NEW YORKEvery dermatologist should be able to perform excisional surgery and leave only a fine line scar on the patient's face, Dr. C. William Hanke said at a meeting on medical and surgical dermatology sponsored by Mount Sinai School of Medicine.
Dermatologists who are not able to leave only a fine line scar are falling behind some of the family physicians who are doing excisional surgery, he said. And a scar that is long and noticeable is poor marketing for the physician.
Dr. Hanke, a dermatologic surgeon in Carmel, Ind., who founded the Mohs Micrographic Surgery Unit at Indiana University, Indianapolis, offered several techniques for achieving superior results with excisional surgery.
Make incisions in normal anatomic boundary lines or relaxed skin tension lines to hide scars. "That's where you want your scars to be so that they don't look like scars," he said.
Handle tissue atraumatically by avoiding touching the skin surface with forceps; instead, grab tissue from the bottom.
Make scars as short as possible. A scar longer than 2 cm will be much more noticeable than will shorter scars. By using an M-plasty, the incision can be shortened by about a third.
Don't bury unnecessary suture material. Tying the appropriate number of knots on buried sutures allows you to keep the amount of buried foreign material to a minimum. "The wound doesn't have to work as hard to heal with that smaller volume of foreign material," he said.
Use fine-caliber suture material to reduce trauma and choose simple closures over complex ones. "If you do a complex closure in a case where you could have done a simple closure and there's a complication, you've got a big complication."
Undermine appropriately to relieve wound tension and facilitate wound-edge eversion. Some dermatologists do a lot of unnecessary undermining and others never do it, but the right balance is likely somewhere in between, he said.
Use appropriate methods of hemostasis. Dr. Hanke said he does some suture ligature and uses a lot of electrocoagulation. Electrocautery is needed sometimes for patients with pacemakers. Pressure also is important, he said.
Use "tie-over" sutures to relieve tension and don't tie sutures tightly. Doing so can result in strangulated tissue that won't be evident until suture removal.
Be a student of dog-ear repair and close wounds rapidly. The medical literature shows that wounds that stay open for more than an hour or 2 have a higher rate of infection.