Advanced Suturing

Dennis LaRavia, MD, DiplomateABFM; Fellow AAFPProfessor, LSUHSC-NO School of Medicine, Dept. of Family MedicineResidency Director, LSU Rural Family Medicine Program, Bogalusa, LA

BASIC SUTURING: A REVIEW

Cleansing and IrrigationAnesthetic ChoicesSuture SelectionHealing ConsiderationsSuture Removal ConsiderationsPost-op Discussion

Basic Closure: Review

Thorough Debridement and CleansingAppropriate AnesthesiaProper Selection of SutureGood closure techniques:

Approximation, not strangulationMild eversion, no inversion Suture not too close to skin edge

Basic Closure: Continued

FollowupSuture Removal TimingLong-term skin careWound Healing:

0-5 Days= Initial Lag Phase5-14 Days= Initial Healing Phase14-365 Days= Complete Healing

Initial Goals: Advanced RepairEvaluate Lesion/Lesions for possible excision/RepairUnderstand Patient’s Expectations

Discuss options and choose correct optionInformed Consent ProcessPerform the procedure correctlyPost-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:BiopsyExcisionSurveillanceRepair

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 patientDevelop Best Plan with patient’s agreementDiscuss details of approachDiscuss, in general, post-op and healing expectations

Informed Consent Process

Informed consentPhoto consentPhotograph the lesion(s): Preferably digital*All documentation into EMR or Paper RecordReaffirm Allergies/Sensitivities

Perform the “Right” Procedure Correctly

Review anatomy of regionUnderlying structures

Preparation of the WoundType 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 AreasNeck AreasWrist and HandOther areas with significant deep structures to the wound or lesion

Perform the Procedure Correctly-Preparation of Wound

Antiseptic/Aseptic PrepBetadineAlcoholSoap CleanserOther Prep

Site and individual Dependent

Perform the Procedure Correctly-Preparation of Wound (cont)

AnesthesiaWho-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)

AnestheticBlockLocalBuffered Solution: Why?

1:8 to 1:10 Dilution of Sodium Bicarbonate to AnestheticChoice of materials

LidocaineMepivacaineWith or without epinephrine

Anesthetic Concentrations:EquivalentConcentration Local Anesthetic Onset Duration

1% Lidocaine 1 min 45-60 minutes

1% Lidocaine w/epi 1 min 2 – 6 hours

1% Mepivacaine 3-5 mins 45-90 minutes

.25% Bupivacaine (Marcaine) 5 mins 2-4 hours

.25% Bupivacaine w/epi 5 mins 3-7 hours

Perform the Procedure Correctly- Suture Selection

Non-ResorbableMonofilament

Resorbable (Absorbable)MonofilamentBraidedCatgut

PlainChromic

Healing Time

Sutures

Suture/Types Tissue Reaction Absorption RateAbsorbable Sutures:Gut/Plain Moderate 70 daysGut/Chromic Moderate 90 daysPolyglycolic/Mono (Dexon) Mild 40% 7 daysPolyglactic/Braided (Vicryl) Mild 60-90 days

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 & InstructionsPatient Responsibilities:

Clean-Daily?Dry or wet-Antibiotic ointment?Covered or not

o Site Dependento Individual Dependent

Return timeCall/Come In for departures from the expected

Post-Op Care (continued)Physician Responsibilities:

Suture Removal-When?Face,Scalp, and NeckHands, Arms, and FeetTrunkLegs

Post-op evaluationIndividual careReturn 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 assistantComplete set of instrumentsComplete set of supplies/Including plenty of backup sets “Ready to Go”Appropriate time set aside for procedureGood lighting (and glasses if necessary)

Preparation of the Mayo Stand What is on the stand?

Metzenbaum ScissorsSmooth forceps, tissueIris Scissors, curved or straightMosquito hemostats, curved twoHemostats, straight, twoSkin retractors, twoAllis forcepsScalpel, #15

Needle HoldersSuture Scissors4x4’s2x2’sH2O2?Sterile SalineExtra Buffered anesthetic with a small needleSuture, Varieties

Support EquipmentHot penElectrocauteryCryogun

Wound Healing ConsiderationsColor of SkinKeloid former?Child or Adult?Size of Lesion and RepairWhen to take out suturesWho to take out suturesSteri Strip Usage/BenzoinDiabetic?Immune compromisedOn blood thinnersLikelihood of infection

FarmerChild (particularly boys)

Considerations in Selecting and Planning Technique of Excision

BiopsyExcisional, ellipseKey punch

Variety of sizesSuggested size—4 mms

Considerations: other closures

Skin Glue(Dermabond)When to useWhere to use

StaplersWhen to useWhere to use

Considerations, continued

Definitive ExcisionSite/Proximity to underlying structuresAge of PatientColor of SkinElasticity of SkinPotential shortfalls of approach/complications

Plastic Repairs

Lines of Langerhans

Lines of Langerhans cont’d

Basic Closures

Interrupted

Continuous (Running) Suture

Mattress, Vertical

ShorthandRegular

Mattress, Horizontal

Corner Suture

Deep Inverted Suture

Subcuticular

Undermine?

