Soft Tissue Surgery (Advanced)

Edward A. Jackson, MD, FAAFP Daniel Stulberg, MD, FAAFP ACTIVITY DISCLAIMER

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

This CME session is supported in the form of disposable supplies (non-biological) to the AAFP from Johnson & Johnson Medical Devices Company. DISCLOSURE

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Edward A. Jackson, MD, FAAFP

Medical Director, Florida Hospital Osteopathic Family Medicine Residency, Orlando

Dr. Jackson specializes in procedures and dermatology topics. He has more than 20 years of residency teaching experience and considers training qualified new physicians to be the most critical challenge currently facing family medicine. He believes that funding of practice and patient care is critical to ensure students will be interested in family medicine. A frequent speaker at the AAFP Family Medicine Experience (FMX), Dr. Jackson was the recipient of the Michigan Family Medicine Educator of the Year award in 2009. Daniel Stulberg, MD, FAAFP

Professor and Vice Chair of Education, Department of Family and Community Medicine, University of New Mexico (UNM) School of Medicine, Albuquerque

Dr. Stulberg completed the Integrated Premedical-Medical Program and residency at the University of Michigan. He is a professor and the vice chair of education for the Department of Family and Community Medicine at the University of New Mexico, where he also directs the UNM School of Medicine’s preceptorship programs. A frequent speaker for the AAFP, Dr. Stulberg has published many articles and book chapters on skin conditions in family medicine. Learning Objectives

1. Demonstrate proficiency in a variety of surgical skills, including advanced suturing, wound closure and redundant skin techniques.

2. Utilize different wound closer materials, which may include surgical needles, sutures, skin staples, dermabond, tapes, bandages or adhesive.

3. Use adequate volumes of anesthesia or the use of field blocks to obtain a good area of anesthesia to perform a flap and plasty procedure.

4. Establish appropriate billing and coding protocols for performing advanced soft tissue procedures. Brief Review of Basic Skin Surgery Concepts INSTRUMENTS FOR SKIN SURGERY GENERAL PRINCIPLES All instruments for delicate skin work should be about 4 to 5 inches in length, so there is good balance of the instruments in the hand. Physicians should feel comfortable holding the instruments used during cutaneous surgery.

SUGGESTIONS FOR ADMINISTRATION OF ANESTHETICS

• Use small-caliber needles (30 gauge) • Pause after needle insertion • Administer solution slowly, under low pressure • Initially administer subdermally • Stretch the skin prior to injection • Consider vibrating skin to reduce discomfort • Talk to the patient (verbal anesthesia) SKIN EDGE EVERSION

• Everted skin edges counteract the natural tendency of all wound edges to invert • Inverted edges produce poorer cosmetic results • Inverted scars on the face cast a shadow, magnifying the appearance of the scar • Eversion resists the tendency for a wound edge to roll under • Everted edges result in faster wound healing and result in fewer wound infections

PRINCIPLES OF SUCCESSFUL KNOT PLACEMENT

• The first double loop is teased and snuggled down to coapt wound edges, and then the suture is slightly lifted to align/evert skin edges • After 1st loop is placed, maintain traction on one strand to avoid loosening of the throw • Compl. knot is tied firmly to avoid unraveling • Avoid tying too tightly to avoid tissue necrosis • Final throw is placed in a horizontal plane • Extra ties only add bulk, not strength to knot

THE SIMPLE INTERRUPTED SUTURE • Fundamental tool of skin surgery • Generally this suture is not used for bringing together wound edges under tension • Simple inter. sut. are used alone for shallow wounds or for lacerations w/o edge tension • Use other tech. for placement of simple sut., incl. flask-shaped suture path & halving tech. • Placement of tightly clustered sut. close to wound edge produces less wound tension PRINCIPLES OF HALVING THE LINES OF LEAST SKIN TENSION • Scars that parallel the lines of least skin tension tend to be narrower, heal faster, and are stronger • Hypertrophic scar formation often develops in wounds that are oriented across flexor creases • Follow the lines whenever possible to produce superior cosmetic & functional results

