Principles of Plastic Surgery for General Practice

I learnt, through observation of and discussion with the surgeons, various general principles in performing incisions and the primary closure of wounds which should be applied by any medical practitioner in order to obtain acceptable functional and cosmetic results. This section covers a familiar subject, but in greater depth.

Choosing the appropriate blade

Surgical blades come in various shapes and sizes, each designed for specific purposes. Below are a selection of common surgical scenarios with the appropriate blade for that scenario.

Commonly used knife blades. A, no. 11 blade; B, no. 15 blade; C, no. 10 blade. (Sampled from Practical Plastic Surgery for Nonsurgeons by Nadine Semer)

Abscess drainage Shave biopsy Biopsy (incisional/excisional) Facial incisions Incisions < 5cm Incisions > 5cm Wound debriding

No. 11 No. 11 No. 15 No. 15 No. 15 No. 10 No. 10

Planning the incision

When planning an incision, first draw the planned incision lines on the patients skin. This is crucial - it allows you to visualise and then adjust the planned incision to produce the most functional (less contractures) and cosmetically acceptable scars. Plan the incision so that the resultant scar aligns with lines of relaxed skin tension or the natural creases of the skin. See below for a diagram which illustrates the recommended incision lines for a excision biopsy. If possible, attempt to place a facial scar in a position where it will be least conspicuous (e.g. on the philtrum or on the hairline). When performing excisions which cross a fold (e.g. on the hand), make the incision to the fold and then deflect - straight scars crossing hand folds cause contractions. If you are sufficiently experienced attempt to create non-linear scar they are less conspicuous than linear scars.

Avoid distortion of local structures when the excisional wound is to be closed. This can be tested for by manipulating the skin according the predicted tension of the wound closure.

Relaxed skin tension lines

Relaxed skin tension lines (RSTL) can be determined by observed the skin whilst pinching it in different directions. The RSTL around body apertures (e.g. the mouth, nose, anus and vagina) radiate from the centre of the aperture (they are perpendicular to the edge of the orifice). The palpebral fissure is an exception the RSTL only radiate from the commissures and are parallel to the fissure inferiorly and superiorly.

Course of the wrinkle lines of the face (sampled from Netters Atlas of Human Anatomy 4e)

How to excise multiple lesions which are close together (sampled from Relaxed Skin Tension Lines, Z-plasties on Scars, and Fusiform Excision of Lesions by Borges and Alexander)

Performing an incision
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Place the tissue under tension by stretching it with your nondominant hand. Perform the cut with the rounded part of the blade, not the tip. Apply pressure with the blade modestly than excessively lest one accidentally injures underlying structures. If the tissue surface is not completely horizontal and more than one parallel cuts are made, cut the inferior area first to prevent blood from the top wound flowing over the inferior incision site, obscuring your view before you have performed the incision. Perform in an incision preferably in one continuous, smooth movement of the hand.

Performing a Z-plasty
A simple Z-plasty is a useful technique to disrupt contracted linear scars which do not follow the RSTL. It is based on the principle that scars which are aligned parallel to the relaxed skin tension lines result in less contracted scars. Small antitension line scars may be improved by a single Z-plasty. The scar is excised and two additional incisions are made on opposite sides of the resultant (relatively) linear wound, one at each end.

(sampled from scrubbedin.wordpress.com) These additional incisions are made at equal angles from the former incision and are both equal to its length (so that the skin edges align perfectly). The limbs should be designed to align with the RSTL as far as possible.

(sampled from Relaxed Skin Tension Lines, Z-plasties on Scars, and Fusiform Excision of Lesions by Borges and Alexander)

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The goal is to decrease the tension caused by the contracted scar. The greater the angle chosen, the more length is gained from releasing the contracted scar. However, the greater the angle, the more the skin and subcutaneous tissue will be twisted, potentially causing dog-ears or excessive wound tension.

(sampled from aafp.org) Larger scars, or oblique scars, may be improved by performing 1 or more small Z-plasties (which do not cover the entire scar line). This will interrupt the contracture and reduce tension. Excessively large Z-plasties will only create more unsightly scars and may distort skin significantly and compromise blood flow to the skin (as transposition of the skin will require extensive undermining).

(sampled from Relaxed Skin Tension Lines, Z-plasties on Scars, and Fusiform Excision of Lesions by Borges and Alexander) Z-plasties are only feasible if the antitension line scar deviates significantly from the RSTL, otherwise the Z-plasty will only result in additional scars without improving the original scar, or even create more antitension line scars.

A small oblique scar which is almost aligned with the RSTL should rather be excised with a elliptical excision.

