiotics are often rotated
to prevent problems with resistant organisms. Systemic
and intralesional steroids can also be used as well as
isotretinoin.
Surgical intervention is used frequently in the management
of this difficult condition. Incision and drainage of newer
inflammatory lesions is frequently employed. However,
over time this can result in sinus tract formation and
marked fibrosis.33 Exteriorization of cysts and sinus tracks
is considered the preferred method of treatment.34 An
incision is made, which exposes the area of inflammation.
Inflammatory tissue and granulation tissue are curetted
and removed. Any overlying tissue is also removed to allow
for adequate unroofing. The site is then allowed to heal by
second intention. Surgical excision of large scarred sinuses
and cysts is sometimes necessary and may be done in conjunc-
tion with skin grafting. Large defects are best allowed to
granulate.35
Figure 12.16  Hidradenitis suppurativa on the posterior neck
demonstrating inflammatory papules, cysts, and sinus
tracts.
Hidradenitis suppurativa
 Treat with rotating oral and topical antibiotics to prevent
infection with resistant organisms.
 Weight reduction is often helpful.
 Use incision and drainage sparingly to avoid sinus tract
formation and fibrosis.
 Exteriorization of cysts and sinus tracts is the preferred
method of treatment.
 Allow unroofed areas to heal by second intention if possible.

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Part 2  Essential Surgical Skills
tic and fibrous nature of the scalp makes undermining and
closing of the dead space much more difficult.
Scrotal cysts have unique characteristics. The lack of
underlying rigid structures yields less support and stability
and makes the excision technically more difficult. Frequently
the lesions are calcified and more fibrotic, lending themselves
to fusiform excision. Sutures may also have to be left in
longer, as healing is slower. More often than not, postopera-
tive pain medications are also required.
The posterior triangle of the neck poses the problem of
potential involvement or injury to underlying vascular or
nervous structures. Erb’s point or punctum nervosum is
located over the lateral root of the brachial plexus approxi-
mately 2–3 cm above the clavicle at the posterior edge of the
sternocleidomastoid muscle. This area encompasses C5 and
part of C6, which innervates the biceps/brachialis/deltoid
and other muscles. Injury of these nerves can create ‘porter’s
tip hand’ deformity where one sees shoulder droop with the
hand rotated medially.
 PITFALLS AND THEIR MANAGEMENT
The incision and drainage performed for hidradenitis are
ideally done with the goal of maximally unroofing the area of
abscess formation. This allows it to heal from the inside out
by second intention, rather than forming a fistula or scar
track, which will become a chronic focus for further inflam-
mation in the future.
 POSTOPERATIVE CARE
Postoperative care for incisional surgery involves many of the
general care guidelines used with any surgery as well as some
special instructions for certain situations. For patients who
have had lipomas or larger cysts removed, it is important that
they avoid any exercise or activity that might cause seroma
or hematoma formation. Ice is very effective for reducing
swelling and postoperative bleeding. Instruct the patient to
ice the area in cycles of 30 minutes on and 30 minutes off
for several cycles immediately postoperatively. Pressure
dressings help to prevent postoperative hematoma formation.
When removing uncomplicated lipomas and cysts with inci-
sional surgery, postoperative antibiotics are rarely needed.
They are, however, helpful in some cases. If there is a concern
over contamination or possible inflammation or infection in
and around the surgical area, postoperative antibiotics should
be considered.
In removing milia, apocrine hidrocystomas, and steato-
cystomas there is rarely a need for sutures or substantial
postoperative care. Frequently topical antibiotic ointment
speeds healing. Occasionally, a light dressing is useful for any
drainage within the first 24–48 hours.
When incising and draining acute abscesses or inflamed or
infected cysts, postoperative care and dressing maintenance
are very important. For larger abscesses and cysts, use of a
packing material helps to keep the area open and allows for
adequate drainage, while allowing healing to occur from the
inside out. Either Iodoform (NU Gauze; Johnson and Johnson
Medical, a division of Ethicon, Arlington) or plain gauze
ribbon can be used to pack larger lesions. A wick of material
is left extruding out through the incised and drained area.
This is advanced approximately 1 cm daily with each dressing
change until it is removed. It is important to use a large
amount of absorbent dressing material when bandaging
incised and drained abscesses, or infected or inflamed cysts.
Drainage can often be heavy for the first few days following
the procedure. A dressing consisting of five 8-cm gauze pads
stacked over the wound and held in place with a flexible
dressing material such as CoverRoll (BSN Medical, Hamburg,
Germany) works well. The dressing will often need to be
changed daily or sometimes twice daily in the initial stages of
healing if drainage is heavy. Antibiotics such as erythromycin
or cefalexin are good choices to cover for Staphylococcus and
Streptococcus spp. which can frequently be found in abscesses
and infected cysts. Postoperatively, long-term abnormal scar-
ring can occur after incisional surgery. Traditional methods
for scar treatment including intralesional steroids, and sili-
cone gel sheeting is often helpful. Pulsed-dye laser therapy
can be useful in some cases.
Special considerations due
to anatomic locations
Due to the vascularity of the scalp, more bleeding can occur,
necessitating the use of a good pressure dressing. The inelas-
Pitfalls and their management
 For cysts and lipomas and other subcutaneous lesions,
make the initial incision equal to the radius of the lesion; it
can be lengthened later in the procedure if necessary. For
cysts, include the overlying punctum in the initial incision. In
addition to lengthening the incision, it can be converted to a
fusiform excision if one encounters considerable surrounding
fibrosis. Make sure no residual cyst wall or lipoma remains
in the surgical cavity. Irrigation of cysts is helpful to remove
remaining remnants of keratin.
 Meticulous hemostasis must be obtained when excising
subcutaneous lesions. The use of pressure dressings and/or
drains may be needed due to the location or size of the lesion.
Drains, if employed, are typically removed in 72–96 hours.
 Always be mindful of underlying anatomic structures. CT or
MRI scans or other imaging may be helpful to elucidate the
extent of involvement. Occasionally, referral to a head and
neck or general surgeon may be necessary for more extensive
and anatomically difficult lesions.
 Always send tissue for pathologic confirmation.
 While the surgeon is primarily concerned with complete
removal of the lesional tissue, one must be vigilant to preserve
the surrounding normal tissue.
 It is best to refer pilonidal cysts to general surgeons.
 It is important to communicate to the patient that these
subcutaneous lesions are usually benign and surgery is
elective. However, stress the importance of cosmesis. The
patient must also be aware that the ultimate diagnosis of the
lesion can only be confirmed histologically. They must also be
informed of the potential for rupture/infection, future growth,
and presence of pain induced by growth or pressure.
When removing lipomas, one of the most common pitfalls is
incomplete removal. This frequently results from inadequate
marking prior to surgery, or limited palpation of the wound
after extracting the mass to assess for any firm areas which
may represent residual lipoma. In removing forehead lipomas,
it is especially important to isolate and mark the lipoma well
prior to removal. Small lipomas are very easy to miss if not
precisely located and marked preoperatively. For infiltrating

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Chapter 12  Incision, Draining, and Exteriorization Techniques
patient the importance of cosmesis and the fact that the
nature of these lesions can only be confirmed histologically.
One must also communicate the potential for rupture or
infection and the possibility of pain or discomfort from the
pressure or mass effect of the underlying lesion. To ensure
optimal results, it is important to utilize sound surgical tech-
nique. Spending extra time to thoroughly review postopera-
tive care instructions and answer any of the patient’s questions
helps avoid potential problems and ensures a successful
outcome.
 REFERENCES
1. Breasted JH. The Edwin Smith surgical papyrus. Chicago: University of
Chicago Press; 1930.
2. Enzinger FM, Weiss SW. Soft tissue tumors. St Louis: CV Mosby 1983;
199–241.
3. Rhydholm A, Berg NO. Size, site, and clinical insights of lipoma. Act
Orthop Scand 1983;54:929.
4. Truhan AP, Garden JM, Caro WA, et al. Facial and scalp lipomas:
case reports and study of prevalence. J Dermatol Surg Oncol 1985;
11:91.
5. Salasche SJ, McCollough ML, Angeloni VL, et al. Frontalis-associated
lipoma of the forehead. J Am Acad Dermatol 1989;20:462–468.
6. Andrews K, Ghauami A, Mowlavia, et al. The youthful forehead: placement
of skin incisions in hidden furrows. Dermatol Surg 2002;5:489–490.
7. Harrington AC, Admot J, Chesser RS. Infiltrating lipomas of the upper
extremities. J Dermatol Surg Oncol 1990;16:834–836.
8. Kindblom LG, Angervall L, Stener B. Intermuscular and intramuscular
lipomas and hibernomas: a clinical, roentgenologic, histologic, and prog-
nostic study of 46 cases. Cancer 1974;33:754–762.
9. Fitzpatrick TB, Eisen AZ, Wolff K, et al. Benign epithelial tumors. In:
Fitzpatric TB, ed. Dermatology in general medicine, vol I, 4th edn. New
York: McGraw-Hill 1993; 866–870.
10. McGavran MH, Binnington B. Keratinous cysts of the skin. Arch Derma-
tol 1966;94:499.
11. Krull EA. The ‘Little’ curet (surgical gems). J Dermatol Surg Oncol
1978;4:656.
12. Epstein W, Kligman AM. The pathogenesis of milia and benign tumors
of the skin. J Invest Dermatol 1956;26:1–11.
13. Brody MJ. Complications of chemical resurfacing. Dermatol Clin
2001;19:427–438.
14. Thami GP, Kaur S, Kanwar AD. Surgical pearl: enucleation of milia with
a disposable hypodermic needle. J Am Acad Dermatol 2002;47:6023.
15. McGavran MN, Binnington B. Keratinous cysts of the skin: identification
and differentiation of pilar cysts from epidermal cysts. Arch Dermatol
1966;94:499–508.
16. Leppard BJ, Sanderson KV, Wells RS. Herditary trichilemmal cysts:
heredity pilar cysts. Clin Exp Dermatol 1977;2:23–32.
17. Brownstein MH. Steatocystoma simplex: a solitary steatocystoma. Arch
Dermatol 1982;118:409–411.
18. Noojin RO, Reynolds JP. Familial steatocystoma multiplex: twelve cases
in three generations. Arch Dermatol Syph 1948;57:1013–1018.
19. Adams BB, Mutashim OF, Nordlund JJ. Steatocystoma multiplex: a
quick removal technique. CUTIS 1999;64:127–130.
20. Kaya TI, Ikozoglu G, Kokturk A, et al. A simple surgical technique for
the treatment of steatocystoma multiplex. Int J Dermatol 2001;40:785–
788.
21. Sato K, Shibuya K, Taguchi H, et al. Aspiration therapy in steatocystoma
multiplex. Arch Dermatol 1993;129:35–37.
22. Krahenbuhl A, Eichmann A, Pfaltz M. CO2 laser therapy for steato-
cystoma multiplex. Dermatologica 1991;183:294–296.
23. Smith JD, Chernosky ME. Aprocrine hidrocystoma (cystadenoma). Arch
Dermatol 1974;109:700–702.
24. Hashimoto K, Lever WF. Appendage tumors of the skin. Eccrine hidro-
cystoma. Springfield, IL: Charles C Thomas 1968; 19–25.
25. Cramer HJ. Das schwarze Hidrocystoma (Monfort). Dermatol Monatss-
chr 1980;166:114–118.
26. Malhotra R, Bhawan J. The nature of pigment in pigmented apocrine
hidrocystoma. J Cutan Pathol 1985;12:106–109.
27. Bieter RN. Applied pharmacology of local anesthetics. Am J Surg
1936;34:500–508.
28. Brook I. Microbiology of infected epidermal cysts. Arch Dermatol
1989;125:1658–1661.
29. Lane JE. Hidrosadenitis axillaries of Verneuil. Arch Dermatol Syph
1933;28:609–614.
lipomas of the upper extremities, it is particularly important
to identify the precise location of the lipoma prior to removal.
MRI scanning for larger lesions helps to avoid injuring neu-
rovascular structures or other structures that may be adjacent
to the lipoma.
Scarred cysts are often difficult to remove. Dissecting the
scar tissue as well as the cyst wall frequently gives the best
result. If substantial scar tissue is left behind, it may be dif-
ficult to tell whether there is residual cyst or simply scar
tissue after the area heals. In removing milia, steatocystomas,
and apocrine hidrocystomas, minimal surgery should be done
to avoid possible excess scar formation. Cautery should also
be used minimally as it can cause hypopigmented scarring.
Histologic material should be submitted for confirmation of
the presumed clinical diagnosis. This is especially true for
apocrine hidrocystomas, which frequently can mimic basal
cell carcinoma.
In draining inflamed or infected cysts and abscesses occur-
ring either in association with hidradenitis suppurativa or as
an isolated event, it is important to completely drain the
inflamed area if possible. A hemostat is often useful in spread-
ing the subcutaneous tissue to allow for optimal drainage. In
cases associated with hidradenitis suppurativa, unroofing the
cavity completely and curetting the base is helpful for avoid-
ing chronic sinus tract formation. Incision and drainage for
hidradenitis should be used sparingly. Multiple antibiotics are
frequently used in treating hidradenitis and a wound culture
at the time of the incision and drainage is often quite helpful.
If material is going to be taken for culture, it should be
removed immediately upon entering the abscess cavity. Ini-
tiating empiric antibiotic therapy is frequently appropriate
and the antibiotic can be changed if needed when results of
the culture and sensitivity testing become available.
Scrotal cysts also may be calcified and more fibrotic, lending
themselves to fusiform excisions. Sutures may also have to
be left in longer, as healing is slower. More often than not,
pain medications are also required.
 SUMMARY
Despite the many advancements in medicine and surgery,
incision, draining, and exteriorization techniques continue to
be an important treatment method for a number of condi-
tions. These techniques can be used to remove a variety of
benign subcutaneous neoplasms including lipomas and a
variety of cysts. They are also quite useful for incising and
draining abscesses and inflamed or infected cysts. Hidrad-
enitis suppurativa, which is a common condition, often ideally
requires incision, drainage, and exteriorization of chronically
inflamed and infected areas. While the surgeon is primarily
concerned with complete removal of the lesional tissue, one
must be vigilant to preserve the surrounding normal tissue.
One must also remember to send all tissue for histopathologic
confirmation.
For these techniques to be successful, the clinician must
adhere to thorough preoperative evaluation and planning.
Attention must be given to anatomic location and underlying
structures to avoid potential pitfalls. Referral to a head and
neck or general surgeon may be necessary for more extensive
lesions.
It is important to communicate to the patient that these are
usually benign lesions and surgery is elective. Stress to the

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30. Brunsting HA. Hidradenitis suppurativa. Arch Dermatol Syph
1939;39:108–120.
31. Shelley WB, Cahn MM. Pathogenesis of hidradenitis suppurativa in man:
experimental and histologic observations. Arch Dermatol 1955;72:562–
565.
32. Yu CC, Cook MG. Hidradenitis suppurativa: a disease of follicular epi-
thelium, rather than apocrine glands. Br J Dermatol 1990;122:763–769.
33. Banerjee AK. Surgical treatment of hidradenitis suppurativa. Br J Surg
1992;79:863–866.
34. Mullins JF. Treatment of chronic hidradenitis suppurativa: surgical mod-
ifications. Postgrad Med 1959;26:805–808.
35. Morgan WP, Harding KG, Richardson G, et al. The use of Silastic foam
dressing in the treatment of advanced hidradenitis suppurativa. Br J Surg
1980;67:277–280.

189
13
Suturing Technique and Other
Closure Materials
Sarah Weitzul MD and R Stan Taylor MD
Summary box
 Choice and placement of wound closure materials play critical
roles in the outcome of incisional surgery.
 The properties of suture materials combine to give each
suture unique characteristics.
 Sutures must be placed at the same vertical level across the
wound to prevent step-off deformity of the incision.
 Proper placement of sutures will approximate and evert
wound edges.
 Buried sutures are used to close dead space, redistribute
tension, decrease dehiscence, and increase wound eversion.
 Time to suture removal varies by location; whenever possible,
sutures should be removed at the earliest point.
 INTRODUCTION
The cutaneous surgeon must become familiar with the various
physical properties of sutures and other closure materials in
order to make educated choices. In addition, learning the
various suture techniques and the appropriate situations in
which to use them is essential.
 PREOPERATIVE EVALUATION
One of the most important considerations selecting closure
materials and techniques is lesion location. In general, finer-
caliber sutures are used on the face, while larger sutures are
used on the scalp, trunk, and extremities. Staples are often
used to close wounds of the scalp and trunk. Other important
wound characteristics to consider include size, type of planned
repair, and anticipated wound tension. Larger-caliber sutures
are required for wounds under more tension. Another con-
sideration is patient characteristics. For example, the surgeon
may elect to use absorbable sutures in patients who are unable
or unwilling to return for suture removal. Similarly, needle-
free tissue adhesives are commonly used to repair simple
lacerations in the pediatric population.
Another important preoperative step is selecting instru-
ments of the appropriate type and size. The size of the needle
driver should be proportional to the size of the needle and to
the size of the wound. Forceps with teeth are preferred when
placing suture because the teeth hold the tissue without
crushing it. In contrast, forceps without teeth are favored for
grasping suture at the time of suture removal. When under-
mining wound edges, skin hooks are the least traumatic
means of stabilizing and mobilizing the wound edges. Suture
should be cut with designated suture scissors and not with
delicate tissue scissors. Alternatively, special needle holders
are available that incorporate a suture cutting function in
their design, thereby eliminating the need for a separate pair
of suture scissors and shortening the time to perform the
closure. Finally, quality needle holders, skin hooks, scissors,
and forceps should be used and maintained for ideal surgical
results. Educating the surgical staff about these principles
is important to optimize efficiency and performance and to
preserve the surgical instruments.
 CHOOSING A CLOSURE MATERIAL
Suture
Physical properties of suture
Each type of suture has inherent characteristics which affect
its handling, tying, and stability in tissue. Characteristics to
be considered include configuration, capillarity, tensile
strength, size, knot strength, elasticity, plasticity, memory,
and flexibility (see Chapter 4, pp 68–9).
Configuration
The configuration of suture denotes its composition: mono-
filament suture is made up of a single strand, and multifila-
ment suture is made up of several strands. Strands of
multifilament suture are often twisted or braided for cohe-
siveness. Advantages of braiding include increased tensile
strength, improved handling and knot-tying properties, and
decreased fraying of cut ends. However, braided sutures have
an increased propensity to retain microorganisms and encoun-
ter more resistance when pulled through tissue.
Coating
Sutures may be coated with various materials to improve the
coefficient of friction and thus facilitate passage through
tissue. Coating braided sutures with silicone, Teflon (DuPont,
Wilmington, DE), and wax decreases friction, allowing the
suture to slide more easily through the skin. Newer innova-
tions include suture coatings with either antibacterial or anti-
tumor qualities. For example, polyglactin 910 has been coated
with the antimicrobial agent triclosan and has been shown to

