B. J. Cowan, BSc, MSc, MD, PhD, FRCSC
Division of Dermatology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
In an age where our patients are becoming much more cosmetically sensitive, patients often express significant concern over scars that will be left in visible anatomic locations. With the progressive aging of our “baby boomers”, Canadian dermatologists, family physicians and surgeons are being faced with increased demands for skin biopsies and surgical procedures to treat skin malignancy and disease. Achieving an excellent surgical result while managing disease can be a daunting task when the basic surgical principles we were all taught have been lost to time and the perpetuation of poor surgical habits that were adopted from others. Here are a few strategies that can help to improve your scar outcomes.
First, place incisions parallel to relaxed skin tension lines or in existing facial rhytids. These “lines of election” are found perpendicular to the long axis of the underlying facial muscles. Observing the patient in states of facial animation and repose will help exaggerate these lines for easier identification.
Second, convert all circular defects to ellipses prior to primary closure. Observe the 4:1 rule where the length of the ellipse should be four times the diameter of the initial defect to achieve a primary closure without unnecessary skin redundancy.
Third, incise tissues at right angles. This helps ensure perfect wound edge approximation and avoids one skin edge riding over the other. If you can’t correct beveled edges then take a deep bite on the thick skin side and a shallow bite on the thin side to correct the difference.
Fourth, minimize tissue trauma by handling the tissue only with appropriate forceps and by limiting the pressure you use to hold the tissue. Increased amounts of skin edge trauma will reduce the result of the final scar. Holding the skin at the dermal level avoids surface marks made by the instruments.
Fifth, observe meticulous hemostasis. Unwanted hematomas increase the local inflammation and scarring in a given area as well as serving as a focus for infection. Hyfercators, designed for office use, are an affordable way to add this technical control to your practice.
Sixth, obliterate all dead spaces and use layered closure. Dead space obliteration can occur while placing your absorbing inverted dermal stitches. Although they take time to place, the use of interrupted dermal stitches will almost eliminate the complication of wound dehiscence and allow you the confidence to remove the skin stitches early. Remember that for the first few weeks, all of the strength of the closure is provided by your stitches.
Seventh, design a tension-free closure. This is achieved by appropriate design of the excision or flap, by adequate tissue undermining, and through the use of dermal sutures. More intricate techniques are used to achieve this end in advanced closures.
Eighth, ensure perfect wound edge approximation and skin edge eversion. Limited undermining of the margin allows greater control and easier eversion. Depth of suture bites and distance from the skin edge to the suture entry and exit points should be the same on each side of the wound closure. Fine bites with little tissue actually held by the suture will give less eversion than more substantial bites.
Ninth, use nonabsorbable stitches for surface closure. Absorbing stitches are more reactive, thereby increasing local inflammation and scarring.
Tenth, use interrupted stitches. Although running stitches are faster, they have been shown to strangulate the wound edge and it can be harder to control the level of the wound edge particularly for less experienced hands.
Eleventh, use small skin stitches and remove them early. You must practice a layered closure method in order to do this or you will get a wide-stretched scar or wound dehiscence.
Twelfth, instruct your patients in proper post-operative wound care techniques.