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Advanced Suturing

Dennis LaRavia, MD, Diplomate ABFM; Fellow AAFP
Professor, LSUHSC-NO School of Medicine, Dept. of Family Medicine Residency Director, LSU Rural Family Medicine Program, Bogalusa, LA

BASIC SUTURING: A REVIEW
Cleansing and Irrigation Anesthetic Choices Suture Selection Healing Considerations Suture Removal Considerations Post-op Discussion

Basic Closure: Review
Thorough Debridement and Cleansing Appropriate Anesthesia Proper Selection of Suture Good closure techniques: Approximation, not strangulation Mild eversion, no inversion Suture not too close to skin edge

Basic Closure: Continued
Followup Suture Removal Timing Long-term skin care Wound Healing: 0-5 Days= Initial Lag Phase 5-14 Days= Initial Healing Phase 14-365 Days= Complete Healing

Initial Goals: Advanced Repair
Evaluate Lesion/Lesions for possible excision/Repair Understand Patient’s Expectations Discuss options and choose

correct option

Informed Consent Process Perform the procedure correctly

Post-op Instructions and Follow-up

Evaluate Lesion/Lesions
History >Diabetes Mellitus >Immune Problem >Keloid Former >Prior Repairs: how did they heal?

Evaluate Lesion/Lesions(cont)
Physical >Review any prior excisions/scars >How compliant is skin? >What type of complexion and skin color does patient have? >Circulatory/cardiac status?

Evaluate Lesion/Lesions(cont)
Cogitate on Options: Biopsy Excision Surveillance Repair

Understand Patient Expectations
Patient Education > Basic Healing Explanation > Options for Patient to consider Patient Expectations > Make sure communication is occurring!

Discuss Options/Choose Option
Develop options for treatment with the patient Develop Best Plan with patient’s agreement Discuss details of approach Discuss, in general, post-op and healing expectations

Informed Consent Process
Informed consent Photo consent Photograph the lesion(s): Preferably digital *All documentation into EMR or Paper Record Reaffirm Allergies/Sensitivities

Perform the “Right” Procedure Correctly
Review anatomy of region
Underlying structures

Preparation of the Wound Type of anesthesia Type of suture
Take care to place the right suture in the right place (set a high standard)

Perform the Procedure Correctly-Review Anatomy
Facial Areas Neck Areas Wrist and Hand Other areas with significant deep structures to the wound or lesion

Perform the Procedure Correctly-Preparation of Wound
Antiseptic/Aseptic Prep
Betadine Alcohol Soap Cleanser Other Prep

Site and individual Dependent

Perform the Procedure Correctly-Preparation of Wound (cont)
Anesthesia Who-is the patient? What-is the procedure? Where-is the site we are reviewing? How- long will the procedure take?

Conscious Sedation: should it be considered?

Perform the Procedure Correctly-Preparation of Wound(cont)
Anesthetic Block Local Buffered Solution: Why?
1:8 to 1:10 Dilution of Sodium Bicarbonate to Anesthetic

Choice of materials Lidocaine Mepivacaine With or without epinephrine

Anesthetic Concentrations:
Equivalent Concentration 1% 1% 1% .25% .25% Local Anesthetic Lidocaine Lidocaine w/epi Mepivacaine Bupivacaine (Marcaine) Bupivacaine w/epi Onset 1 min 1 min 3-5 mins 5 mins 5 mins Duration 45-60 minutes 2 – 6 hours 45-90 minutes 2-4 hours 3-7 hours

Perform the Procedure Correctly- Suture Selection
Non-Resorbable
Monofilament

Resorbable (Absorbable)
Monofilament Braided Catgut
Plain Chromic

Healing Time

Sutures
Suture/Types Tissue Reaction Absorption Rate Moderate Moderate Mild Mild 70 days 90 days 40% 7 days 60-90 days Absorbable Sutures: Gut/Plain Gut/Chromic Polyglycolic/Mono (Dexon) Polyglactic/Braided (Vicryl)

Needles

Cutting/Reverse Cutting

Suture: How will I decide?
What is the extent of the wound or proposed lesion excision? Where is the lesion/wound? How long do I want the sutures to remain? What likelihood is there of infection? What about the individual patient?