190
Part 2  Essential Surgical Skills
Plasticity
In contrast to elasticity, sutures such as polypropylene
exhibit plasticity, and thus have the ability to retain their
deformed shape rather than return to their original shape
when stretched. As tissues swell, sutures that exhibit plastic-
ity are able to stretch to accommodate the edema. However,
as swelling resolves, sutures with plasticity remain stretched,
and this can decrease close approximation of tissues. Plastic-
ity may be advantageous in knot tying because deformation
of the suture may lead to a more secure knot.
Tissue reaction
All sutures exhibit at least some inflammatory response when
placed in tissue, but the degree varies widely. This suture
property is very important because exuberant inflammatory
reactions have been shown to delay wound healing, to jeop-
ardize wound apposition, and predispose to infection.6 Many
factors contribute to tissue reactivity (Table 13.1). The
caliber of suture is directly proportional to its reactivity; thus
the greater the suture diameter, the greater the chance of
tissue reaction.
Configuration also affects a suture’s ability to cause tissue
reaction: monofilament sutures cause less reactivity than mul-
tifilament sutures.4 Synthetic sutures such as nylon or poly-
propylene also cause less of an inflammatory response than
sutures made of natural materials such as silk and surgical
gut.7 All absorbable sutures – synthetic and natural – induce
an immune response which is responsible for their dissolution.
Sutures made of natural materials (gut and silk) are degraded
by proteolysis, in contrast to synthetic sutures which are
degraded by hydrolysis. Proteolysis causes a more brisk
immune reaction than hydrolysis. Non-absorbable sutures
cause less tissue reaction because they induce a fibrous shell
which coats the suture and decreases the host response.4
On rare occasions, true suture allergy may occur, particu-
larly with sutures made of gut. Allergy to gut suture may be
due to the foreign collagen or to chromic salts in chromate-
sensitive patients.8 Immediate-type IgE-mediated hypersen-
sitivity reactions have been reported with bovine collagen
materials, which may be found in gut suture. In the cases
reported, presence of allergen-specific IgE was confirmed by
skin-prick testing.9 Silk can rarely cause an extensive, destruc-
tive, suppurative, and granulomatous response which may be
a type of delayed-type hypersensitivity reaction. Such sensi-
tivity to silk can be confirmed or predicted with an intrader-
mal skin test.10
Absorption
By definition, absorbable sutures as a group are defined as
sutures that lose the majority of their tensile strength within
prevent in-vitro colonization of Staphylococcus aureus and
Staphylococcus epidermidis.1,2 In addition, monoclonal anti-
body-coated suture which may enhance a patient’s antitumor
immune response is under investigation.3
Capillarity
Capillarity denotes a suture’s ability to wick fluid from an
immersed end to its dry end. Sutures with increased capil-
larity, such as braided sutures, are more likely to harbor
bacteria.
Tensile strength
Tensile strength is defined as the weight necessary to break
a suture divided by the cross-sectional area. Tensile strength
is proportional to the square of the suture diameter, so larger
sutures have increased tensile strength. Various factors can
affect tensile strength, including twisting or braiding, which,
due to shearing forces between the strands, decreases tensile
strength. Tensile strength can also be decreased by physical
factors including wetness or increased age of sutures. Syn-
thetic sutures tend to have increased tensile strength com-
pared to sutures of natural materials. The exception is
stainless steel, which has the greatest tensile strength.4
Size
To allow surgeons to compare sutures made of different
materials, the United States Pharmacopoeia (USP) assigns a
number to all commercially available sutures. This number or
‘size’ ranks sutures according to tensile strength, represented
by a number of zeros. The greater the tensile strength the
fewer the zeros. Therefore a 2-0 suture has more strength
than a 6-0 suture. The strength quality inherent in the mate-
rials used to make sutures varies; thus the caliber of a 5-0
nylon will be smaller than that of a 5-0 gut because nylon is
a stronger material.
Knot strength
Knot strength refers to the security of a tied knot and is
defined by the degree of slippage that occurs in a knot. Sutures
with a decreased coefficient of friction slide more easily and
have lower knot strength. Sutures vary widely in their knot
strength. For example, catgut suture has low knot strength
while polyglycolic acid has one of the highest knot strengths.5
Memory
Memory is the ability of a suture to regain its former shape
after bending. Knots in sutures with increased memory, such
as polypropylene and nylon, have a greater tendency to untie
themselves, and the surgeon therefore should throw extra ties
with these sutures. In general, sutures with increased memory
are more difficult to handle.
Elasticity
Elasticity denotes a suture’s capacity for returning to its orig-
inal size and shape after being stretched. This quality may be
desirable in selecting a surface suture because tissue usually
swells after a trauma such as surgery. Sutures with elasticity
can stretch with the tissue, and will also recoil when the
swelling subsides. Polybutester is a synthetic non-absorbable
suture which exhibits elasticity.
Table 13.1  Suture properties that affect immunogenicity
MORE
IMMUNOGENIC
LESS
IMMUNOGENIC
Material
Natural
Synthetic
Configuration
Multifilament
Monofilament
Absorption
Absorbable
Non-absorbable
Diameter
Large
Small

191
Chapter 13  Suturing Technique and Other Closure Materials
has similar handling properties to polyglycolic acid but has
more tensile strength.15 After tissue placement, polyglactin
retains 75% of its tensile strength at 2 weeks and 50% at 3
weeks. It is essentially completely resorbed after 56–70 days.
Polyglactin 910 is widely used in cutaneous surgery, and was
the subcutaneous suture of choice in 73% of surgical derma-
tologists according to one survey.16 It has been compared
directly with both polydioxanone for use in rhytidectomy
reconstruction and polytrimethylene carbonate in Mohs
reconstruction without any statistical difference in scar
quality.17,18 Other studies have shown an increased incidence
of hypertrophic scars with polyglactin 910-sutured incision
compared to those sutured with either polydioxanone or
poliglecaprone 25.19,20
Polyglactin 910 also comes in a more rapidly dissolving
form called Vicryl-rapide (Ethicon) which was developed to
mirror the performance of surgical gut suture. Vicryl-rapide
is composed of a polymer material with a lower molecular
weight than the regular polyglactin 910, which increases its
absorption rate in tissue. It loses 50% of its tensile strength
at 5 days and essentially all tensile strength within 10–14
days. Vicryl-rapide has been shown to have similar perform-
ance to nylon in the closure of punch-biopsy sites, without
the need for suture removal.21
Lactomer (Polysorb; USSDG)
Like polyglactin 910, lactomer is a coated, braided multifila-
ment suture made of copolymers of lactic and glycolic acids.
Lactomer retains 80% of its tensile strength at 2 weeks and
over 30% at 3 weeks. It is completely absorbed 56–70 days
after implantation. Compared with polyglactin 910, lactomer
has been reported to have superior handling and knot char-
acteristics.22,23 In one study, lactomer had greater initial
tensile strength than polyglactin 910 and polyglycolic acid,
but it lost strength more rapidly than the others after tissue
implantation.23
Polydioxanone (PDS: Ethicon)
Polydioxanone was introduced in 1982 as the first monofila-
ment synthetic absorbable suture. Its monofilament configura-
tion allows for easier passage through tissue, decreased tissue
reactivity, and decreased risk of wound infection. This con-
figuration also confers decreased handling and knot strength
due to the decreased coefficient of friction. Polydioxanone has
decreased initial tensile strength when compared to polyglac-
tin 910 or polyglycolic acid. However, polydioxanone is more
slowly resorbed and retains its tensile strength for longer. It
retains 70% of its original tensile strength at 2 weeks, 50% at
4 weeks, and 25% at 6 weeks. Absorption is negligible until
the 90th postoperative day, and complete resorption takes
approximately 6 months. Therefore, this suture may be useful
in wounds under higher tension or wounds that require pro-
longed dermal support. Indeed, prolonged dermal support for
at least 6 months has been associated with decreased scar
spreading.24 The original polydioxanone suture was replaced
with an updated product, PDS II, which has improved han-
dling characteristics.
Polytrimethylene carbonate (Maxon: USSDG)
Polytrimethylene carbonate is another monofilament syn-
thetic absorbable suture. It has greater initial tensile strength
than polydioxanone. It retains 81% of initial tensile strength
60 days after placement in living tissue. Non-absorbable
sutures therefore maintain their tensile strength for periods
greater than 60 days. All suture materials, excluding stainless
steel wire, lose integrity or are absorbed to some degree if
left in the skin for long enough. Depending upon the material
used, integrity may range from 6 days to 6 months, or longer.
The rate of absorption depends on the suture type, the pres-
ence of infection, and site of placement. Presence of infection
increases suture absorption, as does placement in locations
where there is high secretion of proteolytic enzymes, such as
mucosa.11
Commonly used sutures in
dermatologic surgery
Absorbable sutures
Surgical gut
Surgical gut is the only absorbable suture made of natural
materials. Derived from the intestines of sheep or cows, gut
suture is a twisted multifilament suture composed mostly of
collagen. Gut sutures commonly come in three varieties:
plain, fast absorbing, and chromic (Table 13.2). Plain surgical
gut loses much of its tensile strength in 7–10 days and is
completely absorbed by 70 days.12 Fast-absorbing gut is heat
treated for more rapid degradation. This suture is used in
facial wound closures or the placement of skin grafts when
rapid absorption of suture is desirable. Nearly all of its tensile
strength is lost within 7 days, and complete absorption takes
21–42 days. Chromic gut has been treated with chromate
salts, which decrease the rate of absorption in tissue. Chromic
gut maintains its tensile strength for 10–21 days and is com-
pletely absorbed after approximately 90 days. This suture
may be used to ligate vessels in open wounds or to suture
mucosal wounds. A history of chromate sensitivity should
preclude the use of this suture. Disadvantages to gut sutures
include unpredictable absorption rates, low tensile strength,
and increased tissue sensitivity when compared with other
absorbable sutures.
Polyglycolic acid (Dexon S, Dexon II: USSDG,
Norwalk, CT)
Polyglycolic acid was the first synthetic absorbable suture,
first available in 1970. It is a braided multifilament suture,
which creates significant drag when pulled through tissue. To
alleviate this problem it is available with a polycaprolate
coating; this is marketed as Dexon II. Nonetheless, some
surgeons prefer the uncoated Dexon S because it has better
knot security. Both coated and non-coated suture retain 65%
of tensile strength 2 weeks after placement and 35% 3 weeks
after implantation. It is completely resorbed between 60 and
90 days after placement. Advantages to its use include good
handling and knot security and low tissue reactivity.13 One
study showed a decreased incidence of wound infections with
polyglycolic acid-sutured incisions when compared with inci-
sions sutured with chromic gut and nylon.14
Polyglactin 910 (Vicryl: Ethicon, Inc, Somerville, NJ)
Polyglactin was the second synthetic absorbable suture to
become available. It is a coated, braided multifilament suture
like polyglycolic acid. Polyglactin 910 consists of a copoly-
mer made from 90% glycolide and 10% l-lactide. This suture

192
Part 2  Essential Surgical Skills
Table 13.2  Properties of absorbable sutures
SUTURE
(BRAND NAME)
CONFIGURATION
HANDLING
KNOT
STRENGTH
TISSUE
REACTIVITY
INITIAL
TENSILE
STRENGTH
LONGEVITY
OF TENSILE
STRENGTH
TIME TO
COMPLETE
ABSORPTION
COMMENTS
Surgical gut, plain
Multifilament
Twisted
Interm
Poor
High
Low
Lost in 7–10
days
70 days
Unpredictable absorption rates
Fast-absorbing gut
Multifilament
Twisted
Interm
Poor
High
Low
Lost in 3–7
days
21–42 days
High reactivity
True allergy possible
Chromic surgical gut
Multifilament
Twisted
Interm
Fair
Moderate to
high
Low
Lost in 10–21
days
90 days
Unpredictable absorption rates
High reactivity
True allergy possible to collagen or
chromate
Polyglycolic acid (Dexon S)*
Multifilament
Branded
Good
Good
Low to interm
Interm
35% strength at
3 weeks
60–90 days
Uncoated
Polyglycolic acid (Dexon II)*
Interm
Coated
Polyglactin 910 (Vicryl)†
Multifilament
Branded
Good
Good
Low to interm
Quite high
50% strength at
3 weeks
56–70 days
Coated
Higher tensile strength than Dexon
Polyglactin 910 (Vicryl-
rapide)†
Good
Good
Low to interm
50% strength at
5 days
42 days
Lactomer (Polysorb)*
Multifilament
Branded
Good
Good
Low to interm
Quite high
>30% strength
at 3 weeks
56–70 days
Coated
Polydioxanone (PDS II)†
Monofilament
Poor
Poor
Low
High
50% at 4 weeks
25% at 6 weeks
90–180 days
High memory
Very slow absorption
Polytrimethylene carbonate
(Maxon)*
Monofilament
Very good
Very good
Very low
Very high
59% strength at
4 weeks
30% at 6 weeks
60–180 days
Has higher initial tensile strength
than PDS but absorbed more
quickly
Poliglecaprone 25
(Monocryl)†
Monofilament
Very good
Very good
Very low
Highest
30% at 2 weeks
All lost at 3–4
weeks
90–120 days
Highest initial tensile strength
Highest knot security of synthetic
absorbable sutures
Glycomer 631 (Biosyn)*
Monofilament
N/D
N/D
N/D
N/D
49% retained at
3 weeks
90–110 days
Decreased coefficient of friction
than Monocryl
Seldom used in dermatologic
surgery
*Trademark of USSDG Sutures, US Surgical Corporation, Norwalk, CT.
†Trademark of Ethicon, Inc, Johnson & Johnson, Somerville, NJ.
N/D, no data available.
Very low—low—poor—fair—good—moderate—intermediate—relatively high—very high—very good—highest.

193
Chapter 13  Suturing Technique and Other Closure Materials
high degree of memory, decreasing its pliability, handling, and
knot security. It may also tear through delicate tissue. Multi-
filamentous nylon has improved handling and tying properties,
but is associated with higher tissue reactivity and expense.
Nylon is made more pliable by moisture, and Ethicon makes
a premoistened monofilament nylon suture for cosmetic
surgery that has significantly improved handling and tying
properties when compared to regular monofilament nylon.
Polypropylene (Prolene: Ethicon; Surgipro: USSDG)
Polypropylene is a monofilament synthetic suture with
somewhat lower tensile strength than other synthetic non-
absorbable sutures. It is fairly stiff and has high memory,
decreasing its handling and tying properties. Polypropylene
has low tissue reactivity and an extremely low friction coef-
ficient, making it ideal for running intradermal stitches. This
slippery characteristic decreases knot security, and surgeons
must take care to throw extra loops in the knots of polypro-
pylene to increase their security.12 Unlike nylon and silk,
polypropylene is not degraded in tissue and may be used when
long-term support is useful. For example, clear polypropylene
may be used to reapproximate ear cartilage. Polypropylene
also exhibits significant plasticity and expands to accommo-
date swelling tissue. However, when swelling subsides, the
suture will not regain its former shape, which may affect
wound apposition.
Polyester
Polyester is a braided multifilamentous, synthetic suture with
uses similar to those of multifilamentous nylon. It is soft and
pliable and has a high tensile strength; in fact, its tensile
strength is only exceeded by metal sutures.29 Due to its
braided nature, uncoated polyester suture (Dacron: USSDG;
Mersiline: Ethicon) has significant tissue drag and is therefore
available in coated forms. It may be coated with Teflon,
silicone (Ticron: USSDG), or polybutylate (Ethibond Excel:
Ethicon). Polybutylate adheres well to the suture in contrast
to Teflon and silicone, which may break off in tissue, causing
an intense immune response.30 Polyester suture’s soft, pliable
nature makes it useful for mucosal tissue or in intertriginous
areas. However, polyester is costly and is little used in der-
matologic surgery.
Polybutester (Novafil: USSDG)
Polybutester is a newer type of polyester which is available in
a monofilament suture. It is a copolymer composed of poly­
glycol terephthate and polybutylene terephthate. Polybutester
has a lower coefficient of friction and lower tissue reactivity
than the older polyester sutures. It also offers better handling
than polypropylene, including lower memory, increased flex-
ibility, and better knot security.4 Polybutester exhibits elastic-
ity and can regain its former shape when stretched, unlike
polypropylene.31 One study comparing polybutester Novafil
with polypropylene showed improved handling, easier
removal, and cosmetically superior scars in patients receiving
polybutester sutures.32 Little is written about polybutester in
the dermatologic literature, reflecting its rare usage.
Polyhexafluoropropylene-VDF (Pronova: Ethicon)
Poly­hexafluoropropylene-VDF is the newest monofilamen-
tous non-absorbable suture, composed of a polymer blend of
at 2 weeks, 59% at 4 weeks, and 30% at 6 weeks.25 However,
polytrimethylene carbonate is absorbed more quickly than
polydioxanone; its absorption begins 60 days after implanta-
tion compared to 90 days with polydioxanone. Polytrimeth-
ylene carbonate has greater knot strength and handling
properties compared to polydioxanone, polyglycolic acid, and
polyglactin 910.12,18
Poliglecaprone 25 (Monocryl: Ethicon)
This monofilament absorbable synthetic suture became avail-
able in 1993 and offers superior handling and tying properties
due to its increased pliability. Its knot strength is superior to
all of the aforementioned synthetic absorbable sutures.26 In
addition, it has higher initial tensile strength than PDS II or
Maxon; however, this strength diminishes more quickly than
with the other monofilament synthetic sutures. It retains 60%
of its initial tensile strength at 7 days, 30% at 2 weeks, and
loses all tensile strength by 3–4 weeks.27 Like many other
absorbable sutures, Monocryl is available in both clear and
dyed (violet) sutures; the dyed Maxon sutures retain their
tensile strength and remain in tissue slightly longer than the
clear sutures. Absorption of both varieties is essentially com-
plete by 3–4 months. When compared to Vicryl-rapide in the
closure of breast reduction incisions, Monocryl is associated
with smaller, less reactive scars, and with a lower predisposi-
tion to form hypertrophic scars.20
Glycomer 631 (Biosyn: USSDG)
Glycomer 631 is the newest monofilament synthetic absorb-
able suture. It dissolves more slowly than poliglecaprone 25.
It retains 75% of its original tensile strength at 2 weeks and
49% at 3 weeks. It is completely absorbed between 90 and
110 days. When compared with poliglecaprone 25, glycomer
631 has a decreased coefficient of friction, making its passage
through tissue easier, and its knots are slightly less secure.28
At present, this suture is seldom used in dermatologic surgery.
Non-absorbable sutures
Silk (Perma-Hand: Ethicon; Sofsilk: USSDG)
Surgical silk is a multifilament suture composed of braided
fibers of protein harvested from the cocoon of the silkworm
larva. To improve passage through tissue, the suture is usually
coated with wax or silicone. Although surgical silk is classified
as a non-absorbable suture, it is slowly absorbed when
implanted in tissue, losing almost all its tensile strength 1 year
after implantation, and being completely absorbed within 2
years. Silk suture is very soft, which makes it a good suture
to close biopsy sites or small incisions in sensitive locations
such as mucosa or intertriginous areas. Although silk suture
has superior handling and knot-tying characteristics, its ten-
dency to cause tissue reaction limits its use (Table 13.3).
Nylon
Nylon is the most commonly used non-absorbable suture in
dermatologic surgery. Nylon suture is available both in mono-
filamentous (Monosof, Dermalon: USSDG; Ethilon: Ethicon)
and coated multifilamentous (Nurulon: Ethicon; Surgilon:
USSDG) varieties, with the latter being more common. Both
have high tensile strength and are absorbed at a rate of 15–20%
per year if left in tissue. Monofilamentous nylon passes easily
through the skin and causes minimal tissue reactions but has a

194
Part 2  Essential Surgical Skills
Table 13.3  Properties of non-absorbable sutures
SUTURE
(BRAND NAME)
CONFIGURATION
HANDLING
TENSILE
STRENGTH
KNOT
STRENGTH
MEMORY
TISSUE
REACTIVITY
COMMENTS
Silk (Sofsilk)*
Perma-Hand)†
Multifilament
Braided
Excellent
Low
Excellent
Low
High
Use limited by high incidence of tissue reaction
Very slowly absorbed in tissue
Nylon (Monosof)*
(Dermalon)*
(Ethilon)†
Monofilament
Poor
High
Poor
High
Low
Monofilament nylon may tear through delicate tissue
Very slowly absorbed in tissue
Nylon (Nurulon)†
(Surgilon)*
Multifilament
Good
High
Fair
Moderate
Polypropylene
(Prolene)†
(Surgipro)*
Monofilament
Poor
Moderate
Poor
High
Low
Does not degrade in tissue
Polyester, uncoated
(Dacron)*
(Mersiline)†
Multifilament
Braided
Very good
Very high
Very good
Moderate
Moderate
Expensive and rarely used in dermatologic surgery
Very high tensile strength
Polyester, coated
(Ticron)*
Multifilament
Braided
Silicone coated
Very good
Very high
Good
Moderate
Moderate
If silicone dislodges from suture, significant tissue
reaction can occur
Polyester, coated
(Ethibond Excel)†
Multifilament
Braided
Polybutylate coated
Very good
Very high
Good
Moderate
Moderate
Polybutylate coating very adherent to suture and very
seldom breaks off into tissue
Polybutester
(Novafil)*
Monofilament
Good
High
Good
Low
Low
Exhibits elasticity
Polyhexafluoro-
propylene-VDF
(Pronova)†
Monofilament
N/D
N/D
N/D
N/D
N/D
Low friction coefficient
Very seldom used
*Trademark of USSDG Sutures, US Surgical Corporation, Norwalk, CT.
†Trademark of Ethicon, Inc, Johnson & Johnson, Somerville, NJ.
N/D, no data available.