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(sampled from Relaxed Skin Tension Lines, Z-plasties on Scars, and Fusiform Excision of Lesions by Borges and Alexander)

Using electrosurgical devices

Electrosurgery is the process of passing a current through tissue, generating heat to effect coagulation or to cut through tissue.

Bipolar versus Unipolar

Bipolar devices have to active (small) electrodes set in the tips of a forceps. The current passes directly through tissue grasped by the forceps. These devices do not require dispersion pads (contact plates). Unipolar devices have one active (small) electrode and a contact plate (large contact area). The current passes through a large section of the patients body and may cause pain/discomfort if the patient is not anaesthetised.

Bipolar electrosurgery forceps (picture sampled from katale.com.mx)

Coagulation versus Cut

The coagulation setting produces an intermittent pulse of high-voltage current. The ration of current on to current off period can be adjusted. This allows for the tissue to cool down slightly and slowly dry out (desiccate) rather than explode (vapourise), causing more effective coagulation.

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The cut setting produces a continuous low-voltage current which vapourises cells - it is more destructive (it causes cells to explode) and slices through tissue more effectively. Loose contact produces more heat and thus more effective cutting. Additionally, fulguration occurs when the electrode is close to tissue, but there is no contact. The current arcs across the space and makes contact over a wide area. This is useful for coagulating a large area of bleeding tissue or the diffusely bleeding raw surface of a solid vascular organs.

Important principles and hints:

The smaller the area through which current passes, the higher the current concentration, the more heat is generated. This may cause contact plate burns if the contact plate is placed of hairy areas, skin folds or bony protuberances which may reduce the contact area. Also, structures which are connected to other tissue via a small structure may be potential sites for the pedicle effect - the current concentration is increased in the narrow connecting structure and heat may be excessive and cause tissue damage. More electrically resistance tissue(e.g. hypovascular tissues, hair) generate more heat when a current passes through. Higher voltage currents may jump (conduct through air), a principle which is used for fulguration. High frequency alternating current may be conducted through an insulator to another conductor (capacitive coupling). This may cause unwanted burns if the latter conductor has poor (but present) contact with the patient. Using two electrocautery devices simultaneous causes addition of currents if the currents pass through the same areas of tissue. The may generate more heat than expected and cause e.g. contact plate burns. Ensure that the insulation of the electrodes are intact and that the active electrode is properly attached to the handle to avoid unwanted active contact points.

Performing blunt dissection

This is the technique of choice in separating tissue for inexperienced surgeons and tissue with many important structures which should be spared. Blunt dissection may be performed with a finger, clamp or a pair of closed blunt-tipped scissors. Subcutaneous tissue and muscle separate with ease while nerves, vessels and tendons usually remain intact (if not performed too vigorously).

Performing sharp dissection

The inexperienced surgeon should on use this technique in emergency situations (e.g. creating an airway in the neck and locating a life-threatening haemorrhage).

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Undermining skin edges

Skin edges are undermined in order to increase the mobility of skin for the purpose of tensionfree wound closure. The edge of the skin is lifted with forceps and a knife or scissors are used to separate subcutaneous tissue around the wound until the desired skin mobility is acquired. Remain at the same depth/plane. Undermining a skin edge tends to haemorrhage less when performed at the plane between subcutaneous tissue and the fascia of underlying mucle (as opposed to cutting through subcutaneous tissue).

Ensuring haemostasis
Bleeding from the wound edges
This may be controlled by any of the following measures: a) Apply pressure b) Electrocautery c) Wound closure with continuous locking suture (this places more tension on the skin edges and is especially useful for bleeding from a scalp wound)

Bleeding from a vessel

a) Apply pressure (for at least 5-7 minutes) b) Electrocautery (for small veins and arteries < 3mm in diameter) c) Ligate the vessel (for larger veins and arteries 3-4mm in diameter) with either a regular tie or a stick tie (for larger vessels)

Regular tie
This is usually adequate for veins and 2-3mm arteries. One end of the vessel is grasped with a clamp and gently lifted from the surrounding tissue. A piece of silk or Vicryl (3-0 or 4-0) is passed around the vessel below the clamp and tied with 3 to 4 secure knots.

(Sampled from Practical Plastic Surgery for Nonsurgeons by Nadine Semer)

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Stick tie
This is appropriate for arteries (due to their thick wall and higher blood pressure) as regular ties tend to fail. One end of the vessel is grasped with a clamp and gently lifted from the surrounding tissue. A piece of silk or Vicryl (3-0 or 4-0) with a round needle is passed through the center of the vessel directly below the clamp. Tie the suture once. Pass one of the suture ends around the vessel (passing below the clamp) and tie the suture. Remove the clamp and perform 3 to 4 additional knots.

