Mark a triangle (Burow's triangle) after determining the lengths of both

wound edges to equalize it. The width of the base of the triangle should be
equal to the difference in the length of the both wound edges.
Retract the skin at the end of the marked triangle to equalize the wound
edges.
TIP Skin retraction To facilitate undermining of the subcutaneous tissue, the
skin can be lifted and everted using a single prong skin hook. This allows
less chance of soft tissue trauma compared to when using tissue forceps.
Undermine the subcutaneous tissue for increased mobility of the
subcutaneous tissue and skin. This facilitates tension-free closure.
Approximate the skin with standing sutures.
TIP Principle of halving sutures To approximate the skin, the first suture is
placed in the middle of both wound edges. Then, the subsequent sutures
are placed equally between the wound border and the previously placed
sutures - this is called the principle of halving sutures.
Close the skin after the positioning of the few approximating sutures.
Excise the excess skin along the previously created markings of the Burow's
triangle. Note, these markings are a guide. Due to the skin characteristics,
the amount of excess skin can differ.
Close the newly created skin defect with standing sutures.
INSTRUMENTS AND MATERIALS

A basic surgical tray is used in this procedure. A case-specific, useful

instrument is the single prong skin hook, which may be used in the
procedure.

POSITIONING

The positioning of the patient depends on the location of the performed

procedure.
COMPLICATIONS

Besides general complications, specific complications can occur after defect

closure, such as skin infection and necrosis.

Skin infection

Wound infection is a major risk factor for developing wound dehiscence,

and therefore preventive measurements should be taken. The 2008
National Institute for Health and Clinical Excellence guidelines for the
prevention and treatment of surgical site infection can be followed [1].

Skin necrosis

The microcirculation system in the subcutaneous fat provides the

vascularization of the skin. In an area where the skin is raised, this
microcirculation may be compromised which can lead to necrosis of the
area. During surgery, it is important to dissect carefully in order to avoid
damaging this microcirculation. Furthermore, prolonged traction on the
wound edges should be avoided as this may harm the microcirculation too.
During closure, the skin edges should be inspected. When the skin edges
are darker with a prolonged capillary refill time, it is an indication for
resection.