195
Chapter 13  Suturing Technique and Other Closure Materials
geons use the 3/8 circle needles most frequently, but 1/2
circle needles may be used to suture small flaps.
Needles come in a wide variety of types that are based on
the cross-sectional shape of the body and tip. Most com-
monly, curved needles with triangular shapes are used. These
triangular needles come in two types: conventional cutting
and reverse cutting (Fig. 13.2). A conventional cutting needle
has its primary cutting edge on the inside of the curve, and
when passed through tissue, its tapered puncture is left the
closest to the incision. Because the tension vectors go in the
direction of the incision, sutures placed with cutting needles
may tear through the wound edge. In contrast, reverse cutting
needles have their primary cutting edge on the outside of the
needle, leaving the tapered point directed away from the
wound edge, resulting in less tissue tearing by the suture after
tying. Reverse cutting needles are used much more often than
conventional cutting needles. Needles can also have a tapered,
round shape. These rounded needles cause less tissue tearing
than conventional or reverse cutting needles and may be
useful for delicate areas or in fascia.
The nomenclature of needles is very confusing and varies
by company. The Ethicon Corporation currently manufac-
tures over 80% of the surgical needles used in North America,
and a brief description of their needle designations is listed
in Table 13.4. Because the company US Surgical bought
Davis and Geck Corporation, their suture product line has
been merged under the USSDG division. USSDG needle
terminology is very difficult to discern, and many needles
with the same specifications have different designations.
Table 13.5 lists the most common types of sutures used in
dermatologic surgery and includes needle designations of the
three most prominent suture manufacturers.
Shank
Body
Tip
Grasp needle
in this region
The surgical needle
Figure 13.1  The surgical needle is composed of the tip, body,
and shank. The body is the strongest portion of the needle, and
should therefore be the portion grasped by the needle holder.
The needle should be held one-half to two-thirds of the way
from the tip. (Adapted from Taylor RS. Needles, sutures, and
suturing. Atlas Office Proced 1999;2:53–74.)
polyvinylidene
fluoride
and
polyvinylidene
fluoride-
cohexafluoropropylene. It has a low coefficient of friction,
making it easy to pass through and remove from tissue. Very
little clinical data are available regarding the use of this suture.
Suture needles
Proper needle selection and needle handling prevent needle
damage, minimize tissue damage, and facilitate suture place-
ment. There is a great variety of needle designs, but relatively
few are routinely used by the cutaneous surgeon. Most
needles are made of stainless steel and differ in size, degree
of tip sharpness, and body design. Needle cost depends on
the sharpness and quality of the stainless steel used in its
composition. When choosing a needle for cutaneous surgery,
one must consider various factors including wound location,
tissue type, suture size, and cost.
An ideal needle is malleable, strong, and sharp. Ductility
or malleability refers to a needle’s resistance to breaking
under a given degree of bending. Needle breakage during
surgery can be a very difficult situation and every precaution
should be taken to avoid this occurrence. Needle strength is
determined by how well it resists deformation when being
placed repeatedly through tissue. Such needle deformation
can cause increased tissue trauma, unnecessary delay, and
inadvertent needle-stick injury. In addition, reshaping a bent
needle may affect the needle’s strength or lead to breakage.
Tip sharpness is also very important; sharp needles result in
less tissue trauma and better cosmetic results. Most needles
are machine sharpened, but for very fine work cosmetic sur-
geons use the more expensive, sharper hand-honed needles.
Needle coating can also affect performance. Modern needles
are often coated with silicone or other lubricants to improve
the ease of needle penetration.
A needle is composed of three different parts: the shank,
the body, and the point (Fig. 13.1). The shank is the portion
of the needle that attaches to the suture and it is the weakest
part of the needle. Up until the mid-1900s, needles had eyes
which were threaded like conventional sewing needles.
However, nowadays needles are almost exclusively swaged,
meaning they are attached directly to the suture without an
eye. This is done by placing one end of the suture in the hol-
lowed end of the needle; then the end, or shank, is crimped
down around the needle to secure the suture. Its hollow
nature allows seamless connection of the needle to the suture
but also imparts weakness to this subunit. The shank is the
largest part of the needle–suture unit, and hence it deter-
mines the size of the suture tract.
The point of the needle extends from the tip of the needle
to the largest cross-section of the body. To avoid dulling and
injury, the tip should not be handled with the hands or with
instruments.
The body is the middle portion of the needle between the
shank and point. It is the strongest portion of the needle and
this part should therefore be grasped with the needle holder.
This prevents damage to the needle tip and crushing of the
weaker swaged end of the needle, which leads to bending or
breakage. Proper handling of needles is very important to
maintain optimum performance. The needle should always
be handled by instruments instead of fingers to prevent
injury.
Needles may be straight or curved. Curved needles are used
almost exclusively in dermatologic surgery. Dermatologic sur-

196
Part 2  Essential Surgical Skills
Table 13.4  Ethicon needle abbreviations
ABBREVIATION
MEANING
COMMENTS
P
Plastic
Reverse cutting
PC
Precision cosmetic
Conventional cutting
PS
Plastic surgery
Reverse cutting
FS
For skin
Significantly lower-
quality honing and
steel than P, PC, PS
Staples
Surgical stainless steel staples offer an efficient means of
wound closure and have been used for decades. Staple place-
ment is 80% faster than suture placement, making it more
cost-effective when staff time is factored in.33 Staples are
very strong and have decreased risk of tissue strangulation,
reactivity, and infection than sutures.34 In addition, staples
offer excellent wound eversion. Several studies have com-
pared staples to nylon sutures in epidermal closure, and most
Conventional
Reverse
Round
Needles
Figure 13.2  Conventional cutting needles have their cutting
edge on the inside of the needle arc, and leave their pointed
puncture facing the wound incision. Reverse cutting needles
have their cutting edge on the outside of the arc, leaving the
pointed puncture facing away from the incision which
decreases the chance of suture tearing through tissue.
show equivalent results.35–37 However, flaps that were stapled
had a 62.5% incidence of partial necrosis compared to 20.6%
of sutured flaps.38 In addition, if not removed carefully staples
can cause more patient discomfort than sutures.39 Staples are
used most commonly on the trunk and scalp and may be used
to secure large full-thickness or split-thickness skin grafts.
Usage on the back, over bony prominences, or in intertrigi-
nous areas can lead to patient discomfort.
To place staples, the ejecting surface of the stapler is held
perpendicular to and flush with the wound surface. Care
should be taken to place the staple directly over the center
of the incision. The depth of penetration depends on the
amount of pressure placed on the stapler against the skin.
Releasing the handle of the device disengages the staple.
Staple placement requires some practice and technique varies
depending on the device used. Disposable staplers are used
in dermatologic surgery and come loaded with 5–35 staples
available in two widths: regular (4–6  mm) or wide (6.5–
7.5 mm). The width and height of the staples vary with the
manufacturer. Staple extractors are available to facilitate
removal.
Skin closure tapes
Modern skin closure tapes are made of a microporous mate-
rial with an acrylate adhesive and are available in a variety of
colors and widths. These tapes are used most commonly to
support sutured wounds but can be used alone in very super-
ficial lacerations or for epidermal closure in small tension-free
incisions that have been closed with a layer of subcutaneous
sutures. Advantages include speed of use, cost savings, and
no requirement for in-office removal. However, these strips
may cause wound inversion if used without other means of
epidermal closure and should not be used alone in cosmeti-
cally sensitive areas or wounds closed under tension.
Prior to tape application, the surrounding skin should be
degreased with alcohol. For optimal adhesion and durability,
a tactifier such as tincture of benzoin or Mastisol (Ferndale
Laboratories) is applied around the wound edges where the
strips will adhere, avoiding the wound itself. After the tacti-
fier has dried the strips are applied, taking care not to invert
or misalign the wound edges. If applied in this way, such skin
closure tapes should last 1–2 weeks.
Tissue adhesives
Tissue adhesives are composed of cyanoacrylate compounds.
These chemicals rapidly polymerize and bond to various sur-
faces when applied and pressed into a thin layer. Advantages
of tissue adhesive use include rapidity and ease of use, no
need for suture removal, and no puncture wounds that could
precipitate wound infection or ‘track’ marks. Liquid adhe-
sives are commonly used to repair superficial lacerations,
particularly in the pediatric population. They can also be used
for closure of small, superficial wounds or of low-tension
incisions that have been closed with a layer of subcutaneous
sutures.
The primary differences between the various cyanoacr-
ylates lies in the length of their alkoxycarbonyl (-COOR)
chain.40 Because of tissue toxicity, short-chain cyanoacrylates
have been replaced by longer-chain cyanoacrylates.41
The two cyanoacrylates used in dermatologic surgery are
described below.

197
Chapter 13  Suturing Technique and Other Closure Materials
manner, starting around the wound edges and working
outward. The adhesive should be applied up to the edges
of the wound, taking care not to get it in the wound itself,
which may slow healing. The adhesive must be applied in
three layers, allowing each to dry before application of the
next. The first layer polymerizes in 2.5 minutes, and subse-
quent layers take longer. The polymerization causes genera-
tion of heat, which may be slightly uncomfortable for the
patient.41
Octyl cyanoacrylate has improved flexibility, less tissue
toxicity, and at least three times the bonding strength of
n-butyl-2-cyanoacrylate.47 However, a randomized clinical
trial comparing the two tissue adhesives in repair of pedi-
atric lacerations failed to show any difference between
them regarding time of application, patient-perceived pain,
physician-perceived difficulty, or cosmetic outcome.42
Octyl cyanoacrylate is efficacious for the closure of super-
ficial lacerations, skin grafts, and low-tension incisions.48–50
Several studies have compared cosmetic outcomes in wounds
closed with n-2-cyanoacrylate and those closed with suture;
these studies have shown the former to be superior, equiva-
lent, and inferior.49–51 Although most agree that this and all
tissue adhesives give good cosmetic results in laceration
repair, they should be used with some caution in excisional
surgery in cosmetically sensitive areas because sutures can
evert wound edges and hence may give better cosmesis. In
addition, tissue adhesives are expensive, and may not be
substantially time-saving in cutaneous excisional surgery. In
fact, Shamiyeh et  al. reported octyl cyanoacrylate was 14
times more expensive than suture and took twice as long to
apply when used for skin closure after phlebectomy.52
N-Butyl-2-cyanoacrylate (Indermil: USSDG;
Glu-Stitch, Liquid Bandage: Glu-Stitch, Inc;
Histoacryl: B Braun, Melsugen, AG)
N-butyl-2-cyanoacrylate has a 4-carbon alkyl chain connected
to the carboxyl group. It has been studied extensively outside
the US since the 1970s and has more rapid polymerization,
stronger bond formation, and decreased tissue toxicity com-
pared with the short-chain cyanoacrylates.40,41 Indermil was
approved by the Food and Drug Administration (FDA) in
2002 for use as a wound closure material, and is currently
the only n-butyl-2-cyanoacrylate product in this class with
such approval. Histoacryl and Glu-Stitch are similar products
used outside the US. Liquid Bandage is an n-butyl-2-
cyanoacrylate product marketed in the US for use on unbro-
ken skin. Its approved function is as a skin protectant.
Several studies have shown n-butyl-2-cyanoacrylate to be
equally efficacious and cosmetically equal to sutures in the
repair of lacerations, skin grafts, and wound closures.42–44
Octyl cyanoacrylate, n-2-cyanoacrylate
(Dermabond: Ethicon)
Dermabond is a long-chain cyanoacrylate with an 8-carbon
alkyl chain. It was approved by the FDA in 1998 for the
closure of superficial lacerations or incisions and was the first
tissue adhesive approved for this indication. This adhesive
polymerizes in 2.5 minutes, giving the wound strength equiv-
alent to that provided by 5-0 nylon sutures or subcuticular
absorbable suture.45,46
Octyl cyanoacrylate comes in 0.5-mL single-use ampules
which are used to paint on the adhesive in an elliptical
Table 13.5  Needles commonly used in dermatologic surgery*
Manufacturer
NEEDLE TYPE
CURVATURE
NEEDLE LENGTH
ETHICON
USSDG
LOOK
Premium conventional
cutting
3/8 circle
13 mm
PC-1
PC-10
CP-1
16 mm
PC-3
PC-11
PC-31
PC-5
8 mm
P-6
P-16 (7 mm)
–
Premium reverse cutting
3/8 circle
11 mm
P-1
P-10
C-1
SBE-1
13 mm
P-3
P-13
C-3 (12 mm)
SBE-2
PRE-302
16 mm
PS-3
P-11
PC-34
PRE-3
SBE-3
19 mm
PS-2
P-12
PC-31
SBE-4
PRE-304
24 mm
PS-1
P-14
PC-33
SBE-6
1/2 circle
8 mm
P-2
P-21 (9 mm)
–
Reverse cutting
3/8 circle
19 mm
FS-2
C-13
C-6
24 mm
FS-1
C-14
C-7
*Comparisons are based on latest available manufacturer specifications and do not imply equivalent performance in vivo.

198
Part 2  Essential Surgical Skills
to create a slight eversion of the wound edges without causing
strangulation. The surgeon must remember that the tissue
will swell, which will cause the suture to be even tighter.
Proper positioning and handling of instruments is critical to
correct suture placement. After locking the needle into the
tip of the holder, the holder is grasped in a palm grip, as one
would hold a screwdriver. This allows rotation of the wrist
when advancing the needle through the skin. The index finger
can be placed down the shaft of the needle holder to guide
placement of the sutures. Surgeons must limit finger contact
with the needle to minimize the risk of injury. Forceps with
teeth facilitate advancement of the needle through the tissue
by grasping, stabilizing, and elevating the wound edges. To
minimize tissue trauma, the forceps should grasp the skin
with only light pressure. If used correctly, visible forceps
indentions should not be present on the skin after suturing;
alternatively, skin hooks may be used which offer the least
risk of tissue trauma.
Simple interrupted stitches
Simple interrupted stitches are the most basic and widely
used stitches in cutaneous surgery and are used to close
punch biopsy sites, simple lacerations, and small, low-tension
incisional wounds. They may also be used as the epidermal
stitch, or top surface stitch in layered closures, flaps, and
grafts. In addition, this stitch can be used to fine-tune wounds
that are sutured with other techniques. For example, depth
placement can be used to correct a step-off deformity caused
by uneven suture placement.
To place a simple interrupted stitch, the needle is placed
3–5  mm from the wound edge, perpendicular to the skin
surface. The needle is then directed downward into the skin
with a single motion (Fig. 13.5). When the needle is in the
middle-to-deep dermis, it is rotated through the tissue to the
opposite wound edge, following the inherent arc in the needle
with a rolling wrist motion. In larger wounds, larger amounts
or ‘bites’ of tissue are taken, and it may be necessary to reload
the needle in the center of the wound before placing it across
the wound. Whether the suture is placed in one bite or two,
great care should be taken to place needle and suture at the
exact same vertical level on both sides of the wound edge to
prevent uneven wound edge approximation – so-called ‘step-
off.’ As the needle exits the wound, it is grasped with forceps
(taking care not to grab the tip). Once secured with forceps,
the needle holder releases the needle, which is then pulled
through with the trailing suture. The surgeon may use the
needle holder to regrasp the needle near – but not on – the tip
to pull the needle through the tissue. The needle is then loaded
back on the needle driver with the forceps for the next stitch.
Simple interrupted stitches should be placed to create a
pear-shaped loop when the knot is tied (Fig. 13.6). This is
accomplished by directing the needle away from the wound
opening once introduced through the epidermis and looping
a large piece of dermis before exiting to the opposite epider-
mal edge. The needle should exit the epidermal surface at the
same distance from the epidermal wound edge as the epider-
mal entry point. Incorrect suture placement, characterized by
a larger bite of epidermis than dermis, produces a loop that
resembles a balloon or upside-down pear. This may result in
a wound with well-approximated edges but, once healed,
vertical contraction of the scar will cause a slight inversion of
the edges, resulting in a depressed, more noticeable scar. The
 SUTURING TECHNIQUES
Knot tying
Suture placement technique greatly affects the cosmetic
outcome of wound closure. When planning the closure of a
skin defect, the most important aspect to consider is the
tension that is created across the wound when closure is
attempted. This more than any other factor determines the
ultimate functional and cosmetic outcome. Whenever possi-
ble, tension should be taken off the wound edges, allowing
them to heal together without strain, because significant
wound tension in a sutured incision increases the chances of
dehiscence and of creating a more obvious, widened scar.
Careful placement of removable surface stitches, buried
stitches, or a combination of both can successfully minimize
wound edge tension and provide a good cosmetic result.
Instrument-tied knots are used almost exclusively in der-
matologic surgery, and should be perfected by those wishing
to perform cutaneous surgery. The most commonly used knot
is the square knot shown in Figure 13.3. The needle driver is
held by the non-dominant hand while the suture is looped
around the closed tips of the needle driver (Fig. 13.4). The
suture is then pulled off the needle driver in a direction that
makes the looped suture lie flat against the wound surface.
The initial double throw helps secure the suture, preventing
slippage while the second loop is being thrown. Second, third,
and sometimes fourth single-throw loops are subsequently
made to ensure a secure knot, which is especially important
when using monofilament sutures with decreased friction
coefficients. Each throw should be pulled taught in a direc-
tion directly opposite to the last, in order to square and secure
the knot. Failing to do so will create a less secure knot. The
needle should be carefully held in the non-dominant hand
while tying the knot to prevent needle-stick injuries to the
surgeon or assistants. The knot should be tied tightly enough
Square knot
Square knot
Double throw to lock
Figure 13.3  Illustration of the square knot. The initial double
throw keeps the suture from slipping during tying. (Adapted
from Taylor RS. Needles, sutures, and suturing. Atlas Office
Proced 1999;2:53–74.)

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Chapter 13  Suturing Technique and Other Closure Materials
A
B
C
D
E
F
The instrument tie
Figure 13.4  How to perform the instrument tie. (A) The long portion of the suture is held in the non-dominant hand and wrapped
twice around the end of the needle driver. (B) The needle driver grasps the short end of the suture. The two ends of the suture are
pulled taught in opposite directions (C), causing the tied suture to lie flat against the closing incision. (D) The long end is wrapped
once around the jaws of the needle holder. (E) The suture is again pulled taught in opposite directions. (F) A third throw is placed in
the same fashion. (Adapted from Taylor RS. Needles, sutures, and suturing. Atlas Office Proced 1999;2:53–74.)

200
Part 2  Essential Surgical Skills
can be placed between the exposed loop of suture and the
skin to prevent trauma to the underlying epidermis, which can
occur when postoperative edema ensues. Although they are
useful in many situations, vertical mattress stitches are more
time-consuming to place than simple interrupted stitches.
Horizontal mattress stitches
The horizontal mattress stitch is very useful to decrease and
redistribute wound tension, to close dead space, and evert
wound edges. Its tension-relieving properties make it a good
retention suture to close larger wounds or flaps so that
subsequent sutures can be placed with less tension. To place
a horizontal mattress suture, place the needle 4–10  mm
from the wound edge, passing it through the dermis or
same wound contraction occurs with proper suture place-
ment, but the everted wound edges settle to a flattened posi-
tion, which is much less visible than a sunken scar.
Vertical mattress stitches
Vertical mattress stitches effectively decrease wound tension,
and provide significant closure support while everting wound
edges. This stitch is also very useful for closing dead space.
The vertical mattress stitch begins with penetration of the
epidermis 5–10 mm away from the wound edge (the far entry
point) (Fig. 13.7). The larger and tighter the wound, the
farther the needle is placed from the wound edge. Then
the needle is directed downward, taking a generous bite of
dermis before exiting the vertical edge of the wound near the
base of the defect. Crossing the defect, the needle is intro-
duced into the base of the contralateral wound edge and is
directed upwards toward the epidermis (the far exit point).
The far entry and exit points should be equidistant from the
wound edge. The direction of the needle is then reversed in
the needle driver and introduced through the skin 1–3 mm
from the epidermal edge (the near entry point) on the same
side of the wound as the far exit point. A small bite of epi-
dermis and dermis is taken before exiting into the wound
opening. Crossing the wound, the needle is introduced into
the opposite wound edge at the same level as its last exit.
Another small bite of dermis and epidermis is made before
exiting the epidermis 2–3  mm from the wound edge. The
suture is then gently tied to approximate the wound edges.
The sequence of far–far–near–near is repeated for subsequent
vertical mattress sutures. For optimal results, all needle entry
and exit points should be placed to lie along one vertical line
perpendicular to the wound edge. Care must be taken when
tying this suture to prevent strangulation and subsequent
necrosis of the epidermal wound edge. In wounds under sig-
nificant tension, bolsters made of cardboard, cotton, or rubber
1
2
3
4
Simple interrupted suture
Figure 13.5  Placement of the simple interrupted suture. The
needle penetrates the epidermis (1) and is rotated slightly
outward through the dermis and subcutaneous tissue in certain
wounds. (2) The needle then crosses the wound, looping a
substantial portion of dermis and possibly subcutaneous tissue
before being redirected upwards. (3) The needle then exits the
epidermis where the suture is then tied (4).
Wound edge eversion
Flat scar
Depressed scar
Pear
shape
1
1
2
2
Placement of epidermal sutures
A
B
Figure 13.6  Proper placement of epidermal sutures involves
looping a larger portion of the dermis and/or subcutis than the
epidermis. This creates a pear-shaped suture which everts
wound edges (A). Failure of wound edge eversion often leads
to a more depressed, noticeable scar (B). Numbers indicate
entry points of the needle. (Adapted from Taylor RS. Needles,
sutures, and suturing. Atlas Office Proced 1999;2:53–74.)

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Chapter 13  Suturing Technique and Other Closure Materials
This is helpful for wounds that need wound edge compression
or hemostasis.53
Half-buried horizontal mattress (tip) stitch
Horizontal mattress stitches can also be placed with half of
the suture buried in the dermis. This stitch can be beneficial
for decreasing the risk of suture marks and epidermal stran-
gulation while still closing dead space and everting wound
edges. The first bite is like a simple interrupted horizontal
mattress stitch but the second bite is taken of the opposing
wound edge, directing the needle parallel to the epidermal
surface, entering and exiting at the dermal wound edge. The
third bite is taken of the opposite wound edge, and the needle
is then directed back up through the epidermis, lateral to the
initial epidermal entry site.
subcutaneous tissue to the contralateral side (Fig. 13.8).
Exit through the opposite epidermis at a distance from the
wound edge which is equal to that taken in the initial side.
Re-enter the epidermis 3–5 mm lateral to the last point of
exit. Direct the needle back across the wound edge, coming
out of the epidermis on the same side as the initial puncture
site. Then gently tie off the suture, taking care not to stran-
gulate tissue. When completed, the exposed suture runs par-
allel to the incision. There is a greater theoretical risk of
strangulation of a larger portion of the dermal plexus with this
stitch compared with simple interrupted or even vertical mat-
tress stitches. Thus, it is usually not used in poorly vascular-
ized wounds or in suturing flaps. When used in situations of
significant tension, bolster material such as gauze or cotton is
placed between the exposed suture loops and the skin surface
to prevent the suture from cutting into the epidermis.
A variation of this suture is the locking horizontal mattress
suture. To place this suture, a traditional horizontal mattress
suture is placed, but the loop that is placed in the side con-
tralateral to the entry and exit point is left loose so that the
needle and suture can be passed under it, locking the suture.
A
B
C
1
2
3
4
Vertical mattress stitch
Figure 13.7  Placement of the vertical mattress stitch. (A) The
needle is placed 5–10 mm from the wound edge, and a
deeply-seated simple interrupted suture is placed (1,2).
Numbers indicate entry points of the needle. (B) The needle
is redirected back across the wound more superficially (3),
penetrating the skin edge 2–4 mm from the wound on both
sides (4). (C) Final appearance of this suture after tying.
(Adapted with permission from Robinson JK. Technique of
suture placement. In: Robinson JK, Arndt KA, LeBoit PE,
Wintroub BU, eds. Atlas of cutaneous surgery. Philadelphia: WB
Saunders 1996; 79–90.)
A
B
1
2
3
4
Horizontal mattress stitch
Figure 13.8  Horizontal mattress suture. (A) To place this
suture, begin with a widely-spaced simple interrupted suture
(1,2). Numbers indicate entry points of the needle. Move
laterally down the wound 3–5 mm, and place another
interrupted suture in the opposite direction to the first (3,4).
(B) The appearance of this suture when tied. (Adapted with
permission from Robinson JK. Technique of suture placement.
In: Robinson JK, Arndt KA, LeBoit PE, Wintroub BU, eds. Atlas
of cutaneous surgery. Philadelphia: WB Saunders 1996; 79–90.)

