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    Effective surgical closures require planning, follow-up

    Las Vegas — Achieving optimal surgical closures begins long before — and ends well after — the procedure, says Roger I. Ceilley, M.D., an Iowa dermatologist in private practice and clinical professor of dermatology at the University of Iowa, Iowa City.

    "No matter how good of a job you do at suturing," he says, "you won't get an optimal result if you haven't planned out the excision properly."

    Dr. Ceilley, who spoke at the 2012 Fall Clinical Dermatology Conference. suggests marking excisions while patients are in a neutral position and designing incisions such that closure lines fall along relaxed skin tension lines or expression lines. "This minimizes the tension on the wounds. Wounds that are closed without tension tend not to spread, and they heal with less noticeable scars,” he explains.

    Taking steps such as using a length-to-width ratio of 3:1 or 4:1, undermining (which loosens tissues under the wound) and properly removing dog-ears at the ends of a wound minimizes tension and improves cosmesis, he says.

    Additionally, it's critical to position the patient comfortably – with a properly situated headrest and perhaps a pillow under the knees – to avoid fidgeting during the procedure or closure. "It is equally important to position yourself properly and comfortably," Dr. Ceilley says.

    Similarly, "Taking the extra time to administer the local anesthesia with utmost care and a slow, gentle technique makes a great deal of difference," he adds. Some patients also benefit from nerve blocks, especially for procedures around the ear or nose.

    Deep suturing
    Proper deep suturing removes tension from skin sutures, Dr. Ceilley says. "If you don't have tension on the skin sutures, you're less likely to get stitch marks or other marks on the surface" as the wound heals. For deep suturing, he recommends using dissolvable, nonreactive sutures and averting wound edges. This way, if the wound contracts slightly while healing, "It will heal flat. But if the edges are depressed when you repair the defect, the patient will always have a little groove there."

    For skin suturing, Dr. Ceilley says he uses a smaller monofilament-type suture that requires removal. Dissolvable sutures and tissue glues also can be effective, but only for skin wounds free of tension.

    Finally, Dr. Ceilley says, "It's important to train your staff diligently in all aspects of the procedure. The patient should leave with a good-looking, functional dressing," because a sloppy dressing might create the impression that the surgery underneath was also substandard.

    To maximize post-procedure healing, he says, dermatologists must counsel patients thoroughly regarding how to care for wounds, which activities to temporarily avoid (such as heavy lifting) and what to expect regarding swelling or bruising.

    Disclosures: Dr. Ceilley reports no relevant financial interests.

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    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.

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