UNDERMINING WOUND EDGES

• Process of separ. skin from underlying tiss. to facilitate tissue movement for wound closure • Releases vert. fibrous bands beneath the skin, red. vertical & lateral tension on wound edges • Restores skin surface contour following large, deep excisions • Wound contraction in areas of undermining may actually serve to strengthen the final scar

BURIED SUBCUTANEOUS SUTURE

• Important technique in excisional surgery • Vertical suture placed entirely in SQ tissues • Knot is buried beneath the dermal-fat junction • Technique can be used at several levels in the repair of deep wounds • Reduce dead space, hematoma formation, wound drainage & subsequent scar retraction • Wound dehisc. may be prevented by this suture

THE FUSIFORM EXCISION

• Commonly performed office procedure • Technique has the advantage of one-stage diagnosis and treatment • Proper performance of the fusiform excision involves many other techniques such as local anesthesia administration, undermining & deep buried SQ suture placement • Provides excellent histologic specimens and good cosmetic scars

SUGGESTED SKIN SURGERY TRAY

• No. 15 scalpel blade and handle • Needle holder • Metzenbaum and straight iris scissors • Adson forceps with and without teeth • 2 Mosquito hemostats • 2 inches of 4 x 4 gauze • Fenestrated disposable drape • 21 gauge 1 ½ in needle (bent into skin hook) FIELD BLOCK ANESTHESIA

• Performed by encircling the operative area with a ring of anesthetic • Commonly chosen to anesthetize more distensible skin around more taut skin, avoiding discomfort of injection into ear or nose • Digital block is a field block that uses lidocaine without epinephrine • Add. anesthetic sometimes is needed beneath a SQ lesion to provide adequate deep anesthesia FIELD BLOCK ANESTHESIA

• Installation of local anesthesia to interrupt nerve transmission prox. to skin site needing anesthesia • Field blocks differ from nerve blocks in that more than one nerve is anesthetized • Can provide large areas of anesthesia • Does not disrupt the architecture or contour of skin, allowing for improved cosmetic results • Epinephrine is used on trunk and face, allowing for greater volume of fluid administration

FACIAL NERVE BLOCKS

• Injection of an anesthetic around a nerve • Can anesthetize large anatomic areas • Smaller doses of anesth. usually very successful • May avoid systemic or CNS toxicity that can occur when injecting on the head • Help maintain skin contour and landmarks in producing cosmetically superior closures • 2% lidocaine w/o epinephrine (applied away from surg. field) advocated for facial blocks PROBLEMS WITH FACIAL NERVE BLOCKS • Major cause for inadequate nerve block is failure to deliver anesthetic solution to site • Inadequate time for the block to work: 2 mm – 6 mm of nerve must be exposed to solution • Excess bleeding from highly vascular facial tissues that did not receive epinephrine • Nerve laceration can produce long-term dysesthesias, usually nerve regenerates and sensation returns FACIAL NERVE BLOCKS • Supraorbital-supratrochlear block: for medial portion of forehead • Infraorbital block: anesth. lower eyelid, upper lip, part of med. cheek & lat. nose • Mental block: for upper chin, lower lip, and mucous membranes inside the lower lip

Courtesy of Thomas Zuber

Courtesy of Thomas Zuber

DIGITAL NERVE BLOCK

• One of the easiest to learn and most commonly performed anesthetic procedures • Field block for the four lateral digital nerves • Two injection sites needed • Needle is inserted down to the bone, midway between the dorsal and palmar surfaces • Anesthetic is admin. on side of digit, and then needle angled toward dorsal & palmar surfaces