202
Part 2  Essential Surgical Skills
tip stitch provides increased blood flow to flap tips compared
to simple interrupted sutures.54
Step-off correction
A step-off deformity occurs when a wound is closed by suture
that is placed at different levels in the edges of the wound.
Although severe step-off correction requires removal and
replacement of the offending sutures, mild or moderate
disparity can be corrected with a corrective top stitch. To
place such a stitch, a simple interrupted suture is placed that
goes deeper into the dermis on the lower side and remains
more superficial on the higher side (Fig. 13.10). Once tied,
this will bring the lower wound edge up to meet the higher
wound edge. Sometimes more than one correcting suture is
necessary.
Running stitches
In a running or continuous stitch, individual stitches are
placed in succession without interruption by knots. Place-
ment of running stitches is much faster than for interrupted
stitches. However, a running epidermal stitch is not quite as
strong as an interrupted stitch and should be used with
caution when it is the sole means of wound closure. Running
stitches should not be used alone in wounds under moderate
or significant tension because the running loops of suture
would be pulled tightly and strangulate the superficial and
possibly deep dermal vascular plexus that could damage
tissue. However, when used in the appropriate circumstance,
running stitches are very efficient and offer excellent cos-
metic results. Most epidermal stitches, including simple and
mattress stitches, can be placed in a continuous fashion.
The running simple stitch is the easiest of the continuous
stitches to perform (Fig. 13.11). To begin, a simple inter-
rupted stitch is placed and tied at the end of the wound, but
the suture is not cut free from the needle. The needle is then
This half-buried horizontal mattress stitch is often used as
a ‘tip stitch’ to secure the triangular tips of flaps or M-plasty
incisions. The buried portion of the tip stitch is thus placed
through the dermis of the pointed flap tip, and the transepi-
dermal sutures are placed on the V-shaped contralateral
wound edge (Fig. 13.9). When performed correctly, the tip
stitch perfectly sets the pointed tip of a wound into its
recipient angular wound bed, without placing puncture holes
through a small and fragile tip. In addition, this half-buried
1
2
3
4
Half-buried horizontal mattress tip stitch
A
B
Figure 13.9  Half-buried horizontal mattress tip stitch. (A) This
suture is started as an interrupted suture (1) on the ‘V’ portion
of the wound crossing over to the tip of the flap (2). A horizontal
bite is made through the dermis of the tip (3). The needle is
then directed back across the wound and tied (4). (B) Final
appearance of this suture after placement. Numbers indicate
entry points of the needle. (Adapted with permission from
Robinson JK. Technique of suture placement. In: Robinson JK,
Arndt KA, LeBoit PE, Wintroub BU, eds. Atlas of cutaneous
surgery. Philadelphia: WB Saunders 1996; 79–90.)
A
B
1
2
Step-off correction
Figure 13.10  Step-off correction. (A) To correct a step-off
deformity, place a simple interrupted suture superficially on the
higher wound edge (1) and deeply on the lower wound edge
(2). (B) Tying this suture results in even wound edges. Numbers
indicate entry points of the needle. (Adapted with permission
from Robinson JK. Technique of suture placement. In:
Robinson JK, Arndt KA, LeBoit PE, Wintroub BU, eds. Atlas of
cutaneous surgery. Philadelphia: WB Saunders 1996; 79–90.)

203
Chapter 13  Suturing Technique and Other Closure Materials
surgeon must hold enough tension on the suture during sutur-
ing so that the wound remains closed, but not enough to cause
strangulation of the wound edges. Upon reaching the end of
the wound, the suture is tied off on itself.
When stitching wounds with a high risk of postoperative
bleeding, such as the scalp or posterior ear, the running
simple stitch can be modified to place consistent pressure on
the wound edges. In this technique, the needle is passed
through the remaining suture loop with each stitch. This locks
segments of the suture connecting the loop segments above
the skin surface, instead of allowing them to be looped in the
dermis (Fig. 13.12).
introduced into the epidermis next to the interrupted stitch
and directed diagonally across and down the length of the
wound. A healthy bite of dermis and fat is taken from both
sides of the wound and the needle exits approximately
3–5 mm from the epidermal edge of the opposite side of the
wound. The needle is then introduced through the epidermis
at the same distance from the epidermal edge on the opposite
side of the wound. The needle is passed through the dermis
from one side of the wound to the next as the needle is
directed diagonally down the length of the wound. These
steps are repeated by placing pairs of opposing exit and entry
points 3–7 mm apart until the entire wound is closed. The
1
2
3
4
Running simple suture
Figure 13.11  Running simple
suture. Multiple simple
sutures are placed in
succession, allowing for rapid
closure of wounds. Numbers
indicate entry points of the
needle. (Adapted from Taylor
RS. Needles, sutures, and
suturing. Atlas Office Proced
1999;2:53–74.)
1
2
3
Running locked suture
Figure 13.12  Running
locked suture. A running
simple suture is placed,
passing the needle through
the loop created by the last
suture. This locking suture
facilitates hemostasis.
Numbers indicate entry
points of the needle.
(Adapted from Taylor RS.
Needles, sutures, and
suturing. Atlas Office Proced
1999;2:53–74.)

204
Part 2  Essential Surgical Skills
Traditional buried stitches
Subcutaneous stitches are invaluable for closing dead space,
for redistributing wound tension, and for apposing wound
edges. Their placement gives prolonged dermal support that
dramatically decreases the chance of wound dehiscence and
improves scar cosmesis. Proper placement is critical for
optimal results. If placed too high in the dermis, buried
sutures may extrude or ‘spit’ from the surface, delaying
wound healing. If placed unevenly, vertical disparity of wound
edges, or step-off, will occur. Although not absolutely neces-
sary, undermining wound edges greatly facilitates the place-
ment of buried sutures.
The buried suture is placed by entering the deep aspect of
the wound in the subcutaneous tissue. In undermined wounds,
it is ideal to enter the undersurface of the flap in the subcu-
taneous tissue. The needle is then directed up through the
reticular dermis, following the arc of the needle to exit
through the mid-dermis of the wound edge (Fig. 13.14A). A
mirror image of the preceding step is then performed. The
needle enters the mid-dermis of the opposite wound edge at
the same level in the dermis it just exited. Continuing in an
arc through the dermis, the needle exits through the subcu-
taneous tissue at the base of the wound. Keeping the suture
at the same vertical level on both wound edges prevents a
step-off deformity (Fig. 13.15). The suture is then pulled and
tied, redistributing the tension to the surrounding tissues,
away from the wound edge. Placing the suture in the order
described above will ensure the knot is buried deeply in the
tissue, decreasing the chance the knot will travel to the
surface during healing and ‘spit’ out of the skin. Excess suture
is cut on the knot, because leaving the tail as short as possible
will decrease wound reaction. Buried sutures alone are almost
always used in combination with some form of epidermal
closure, such as sutures, wound adhesives, or staples.
In small wounds where tying off one subcutaneous suture
makes it difficult to place others, several buried sutures may
Running variations of the horizontal and vertical mattress
stitches can also be performed. Because running mattress
stitches can be difficult to visualize in a healed incision, it is
advisable to place a simple running stitch between every two
or three mattress sutures for easier removal.55
Running subcuticular stitch
Using a suture with a low friction coefficient, such as poly-
propylene, the running subcuticular stitch can achieve excel-
lent cosmetic results. The benefit of this stitch is that
epidermal puncture points are minimized, allowing suture to
be left in place longer; this improves wound healing and
decreases the possibility of suture-track scars. To place this
stitch, begin by placing the needle approximately 1 cm distal
to one end of the wound, passing the needle into the apex of
the wound opening, at the level of the dermis (Fig. 13.13).
The suture tail is then secured with tape strips or held by an
assistant to be tied once the entire stitch is run. The needle
is then introduced into the vertical wound edge at the level
of the dermis and threaded, taking a horizontal bite, through
the dermis into the wound edge at the same dermal plane,
exiting 1–1.5 cm distally down the wound. Next, introduce
the needle into the opposite side of the wound at the same
dermal plane but 2–3 mm behind the previous dermal exit
point. By backtracking this way, the suture assumes a zigzag
configuration in the skin, ensuring apposition of the dermal
edges and complete closure. These steps are repeated down
the length of the wound until the end of the wound is
reached. Once reaching the distal wound apex, exit the epi-
dermis approximately 1 cm from the wound opening. Tighten
the suture so the wound edges are well approximated, but do
not tighten so much that the skin bunches. Finally, secure the
tail either by tape or by tying it back on itself. Alternatively,
an absorbable suture can be placed to avoid the need for
removal. In this scenario, the ends are tied off to themselves
underneath the skin surface.
1
2
3
4
5
Running subcuticular suture
Figure 13.13  Running
subcuticular suture. Multiple
horizontally placed dermal
sutures are placed in
succession on alternating
wound edges. This results in
epidermal and dermal
closure without visible suture
marks. Numbers indicate
entry points of the needle.
(Adapted from Taylor RS.
Needles, sutures, and
suturing. Atlas Office Proced
1999;2:53–74.)

205
Chapter 13  Suturing Technique and Other Closure Materials
be placed in succession without tying them. The suture is cut
long and held by hemostats or by an assistant for future tying.
When all sutures are placed, they are tied starting at one
wound end, moving down to the other.
Buried vertical mattress suture
The buried vertical mattress suture offers the advantage of
prolonged wound eversion in addition to the other benefits
of buried suture. This stitch is placed by placing the curved
needle in the subcutaneous tissue and making an arc upwards
toward the superficial dermis, continuing the arc and exiting
through the mid-dermis (Fig. 13.14B). A mirror image of this
step is repeated on the opposite side: enter through the mid-
portion of the dermis, make an upward arc toward the upper
reticular dermis, and continue the curve downward to exit
the subcutaneous surface. Looping of the dermis in this way
causes wound edge eversion when the suture is tied.56
Buried butterfly suture
The buried butterfly suture results in even greater wound
eversion than the buried vertical mattress suture.57 Wound
edges must be undermined prior to its placement. This stitch
is placed by entering the undersurface of the flap in the sub-
cutaneous tissue, directing the needle up through the reticu-
lar dermis, and following the arc of the needle and exiting on
the undersurface of the flap in the subcutaneous tissue (Fig.
13.14C). Next, this process is repeated on the opposite
wound edge: the undersurface of the flap is entered, directing
the needle up through the dermis, and exiting at a point
farther from the wound edge than the entry point. The suture
is then pulled and tied, and the closure tension is distributed
to the surrounding skin, away from the wound edge. This
redistribution may create dimpling in the surrounding skin
and will cause elevation or ridging along the closure line as
the epidermal edges are intentionally everted. These distor-
tions disappear as the skin stretches and the buried stitches
lose integrity. Such wound eversion facilitates the creation of
a fine-line scar by removing all tension from the wound edge.
Purse string suture
A variation of the buried dermal suture called the purse string
suture is very good for closing dead space and decreasing the
diameter of a wound. Instead of vertical bites described in
the traditional buried subcutaneous suture, the purse string
suture involves multiple horizontally-oriented bites spaced
5–10 mm apart, placed continuously along the circumference
of the wound edge. The stitch is placed at the level of the
mid-dermis or deep dermis, taking care to maintain the same
vertical level with each bite. When the last bite has been
taken, the suture is pulled taught, which clinches the tissue
together. An assistant holds the tissue together while the knot
is tied. This stitch may partially or completely close a wound.
Wounds that are partially closed in this manner may be left
to granulate or may be completely closed with an overlying
skin graft.58
Running subdermal stitch
The buried running subdermal stitch is a rapid means of
closure that can be used in wounds under mild tension or
moderate tension. Begin by placing a buried interrupted verti-
cal stitch, cutting only the free suture tail. Then introduce the
1
1
1
2
2
2
A
B
C
Buried dermal sutures
Figure 13.14  Buried dermal sutures. (A) Conventional buried
suture placement results in mild wound eversion. (B) Buried
vertical mattress suture placement results in moderate to
significant wound eversion. (C) Buried butterfly suture
placement results in the greatest degree of wound eversion.
Numbers indicate entry points of the needle.
A
B
Step off
1
2
Step-off deformity
Figure 13.15  Step-off deformity. (A) Uneven placement of
sutures across the wound (B) results in a step-off deformity.
Numbers indicate entry points of the needle. (Adapted from
Taylor RS. Needles, sutures, and suturing. Atlas Office Proced
1999;2:53–74.)

206
Part 2  Essential Surgical Skills
to approximate wound edges without tissue strangulation. In
addition, the wound edges should be handled very carefully,
either using toothed forceps or skin hooks to avoid crushing.
Surgeons must also train their assistants in the optimal ways
to cut suture. Buried sutures should be cut on the knot to
minimize the amount of suture material being left in the
wound. The tails of surface stitches should be cut to a length
that provides ease of grasping at the time of removal. When
placed in the periorbital areas, tails should be secured by
taping to the skin, cutting shorter tails, or securing under
other sutures to prevent damage to the eye.
 POSTOPERATIVE CARE
Sutures should be removed at a time that is long enough for
the development of initial wound healing and strength.
However, sutures left in too long will promote wound infec-
tion, delay wound healing, and promote suture-track forma-
tion.60 These track marks, which can look like ‘railroad’ scars
and only occur when the epidermis is punctured, are formed
when keratinocytes form a complete track around the suture
material. Formative epithelialization of suture occurs even in
the first days after suture placement, but complete suture-
needle into the side of the wound at the base of the defect,
5–10 mm down the length of the defect. Advance the needle
up in a vertical fashion, exiting directly above the entry point
after looping through subcutaneous fat and dermis. Moving to
the opposite vertical wound edge, loop the needle downward
through dermis and fat. This sequence is repeated down the
wound edge, keeping enough tension to close the wound
without clinching it too tightly. This suture should not be
used in wounds under moderate to severe tension because it
offers less strength than interrupted sutures, and if one strand
breaks the entire wound may dehisce.
Pulley stitch
The pulley stitch allows closure of wounds under tension. It
is commonly used to close wounds on the scalp or large
wounds of the trunk. Several ways of placing the stitch have
been described, similar to the vertical mattress stitch.59 Key
to the design of this stitch is the multiple passes through the
tissue. This creates enough resistance so that when the suture
is placed and pulled to close the wound, and then released
to tie, the suture does not slip. Figure 13.16 shows the suture
paths that can be used.
 OPTIMIZING OUTCOMES OF
SUTURED WOUNDS
The appropriate wound closure material and method should
be chosen based on the wound characteristics, such as size,
location, wound tension, and type of repair. In addition, high-
quality instruments of the proper size must be used and
maintained.
Skin surgeons often close wounds under tension. Large
wounds, or wounds in areas of the body where the skin does
not readily move, can force a closure under varying degrees
of tension. Proper placement of buried stitches in a wound
with undermined edges can distribute tension away from
wound edges, but placement of the initial stitch can be prob-
lematic. Assistants can be taught to push and hold wound
edges together while the first knot is being thrown. Three
wraps around the needle driver – instead of two – can also
be used for the first throw to prevent the knot from slipping
while the second and subsequent throws are being performed.
The pulley stitch was designed to be used in these situations.
Finally, a towel clamp can be used to hold the wound edges
together while placing suture, but this approach will leave
puncture scars on either side of the wound.
When closing the epidermis, the surgeon should select
suture of the finest caliber to close the wound adequately, in
order to minimize puncture marks and suture tracks. If the
closure is under any tension, the surgeon should consider
using a buried absorbable suture that is at least one suture
size larger than the epidermal suture. While the epidermal
suture should be placed to provide precise epidermal wound
edge approximation, the stitch chosen for placement of the
buried suture should redirect tension away from the wound
edge and provide good wound edge eversion.
Placement of suture requires practice, skill, and attention
to detail. Buried suture should be placed at even levels across
the wound to prevent step-off deformity. Prior to placing the
epidermal or top stitch, all tension should be off the wound
edges so they can be easily approximated. When placing the
top stitch, care must be taken to tie the suture tight enough
A
B
C
1
1
2
2
3
3
4
1
2
3
4
4
Buried pulley stitch
Figure 13.16  Pulley stitches. (A) Buried pulley stitch.
(B) Partially buried pulley stitch. (C) Epidermal pulley stitch.
Numbers indicate entry points of the needle.

207
Chapter 13  Suturing Technique and Other Closure Materials
track formation, which takes 8–12 days, is responsible for the
track marks.61 Therefore, sutures should be removed earlier
rather than later whenever possible. To remove interrupted
sutures, grasp the tail of the suture knot with forceps. Lifting
the suture away from the wound, cut the suture underneath
the knot (Fig. 13.17). After cutting, continue lifting the tail
A
B
Suture removal
Figure 13.17  Suture removal. (A) Pull the tail of the suture
away from the wound and with one side of the suture
underneath the knot. (B) The cut suture is lifted straight up from
the incision for complete removal.
Table 13.6  Recommended suture removal times
AREA SUTURED
REMOVAL TIMES
Eyelid
2–4 days
Face
4–6 days
Neck
5–7 days
Scalp
5–7 days
Trunk
7–12 days
Extremities
10–14 days
Table 13.7  Pitfalls: causes and management
PITFALL
POSSIBLE CAUSES
PREVENTION/MANAGEMENT
Suture breaking
during tying
Choice of suture material with too low tensile
strength or too fine caliber
High-tension wound
Use suture with more tensile strength or larger caliber
If possible, undermine wound edges farther
Knot slippage
Use of suture with high friction coefficient
High-tension wound
Increase number of initial throws of knot
Have assistant hold together wound during knot tying
Undermine more widely
Incision step-off
Uneven placement of sutures
If severe, remove and replace offending sutures
If mild, place corrective interrupted suture(s)
Needle bending
Using too small a needle
Not using arc motion to place suture
Use larger-size needle
Rotate needle through arc while placing suture
Wound edge
inversion
Incorrect placement of buried and/or top
sutures
Ensure eversion by looping portion of dermis with buried suture
Ensure eversion by arcing needle slightly away from wound edge when
placing top stitch
Use corrective everting top stitches such as interrupted vertical mattress
Suture tracks
Sutures left in place too long
Needles and suture caliber too large
Sutures tied too tightly
Remove sutures at earliest possible time
Use epidermal suture with smallest caliber possible
Tie knot only tight enough to approximate wound edges; do not
strangulate
of the suture to complete its removal. It is important to only
cut one end of the suture under the knot; cutting both ends
of the suture underneath the knot will prevent the buried
portion of the suture from being removed. Running sutures
can be removed in the same fashion if the incision is relatively
small. To prevent patient discomfort from pulling long con-
tinuous sutures out, the suture can be cut at shorter intervals
along the incision and removed in a similar manner.
If necessary, wound adhesive strips may be used after
suture removal to reinforce the wound. Incisions that have
been closed with subcutaneous sutures allow for earlier
removal. However, wounds under significant tension or in
high-movement areas such as the extremities may require
staged suture removal. For example, every other suture may
be removed first, with complete removal following several
days later. Recommended suture removal time varies by loca-
tion (Table 13.6).
 PITFALLS AND THEIR MANAGEMENT
Most pitfalls in surgical repair can be avoided by proper
preparation, knowledge, and technique (Table 13.7). Correc-
tions of any detectable imperfections should be made at the

