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Linear Excisions and Repairs
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Suturing techniques play a critical role in the efficiency of surgical reconstruction, and technique choice may also affect the design of linear closures.
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Historically, most linear closures relied on a bilayered closure approach, with sutures placed in the dermis for tension relief and transepidermally for wound-edge approximation. This paradigm has shifted over the past few years, with the realization that recruiting deeper tissue planes may have a profound effect on wound strength and cosmesis.
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Fascial plication is one of the most useful techniques for linear closures, as it confers several advantages simultaneously.1 First, it leads to significant tension reduction over the wound surface by shifting tension to the deep fascia. Second, it decreases the amount of undermining needed to permit effective closure, theoretically improving vascular supply to the undersurface of the advancing wound edges and reducing the risk of potential space formation that may increase the risk of hematoma formation. Finally, fascial plication has a significant effect on wound geometry, as a single fascial plication suture shifts a wound from a 3:1 fusiform shape to a 6:1 ratio and decreases the apical angles significantly.
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Fascial plication sutures need not be used for all linear closures. This technique is most appropriate for areas under significant tension or large excisions where minimizing the postoperative wound length is desirable. On the face, recruiting the superficial musculoaponeurotic system (SMAS) may be very helpful. When designing the closure of a round defect, the fascial plication suture should be placed prior to removing the dog ears. The risks of fascial plication sutures include possible pain, a theoretically increased infection risk (since the fascial envelope has been pierced by suture), and a theoretical risk of vascular compromise through inadvertent pressure-induced ligation of perforating vessels. In practice, these complications are infrequent, though patients may experience transient pain during needle entry and immediately after the fascial plication suture is tied. If pain persists for more than 5 minutes, the suture should be removed.
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Buried dermal sutures are the cornerstone of linear repairs. Two central suturing techniques are useful, the buried vertical mattress suture and the set-back dermal suture. The former yields significant wound-edge eversion and epidermal approximation, while the latter is easier to execute, provides even more eversion, and results in better cosmesis. Indeed, a randomized controlled trial has suggested that the set-back suture leads to cosmetically more appealing scarring than the buried vertical mattress suture. Its ease of use is a significant advantage as well, particularly as effective wound-edge eversion is one of the most challenging (and clinically critical) components of the linear excision and closure.
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Set-back dermal sutures result in marked wound-edge eversion, though this can be adjusted based on how set back each bite is taken from the incised wound edge.
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Though many manuscripts and chapters addressing linear closures advocate the placement of a key ...