PITFALLS FOR DIGITAL NERVE BLOCK • Ring of anesthetic around digit is discouraged, as lg volumes of fluid can impede circulation • Circulatory difficulties are more common when the patient has vasospastic dis., digit is swollen before inj., or if > 8 ml. administered • Use of epinephrine not advocated, although epi. may be safer than previously thought • Administer 1-3 ml of 2% (not 1%) lidocaine, as higher strength lidocaine more effective THE PRINCIPLES OF FLAP CLOSURE • Local skin flaps provide a sophisticated approach to clos. of large cutaneous defects • When nearby structures (nose) or inadequate skin laxity prevents simple closure, consider recruitment of nearby skin • Always seek the simplest effective closure that provides good functional/cosmetic results • Skin flaps carry their own blood supply unlike skin grafts CLASSIFICATION OF SKIN FLAPS • Historically, local flaps were described as axial pattern flaps that followed the anatomy of a specific artery, or random pattern flaps that did not follow a specific arterial pattern • Most local flaps derive their blood supply from the dermal arterial and capillary blood flow • Random pattern flaps are reviewed in this course; axial pattern & myocutaneous flaps are complex tech. best left to experienced surgeons FLAP CLOSURE FOLLOWING SKIN CANCER REMOVAL • Many flaps are performed to close defects following skin cancer removal • Margin clearance of cancer should be assured whenever possible with Mohs technique, multiple frozen sections, or permanent sections and delayed closure • Flap closure following malignancy excision should be deferred if there is significant risk of tumor-positive margins PLANNING A SKIN FLAP CLOSURE • Many considerations go into planning a flap • Donor skin is sought w/ adequate tissue laxity • Match the surrounding skin to the area of the defect for skin thickness, color, texture • Recruit skin perpendicular to resting skin tension lines to hide final scar • Orient clos. lines w/ expression lines/ wrinkles • Dog-ears should be avoided • Flaps are easier in elderly due to skin laxity MARGINS FOR SKIN CANCER REMOVAL • Surg. exc. is preferred tmt for many in U.S. • Unfortunately, BCC recurs 10% when adeq. exc., and up to 30% when margins involved • Mohs micrographic surgery is a layer by layer eval. by the surgeon of undersurface of excised specimen with lowest recurrence rates • Mohs surgery cannot be universally applied due to higher costs, lack of availability • Frozen sect. eval. is costly and time-consuming MARGINS FOR BCC

• 4 mm margin of clinically normal-appearing skin around a discrete, primary, small (<2cm) BCC will result in complete exc. in 98% • Lesser margins, even for small BCC (<0.6 cm) drop the rate of complete excision to 80% • 10 mm margin often prod. complete exc. for large BCC (>2 cm) but lg amount tis. removed • Adequate depth is level of midfat • Mohs for large, aggressive, H-zone tumors THE H-ZONE AREAS ON HEAD ASSOCIATED WITH HIGH RATES OF SUBCLINICAL EXTENSION AND RECURRENCE INCLUDE: Around the eyes and lower eyelid Ears Nose Upper lip Temple area

Practice Recommendation • In a structured abstract of a systemic review of treatment modalities for primary basal cell carcinomas done for the Cochrane Database, it was recommended that Moh’s surgery be used for larger, morphea-type BCCs located in the danger zones. For smaller BCCs of the nodular and superficial types, surgical excision remains the first treatment of choice. Other treatment modalities can be used in patients in whom surgery is contraindicated.

AAFP-approved source: DARE Specific website: http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=11999002074 Thissen MR, Neumann MH, Schouten L J.A systematic review of treatment modalities for primary basal cell carcinomas. Arch of Derm 1999;135(10):1177-1183.