208
Part 2  Essential Surgical Skills
22. Faulkner BC, Gear AJ, Hellewell TB, et al. Biomechanical performance
of a braided absorbable suture. J Long Term Effect Med Implants 1996;
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23. Debus ES, Geiger D, Sailer M, et al. Physical, biological and handling
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24. Elliot D, Mahaffey PJ. The stretched scar: the benefit of prolonged
dermal support. Br J Plast Surg 1989;42:74–78.
25. Katz AR, Mukherjee DP, Kaganov AL, et al. A new synthetic monofila-
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26. Trimbos JB, Niggebrugge A, Trimbos R, et al. Knotting abilities of a new
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27. Bezwada RS, Jamiolkowski DD, Lee IY, et al. Monocryl suture, a new
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28. Molea G, Schonauer F, Bifulco G, et al. Comparative study on biocom-
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Surg 2000;53:137–141.
29. Herrmann JB. Tensile strength and knot security of surgical suture mate-
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30. Conn J, Beal JM. A study of polybutilate lubricated polyester sutures.
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31. Rodeheaver GT, Shimer AL, Boyd LM, et al. An innovative absorbable
coating for the polybutester suture. J Long Term Effect Med Implants
2001;1–2:41–51.
32. Bang RL, Mustafa MD. Comparative study of skin wound closure with
polybutester (Novafil) and polypropylene. J R Coll Surg Edin 1989;
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33. Orlinsky M, Goldberg RM, Chan L, et al. Cost analysis of stapling versus
suturing for skin closure. Am J Emerg Med 1995;13:77–81.
34. Bennett RG. Selection of wound closure materials. J Am Acad Dermatol
1988;18:619–637.
35. Medina dos Santos LR, Freitas CA, Hojaij FC, et al. Prospective study
using skin staplers in head and neck surgery. Am J Surg 1995;170:
451–452.
36. Khan A, Dayan PS, Miller S, et al. Cosmetic outcome of scalp
wound closure with staples in the pediatric emergency department: a
prospective, randomized trial. Pediatr Emerg Care 2002;18:171–173.
37. Meiring L, Ciliers K, Barry R, et al. A comparison of a disposable skin
stapler and nylon sutures for wound closure. S Afr Med J 1982;62:
371–372.
38. Coupland RM. Sutures versus staples in skin flap operations. Ann R Coll
Surg Engl 1986;68:2–4.
39. Stockley I, Elson RA. Skin closure using staples and nylon sutures: a
comparison of results. Ann R Coll Surg Engl 1987;69:76–78.
40. Leonard F, Hodge JW, Houston S, et al. Alpha-cyanoacrylate adhesive
bond strengths with proteinaceous and nonproteinaceous substrates. J
Biomed Mater Res 1965;3:281–289.
41. Ammirati CT. Advances in wound closure materials. Adv Dermatol
2002;18:313–338.
42. Craven NM, Telfer NR. An open study of tissue adhesive in full-thickness
skin grafting. J Am Acad Dermatol 1999;40:601–611.
43. Naik SS, Wright V, Timmons J, et al. A single blind, prospective, rand-
omized trial comparing n-butyl-2-cyanoacrylate tissue adhesive (Inder-
mil) and sutures for skin closure in hand surgery. J Hand Surg 2001;26B:
264–265.
44. Goktas N, Karcioglu O, Coskun F, et al. Comparison of tissue adhesive
and suturing in the repair of lacerations in the emergency department.
Eur J Emerg Med 2002;9:155–158.
45. Penoff J. Skin closures using cyanoacrylate tissue adhesives. Plastic
Surgery Educational Foundation DATA Committee. Device and Tech-
nique Assessment. Plast Reconstr Surg 1999;103:730–731.
46. Shapiro AJ, Dinsmore RC, North JH. Tensile strength of wound closure
with cyanoacrylate glue. Am Surg 2001;67:1113–1115.
47. Quinn J, Wells G, Sutcliffe T, et al. A randomized trial comparing octyl-
cyanoacrylate tissue adhesive and sutures in the management of lacera-
tions. JAMA 1997;277:1527–1530.
48. Osmond MH, Quinn JV, Sutcliffe T, et al. A randomized, clinical
trial comparing butylcyanoacrylate with octylcyanoacrylate in the man-
agement of selected pediatric facial lacerations. Acad Emerg Med 1999;
6:171–177.
49. Tamez OA, McGuff HS, Prihoda TJ, et al. Securing meshed split-
thickness skin grafts with 2-octylcyanoacrylate. Otolaryngol Head Neck
Surg 1999;121:562–566.
50. Toriumi DM, O’Grady K, Desai D, et al. Use of octyl-2-cyanoacrylate
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2209–2219.
earliest possible time, preferably during surgery. It is much
easier to remove and replace improperly placed sutures than
to revise a scar at a later date.
 SUMMARY
Acquiring a working knowledge of wound closure materials
and their appropriate use is an important component of the
surgeon’s education. Attention to detail and meticulous exe-
cution of suturing techniques can vastly improve the cosmetic
and functional surgical results. Similarly, proper training and
use of the surgical staff is an important step to ensure that
optimum outcomes are achieved.
 REFERENCES
1. Rothenburger S, Spangler D, Bhende S, et al. In vitro antimicrobial evalu-
ation of coated VICRYL plus antibacterial suture (coated Polyglactin 910
with triclosan) using zone of inhibition assays. Surg Infect (Larchmt)
2003;3(Suppl 1):79–87.
2. Storch M, Perry LC, Davidson JM, et al. A 28-day study of the effect of
coated VICRYL plus antibacterial suture (coated Polyglactin 910 suture
with triclosan) on wound healing in guinea pig linear incisional skin
wounds. Surg Infect (Larchmt) 2003;3(Suppl 1):89–98.
3. Shibuya TY, Wei WZ, Zormeier M, et al. AntiCD3/AntiCD28 mono-
clonal antibody-coated suture enhances the immune response of patients
with head and neck squamous cell carcinoma. Arch Otolaryngol Head
Neck Surg 1999;125:1229–1234.
4. Bennett R. Materials for wound closure. In: Bennett RG, ed. Fundamen-
tals of cutaneous surgery. St Louis, MO: Mosby 1988; 274–309.
5. Tera H, Aberg C. Strength of suture knots after one week in vivo. Acta
Chir Scand 1976;142:1–7.
6. Brunius U, Zederfeldt B. Suture materials in general surgery: a comment.
Prog Surg 1970;8:38–44.
7. Hurty CA, Brazik DC, Law JM, et al. Evaluation of the tissue reactions
in the skin and body wall of koi (Cyprinus carpio) to five suture materials.
Vet Rec 2002;14:324–328.
8. Engler RJ, Weber CB, Turnicky R. Hypersensitivity to chromated catgut
sutures: a case report and review of the literature. Ann Allergy 1986;
56:317–320.
9. Mullins RJ, Richards C, Walker T. Allergic reactions to oral surgical and
topical bovine collagen. Anaphylactic risk for surgeons. Aust N Z J Oph-
thalmol 1996;24:257–260.
10. Hocwald E, Sichel JY, Dano I, et al. Adverse reaction to surgical sutures
in thyroid suture. Head Neck 2003;25:77–81.
11. Van Winkle W, Hastings JC, Barker E, et al. Effect of suture materials
on healing skin wounds. Surg Gynecol Obstet 1975;140:7–12.
12. Terhune M. Materials for wound closure.
derm/topic825.htm. Accessed March 2002.
13. Auerback R, Pearlstei MM. A comparison of polyglycolic acid (Dexon),
nylon and silk sutures in skin surgery. J Dermatol Surg 1975;1:38–40.
14. Wetter LA, Dinneen MD, Levitt MD, et al. Controlled trial of polygly-
colic acid versus catgut and nylon for appendectomy wound closure. Br
J Surg 1991;78:985–987.
15. Rodeheaver GT, Thacker JG, Edlich RF. Mechanical performance of
polyglycolic acid and Polyglactin 910 synthetic absorbable sutures. Surg
Gynecol Obstet 1981;153:835–841.
16. Adams B, Levy R, Rademaker AE, et al. Frequency of use of suturing and
repair techniques preferred by dermatologic surgeons. Dermatol Surg
2006;32:682–689.
17. Guyuron B, Vaughan C. Comparison of polydioxanone and Polyglactin
910 in intradermal repair. Plast Reconstr Surg 1996;98:817–820.
18. Moy RL, Kaufman AJ. Clinical comparison of polyglactic acid (Vicryl)
and polytrimethylene carbonate (Maxon) suture material. J Dermatol
Surg Oncol 1991;17:667–669.
19. Hohenleutner U, Egner N, Hohenleutner S, et al. Intradermal buried
vertical mattress suture as sole skin closure: evaluation of 149 cases. Acta
Derm Venereol 2000;80:344–347.
20. Niessen FB, Spauwen PH, Kon M. The role of suture material in hyper-
trophic scar formation: Monocryl vs Vicryl-rapide. Ann Plast Surg 1997;
39:254–260.
21. Gabel EA, Jimenez GP, Eaglstein WH, et al. Performance comparison of
nylon and an absorbable suture material (Polyglactin 910) in the closure
of punch biopsy sites. Dermatol Surg 2000;26:750–752.

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51. Bernard L, Doyle J, Friedlander SF, et al. A prospective comparison of
octyl cyanoacrylate tissue adhesive (Dermabond) and suture for the
closure of excisional wounds in children and adolescents. Arch Dermatol
2001;137:1177–1180.
52. Shamiyeh A, Schrenk P, Stelzer T, et al. Prospective randomized blind
controlled trial comparing sutures, tape, and octylcyanoacrylate tissue
adhesive for skin closure after phlebectomy. Dermatol Surg 2001;27:
877–880.
53. Hanasono MW, Hotchkiss RN. Locking horizontal mattress suture. Der-
matol Surg 2005;31:572–573.
54. Kandel EK, Bennett RG. The effect of stitch type on flap tip blood flow.
J Am Acad Dermatol 2001;44:265–272.
55. Krunic AL, Weitzul, Taylor RS. Running combined simple and vertical
mattress suture: a rapid skin-everting stitch. Dermatol Surg 2005;31:
1325–1329.
56. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg
Oncol 1989;15:17–19.
57. Breuninger H, Keilbach J, Haaf U. Intracutaneous butterfly suture with
absorbable synthetic suture material. Technique, tissue reactions, and
results. J Dermatol Surg Oncol 1993;19:607–610.
58. Harrington AC, Montemarano A, Welch M, et al. Variations of the
pursestring suture in skin cancer reconstruction. Dermatol Surg 1999;
25:277–281.
59. Snow SN, Dortzbach R, Moyer D. Managing common suturing problems.
J Dermatol Surg Oncol 1991;17:502–508.
60. Bennett R. Basic excisional surgery. In: Bennett RG, ed. Funda-
mentals of cutaneous surgery. St Louis, MO: Mosby 1988; 381–
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211
14
Complex Layered Facial Closures
Edgar F Fincher MD PhD, Hayes B Gladstone MD, and Ronald L Moy MD
Summary box
 Facial skin is divided into discrete cosmetic subunits whose
aesthetic characteristics are derived from regional variations
in the composition of the underlying tissue layers. Careful
attention to restoring these subunits during reconstruction is
critical.
 The human face is composed of an interrelated functional unit
of muscle, connective tissue, and overlying skin that should
be treated as a single unit to obtain optimal results.
 Layered closure is crucial in optimizing the ultimate outcome
of cutaneous reconstruction. Careful reapproximation of the
individual tissue layers to restore the disrupted integrity of
skin must be obtained.
 Human skin has both viscoelastic and anisotropic
characteristics. Understanding these tissue properties and
their effects during flap manipulation and skin closure are
fundamental principles of cutaneous surgery.
 Suspension sutures are effective in stabilizing the skin against
the opposing vector forces of the elastic dermis and the
forces of gravity, and are used in both reconstructive and
cosmetic surgery.
 Performing complex closures often requires the use of a
combination of techniques (flaps, grafts, and primary closure)
to obtain optimal results.
 INTRODUCTION
Successful surgical reconstruction and enhancement of the
face requires a comprehensive knowledge of the anatomy of
the skin and its underlying support structures as well as an
understanding of tissue biomechanics and the tension vector
forces at play. Surgeons must combine this knowledge with
skilled wound closure techniques to maximize the outcome.
The responsibility of the surgeon, whether it be for recon-
struction of a defect following tumor extirpation or for cos-
metic enhancement of the aging face, is to recreate or enhance
the normal anatomy to ensure proper form and function.
Many times, this simply requires the reapproximation of
existing landmark structures without disruption of any under-
lying deep tissue. However, the surgeon is often faced with
reconstructing a large full-thickness defect after tumor exci-
sion or, alternatively, is asked to recreate what time and
nature has altered. To achieve optimal functional and cos-
metic results, tissue layers must be moved, repositioned, and
reconstructed in a manner that will overcome tissue deficits
or redundancies and forces opposing wound closure.
This chapter examines the functional anatomy and biome-
chanics of the skin and fundamental principles that are appli-
cable to complex wound closures. An approach to treating
the skin as an integrated multilayered structure is presented
with relevant surgical techniques that have been developed
for the reconstruction and enhancement of this integrated
unit. Special consideration will be given to surgical recon-
struction and enhancement of the head and neck.
 HISTORICAL VIGNETTE
In 1976, Mitz and Peyronie published their landmark paper1
identifying the presence of a superficial musculoaponeurotic
system (SMAS) in the head and neck. In this report, they
proposed the benefits of using suspension sutures from the
SMAS flap to the pretragal area to provide superior results
in both rhytidectomy and repair of facial nerve palsy. This
concept revolutionized approaches to facial rejuvenation and
reconstructive surgery of the head and neck.
 PREOPERATIVE PREPARATION
Fundamental objectives of wound closure
Successful design of wound closure begins with an under-
standing of cosmetic subunits, tissue biomechanics, and
anatomic layers of the skin and subcutaneous tissues.
Structurally, the integument is best thought of as a multilay-
ered unit of epidermis, fibrous connective tissue, subcutane-
ous adipose tissue, and muscle that provides structure and
texture to the skin. Regional variations in the relative com-
position of these layers provide the characteristic textural
qualities of various anatomic sites. These regional variations
in skin quality and texture and their resultant qualitative
effect upon the aesthetic appearance of the skin are most
notable in the head and neck region. Careful attention to
these regional variations is paramount for planning a recon-
struction that best recreates the natural appearance. When
primary closure is not an option, careful selection of local skin
flaps and skin grafts that match both tissue color and texture
of the recipient site will provide the best cosmetic outcome.
A second fundamental principle that should be obeyed
when planning closures on the head and neck is to respect

212
Part 2  Essential Surgical Skills
Overlying the cranium and facial muscles is a continuous
fascial layer, the SMAS.1 This layer has attachments to the
cranium and invests the facial musculature, forming an inter-
connected sling that both provides support to the facial struc-
tures and acts to integrate the functional activity of facial
movements. The SMAS begins in the forehead as a continua-
tion of the galea aponeurotica. It progresses inferiorly, being
continuous with the temporalis fascia and zygoma laterally,
and with the superficial parotid fascia and malar prominence
in the preauricular zone and mid-face, respectively. The
SMAS then crosses over the mandible to become continuous
with the platysma and inserts into the clavicle, the pectoralis
fascia, and sternocleidomastoid fascia of the neck (Fig. 14.1).
The SMAS is the unifying structural component of the face
linking muscles of facial expression as an integrated network
that enables the countless numbers of facial maneuvers. Facial
muscles are linked to the SMAS through direct interdigita-
tions as well as via several well-defined mid-facial ligaments.3–5
These connections permit mimetic actions to be transferred
to the SMAS and subsequently to the overlying skin.
The functional importance of the SMAS along with an
understanding of the major bony attachments of the cranium
cannot be overemphasized to the surgeon attempting complex
closures of the face. Manipulation of these structures is crucial
to overcoming opposing vector forces that resist closure of
cutaneous defects to achieve optimal cosmetic results.
Functional skin biomechanics
The heterogeneous cutaneous anatomy contributes to the
unique biomechanical properties of skin. Although most of
these properties are derived from the dermal collagen and
elastin, the subcutaneous fat, blood vessels, and nerves also
play a role. Interestingly, the epidermis plays only a small role
in skin deformation. Understanding these biomechanical
characteristics not only enables the surgeon to choose the
best option for a particular defect but also to perform more
precise closures.
Unlike other static materials such as steel, skin’s stress–
strain relationship varies with time. Skin is both viscoelastic
and anisotropic, meaning that its ‘stretchability’ is non-linear.
Movement of skin is also characterized by its ability to stretch
over time (‘creep’), and at a certain point in the stress–strain
curve to almost completely relax (‘stress relaxation’).6 This
quality is most likely because of the breakage of collagen
fibers. Although studies have investigated these properties in
porcine models, cadavers, and intact human skin rather than
incised living skin, the application of these principles to living
skin biomechanics during cutaneous surgery has a number of
important clinical implications. More recently, the use of
computer-generated finite element modeling has increased
our understanding of human skin biomechanical properties.7–9
The primary axiom of closing a wound without tension
derives from these tissue mechanics. Increased tissue stretch
affects the skin’s microcirculation, most likely through a com-
bination of narrowing of blood vessel lumina and by causing
shear fractures.7,8 This tension may also result in venous con-
gestion that can compromise closures. While highly vascular-
ized regions may withstand some degree of tension, poorly
perfused areas are susceptible to necrosis. Knowledge of the
regional anatomy is critical for understanding the appropriate
tissue plane to undermine to reduce tension. Additionally,
recognizing that after a certain point, undermining will not
the natural lines of demarcation. Aesthetically, the face is
composed of multiple cosmetic subunits (see Figs 1.4–1.6).
Natural skin folds, variations in tissue thickness and composi-
tion, and the underlying bony structure collectively create the
natural lines of demarcation along these subunits. In most
cases, these subunits have a corresponding symmetrical
unit on the contralateral face. These natural undulations and
demarcations of the face define the individuality of the
patient and the primary challenge to the reconstructive
surgeon is to restore this symmetry and individuality to the
patient. Planning a reconstruction so that incision lines fall
within the boundaries between these cosmetic subunits will
provide the least conspicuous scar.2 A scar that passes within
a single subunit or that crosses lines of demarcation between
two subunits can disrupt the natural contour and symmetry
of the face and will be most apparent. Adhering to this fun-
damental principle often means using larger than necessary
tissue flaps or resecting extra tissue so that suture lines can
be placed within the boundary to avoid disrupting the subunit.
Although this technique can be more laborious and may
create a larger defect, ultimately it will yield a superior cos-
metic result.
Defects that cross boundaries between cosmetic subunits
are often best repaired using a combination of flaps (complex
repairs) or special suturing techniques (i.e. tacking or suspen-
sion sutures) to redefine the disrupted lines of demarcation.
Complex repairs and suspension sutures in reconstructive
surgery are the primary focus of this chapter.
Functional facial anatomy
A comprehensive knowledge of anatomy is a prerequisite for
successful reconstructive or cosmetic surgery. Tissue layers
consist of epidermis, dermis, subcutaneous adipose, fascia,
and muscle. Each of these layers has its own inherent specific
characteristics, but it is the collective contribution of these
different layers that contributes to the overall integrity and
texture of the skin. In the head and neck, these layers are
interconnected through a series of interdigitating adhesions
that enable the human face to function as an integrated unit.
The activity of specific combinations of facial muscle groups
is transferred to the overlying skin through this connective
tissue scaffolding and provides the functional capacity to
perform complex maneuvers such as eating, drinking, kissing,
and speech. These coordinated movements also provide
humans with their characteristic ability for emotional expres-
sion through complex animated facial movements.
Before embarking upon a discussion of techniques for
complex closures, it is pertinent to review briefly the major
structural anatomy of the face. The underlying framework of
the human face begins with the concrete origins of the bony
skeleton. The topography of the cranium consists of promi-
nences and valleys that not only create the aesthetics and
individuality of the human face but also serve as key anchor-
ing points for facial muscles. For example, the forehead
anchors the frontalis muscle against gravity and enables raising
of the brow, the orbital rim provides structural support for
the delicate sphincter muscles that protect the orbit, and the
malar prominence and zygomatic arch are the anchor points
that permit elevation of the upper lip. These and many other
key anchoring points provide support for the facial structures,
offset the forces of gravitational pull on the face, and permit
normal functioning of the facial muscles.

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Chapter 14  Complex Layered Facial Closures
erties of time-dependent creep and stress relaxation can be
manipulated to aid in the closure of difficult defects. For
example, the surgeon can take advantage of these properties
when closing a linear defect whose width to length ratio is
less than the optimal 1 : 3 proportions (i.e. excessive width).
reduce closure tension, but will in fact increase the risk of
adverse effects such as hematomas or nerve damage, is equally
important.
Once the inherent properties and limitations of skin bio-
mechanics are understood, it becomes evident that the prop-
A
B
Muscles of facial expression
(lateral fibers of orbicularis oculi muscle)
SMAS (superficial temporalis fascia)
Temporalis muscle
Superior lateral tension in pretragal
area shifts labial commissure and neck
Deep temporalis fascia
Temporal branch of facial nerve
Branch of facial nerve
Coronoid process of mandible
Zygoma
Auriculotemporal nerve and
superficial temporal vessels
Dermis
SMAS or superficial fascia
Parotid fascia
Parotid gland
Masseteric fascia or deep fascia
Masseter muscle
Fibrous septa connecting SMAS to dermis
Platysma muscle
Cervical branch of facial nerve
Composite conceptualization of lateral cheek and temple regions
Figure 14.1  (A) Although the SMAS is a single connective tissue layer intricately connected to the muscles of facial expression,
the scalp and forehead seem to be discontinuous with the lower face. The red pretragal line shows the location of the anatomic
cross-section. The blue line at the level of the brow indicates this demarcation of the scalp and forehead from the lower face.
(B) The labial commissure and anterolateral neck skin are mobilized and shifted by tension on the SMAS in the pretragal area
below the zygomatic arch (the area indicated by the red line in (A)).

