MONTEREY, CALIF. Closing defects is one of the most challenging tasks in dermatologic surgery, but at the annual meeting of the Pacific Dermatologic Association, Dr. Michael J. Fazio shared several clinical pearls that make the job easier and improve the cosmetic results.
To start with, "don't scrimp on the setup," said Dr. Fazio of the University of California, Davis. "Get yourself some nice instruments. I always like to use the golden-handled instruments that have a bit of a sharper edge to them. They last longer, and they sharpen better. They're a little more expensive, but they go on forever."
Dr. Fazio finds that skin hooks provide a more delicate and elegant way of handling tissue, compared with forceps. With forceps, it's important not to pinch down too tightly. Tissue held by the forceps may become necrotic.
Dr. Fazio is a proponent of using bicarbonate in local anesthesia, and he recommends that any physicians who are not using bicarb should try a self-injection. They'll see that the injection is far more painful without bicarbonate. He recommends a 1:10 dilution, adding 5 mL of stock bicarbonate solution to 50 mL of lidocaine with epinephrine. Bicarbonate can destabilize the lidocaine solution over a long period of time, but that's usually not an issue in a busy dermatologic surgery practice.
When preparing to remove a lesion, mark the favorable lines of closure before injecting the anesthetic, which may cause distortion. During creation of the ellipse, it's important that it be long enough; Dr. Fazio prefers that the length be at least three times as long as the width. Inexperienced residents are often reluctant to lengthen the ellipse sufficiently, fearing that the scar will be too large. "If you make a quality scar, you're not going to see it," Dr. Fazio said. "If you make a scar and it's too small, you're going to have lumps on both sides [that] are going to be very noticeable."
Undermine the entire ellipse, the ends as well as the sides, to allow the tissue to slide. As the ellipse is closed it will tend to elongate, and if the ends aren't mobile they will pucker up.
"As I got older and more experienced I started letting things heal more by second intention," Dr. Fazio said. But one needs to be selective in allowing things to heal by themselves. The results tend to be better on convex surfaces of the face than on concave surfaces, for example.
Be aware that wounds healed by second intention tend to shrink by about 50%, so it's not a good idea around free tissue margins such as the eye, nose, and mouth. But on the upper foreheador even on the scalp in patients lacking hairsecond-intention healing can work superbly, especially with a large defect in which it would otherwise be necessary to mobilize a large flap and undermine a wide area.
Second-intention healing also works well in the extremities, and Dr. Fazio prefers this to skin grafts. With split-thickness skin grafts, patients often complain about pain at the donor site, the graft itself can easily become infected, and it can take up to 3 months to heal.
Dr. Fazio's favorite suture materials are 60 fast-absorbing gut and 50 monofilament. He advocates closing defects subcutaneously so that the cutaneous sutures are used only for epidermal kissing. He has his patients return in a week for suture removal, but the fast-absorbing gut will be mostly or entirely gone by then, so the return visit is mainly for patient reassurance.
Dr. Fazio favors subcutaneous mattress sutures, which work as well as cutaneous vertical mattress sutures but don't give the railroad-track effect. He applies the subcutaneous sutures every 24 mm along the scar line so that there's tension on the surface. He then closes the epidermis with a running suture using the 60 fast-absorbing gut.