Post-Op Care & Instructions
Patient Responsibilities:
Clean-Daily? Dry or wet-Antibiotic ointment? Covered or not
o o

Site Dependent Individual Dependent

Return time Call/Come In for departures from the expected

Post-Op Care (continued)
Physician Responsibilities:
Suture Removal-When?
Face,Scalp, and Neck Hands, Arms, and Feet Trunk Legs

Post-op evaluation Individual care Return Appointments

Consider……
Loss of a Flap: What are my options? Infection: How do I intervene? Other adverse results

Preparation of the Office/ED
Well trained assistant Complete set of instruments Complete set of supplies/Including plenty of backup sets “Ready to Go” Appropriate time set aside for procedure Good lighting (and glasses if necessary)

Preparation of the Mayo Stand
What is on the stand?
Metzenbaum Scissors Smooth forceps, tissue Iris Scissors, curved or straight Mosquito hemostats, curved two Hemostats, straight, two Skin retractors, two Allis forceps Scalpel, #15 Needle Holders Suture Scissors 4x4’s 2x2’s H2O2? Sterile Saline Extra Buffered anesthetic with a small needle Suture, Varieties

Support Equipment
Hot pen Electrocautery Cryogun

Wound Healing Considerations
Color of Skin Keloid former? Child or Adult? Size of Lesion and Repair When to take out sutures Who to take out sutures Steri Strip Usage/Benzoin Diabetic? Immune compromised On blood thinners Likelihood of infection Farmer Child (particularly boys)

Considerations in Selecting and Planning Technique of Excision
Biopsy
Excisional, ellipse Key punch
Variety of sizes Suggested size—4 mms

Considerations: other closures
Skin Glue(Dermabond)
When to use Where to use

Staplers
When to use Where to use

Considerations, continued
Definitive Excision
Site/Proximity to underlying structures Age of Patient Color of Skin Elasticity of Skin Potential shortfalls of approach/complications

Plastic Repairs
Lines of Langerhans

Lines of Langerhans cont’d

Basic Closures

Interrupted

Continuous (Running) Suture

Mattress, Vertical
Shorthand Regular

Mattress, Horizontal

Corner Suture

Deep Inverted Suture

Subcuticular

Undermine?
Why undermine? How to undermine Burow’s Triangle

Other Closures Pearls
Leveling Suture Approximate—Do not Strangulate If you are not happy with the suture, cut it out and replace with a better suture!

SUTURE, LOAD LEVELING

Keloid and other Intralesional injections
Mixture: Kenalog 10(Kenalog 10mgs/cc) and lidocaine 1:1; usually about 0.25 cc:0.25 cc. Use fine needle; 27 to 30 guage needle Luer-lock preferred Interval: usually 6-12 weeks Keloid: Do not attempt re-excision until patient has received 3 injections

Advanced Closures

Z-Plasty

Z-Plasty
Good Choice for:
o o

Pilonidal Cyst Scar or sinus Repair over a joint (finger)

Dog Ear Correction

Dog Ear Correction
Good Choice for:
o

Any repair or elective excision where you have too much skin on one side of the repair that will immediately or ultimately result in a Dog Ear Deformity.

Single Advancement Flap

Double Advancement Flap

Single and double Advancement Flaps
Good Choice for:
o o o o

Back Thigh Abdomen Calf, maybe

Rotation Advancement Flap

Rotation Advancement Flap
Good Choice for:
Neck Scalp Face Anywhere where you have loose skin adjacent to an area that is “tight” or where there is limited skin for a flap or “good closure” without undue stress

M-Plasty

M-Plasty
Good choice for:
o o o o o o o

Scalp Face Arm Leg Foot Ankle Almost anywhere (especially where there is limited skin to flap)

Triple U Plasty

Triple U Continued

Triple U Continued

Triple U Conclusion

Triple U-Plasty
o

Good choice for:
o o o

Nose Neck Ear

V to Y Slide 1
1.

Circular Defect

2.

Plan triangle, using skin lines

V to Y Slide 2
3. Incise the triangle, then undermine thoroughly.

4. Thin base of triangular flap to fit defect.

V to Y Slide 3
5. Remove triangle

base.

6. Suture

V to Y Slide 4
7.

Suture long limb.

8.

Close remaining incisions.