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Part 2  Essential Surgical Skills
13). The dermal wound edges must be realigned in both
horizontal and vertical orientations and the epidermis must
be reapproximated accurately to create a wound without any
visible step-off or undulations. Layered closure allows the
surgeon to achieve these fundamental goals. First, a deep layer
of sutures is used to close dead space and re-establish the elastic
tensile strength/holding strength of the dermis. A superficial
layer of sutures is then used to finish the wound. This super-
ficial layer reapproximates epidermal wound edges to mini-
mize scarring and provide maximal cosmesis. Because the
deep layer holds tension and provides strength to the wound,
the superficial layer can be placed under minimal tension and
can be removed after 5–7 days after epithelialization has
occurred and before any suture marks are left on the skin.
 TECHNICAL ASPECTS
Complex closures
Although most surgical defects can be closed with standard
multilayered linear closures, flaps, or skin grafts, including the
use of suspension sutures as an adjunct, some wounds defy
the conventional wisdom because of their large size involving
multiple cosmetic units, or a critical structure such as the
eyelid. The most important aspect of designing a closure for
these types of defects is to simultaneously follow the princi-
ples of cutaneous biomechanics and geometry while not being
constrained by the dogma of the standard closures. In short,
it is necessary to understand where there is the most tissue
laxity and the biomechanics of that region, to use one’s expe-
rience, investigate how others have closed analogous wounds,
and to ultimately ‘think out of the box.’ The head and neck
have an excellent vascular supply that permits the use of very
large surface areas for tissue transfer. One such example, the
cervicofacial rotation flap, appears technically demanding
with elevation of the entire cheek as well as the lateral neck
skin (Fig. 14.2). However, when reduced to its fundamental
technical components it is merely an extension of the stand-
ard rotation flap technique. In principle, any basic flap design
Multiple techniques are often applied to take advantage of
the elastic properties of skin. Intraoperative tissue expansion
can be performed by a number of methods. The rule of halves
may be applied in suturing, with each subsequent stitch
leading to a progressive reduction of the tension across the
wound. Or initially an interrupted suture or ‘pulley stitch’
may be placed at the center of the wound to reduce tension
while the remainder of the wound is closed. With the tension
across the wound decreased, buried sutures can be placed
more easily and more accurately. Once the deep layer has
been sutured, the pulley stitch is no longer needed and can
be replaced by a new layer of epidermal sutures. Alterna-
tively, in many instances, one can begin suturing from one
end of the wound toward the opposite pole. By approaching
the closure in this manner, the surgeon is taking advantage of
sequential wound creep.
Layered closures
The objectives for wound closure should be restoration
of functional anatomy, recreation of anatomic form, and
minimization of the visible scar. Layered closure allows the
surgeon to recreate the tissue planes that have been disrupted
and provides strength to the wound as it heals.
Wound strength and elasticity are predominantly factors of
the cross-linked dermal collagen and elastin fibers. The inher-
ent elasticity of the dermis becomes obvious upon disruption
of these connective tissue layers. A full-thickness wound that
severs the dermis leads to retraction of the wound edges with
a net tension vector perpendicular to the direction of the
wound or incision. As a result of this dermal retraction, the
overlying epidermal wound edge becomes inverted into
the wound. If left to heal naturally, the tendency will be for
a wound to heal with a wide, depressed scar. Successful
wound closure must counteract these intrinsic forces to
achieve acceptable cosmesis. Failure to do so can lead to poor
tensile strength, scar retraction, and spreading.
Proper suturing technique of both dermal and epidermal
layers is the key to successful wound closure (see Chapter
A
B
Figure 14.2  Cervicofacial flap. (A) Flap elevated before closure. (B) Flap sutured into place. A suspension suture anchors the flap to
the zygoma.

215
Chapter 14  Complex Layered Facial Closures
reservoirs. In this situation, combination flaps or flaps com-
bined with skin grafts offer excellent options.
While small, complex closures of defects involving the
anterior lamella of the upper eyelid extending onto the peri-
orbital skin still require an intricate understanding of tissue
biomechanics and wound contraction to predict how it will
affect the natural eyelid anatomy. Second intention healing
can lead to contraction and distortion of the eyelid. A full-
thickness skin graft has a high risk for failure given the con-
tinual rapid movement of the eyelid. A flap from the lateral
inferior aspect of the area near to the wound will likely distort
the lateral canthus. One viable solution would be a supra­
orbital transposition flap. This method utilizes adjacent skin
offering good color and thickness match as well as an excel-
lent vascular pedicle. Tissue transposition results in a low-
tension closure with minimal risk of distorting the eyelid (Fig.
14.3). Because the supraorbital flap is a thin flap, the second-
ary defect can be left to heal by second intention with a good
functional and cosmetic result.
Although these complex skin maneuvers are extremely
useful and yield excellent results when used in the appropri-
ate setting, often the most simplistic approach is the best
choice. Healing by second intention is an excellent choice for
wound closure, either when used alone or in combination
with flaps. The utility of second intention healing is well
documented in the history of Mohs surgery.14
One final technique that can be considered for wound
closure is the use of artificial skin equivalents. These devices
are available in a variety of compositions including human-,
bovine-, or porcine-derived tissues. They are either living
tissues composed of fetal foreskin fibroblast and keratinocyte
bilayers (Apligraf, Organogenesis, Inc, Canton, MA), or are
tissue-derived collagen matrices – Integra (Johnson & Johnson,
may also be used for the closure of larger defects; thus a
rhombic flap can transpose skin from the neck to repair a
large cheek defect. Another option is utilizing a bilobed flap,
most commonly performed for small-to-medium distal nasal
defects to repair large cheek defects with the neck acting as
the donor reservoir.
When available tissue reservoirs are limiting or anatomic
constraints impose physical limitations, it may be necessary
to use multiple flaps or combinations of closures to repair a
single defect. As an example, one can consider the options
for repair of a large scalp defect. On the scalp, the amount
of adjacent skin available for transfer is severely limited by
the inherent inelasticity of the regional skin. The pinwheel
closure (O–Z flap) consisting of multiple rotation flaps is an
option because it distributes the amount of donor tissue over
two separate regions. Another alternative in this area would
be to borrow from the hair restoration experience, and
perform multiple transposition flaps,10–13 again utilizing two
separate regions to donate suitable tissue that would other-
wise be insufficient from a single adjacent region.
Other alternatives for complex closure include a combina-
tion of a flap and a full-thickness skin graft. This combination
is used frequently on the cheek with excellent results. As an
example, a combined cheek and temple defect that crosses
two cosmetic subunits with distinctly different skin textures
and thicknesses requires a large surface area of tissue for
repair. A combination of a cervicofacial rotation flap utilizing
a suspension suture anchoring the flap to the zygoma to
cover the cheek component and a skin graft to close the
adjacent temple defect is an excellent solution. The forehead
is another region that often requires complex closures to
repair moderate-to-large defects due to the inelastic nature
of the local skin and the limited amount of adjacent skin
A
B
C
D
Figure 14.3  The supraorbital
transposition flap for closure of complex
upper eyelid defects. (A) Postoperative
defect with planned suprabrow
transposition flap outlined. (B)
Transposition flap elevated before
placement and suturing. (C)
Transposition flap sutured in place.
Complex wound is closed without tension
on eyelid and minimal risk of disrupting
the normal anatomy. (D) Secondary
defect healed by second intention.

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Part 2  Essential Surgical Skills
New Brunswick, NJ) and Dermagraft (Smith & Nephew plc,
London, UK). Successful use of these tissue equivalents for
both burn wound closure and surgical wound reconstruction is
widely reported.15–17 Although these skin equivalents are only
temporary tissue grafts, they do aid in accelerating wound
closure and decreasing postoperative pain (see also Chapter 8).
Suspension sutures
Dermatologic surgeons are often faced with the challenge of
reapproximating large tissue defects, either as the result of
tumor extirpation or to enhance the natural facial contour.
These situations often require closure of wounds where large
opposing vector forces are present. This high tension across
the wound, if not properly dealt with, can lead to scar spread-
ing or wound dehiscence and an unsightly outcome. A second
challenge for the surgeon is to maintain or recreate natural
demarcations along cosmetic subunits. Maintaining these
natural boundaries is paramount for re-establishing the sym-
metry of the face and for creating a natural appearance. The
use of deep anchoring sutures, tacking, or suspension sutures
is an effective means of offsetting these opposing vector
forces and achieving the desired outcome. Suspension sutures
are placed between the deep fascia or periosteum and the
overlying dermis and provide fixation to a static structural
support, thus preventing migration or slippage of the closure.
The anatomic location of these anchoring points and their use
in facial reconstructive surgery are well documented in the
dermatology literature (Fig. 14.4).18–22
Preauricular
region
Bone anchoring points for suspension sutures
Figure 14.4  Bone anchoring points for suspension sutures.
Bone anchoring points are shown in blue.
Epidermis
Dermis
Subcutaneous fat
Muscle
Periosteum
Bone
1
2
3
Suspension suture placement technique
Figure 14.5  Suspension suture placement. (Adapted from J
Dermatol Surg Oncol 1987;13(9):973–978.)
Basic technique
The basic technique utilizes a buried suture passing between
the leading edge of the wound and an underlying fixation
point. The first throw of the needle is an inverted pass placed
approximately 5–7 mm from the wound edge that is under
the greatest tension. This pass should be placed through
the reticular dermis such that a stable bite is obtained and so
that no slippage occurs. Too superficial a pass will cause
dimpling of the overlying skin and an undesirable outcome.
The second throw of the needle passes through the deep
subcutaneous tissue at the position of the desired point of
wound closure. The needle is advanced until its point con-
tacts bone, at which time it is then reversed and redirected
in a slightly more superficial plane to catch a substantial bite
of periosteum and deep tissues. The surgeon then rotates the
needle through its remaining radius exiting the deep tissue.
The suture is then tightened such that the wound edge is
advanced into the appropriate position for closure (Fig. 14.5).
Because this second pass proceeds blindly through deeper
tissue structures, it is emphasized that the surgeon must have
a solid understanding of the local anatomy to avoid injury to
neurovascular structures that may lie in these deep tissue
planes. The simple act of anchoring the advancing edge of a
skin flap to the underlying periosteum, tendons, and fascia
will advance tissue to fill the surgical defect and remove
tension from the wound edge. Furthermore, with proper
closing tension, a deep tacking suture can even be used to
create a downward force that inverts tissue to recreate a
natural skin fold.
Regional applications of suspension sutures
Forehead
The forehead and eyebrow region of the human face is pri-
marily under the control of the frontalis and orbicularis oculi
muscles and the overlying SMAS. These structures create a
sling that suspends the overlying skin during periods of rest
and mobilizes the upper face and eyebrows during facial
expression. As such, the position of the eyebrows and upper

217
Chapter 14  Complex Layered Facial Closures
fibers of the orbicularis oculi condense to form thickened
fibrous attachments to the orbital rim. These lateral and
medial canthal tendons provide the primary structural support
for the sphincter function and their relative positioning is
responsible for establishing the canthal angle. The normal
youthful position of the lateral canthal angle places the lower
eyelid in line with the inferior edge of the pupil. Normal aging
or scarring can lead to dehiscence of the lateral canthal
attachments and a downward displacement of the lower lid.
This downward displacement leads to increased scleral show,
a ptotic or tired appearance of the eye and, if excessive, may
cause dysfunction of eyelid closure.
Suspension of the lower eyelid to counteract downward
forces and prevent or correct ectropion can be accomplished
by the placement of a suspension suture at the lateral canthus.
The various techniques and indications for lateral canthopexy
have been reviewed recently by McCord et al.28 Lateral can-
thopexy is accomplished by attaching single or multiple sus-
pension sutures from the conjoined tendon of the lower lid
traveling superiorly and laterally to anchor in to the perios-
teum of the inner aspect of the orbital rim (Fig. 14.6). Suture
tension is then set to align the lower lid with the inferior edge
of the pupil. The net effect of this suspension is to create an
upward and lateral pull on the lower eyelid that re-establishes
the normal youthful position of the lower lid. This suture also
provides anchoring of the lid to the orbital rim so that func-
tional eyelid closure is re-established.
Mid-face and preauricular zone
The anatomy of this area has received a great deal of attention
mostly because of the focus on enhancing and maintaining
the youthful appearance of the face. The mid-face is bounded
by the zygomatic arch superiorly, the preauricular area later-
ally, the mandible inferiorly, and the melolabial junction and
nose medially. The malar eminence along with the zygomatic
arch forms the major structural component of the mid-face
and forms the basis for the cosmetic subunit of the cheek.
The structure of the cheek is further defined by a prominent
malar fat pad which overlies the zygoma and whose position
eyelids is a direct result of the joint action of these struc-
tures.23 A compromised frontalis muscle resulting from tem-
poral branch disruption, facial nerve palsy, or a relaxed SMAS
secondary to the natural course of aging, results in a ptotic
brow and a drooping eyebrow and upper eyelid. Temporal
nerve disruption occurring after tumor excision creates an
asymmetry compared to the normal contralateral face and, in
severe cases, may obstruct normal vision. An aged ptotic brow
creates bilateral sagging and gives the patient a sleepy, tired
appearance. Each of these scenarios results from downward
gravitational forces acting on the brow and are common pres-
entations to the cutaneous surgeon. Surgical intervention
with a brow lift is required for correction of the abnormality.
Many different techniques have been devised to lift the
brow and range from a simple elliptical skin excision to endo-
scopic procedures or a coronal incision brow lift.24–26 Although
these procedures differ significantly in their degree of diffi-
culty, they all employ the use of single or multiple suspension
sutures as a unifying concept to elevate and resuspend the
ptotic brow. Rafaty et al.24 described a direct brow lift in
1975 performed through a simple elliptical excision of skin
placed just above the eyebrow. Although designed as a simple
procedure, these authors do recognize the need to offset
gravitational forces to prevent scar stretching and wound
dehiscence. They describe the use of multiple non-absorbable
suspension sutures anchoring eyebrow skin superiorly to the
frontalis fascia and periosteum of the forehead. The net
effect of these suspension sutures is to create an upward pull
on the eyebrow and to reset the position of the eyebrow and
upper eyelid. Erol et al.27 described a minimally invasive
technique for applying suspension sutures to correct brow
ptosis. This technique introduces multiple suspension sutures
through small stab incisions placed at the temporal hairline
and at the orbital rim to provide excellent lifting of the ptotic
brow with limited scarring.
Lower eyelid
The thin skin of the lower eyelid makes it exquisitely sensi-
tive to deformities resulting from aberrant tension forces.
Several situations exist that may alter the normal vector
forces upon the eyelid. Abnormal forces can result from
increased directional tension secondary to wound contracture
following tumor excision on the cheek or eyelid or may occur
following lower lid blepharoplasty or laser rhytidectomy. Fur-
thermore, gravitational pull resulting from natural changes in
the aging face will also lead to increased downward or infe-
rolateral forces on the lower lid. Each of these situations may
lead to lid eversion and downward migration with a resultant
ectropion and sequela of a dry eye. Of these, scar contraction
is probably the most common concern for the cutaneous
oncologic surgeon. The potential for cicatricial ectropion
must always be considered when operating on the upper
cheek and eyelid. Incisions and subsequent repairs in this area
must be planned carefully to avoid these complications. In
the same manner, the cosmetic surgeon is consulted fre-
quently for correction of a lower lid ptosis or sagging lateral
canthal angle and specific surgical techniques must be
employed to offset these altered forces and to achieve the
desired outcome.
The orbicularis oculi muscle forms a sphincter overlying the
orbit. Its fibers attach to the superior orbital rim and inter-
digitate with the frontalis muscle. Laterally and medially the
Lateral canthus
Orbital rim
1
2
3
4
Lateral canthopexy/canthoplasty
Figure 14.6  Lateral canthopexy. Horizontal mattress sutures
are placed between the lateral canthal tendon and the
periosteum of the orbital rim. The tension created by the suture
creates an upward and lateral repositioning of the lower eyelid.

218
Part 2  Essential Surgical Skills
concern for damage to the facial nerve since its course in the
preauricular area lies within the body of the parotid gland.
Once the skin flap is raised and the SMAS exposed, one of
two techniques, plication or imbrication of the SMAS, is
performed to mobilize and tighten the mid-facial structures.33
Imbrication involves excising the redundant SMAS followed
by suturing the two free ends together. This technique carries
with it a risk of injury to the underlying facial nerve and thus
the alternative method of plicating the SMAS has become
more common. Plication of the SMAS is accomplished by
placing a series of interrupted suspension sutures from the
SMAS overlying the cheek passing superiorly and posteriorly
in a 45° direction to the deep temporal or preauricular fascia
(Fig. 14.8). The sutures are tightened, causing an upward
mobilization and suspension of the SMAS and facial struc-
tures. By elevating the SMAS and securing it to the fixed
structural support of the preauricular fascia, all of the tension
is transferred to the static bony structures of the face, allevi-
ating tension on the overlying cutaneous flap. This prevents
tension across the incision line and avoids scar stretching and
the possibility of dehiscence. Moreover, it accomplishes the
goal of tightening the facial skin to correct jowling and better
define the contour along the jaw.
The same principles of SMAS suspension are extremely
useful for closure of preauricular or cheek defects under high
tension. Reconstruction of large defects in the mid-face
requires the mobilization of tissue flaps to cover the defect.
These are most often accomplished using cervicofacial rota-
tion or transposition flaps with the lower face and neck as
the tissue reservoir.34 Despite wide undermining, these flaps
still retain a high degree of oppositional tension that must
be offset to achieve a successful closure. This tension can
be attenuated by stable anchorage to the preauricular fascia
much in the same manner as described with a face-lift pro-
cedure. Placement of suspension sutures from the flap to
the preauricular fascia or periosteum of the orbital rim will
advance the flap into the primary defect, will alleviate
tension from the wound edge and, if properly placed, can
aid in recreating the normal contour of the cheek. Addition-
ally, in the case of a large cervicofacial rotation flap, this
suspension technique has the added benefit of redirecting
tension forces in the superolateral direction such that a
downward pull on the lower eyelid and the potential for
ectropion are avoided. The use of SMAS plication is appli-
cable even for small elliptical incisions along the preauricular
zone. With the removal of small amounts of tissue, this area
may be subject to closure against high tension. Placement of
one or two plicating sutures in the preauricular SMAS will
help to approximate the wound edges and reduce tension
across the defect (Fig. 14.9).
Recently, several minimally invasive cosmetic procedures
that utilize suspension sutures for repositioning the malar
fat pad and redefining the mid-facial contour have been
described.35–39 Terms such as the mid-face lift, the puppet
face lift, or suborbicularis oculi fat (SOOF) lift have been
coined for these various procedures. The basic technique
employed in a mid-face suspension lift is the percutaneous
introduction of multiple suspension sutures at the nasolabial
fold, which then tunnel superiorly in a subcutaneous plane
toward the zygomatic arch or orbital rim. The positioning of
these sutures encompasses the malar fat pad and the soft
tissues of the cheek, incorporating them into a sling that
can then be suspended from a more cephalad fixation point
is maintained by the collective contributions of the overlying
SMAS and several musculocutaneous ligaments.4,5 Through
the natural process of aging, the skin loses elasticity and suc-
cumbs to the forces of gravity and repetitive motion of the
facial muscles. Additionally, the malar fat pad begins a down-
ward migration that further accentuates the nasolabial fold
and jowling. This downward migration creates a hollowed
atrophic appearance in the superior aspect of the cheek and
a prominent nasojugal fold. The net result of these processes
is the formation of jowls, the accentuation of skin lines, and
an overall aged appearance to the face.
These dramatic changes and the associated stigmata of an
aged appearance cause many patients to seek surgical correc-
tion in an effort to regain their lost youthful appearance. In
the practice of cutaneous oncology, surgeons are often faced
with the challenge of reconstructing the normal contour of
the cheek following the excision of large tumors. To meet
these challenges, surgeons have developed techniques that
involve raising cutaneous flaps and repositioning the tissue to
restore the pre-existing state. These procedures employ
various suspension techniques to tighten the preauricular skin
and recreate the malar prominence and nasolabial crease to
restore definition to the cheek.
The face lift or rhytidectomy is the hallmark procedure for
repositioning the mid-face and has undergone many modifica-
tions over the years in an effort to perfect this aim. The face
lift and the S-lift are two similar procedures that are com-
monly performed to tighten the mid-face and jawline in an
effort to restore the youthful anatomy of the face (see also
Chapters 37 and 38).29–32 Although there are significant tech-
nical distinctions between these two procedures, for the
purpose of this chapter they will be considered as one method
with attention focused upon the preauricular and cheek area.
A preauricular incision is made and continued inferiorly
around the earlobe into the postauricular area. Next, working
in a subcutaneous plane, a skin flap is developed that has the
SMAS as its floor and the subcutaneous fat and skin as the
roof (Fig. 14.7). This flap can be developed safely without
Figure 14.7  SMAS flap during facial rhytidectomy. The skin flap
is dissected from the underlying SMAS. The SMAS is the floor
of the wound and the subcutaneous fat and skin are the roof
over the cavity.

219
Chapter 14  Complex Layered Facial Closures
A
Subcutaneous
musculoaponeurotic
system (SMAS)
Plication of the superficial
musculoaponeurotic system
B
Figure 14.8  Plication of the SMAS. (A) A series of suspension sutures plicate the SMAS and create lift during rhytidectomy. Sutures
are placed at a 45° angle. (B) The technique of placing suspension sutures in the SMAS and anchoring this to the preauricular fascia.
A
B
C
Figure 14.9  Preauricular suspension sutures in wound closure.
(A) Direct closure of this wound would create sufficient tension
as to risk wound dehiscence and flap necrosis. (B) SMAS
plication by suspension sutures anchoring the SMAS to the
preauricular fascia. Tightening the suture advances the skin flap
into the defect. (C) After placing a series of SMAS plication
sutures, the flap is advanced into the wound and tension is
reduced.