(Sampled from Practical Plastic Surgery for Nonsurgeons by Nadine Semer)

Techniques for decreasing wound tension

Undermine wound edges Vertical mattress sutures Deep sutures Z-plasty (requires experience) Small random local flaps (requires experience) Placement of drains into dead space (prevents formation of haematomas and serous collections) Bandages, splints and slings (reduces the activity at the wound site) Reduce physical activity

Basic tools for suturing

1. 2. 3. 4. Needle holder Suture scissors Toothed tissue forceps or skin hook Appropriate suture material

Selecting the appropriate needle

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Curved needles can be divided into round (tapered), conventional cutting and reverse cutting needles. Round needles do not have a cutting edge and are ideal for subcutaneous and deep soft tissue (which tends to tear much easier than skin). Conventional cutting needles have their cutting edge on the inside of the curve and reverse cutting needles have their cutting edge on the outside of the curve. Reverse cutting needles tend to cause less tissue tearing than conventional cutting needles and are preferred.

Selecting the appropriate suture material

The most important considerations are the tension and location of the wound. Thinner suture material tends to cause more tissue tearing. 3-0 and 4-0 suture material is the standard for closure of wounds on the trunk and extremities. 5-0 and 6-0 suture material is preferred for closure of facial wounds. Absorbable suture material is typically used for buried sutures and does not require removal. Non-absorbable material is typically used for cutaneous sutures and requires removal. Absorbable sutures are degraded by tissue enzymes or hydrolysis. Those degraded by hydrolysis (e.g. PDS) are absorbed at a much slower rate.

Characteristics of monofilaments: Low infection risk and are preferred in contaminated wounds Lower coefficient of friction (slides through wounds easily, but knot unravels easily) Poorer handling Poorer knot security Characteristics of polyfilaments: Handle with ease Good knot security High infection risk (due to potential for harbouring organisms and high capillarity, the transfer of fluid, thus increasing the potential for colonisation of the wound) and are avoided in contaminated wounds Absorbable suture material
Ideal for Mono/ polyfilament Braided Strength retention Advantages Disadvantages

Chromic gut Polyglactin 910 (Vicryl) Poliglecaprone 25 (Monocryl)

Mucosa Subcutis

Areas where minimal reaction is essential

Mono

10-14 days 75% at 2w 50% at 3w 0% at 5m 50% at 7d 0% at 3m

Minimal reaction Does not tear tissue Great handling and knot security

High tissue reaction Occasionally persists as small nodule

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Polydioxanone (PDS II) Polytrimethylene carbonate (Maxon) Glycomer 631 (Biosyn)

High tension wounds Contaminated wounds Cartilage High tension wounds

Mono

Mono

70% at 2w 50% at 4w > 6m 80% at 2w 60% at 4w 0% at 6m = Maxon

Minimal reaction (< Vicryl) Prolonged strength Minimal reaction Prolonged strength Good handling Good knot security Minimal reaction = Monocryl Prolonged strength

Poor handling Poor knot security

= Monocryl

Mono

= Monocryl

Non-absorbable suture material

Ideal for Nylon Mono/polyfilament Mono Advantages Cheap Minimal reactivity Strong Handling High elasticity (responds well to tissue oedema) Very low friction Good plasticity Great handling Great knot security Great pliability Strong Handling Low reactivity Pliable Disadvantages Handling Knot security

Polybutester

Subcuticular running sutures

Mono

Polypropylene

Subcuticular running sutures Facial repairs Mucosa Intertriginous areas

Mono

Silk

Braided

Elasticity Knot security Expensive Weak High friction High reaction High capillarity

Polyester (Dacron)

Mucosa

Braided

Handling the needle driver

The palm grip may be used or the thumb and ring-finger may be passed through the rings with the index finger stabilises the driver at the screw/pin. The needle must be driven by rotating the wrist (causing the needle to perform a circular motion).

Different suture techniques

Interrupted sutures
Better tensile strength More time-consuming Preferred for possibly contaminated wounds (individual sutures may be removed without disrupting the entire wound) 17

Continuous sutures
Performing cutaneous continuous sutures, one section of every loop is diagonal and the following section is perpendicular to the wound edge. See below.

(Sampled from Practical Plastic Surgery for Nonsurgeons by Nadine Semer)

Significantly time-saving Distribution of wound tension Weaker tensile strength May strangulate skin edges in high-tension wounds Advantageous for stopping bleeding from wound edges (scalp wounds)

Continuous locking sutures

This is performed very similarly to simple continuous sutures, the difference being that when the needle exits at the skin surface, the needle is pulled through the loop of the thread (the thread is thus ahead of it). This places addition pressure along one side of the wound edge, helping to control bleeding. See below.