V to Y Plasty
Good choice for:
o o

Inferior Orbital area Pre-auricular area

Rhomboid Flap

Rhomboid Plasty
Good Choice for:
o o o o

Back Neck Thigh Abdomen

Advanced Considerations in Skin Closures
Tendon Repairs Variant Sutures Refinement of Skills What to tackle Penrose Drains Conscious Sedation

Skin Grafts
Donor Sites Pinch Dermatome

Treatment of Donor Site
Warm Saline Antibiotic Teflon cover (or Adaptic)

Tendon Repair
Suture Approach Preparation Post-Op Consideration

TENDON REPAIR

Use of Penrose Drains
When to use How to use When to remove Proper selection of patient and procedure is the Key How to secure them

Conscious Sedation
Midazolam 2-10 mgs Fentanyl 25-200 mcgs

Coding & Billing
Coding and billing becomes very complex for laceration repair and excisions. Important factors to list for billing personnel are:
Location Size of lesion Length of closure or excision Simple or intermediate repair Benign or malignant status Whether a true skin lesion or subcutaneous tumor or deep tumor was excised Method of removal

Coding & Billing continued
Suture removal is included in the initial charge if the original sutures were placed by the same group of physicians. Suture removal can be billed if performed by an unassociated physician or group. Anesthetic, materials and supplies are customarily also included in the reimbursement fees. If a lesion is excised and repaired in a simple fashion (no undermining, deep sutures, flaps, or plasties), the fee for excision includes repair and suture removal.

VERTICAL MATTRESS SUTURES: VARIANTS
Far-Far/Near-Near Near-Far/Near-Far Far-Near/Near-Far Near-Far/Far-Near Space-Obliterating Pulley or Loop Half-Buried

Vertical Mattress: Classical, Far-Far/Near-Near

Vertical Mattress: Classical, Advantages
Everts Skin Edges Reduces Wound Tension Eliminates dead space Provides a strong closure

Vertical Mattress: Classical, Disadvantages
Potentially Strangulating May compress the skin adjacent to the defect causing: scarring focal necrosis Postoperative edema Take a little more time than running suture

Vertical Mattress: Near-Far/Near-Far

Near-Far/Near-Far Mattress, Vertical: Indications
Promotes Skin Eversion Useful for elevating the deep tissues of a wound

Vertical Mattress: Far-Near/Near-Far

Far-Near/Near-Far Mattress, Vertical: Details
Almost identical to the Near-Far/FarNear suture except, the knotted suture segment connects the two far points as opposed to the 2 near points.

Vertical Mattress: Near-Far/Far-Near

Near-Far/Far-Near Mattress, Vertical: Details
Described as a combination suture of traditional vertical mattress and interrupted suture Main use where tension exists on thin skin including the eyelids and parts of the scalp. Also, creates a pulley effect which may be very helpful when significant tension exists at the time of closure

Vertical Mattress: Space-Obliterating

Space-Obliterating Mattress, Vertical: Details
Involves an additional loop within the dermis Provides a pulley effect to the closure Thought to distribute tension more evenly over a larger area Generally work where there is considerable tension at time of closing

Vertical Mattress: Pulley or Loop

Pulley or Loop Mattress, Vertical: Details
Suture works as a Pulley Produces less tension on either of the suture strands Thus reduces pressure or impingement on the skin surface Also, reckoned as a very strong closure where tension exists at time of closing

Vertical Mattress: Half-Buried

Half-Buried Mattress, Vertical: Details
Placed in a traditional far-far/near-near sequence But the needle does not pierce the skin surface opposite the starting point Chief Advantage: Less scarring and less likelihood of strangulation Approximates edges well, but may not relieve wound tension as well Useful on lip, eyelid, or hairline

REVIEW SUMMARY
1. Review the Basics 2. Review the options for Closure before removal of lesion 3. Make the Advanced Closure “Fit the Site”

REVIEW SUMMARY (cont)
4. Acrostic: Corner Sutures Undermine Burow’s Triangles Extension 5. Self-Refreshers Work on Pigs feet every 3-6 months

REVIEW SUMMARY (cont)
6. Overview: A. Vision- Visualize, in your mind, the finished product! B. Technical- Holder yourself to a higher standard to place every suture in the “right place” C. Flexibility- When things don’t work out just right or look just right---make revisions then to obtain the result the best it can be.

Questions???
Dennis LaRavia, MD, F.A.A.F.P. Professor, TAMU, COM Dlaravia@medicine.tamu.edu Laravia@aol.com College Station, TX 77845

TENDON REPAIR

Questions???
Dennis LaRavia, MD Laravia@aol.com

V to Y

Wound Healing Considerations
Color of Skin Keloid former? Child or Adult? Size of Lesion and Repair When to take out sutures Who to take out sutures

Wound Healing Considerations(cont)
Immune compromised? Diabetic? On blood thinners? Likelihood of Steri Strip Usage/Benzoin? Likelihood of infection? Farmer Children (particularly boys)