220
Part 2  Essential Surgical Skills
the medial aspect of the maxilla. The knot is next tightened
to the appropriate tension such that the newly created nasola-
bial fold is symmetrical with the contralateral face. The sus-
pension suture transfers tension to the periosteum so that
tension across the scar line and the risk of dehiscence or scar
spreading are minimized.
Other sites where this basic technique of utilizing suspen-
sion or tacking sutures to recreate natural skin folds and lines
of demarcation include the alar crease and the mental crease.
These are critical lines of demarcation that separate major
cosmetic subunits and, as such, are landmarks that must be
preserved to restore the natural appearance. Facial recon-
struction of tumor defects by mobilization of skin flaps into
these regions will be enhanced greatly by first placing a
tacking suture to the underlying periosteum. This tacking
suture or suspension suture will redefine the cosmetic subunit,
appropriately position the tissue flap, and eliminate tension
across the flap that can lead to tenting of the flap and distor-
tion of the subunit.
 POSTOPERATIVE CARE
Surgical tapes across the wound minimize mobility and
tension in the postoperative period.
 OPTIMIZING OUTCOMES
such as the deep temporal fascia, the zygomatic arch, or the
orbital rim (Fig. 14.10). Tension placed upon these sutures
results in elevation and repositioning of the malar fat pad in
a superior direction to its normal youthful location to restore
the natural contour of the mid-face.
Nasolabial junction
The natural concavity that exists at the nasolabial junction is
a defining landmark between two cosmetic facial subunits.
Preservation of this landmark is essential for maintaining
facial symmetry and normal contour. Reconstruction of a
medial cheek or low nasal sidewall defect often requires
advancement of tissue from the cheek to perform the repair.
The cheek advancement flap is an excellent option for this
repair because it provides a large reservoir of tissue for wound
closure and the incision lines of the flap are easily disguised
within the natural skin folds. However, in the process of
elevating a cheek flap and mobilizing it medially, the loss of
deep tissue connections combined with the retrograde tension
forces on the flap will cause tenting of the tissue (Fig. 14.11).
If not properly addressed, healing in this manner will cause
blunting of the melolabial fold and a resultant asymmetry.
This situation is a classic example of where a tacking or sus-
pension suture can be used to recreate a natural skin fold. A
single absorbable (Vicryl or Dexon) suture is placed through
the reticular dermis of the advancing skin flap at a position
that coincides with the point of maximum concavity of the
repositioned tissue, the nasolabial fold. The second pass of
the suture is then anchored to the underlying periosteum at
Malar fat pad
Nasolabial
fold
Mid-face suspension lift
Figure 14.10  Mid-face suspension lifting sutures. This
minimally invasive procedure elevates the malar fat pad and
rejuvenates the mid-face with percutaneous placement of a
series of suspension sutures. (Adapted from Arch Facial Plast
Surg 2002;4(1):20–25.)
Figure 14.11  Cheek advancement flap. (A–B) Cheek
advancement flap without the use of suspension sutures.
(A) Arrow shows the area of tenting created by pulling the
cheek skin directly across the concave junction of the nose
and the cheek. (B) Closure without tacking the flap. The depth
of the nasofacial sulcus leaves the flap elevated with blunting of
the sulcus and a potential dead space for a seroma to develop.
(C–D) Cheek advancement flap with suspension suture used to
place the flap into the concave junction of the nasofacial sulcus.
(E–F) The placement of tension on the suspension suture can
be varied. When placed too far superior and with too much
tension, the suspension suture elevates the flap, raises the lip,
and distorts the oral commissure. (Adapted from J Dermatol
Surg Oncol 1987;13(9):973–978.)
Optimizing outcomes
 Plan a reconstruction to fall within the boundaries between
cosmetic units.
 Excise extra tissue so the incision can be placed at the
boundary.
 Suture precisely to evert wound edges with minimal tension.
 Use vertical mattress sutures in wounds under tension for the
areas of high mobility.
 For wounds with minimal tension and lower mobility that may
have the suture in place for an extended period, use a
running subcuticular suture to avoid suture marks.
 Use suspension sutures to minimize tenting of flaps across
natural concavities.

221
Chapter 14  Complex Layered Facial Closures
A
B
C
D
E
F
Cheek advancement flap

222
Part 2  Essential Surgical Skills
planning of wound closure begins with a firm understanding
of these physical properties and their subtle regional varia-
tions across different anatomic subunits.
When assessing options for wound closure, a variety of
techniques should always be considered. Tissue flaps, skin
grafts, primary closure, and healing by second intention can
all be excellent options in specific settings. When planning
the closure of complex wounds, one should always consider
the use of combinations of flaps, grafts, and second intention
healing. The use of suspension sutures to stabilize tissue
against opposing vector forces is a valuable technique for both
reconstructing surgical defects as well as for use in various
cosmetic enhancement procedures. When selecting the most
appropriate closure for a particular defect, the surgeon should
consider multiple options and utilize either single or com-
bined techniques tailored to meet the specific challenges and
requirements to achieve optimal results.
 REFERENCES
1. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS)
in the parotid and cheek area. Plast Reconstr Surg 1976;58:80–88.
2. Dzubow LM, Zack L. The principle of cosmetic junctions as applied to
reconstruction of defects following Mohs surgery. J Dermatol Surg Oncol
1990;16:353–355.
3. Barton FE, Gyimesi IM. Anatomy of the nasolabial fold. Plast Reconstr
Surg 1997;100:1276–1279.
4. Ozdemir R, Kilinc H, Unlu RE, et al. Anatomicohistologic study of the
retaining ligaments of the face and use in face lift: retaining ligament
correction and SMAS plication. Plast Reconstr Surg 2002;110:
1134–1147.
5. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the mid-
cheek and malar mounds. Plast Reconstr Surg 2002;110:885–895.
6. Wilhelmi BJ, Blackwell SJ, Mancoll JS, et al. Creep vs. stretch: a review
of the viscoelastic properties of skin. Ann Plast Surg 1998;41:215–
219.
7. Larrabee WF. A finite element model of skin deformation. I. Biomechan-
ics of skin and soft tissue: a review. Laryngoscope 1986;96:399–405.
8. Larrabee WF, Sutton D. A finite element model of skin deformation. II.
Experimental model of skin deformation. Laryngoscope 1986;96:
406–412.
9. Larrabee WF, Galt JA. A finite element model of skin deformation. III.
The finite element model. Laryngoscope 1986;96:413–419.
10. Juri J. Use of parieto-occipital flaps in the surgical treatment of baldness.
Plast Reconstr Surg 1975;55:456–460.
11. Juri J, Juri C, Arufe HG. Use of rotation scalp flaps for treatment of
occipital baldness. Plast Reconstr Surg 1978;61:23–26.
12. Orticochea M. Four flap scalp reconstruction technique. Br J Plast Surg
1967;20:159–171.
13. Orticochea M. New three-flap scalp reconstruction technique. Br J Plast
Surg 1971;24:184–188.
14. Zitelli JA. Wound healing by secondary intention. J Am Acad Dermatol
1983;9:407–415.
15. Eaglestein WH, Iriondo M, Laszlo K. A composite skin substitute (Graft-
skin) for surgical wounds. Dermatol Surg 1995;21:839–843.
16. Moiemen NS, Staiano JJ, Ojeh NO, et al. Reconstructive surgery with a
dermal regeneration template: clinical and histologic study. Plast Recon-
str Surg 2001;108:93–103.
17. Prystowsky JH, Siegel DM, Ascherman JA. Artifical skin for closure of
wounds created by skin cancer excisions. Dermatol Surg 2001;27:
648–654.
18. Salasche SJ, Jarchow R, Feldman BD, et al. The suspension suture. J
Dermatol Surg Oncol 1987;13:973–978.
19. Dzubow LM. The use of fascial plication to facilitate wound closure
following microscopically controlled surgery. J Dermatol Surg Oncol
1989;15:1063–1066.
20. Zitelli JA. Tips for wound closure: pearls for minimizing dog-ears and
applications of periosteal sutures. Dermatol Clin 1989;7:123–128.
21. Robinson JK. Suspension sutures aid facial reconstruction. Derm Surg
1999;25:189–194.
22. Robinson JK. Suspension sutures in facial reconstruction. Derm Surg
2003;29:386–393.
23. Knize DM. An anatomically based study of the mechanism of eyebrow
ptosis. Plast Reconstr Surg 1996;97:1321–1333.
 SUMMARY
Human skin is an elastic and malleable structural unit that
allows the reconstructive surgeon the ability to manipulate
these properties to fashion flaps and grafts for the closure of
surgical defects. The skin on the human face has distinct
regional variations that reflect the specific composition of the
underlying tissue and bony layers. Careful attention should
be paid to these distinct subunits, not only for preservation
of aesthetic appearances but also for planning appropriate
closures. Each region has its own specific physical properties
(i.e. variable thickness, stretch, and texture) that must be
matched or maintained to achieve optimal results. Successful
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 Incisions crossing lines of demarcation between geometric
units disrupt the natural contour and facial symmetry.
 Functional skin biomechanics – closure of wounds under
high tension can result in poor wound reapproximation,
scar spreading, or wound dehiscence unless appropriate
techniques are utilized. Skin is elastic and ‘stretchable’ and
thus allows for intraoperative or delayed tissue expansion to
assist in wound closure.
 Basic techniques of wound closure – the deep layer sutures
are critical for reapproximating wound margins. Failure to
achieve adequate wound eversion with deep layer sutures can
lead to a widened and depressed scar with poor cosmesis.
 Epidermal sutures – securing the knots of epidermal sutures
with the appropriate tension is crucial for achieving quality
cosmetic results: a knot that is too loose can lead to poor
wound reapproximation; one that is anchored too tight will
constrict tissue and lead to permanent ‘railroad tracking’
on the skin surface. The surgeon must allow for local tissue
edema during healing that may further contribute to tissue
constriction when calculating the appropriate tension of the
knots.
 Complex closures – many postoperative wounds are
challenging to repair because available tissue reservoirs are
limited and attempts to close these wounds using a single
flap or graft can lead to an undesirable cosmetic outcome or
can cause deformities in adjacent anatomic structures. These
complex wounds are best repaired using a combination of
techniques to restore the natural appearance of the tissue
subunits.
 Mid-face and preauricular zone – suspension of the cheek
tissue during a face-lift procedure or a cervicofacial rotation
flap for reconstruction is integral for restoring the natural
appearance, and achieving the appropriate suture tension is
critical for achieving the desired results. A suture placed too
loose will result in a failed procedure; alternatively, too much
tension can lead to dimpling of the skin flap, focal tissue
necrosis, and a poor cosmetic outcome.
 Nasolabial junction – mobilizing tissue across a surface
concavity can lead to blunting of the normal anatomy
unless specific techniques are used to redefine the natural
appearance. Suspension or tacking sutures are ideal for
achieving this goal. Anchoring the tissue flap to the underlying
periosteum will recreate the natural concavity and will help
advance the tissue flap into position.

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Chapter 14  Complex Layered Facial Closures
32. Duminy F, Hudson DA. The mini rhytidectomy. Aesth Plast Surg
1997;21:280–284.
33. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS plica-
tion with SMAS imbrication in face lifting. Laryngoscope 1982;92:
901–912.
34. Herbst, AM, Benedetto AV. The use of spanning suspension suture in
facial reconstruction. Dermatol Surg 2002;28:337–339.
35. Gunter JP, Hackney FL. A simplified transblepharoplasty subperiosteal
cheek lift. Plast Reconstr Surg 1999;103:2029–2035.
36. Olver JM. Raising the suborbicularis oculi fat (SOOF): its role in chronic
facial palsy. Br J Ophthalmol 2000;84:1401–1406.
37. Keller GS, Namazie A, Blackwell K, et al. Elevation of the malar fat pad
with a percutaneous technique. Arch Facial Plast Surg 2002;4:20–25.
38. Sasaki GH, Cohen AT. Meloplication of the malar fat pads by percutane-
ous cable-suture technique for midface rejuvenation: outcome study (392
cases, 6 years’ experience). Plast Reconstr Surg 2002;110:635–654.
39. Yousif NJ, Matloub H, Summers AN. The midface sling: a new tech-
nique to rejuvenate the midface. Plast Reconstr Surg 2002;110:
1541–1553.
24. Rafaty RF, Goode RL, Fee WE. The brow-lift operation. Arch Otolaryn-
gol 1975;101:467–468.
25. Costantino PD, Hiltzik DH, Moche J, et al. Minimally invasive brow
suspension for facial paralysis. Arch Facial Plast Surg 2003;5:171–174.
26. Knize DM. Limited incision foreheadplasty. Plast Reconstr Surg 1999;
103:271–284.
27. Erol OO, Sozer SO, Velidedeoglu HV. Brow suspension, a minimally
invasive technique in facial rejuvenation. Plast Reconstr Surg 2002;109:
2521–2532.
28. McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring. Plast
Reconstr Surg 2003;112:222–236.
29. Fulton JE, Saylan Z, Helton P, et al. The S-lift facelift featuring the
U-suture and O-suture combined with skin resurfacing. Derm Surg
2001;27:18–22.
30. Saylan Z. The S-lift for facial rejuvenation. Int J Cosmet Surg 1999;
7:18–23.
31. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial sus­
pension lift: a modified S-lift. Plast Reconstr Surg 2002;109:2074–
2086.

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225
15
Hemostasis
Tri H Nguyen MD FACMS FACPh and Quenby L Erickson DO
Summary box
 Physiologic hemostasis occurs in three interrelated phases:
initiation (thrombin formation), amplification (platelet
aggregation and activation), and propagation (fibrin formation
and clot stabilization).
 A focused preoperative history is the most valuable way to
screen for patients at higher risk of bleeding.
 In general, anticoagulation prescribed for secondary
thrombotic prophylaxis should not be discontinued for
dermatologic surgery procedures.
 Optimizing anesthesia, and alleviating anxiety and situational
hypertension, will significantly reduce the risk of perioperative
bleeding.
 Some physiologic hemostatic agents have benefits beyond
hemostasis and may promote wound healing and skin graft
survival.
 Electrosurgery and suture ligation for hemostasis should be
precise to minimize excessive collateral tissue injury.
 INTRODUCTION
Hemostasis is defined as the arrest of bleeding through phys-
iologic or surgical intervention. Inadequate hemostasis will
compromise even the most meticulous of techniques, leading
to intra- and postoperative bleeding and the terrible tetrad of
hematoma, dehiscence, necrosis, and infection. Historically,
dermatologists have had few difficulties with surgical bleed-
ing because procedures were often small and limited to biop-
sies, excisions, and closures of simple defects. As dermatologic
surgery has evolved, however, cutaneous surgeons increas-
ingly perform complex procedures and encounter intricate
medical issues and medications in their patients. Achieving
adequate hemostasis requires careful evaluation and manage-
ment of these issues throughout the perioperative period.
 PREOPERATIVE PREPARATION
Hemostatic process
A basic knowledge of physiologic hemostasis is helpful in
understanding newer anticoagulants and in using hemostatic
agents. The coagulation process is a highly evolved system
that involves the interactions of endothelial cells, coagulation
factors (Factors I–XIII), and platelets. Precipitating this
process is endothelial injury (i.e. incision), which exposes
collagen and tissue factor (TF) in subendothelial fibroblasts.
Traditionally, the coagulation cascade was described as two
separate reactions – the intrinsic and extrinsic pathways –
which converged into a common pathway. This model evolved
from in-vitro studies of clotting, but is not consistent with
in-vivo observations. A deficiency of Factor XII (intrinsic
pathway), for example, markedly prolongs activated partial
thromboplastin time, but there is no clinical bleeding. A
newer perspective on coagulation depicts three phases of
hemostasis; initiation, amplification, and propagation.1
Initiation (thrombin formation)
This phase begins with endothelial injury and TF exposure.
Exposed TF binds to circulating Factor VII and activates it
(VIIa). This TF-VIIa complex then activates Factor X and
Factor IX, generating small amounts of thrombin (Factor II).
Amplification (platelet aggregation
and activation)
Platelets serve four functions: they adhere to sites of endothe-
lial injury; store essential clotting cofactors (Factors V, VIII);
aggregate with other platelets to form a primary clot; and
provide a surface for coagulation reactions.
Platelet aggregation begins when circulating von Willebrand
factor (vWF) detects and binds to exposed endothelial col-
lagen. vWF then serves as a glue to attract platelets to the
endothelial wound. This early platelet plug is unstable, is not
sufficient for hemostasis, and must be stabilized by fibrin in
the third stage.
Thrombin, produced during the initiation phase, activates
aggregated platelets. Once activated, the platelet enzymes
cyclo-oxygenase and thromboxane synthase generate throm-
boxane A2, which stimulates the release of clotting cofactors
(adenosine diphosphate (ADP), Factor V, Factor VIII) from
its granules. Factors V and VIII serve as cofactors for further
production of Factor X and thrombin.
Propagation (fibrin formation and stabilization
of the platelet clot)
In this final phase, thrombin (now present in increasing quan-
tities) converts soluble fibrinogen into an insoluble fibrin
meshwork, which is polymerized and stabilized by Factor
XIII and calcium. It is this firm fibrin network that stabilizes

226
Part 2  Essential Surgical Skills
other hand, bleed from mucocutaneous surfaces. A variety of
disorders may impair hemostasis and are listed in Table 15.2.
vWD is the most common inherited bleeding disorder,
affecting up to 1% of the population. Affected individuals
are most challenging to diagnose because symptoms are quite
variable and vWF levels vary with exercise, stress, and even
blood type. Symptoms may be mild and never manifest if
patients have never had surgery. vWF not only facilitates
platelet aggregation but also acts as a carrier for Factor VIII,
protecting it from premature destruction. Consequently,
people with vWD have platelet-type bleeding (mucocutane-
ous) and may also have abnormalities in Factor VIII.4 Patients
with known or suspected vWD are best referred to hema-
tologists for management in the perioperative period.
Thrombocytopenia is rarely an issue for cutaneous surgeons.
Platelets serve as the primary hemostatic plug as well as the
focus of many hemostatic reactions. Abnormalities may be in
the quality and/or quantity of platelets. Platelet function may
be affected by medications, which usually impair the ampli-
fication phase of hemostasis (Table 15.3). Moderate throm-
bocytopenia (50 000–100 000) should not affect hemostasis
in cutaneous surgery. Even counts of 20 000–50 000 may be
acceptable if patients do not have clinical signs and symptoms
of bleeding (i.e. large bruising, petechiae, gingival bleeding),
and if complex reconstruction (interpolation flaps or bone
or cartilage grafting) is not anticipated. Levels below 20 000,
or clinically excessive bleeding regardless of levels, should
warrant caution and consultation with a hematologist.
the early platelet clot and secures the arrest of bleeding.
Calcium is essential throughout these reactions by helping
proteins bind to surfaces. Overall, the final hemostatic plug
derives 55% of its strength from platelets and 45% from the
fibrin network.2
Evaluation
A focused history is the most useful way to screen for patients
with bleeding tendencies. The preoperative evaluation should
concentrate on identifying underlying disorders and medica-
tions that may increase surgical bleeding. Inquiries must be
specific to be informative because one-third of patients with
von Willebrand disease (vWD) deny a bleeding diathesis.3
Bleeding in coagulation disorders is excessive for the injury,
prolonged, and recurrent. Physicians may consider these
three strategic questions as they interview their patients: Is
there prolonged bleeding? Is the bleeding consistent with
platelet or coagulation factor abnormalities? Is it an acquired
or inherited condition?
Physicians may enhance the specificity of positive responses
by clarifying the severity and frequency of symptoms. Table
15.1 lists useful questions for eliciting a bleeding history.
Patients with coagulation factor disorders (hemophilia) have
prolonged surgical bleeding and hemorrhage deeply into
muscles and joints. These patients usually have an established
personal and family history of bleeding and are easily identi-
fied. Patients with vWD and platelet abnormalities, on the
Table 15.1  Interview questions for bleeding history
General questions
Have you ever had prolonged bleeding
after surgery?
Have you required transfusions after
surgery?
Women
Do your periods last longer than 7 days?
Is your menstrual flow heavy for 3 days
or more?
Have you ever had anemia or required
iron supplements as a result of
menstrual bleeding?
Have you ever needed transfusions
after childbirth because of excessive
bleeding?
Coagulation factor
abnormalities (delayed
bleeding and deep
hemorrhage into joints
and muscles)
Have you ever had delayed bleeding
after surgery (>3 days postoperatively)?
Do you have a family history of bleeding
problems?
Have you ever bled into joints or
muscles? (coagulation factor deficiency)
Platelet-type bleeding
(mucocutaneous
bleeding)
Have you had bleeding after dental
surgery?
Did the bleeding require stitching or
packing?
Did the bleeding occur immediately or
the next day?
Have you ever had a nosebleed? If so,
how frequent are they and do they ever
require emergency or hospital care?
Do you have excessive bruising (>5 cm,
truncal locations, absence of injury)?
Table 15.2  Common disorders affecting hemostasis4,5
DISORDERS
COMMENT*
Disorders affecting platelets
Severe renal disease
Uremia may impair platelet function
Heparin considerations with dialysis
Immune
thrombocytopenia
Antibody-mediated platelet destruction
Splenomegaly
Platelet sequestration
Bone marrow failure
Platelet production problem
vWD
Type 1 (70–80%): low levels of vWF and
Factor VIII
Type 2a: abnormal vWF protein, levels
normal
Type 2b: vWF ‘hyperactivity,’ causing
platelet aggregation without endothelial
injury; mild thrombocytopenia
Type 3: Homozygous deletion; zero levels
vWF and Factor VIII; deep joint bleeding
similar to hemophilia
Disorders affecting clotting factors
Severe hepatic
insufficiency
Impaired synthesis of vitamin
K-dependent clotting factors
Alcoholism (liver,
vasodilatation)
Hepatic insufficiency
Direct vasodilator
Vitamin K deficiency
Clotting Factors II, VII, IX, X
Hemophilia A
Factor VIII deficiency
Hemophilia B
Factor IX deficiency
*Bleeding time is not predictive of bleeding risk for any condition; some disorders
may affect both platelets and coagulation factors.