Why undermine?How to undermineBurow’s Triangle

Other Closures Pearls

Leveling SutureApproximate—Do not StrangulateIf 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 needleLuer-lock preferredInterval: usually 6-12 weeksKeloid: Do not attempt re-excision until patient has received 3 injections

Advanced Closures

Z-Plasty

Z-Plasty

Good Choice for:o Pilonidal Cyst Scar or sinuso 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 Backo Thigho Abdomeno Calf, maybe

Rotation Advancement Flap

Rotation Advancement Flap

Good Choice for:NeckScalpFaceAnywhere 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-PlastyGood choice for:

o Scalpo Faceo Armo Leg o Footo Ankleo 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 Noseo Necko Ear

V to Y Slide 11. Circular Defect

2. Plan triangle, using skin lines

V to Y Slide 23. Incise the triangle,

then undermine thoroughly.

4. Thin base of triangular flap to fit defect.

V to Y Slide 35. Remove triangle

6. Suture base.

V to Y Slide 47. Suture long limb.

8. Close remaining incisions.

V to Y Plasty

Good choice for:o Inferior Orbital areao Pre-auricular area

Rhomboid Flap

Rhomboid Plasty

Good Choice for:o Backo Necko Thigho Abdomen

Advanced Considerations in Skin Closures

Tendon RepairsVariant SuturesRefinement of SkillsWhat to tacklePenrose DrainsConscious Sedation

Skin Grafts

Donor SitesPinchDermatome

Treatment of Donor Site

Warm SalineAntibioticTeflon cover (or Adaptic)

Tendon Repair

SutureApproachPreparationPost-Op Consideration

TENDON REPAIR

Use of Penrose Drains

When to useHow to useWhen to removeProper selection of patient and procedure is the KeyHow to secure them

Conscious Sedation

Midazolam2-10 mgs

Fentanyl25-200 mcgs

Coding & BillingCoding and billing becomes very complex for laceration repair and excisions. Important factors to list for billing personnel are:

LocationSize of lesionLength of closure or excisionSimple or intermediate repairBenign or malignant statusWhether a true skin lesion or subcutaneous tumor or deep tumor was excisedMethod of removal

Coding & Billing continuedSuture 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-NearNear-Far/Near-FarFar-Near/Near-FarNear-Far/Far-NearSpace-ObliteratingPulley or LoopHalf-Buried

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

Vertical Mattress: Classical, Advantages

Everts Skin EdgesReduces Wound TensionEliminates dead spaceProvides a strong closure

Vertical Mattress: Classical, Disadvantages

Potentially StrangulatingMay compress the skin adjacent to the defect causing: scarring

focal necrosisPostoperative edemaTake a little more time

than running suture

Vertical Mattress: Near-Far/Near-Far

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

Promotes Skin EversionUseful 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/Far-Near 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 sutureMain 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 dermisProvides a pulley effect to the closureThought to distribute tension more evenly over a larger areaGenerally 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 PulleyProduces less tension on either of the suture strandsThus reduces pressure or impingement on the skin surfaceAlso, 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 sequenceBut the needle does not pierce the skin surface opposite the starting pointChief Advantage: Less scarring and less likelihood of strangulationApproximates edges well, but may not relieve wound tension as wellUseful on lip, eyelid, or hairline

REVIEW SUMMARY

1. Review the Basics2. Review the options for Closure

before removal of lesion3. Make the Advanced Closure “Fit the

Site”

REVIEW SUMMARY (cont)

4. Acrostic:Corner SuturesUndermineBurow’s TrianglesExtension

5. Self-RefreshersWork 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 ahigher 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 ConsiderationsColor of SkinKeloid former?Child or Adult?Size of Lesion and RepairWhen to take out suturesWho to take out sutures

Wound Healing Considerations(cont)

Immune compromised?Diabetic?On blood thinners?Likelihood of Steri Strip Usage/Benzoin?Likelihood of infection?

FarmerChildren (particularly boys)