(Sampled from Practical Plastic Surgery for Nonsurgeons by Nadine Semer)

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More advantageous for controlling bleeding from the wound edge

Vertical mattress suture

When referring to vertical and horizontal sutures, the wound is orientated as horizontal. The needle is introduced 5-10mm from the wound edge and exits 5-10mm from the opposite wound edge. It is reintroduced 1-3mm from the latter edge and exits 1-3mm from edge on the initial side. The knots are tied. Excellent wound support Decreases dead space Superior wound edge eversion

Horizontal mattress suture The needle is introduced 5-10mm from the wound edge and exits at 5-10mm on the opposite side. The needle is reintroduced 3-5mm from the first exit site (on the same side), 5-10mm from the wound edge (making the suture parallel to the wound edge). The needle exits 5-10mm from the wound edge on the initial side, 3-5mm from the initial entry site. The knots are tied. Risk of strangulation with resulting edge necrosis

Cutaneous sutures
The need should enter the skin perpendicular to the surface (this allows the inclusion of more subcutaneous tissue and better wound eversion).

Continous subcuticular suture

Subcuticular sutures may provide the best cosmetic result (if performed correctly). The sutures are placed at the junction of the dermis and epidermis. Bites are taken in the horizontal plane. This provides an even distribution of tension along the wound and only penetrate the surface at each end of the wound where the knot is placed. The wound must be supported with underlying interrupted dermal-subdermal sutures to minimise the tension on subcuticular sutures. Best cosmetic result (minimal epidermal puncture points and track scarring) Minimal tensile strength (must be supported by deeper sutures)

Dermal-subdermal suture
The absorbable suture material is placed completely below the epidermis and is thus not visible. The needle is introduced at the subdermal level and exits at the dermal level, reintroduced at the dermal level and exits at the subdermal level. The knot is tied at the subdermal level. At certain sites where the subcutaneous tissue is too thin (rendering subcuticular suture non-viable due to its poor tensile strength), interrupted cutaneous sutures must be placed. The forehead is a common example. 19

Distributes wound tension from the epidermis to the dermis/subdermis Closes dead space

Tying knots
When tying a knot, pull on the short end of the suture material (pulling on the long end may cause the knot the become fixed in a loose position) Alternate the orientation of overlying knots Tighten sutures by pulling them in opposite directions at a uniform speed and tension (avoid sawing the threads together this undermines their tensile strength) Avoid crimping the suture unnecessarily grasp the free end of the thread only when performing a tie Maintain traction of the thread during ties to prevent loosening of the knot Attempt to place the final throw as close to horizontal as possible Additional (e.g. >3) throws do not increase the strength of a properly tied knot (it only increases bulk)

Removal of non-dissolving sutures

Head and neck: 5-7 days post-operatively Trunk and extremity: 10-14 days post-operatively

Alternative skin closure material

a) Staples (for large trunk or scalp wounds) b) Surgical glue (for wounds with minimal skin tension) c) Wound closure tape (e.g. Steristrips; for wounds with minimal skin tension or support of wound following subcuticular closure)

Golden Nuggets
When making incisions close to an orifice (or wound if this is safe and approriate) and it is easily accessible with your fingers, insert your fingers to stabilise and manipulate the tissue and gauge the thickness/relationship to other structures. Delay closure of oedematous wounds this may give an inaccurate impression of wound size, decreases skin elasticity, distorts wound edges (complicating accurate approximation) and indicates soft tissue damage (which may compromise closure and lead to dehiscence). Pre-emptive analgaesia/anaesthesia is very important for limiting wound site bleeding as it pevents the surge in blood pressure caused by pain. Excisional biopsy ellipses must have 3:1 length-to-width ratio and must not be too rounded (too oval) or their will be excess tissue at ends causing dog-ears. Before closing wound, wash out vigourously to dislodge any clots (which may dislodge after closure!) and ensure hemostasis. 20

Rub immature scars to reduce the bulk and pigmentation changes. When a wound is closed, be aware of dog-ear or indentations. Adjust the flap so that the opposing edges conform better.

Sources
1. The knowledge and experience of the plastic surgeons at Tygerberg and Chris Barnard Memorial Hospital 2. Practical Plastic Surgery for Nonsurgeons (Nadine Semer) 3. Suture materials (dermnetnz.org) 4. Suture techniques (dermnetnz.org) 5. Suturing techniques (Medscape Reference article) 6. Plastic Surgery Essentials for Students (Plastic Surgery Educational Foundation) 7. Preventing Wound Dehiscence - Tension-Relieving and Closure Options [cp.vetlearn.com] 8. Surgical and Knot Tying Tips (ethicon.novartis.us) 9. Electrosurgery tutorial (circlist.com) 10. Overview of electrosurgery (uptodate.com) 11. Relaxed Skin Tension Lines, Z-plasties on Scars, and Fusiform Excision of Lesions (Borges and Alexander)

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