227
Chapter 15  Hemostasis
transfusion or surgical intervention, and functional
compromise.
• Type 3 – minor bleed where the outcome is not
affected but requires additional physician visits or
non-surgical intervention (e.g. compression).
In dermatologic surgery, type 1 and 2 events are extremely
rare. The consequences of thrombotic events (stroke, myo-
cardial infarction, pulmonary embolus) with discontinuation
of anticoagulants, however, are devastating. For most cutane-
ous procedures, medically necessary anticoagulation (for sec-
ondary prevention of previous thrombotic events) should not
be discontinued perioperatively. Supporting this position are
data from recent studies that emphasize four key points:
1. The risk of any complications with dermatologic surgery
is already low.6
Medications and agents
impairing hemostasis
Increasingly, patients present with complex anticoagulation
regimens. Even non-prescription medications and herbal and
vitamin supplements may impair hemostasis. These agents
and their potential effects are reviewed in Table 15.3. A
continuing controversy among dermatologic surgeons is
whether anticoagulation should be discontinued before
surgery (see Chapter 5). The sequelae of bleeding complica-
tions can be serious and may be divided into three types:
• Type 1 – life-threatening bleeds that result in
intracranial, cardiac, or airway compromise (e.g.
expanding cervical hematoma after neck liposuction).
• Type 2 – major (not life-threatening but serious) bleed
resulting in a reduction of hematocrit, a need for
Table 15.3  Oral medications and supplements affecting hemostasis
MEDICATION
MECHANISM OF ACTION
COMMENT
Platelet inhibition
Aspirin
Irreversible inhibition of cyclo-oxygenase, affecting
platelet release of clotting cofactors
Discontinue 10–14 days preoperatively
Non-steroidal anti-
inflammatory drugs
Reversible inhibition of cyclo-oxygenase
Variable, depending on specific drug (usually 2–3 days
preoperatively)
Clopidogrel (Plavix)
Oral inhibitor of platelet aggregation and
adhesion. Also inhibits fibrinogen binding to
platelets
Discontinue 5 days preoperatively
Ticlopidine (Ticlid)
Oral inhibitor of platelet and adhesion. Also
inhibits fibrinogen binding to platelets
Discontinue 10–14 days preoperatively
Prasugrel (Effient)
Same mechanism and class as clopidogrel and
ticlopinine; currently under FDA review
Dipyridamole
(Persantin)
Phosphodiesterase inhibitor with mild vasodilatory
and antiplatelet activity
Dipyridamole alone has no clinical effects on hemostasis;
Aggrenox is dipyridamole with 25 mg aspirin and does impair
hemostasis as a result of the aspirin component
Coagulation factor inhibition
Warfarin
Oral vitamin K antagonist (inhibits clotting Factor
II, Factor VII, and Factor IX)
Discontinue 3–4 days preoperatively (lowers the INR to near
normal)
Herbs and supplements – all enhance anticoagulation effects of warfarin; garlic and vitamin E have
additional effects
Feverfew
For migraine headaches, arthritis, rheumatic disease
Fish oil
40% reduction in thrombin production and vitamin
K-dependent coagulation factors accumulate in
periportal areas of the liver
For lowering cholesterol, and arthritis
Garlic
Inhibits platelet aggregation and thromboxane B2
in vitro; enhances fibrinolysis in vivo
For lowering cholesterol, triglycerides, and blood pressure
Ginger
For reducing nausea, vomiting, vertigo
Ginkgo
Affects platelet aggregation in cAMP- and cGMP-
dependent manner
For increasing blood circulation and oxygenation, memory
Ginseng
For increasing physical stamina and mental concentration,
immune function
Dong Quai root
For antispasmodic, anticlotting, laxative, analgesic effects
Bilberry
For diuretic, astringent effects
Chondroitin
For arthritis
Vitamin E
Decreases platelet adhesion; impairs platelet
aggregation only in patients with abnormal
platelets
Mild anticoagulant effect may be significantly increased when
taken with aspirin, garlic
FDA, Food and Drug Administration; INR, international normalized ratio.

228
Part 2  Essential Surgical Skills
2. The risk for major bleeding or complications with
dermatologic surgery is not increased in patients who
are taking aspirin or warfarin.7–9
3. The risk of thrombotic events is substantially elevated in
patients who discontinue their anticoagulation.10,11
4. The severity of real thrombotic events surpasses any
perceived bleeding risk from cutaneous surgery.12
Inferring from these studies that aspirin and warfarin do
not affect hemostasis is incorrect. These agents do impair
the coagulation process. However, any increased bleeding
during cutaneous surgery is negligible and easily controlled
with direct measures (i.e. electrocoagulation and ligation).
Although warfarin may be continued, the INR should not
exceed 3.0 if possible. Despite a general recommendation to
continue anticoagulation, each patient requires an individual-
ized approach. For patients who do not have a history of
thrombotic events, but are taking aspirin and supplements for
primary rather than secondary prevention, discontinuation is
permissible.
 TECHNICAL ASPECTS
General approach to intraoperative bleeding
Despite all precautions, some degree of intraoperative bleed-
ing will occur with any surgery. Beginning surgeons are often
overwhelmed with surgical bleeding. Where do I start? What
do I do first? Do I electrocoagulate or ligate? What do I do if
I cannot see the bleeding vessel? These and other questions
arise simultaneously and cause great anxiety.
Vessels initially spasm and constrict with injury, for example
transection. This is rapidly followed by vasodilatation unless
epinephrine has been used. With profuse bleeding, compres-
sion by an assistant proximal to the bleeding vessels will slow
hemorrhage and allows time to retrieve supplies or rethink
strategies. Pressure may then be slowly released to identify
the offending vessel(s).
At times, bleeding may occur at so many sites as to be
overwhelming. To maintain focus, the bleeding area should
be mentally divided into several quadrants. While compress-
ing the other quadrants, the surgeon may achieve hemostasis
one section at a time. In general, hemostatic efforts should
be directed from arteries to veins, from larger to smaller
vessels, and from superior to inferior or dependent sections
of the wound. Efforts at hemostasis actually begin before the
first incision, with proper patient positioning and effective
anesthesia. The degree of bleeding and wound depth will
influence the specifics of intervention.
Preparing the surgical field
Visibility and accessibility are critical to the effective manage-
ment of intraoperative bleeding. Proper patient positioning
will enhance surgical hemostasis as well as execution of tech-
nique. Lighting should be bright and able to be directed into
the depths of the wound. Gauze, cotton-tipped applicators
(CTAs), and the electrosurgery unit should all be prepared and
ready. Patients should be relatively flat with the surgical plane
at a slight incline (15°). The mild incline will cause any bleed-
ing to drain inferiorly towards the gauze, reducing blood
pooling at the superior end. This permits the surgeon to con-
centrate on hemostasis at the more visible (superior) portion
of the field. If the incline is too steep (>15°) however, then
surgical technique may be compromised because the surgeon’s
wrist or neck is bent into a non-ergonomic position. Anticipat-
ing which sites are more prone to bleeding (i.e. scalp, nose,
ears, lips, and digits) will assist in equipment preparation.
Hemostatic anesthesia
Epinephrine added to injectable local anesthetics provides
vital vasoconstriction in dilutions of 1 : 100 000 or 1 : 200 000.
A more dilute concentration of epinephrine (1 : 1 000 000)
in tumescent anesthesia is also effective and will provide
pronounced and prolonged vasoconstriction. The tumescent
effect (tissue swelling) itself aids hemostasis by temporarily
compressing small vessels. Tumescent anesthesia is ideal for
large reconstruction, liposuction, hair transplantation, and
full-face laser resurfacing.
To maximize the vasoconstrictive effects of epinephrine,
at least 15 minutes should pass before the first incision.
Clinically, a diffuse blanched appearance of the skin usually
reflects effective hemostasis. More concentrated epinephrine
formulations (1 : 2000 dilution) are available and are useful
with mucosal procedures. Topical lidocaine with epinephrine
(TLE – lidocaine 5% plus epinephrine 1 : 2000), for example,
soaked on a dental roll is effective for intranasal hemostasis.
Epinephrine may also be used alone. Packaged as adrenaline,
epinephrine may be diluted and injected to improve hemo­
stasis. Caution is warranted in patients with severe coronary
artery disease because cardiac ischemia may develop with
significant systemic absorption.
Epinephrine has traditionally been avoided at acral sites,
especially the fingers and toes, for fear of ischemic necrosis
or injury. Several studies now refute this dogma and epine-
phrine appears to be safe, at least as a digital block, for fingers
and toes.13,14 To enhance the safety of epinephrine use in the
digits, the following guidelines are offered: epinephrine dilu-
tions should be 1 : 200 000; inject small volumes (1.5 mL or
less per side); avoid circumferential ring blocks; inject as far
as possible from the surgical site; and avoid in patients with
peripheral vascular disease, diabetes mellitus, or vasospastic/
thrombotic conditions.
Intravenous regional anesthesia (IVRA) or the Bier’s block
provides complete anesthesia and profound hemostasis. IVRA
may anesthetize complete regions on the extremities, such as
from the elbow to fingers or from the knee to toes. The
treated extremity is raised for 5–10 minutes to exsanguinate
venous channels. A specialized tourniquet (not a standard
blood pressure cuff) is placed proximal to the treated region
(arm above elbow or thigh above knee) and inflated to
250 mm Hg. Dilute 0.5–1% plain lidocaine is then injected
slowly and intravenously on the dorsal hand or dorsal foot of
the treated limb (the intravenous line having been secured
preoperatively).15 A total lidocaine dose of 3 mg/kg should
not be exceeded. Onset of anesthesia is within 5 minutes and
complete in 15–20 minutes. The entire region, from the
proximal tourniquet to the distal digits, is completely anes-
thetized. The elevated tourniquet tamponades both arteries
and veins and no pulses are felt. A variety of procedures
(excisions and incisions, carbon dioxide laser destruction, and
botulinum toxin injections) may now be carried out in a
bloodless field.16 The limit to IVRA is time because tourni-
quet inflation is limited to 90 minutes. Serious lidocaine
toxicity may develop if lidocaine leakage occurs either during
injection or during cessation of therapy.17 The minimal

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Chapter 15  Hemostasis
These styptic agents are rubbed onto the wound base for a
hemostatic effect with either gauze or a CTA. Wounds should
be dried of blood immediately before application. Aluminum
chloride is the least likely to leave pigment particles, which
may stain the skin, unlike silver nitrate or ferric sulfate.
A number of topical non-caustic hemostatic agents are also
available (Table 15.4). The ingredients of each agent vary
widely as do their origin (plant, bovine, human) and mecha-
nism of action. Although all are relatively absorbable, the
physiologic hemostatics are resorbed most completely.
Physical hemostatics (gelatin sponge, oxidized cellulose,
microfibrillar collagen hemostat) act as a physical mesh onto
which coagulation can occur and are the most practical, as
well as cost-effective, for dermatologic surgery. A physical
hemostat that is readily available to consumers is Urgent QR
powder. QR contains hydrophilic polymers and potassium
salts that form an artificial scab when applied to bleeding
wounds. Because of the variable granulomatous reaction that
may occur with the physiologic hemostatics, these products
should be avoided near the conjunctiva and should be removed
prior to a layered closure.
Physiologic hemostatics use natural components of the
coagulation cascade to augment either the amplification or
propagation phase of hemostasis. Some products such as
fibrin sealant (Tisseel, Baxter Healthcare) have benefits
beyond hemostasis. Fibrin sealant significantly improves split-
thickness skin graft survival in difficult locations30 and may
promote wound healing. Fibrin sealants have been used for
suture support (reduce operating time, increase suture integ-
rity), tissue sealing (minimize dead space and fluid leakage),
and for delivery of tissue-engineered skin.31 Physiologic
and antifibrinolytic hemostases are prohibitively expensive
(several hundred to several thousand dollars per application)
for routine use in cutaneous surgery.
Purified bovine collagen (Primatrix, TEI Biosciences and
Puracol Plus, Medline) are two new products which have
been developed for partial- to full-thickness wounds. Although
they are indicated as a wound dressing, they can be expected
to be hemostatic for open wounds. The intrinsic pathway of
the clotting cascade is activated by exposure to collagen that
binds Factor XII. The collagen sheets can be cut to size and
sutured to open wounds and pedicles for staged flaps.
Laser surgery
The continuous-wave carbon dioxide laser is a valuable tool for
hemostasis. At a wavelength of 10 600 nm, the carbon dioxide
requirement for the injected lidocaine to be tissue distributed
and protein bound is 30 minutes.18 Tourniquet deflation
before 30 minutes is therefore contraindicated (even if the
surgery has finished) because a systemic lidocaine bolus may
result. Bruising and local pain at the tourniquet site may
occur, especially if compression duration exceeds 60 minutes.
IVRA may be especially useful for surgery on extremity
lesions that have a strong vascular component.
Compression
The simplest, but most often overlooked measure for hemo­
stasis is manual compression. Firm pressure over a bleeding
wound for 15–20 minutes will achieve hemostasis for most
vessels, unless large vessels are involved. Pressure directly
compresses vessels and permits time for either physiologic
clotting or time for other interventions. Pressure is necessary
when topical hemostatic agents are applied, or to facilitate
electrosurgery. Compression is often applied downward, but
may also project upward to tamponade vessels near hollow
openings. Brisk bleeding is often encountered with incisions
on the nasal ala, for instance. By applying upward pressure
from within the nasal vestibule, the alar surface is stabilized
for incisions and blood vessels are compressed (Fig. 15.1).
Upward pressure may be achieved with moistened CTAs, a
dental roll, or an inflated Foley catheter.19 A chalazion clamp
may similarly provide both stabilization and hemostasis for
surgery on the mucosal lip (Fig. 15.2).
An extension of manual pressure is tourniquet compression.
The judicious use of tourniquets can greatly reduce intraop-
erative bleeding and improve the control of bleeding vessels,
especially on fingers and toes. Tourniquets may be fashioned
from the cut finger of a surgical glove or a Penrose drain (Figs
15.3–15.5).20–22 Although proximal tourniquets at the forearm
or distal thigh are generally safe for up to 2 hours,23 the pain
with prolonged compression is usually intolerable without
sedation. Tourniquet use without sedation should therefore
be limited to 60 minutes or less. Elevating the extremity or
digit for 10 minutes before tourniquet placement will achieve
venous exsanguination, which may improve on hemostasis.
Topical hemostatics
Topical caustics such as zinc chloride paste, silver nitrate,
ferric sulfate (Monsel’s solution), or aluminum chloride are
useful as adjuncts to hemostasis.24 These agents have in common
a protein coagulation effect that causes varying degrees of
tissue necrosis and leads to eschar formation and hemostasis.
Figure 15.1  Nasal stabilization and hemostasis with cotton-tip
applicator.
Figure 15.2  Lip stabilization and hemostasis with a chalazion
clamp.

230
Part 2  Essential Surgical Skills
laser targets water and non-specifically destroys tissue. It
may be used in a focused (tissue incision) or defocused (tissue
vaporization) mode while also sealing blood vessels of 0.5 mm
in diameter.32 There is reduced bleeding when compared to
scalpel surgery. This incisional hemostasis is advantageous in
procedures such as blepharoplasty, where meticulous hemo­
stasis is mandatory. Optimal power output for most purposes
is 5–10 watts. The dilemma with carbon dioxide laser hemo­
stasis is that any blood or moisture in the field will absorb the
laser energy and prevent effective coagulation. Therefore,
laser hemostasis is best applied to slow capillary bleeding
because with more brisk hemorrhage it is difficult to achieve
a dry field. Mastering the carbon dioxide laser for surgery and
hemostasis has a steep learning curve as well as significant
investment in equipment and safety. As a result, it is not rou-
tinely used as the primary method of hemostasis.
Another laser for hemostasis is the continuous-wave
neodymium:yttrium aluminum garnet (Nd:YAG) laser
(1064 nm wavelength). In the continuous-wave mode, this
laser generates diffuse thermal damage to several chromo-
phores such as melanin, hemoglobin, and water. It may be
used with a sapphire tip, which permits cutting with direct
tissue contact, simulating a scalpel.33 The Nd:YAG energy
penetrates to a depth of 4–6 mm and diffuses widely, causing
significant thermal coagulation peripherally. Given its diffuse
and deep destruction, the Nd:YAG should be avoided as the
sole instrument for hemostasis.
Electrosurgery
Electrosurgery is an effective method for surgical hemostasis.
Monoterminal electrosurgery includes electrofulguration or
electrodesiccation and provides adequate hemostasis for
superficial procedures. It uses high voltage through a single
electrode to desiccate tissue and thrombose small blood
vessels (<2 mm diameter).34
Biterminal electrosurgery is known as electrocoagulation.
Electrocoagulation generates a low-voltage current and has
two electrodes that may be applied in a unipolar or bipolar
fashion. With all electrosurgery, the treatment electrode and
current are applied directly to the bleeding vessel. Alterna-
tively, the current may flow indirectly through a metal forceps
or clamp that grasps the vessel. Bipolar electrocoagulation is
the safest for patients with implantable defibrillators because
the current is isolated between the two tips of the bipolar
forceps and there is no distal dispersion of electricity. Further,
it achieves hemostasis with the least tissue destruction, causing
three times less tissue necrosis than an equivalent current
through a unipolar electrode.35 In electrocautery, there is no
electrode and sealing of blood vessels occurs through a hot wire
device. It is effective only for the most minimal of bleeding.
With all electrosurgical methods, charring and collateral
tissue damage may occur and is greater with electrodesicca-
tion and electrofulguration than with electrocoagulation (see
also Chapter 9). Precise application of current is essential to
minimize excessive tissue charring, which then leads to poor
wound healing and possible infection. Precision is mandatory
in periorbital areas and with exposed perichondrium. The
periorbital skin is thin and deeper structures may be damaged
with excessive voltages. The perichondrium is also vulnerable
and easily injured, necrosed, and inflamed. Haphazard and
generalized coagulation is inappropriate. The lowest effective
current setting should be used.
A
B
C
Figure 15.3  Surgical glove tourniquet. (A) The middle finger
from a surgical glove is severed at both its base and its tip; (B)
The glove finger is placed over the treated digit and rolled back
proximally, forming the tourniquet. (C) A curved hemostat
grasps the ring tourniquet with the loops facing away from the
surgical field (optional step – provides additional compression
and ensures tourniquet is not forgotten and left in place).

231
Chapter 15  Hemostasis
A ‘wet’ field (presence of blood) disperses electric current
and causes excess charring. Drying the field is critical and may
be achieved with proper use of a CTA or dental roll. The ‘roll
back’ rather than the ‘dabbing’ method is best for precise
electrocoagulation. In the first technique, a CTA compresses
the bleeding area and slowly rolls back towards the surgeon.
As the CTA rolls back, bleeding vessels should be immedi-
ately coagulated and sealed. This ‘roll back’ approach is more
effective than ‘dabbing,’ where the CTA dabs on and off at
the bleeding site and permits a ‘wet’ field in between dabs.
Inadvertent wound edge necrosis is common with electro-
surgery. Electrical current will conduct indiscriminately
through any uninsulated metal and cause damage. If the
device is held slanted (like a pen), for example, the proximal
metal electrode may brush against the epidermal edge and
cause necrosis. Adequate skin edge retraction and holding the
device vertically will minimize this risk. Commercially made
insulating needles (only the distal electrode tip is exposed)
or extemporized insulating devices are also helpful.36
When grasping a bleeding vessel (either with a forceps or
mosquito clamp), there is a tendency to clamp a large cuff of
perivascular tissue. This results in excessive tissue damage
A
B
C
D
Figure 15.4  Exsanguinating tourniquet. (A) A Penrose drain is wrapped around the distal fingertip with a length exposed. (B) The
drain is wrapped proximally under tension with overlapping layers. The wrap should extend beyond the surgical site, leaving an
exposed end proximally as well as distally. (C) The distal end is now unwound slowly and until it reaches the proximal exposed end.
(D) A hemostat secures both ends to form the tourniquet.
Figure 15.5  Penrose drain tourniquet. A Penrose drain is
wrapped around the digit proximal to the treated site, stretched,
and secured at its base with a curved hemostat.