Level(s) of Evidence: Level C Evidence. PREVENTION OF FLAP COMPLICATIONS: HEMATOMA

• Hematomas beneath flaps increase rate of necrosis • Hematomas often relate to drug-induced coagulopathy or inadequate intraoperative hemostasis. • Follow-up visit 1 day after flap surgery allows for removal/drainage of hematomas • Some authors in the past discouraged use of epinephrine, as it may increase risk of flap necrosis, but most employ it because of the utility

PREVENTION OF FLAP COMPLICATIONS: INFECTION • Wound infections complicate about 2% of clean dermatologic surgeries • Flaps over ear cartilage at incr. infection risk • Prophylactic antibiotics controversial, but may be used for 3 days for lengthy procedures or on high-risk sites such as ear, axilla, groin • Prophylactic antibiotics considered for patients with DM, renal insufficiency, or on immunosuppressant treatment PREVENTION OF FLAP COMPLICATIONS: HIGH TENSION • Increased tension signif. cause for flap slough • Flap design plays major role in influencing wound tension and flap circulation • Flap necrosis often occurs when designing too small a flap to cover a defect • Longer flaps have poorer tolerance for tension • Novice physicians should not be intimidated by the size of the skin flaps needed to cover a defect

PREVENTING FLAP COMPLICATIONS: MOIST HEALING

• Moist wound healing has been demonstrated to benefit most surgical wounds • Application of topical creams and ointments over flaps may enhance survival by preventing desiccation by limiting evaporative losses • While many surgeons select antibacterial ointments for their postoperative care, it is not clear that the anti-bacterial effect provides benefit

PREVENTION OF FLAP COMPLICATIONS: TRAPDOOR EFFECT • Trapdoor/pincushioning effect is elev. central tis. prod. by downward contr. of surround. scar • Commonly seen 1-6 mos after facial flap surg. • Z-plasties have been used to break up scars • Wide tissue undermining around a flap also helps by altering horizontal forces around flap • Other techniques suggested include reducing SQ fat under flap center, making flap edges vertical, and use of everting vert. mat. sutures

THE VERTICAL MATTRESS SUTURE

• Vertical mattress suture can be used to pull wound edges together over a long distance • Valuable tech. prod. eversion in wounds that tend to invert, such as neck, forehead creases • Utilizes the far-far, near-near technique • Far-far pass is about 4-8 mm from the wound edge on each side, deep into tissue • Needle is placed backwards in needle holder, passed 1-2 mm from edge shallow in dermis

Shorthand Vertical Mattress • Needle is inserted superficially close to edge • Skin margins gently lifted upward • Needle is reversed and deeply inserted THE VERTICAL MATTRESS SUTURE • Main disadvantage is that it is tedious and time-consuming to place • Using large-caliber material or closing the wound with too much tension will result in “railroad marks” • Necrosis of skin in the exteriorized loops of suture can result when suture is tied too tightly

Vertical Mattress Practice THE O TO Z PLASTY

• The O to Z plasty is a double rotation flap • Following creation of circular defect, 2 sloping arms are incised on opp. sides of the defect • Final Z-shaped scar following flap movement • Each of the sloping arms extends lat. about 1 ½ x the diameter of central circ. defect • Some surgeons envision O to Z as a large fusiform excision without all sides incised • Arms can be extended if tension too great

Courtesy of Thomas Zuber Courtesy of Thomas Zuber Courtesy of Thomas Zuber Courtesy of Thomas Zuber Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD

THE O TO Z PLASTY: INDICATIONS • Closure of a defect on the chin • Closure of a large forehead defect • Repair of a large scalp wound • Closure of a defect below the chin • Repair of a temple defect Practice O to Z Plasty • Plan and practice the O to Z THE CORNER STITCH

• Valuable tool for approx. corner of wound/flap • Technique is a variation of the half-buried mattress suture, closing a corner without compromising blood flow to the tip • Avoids the tedious task of trying to place enough small sutures to hold down both edges of a corner without stitches crossing • Standard corner stitch closes angled corners of 90 degrees, although many variations used THE CORNER STITCH TECHNIQUE

• Suture starts in intact skin 5-8 mm opp. corner • Suture needle passed to mid-dermis 4 mm from the wound corner • A loop of suture passes through the mid-dermis of the flap tip, entering and exiting the edge of the flap 4 mm from the tip • Suture needle reenters intact skin 4 mm from the corner on the other side, exiting skin equidistant from corner as the entry point

Practice Corner Stitch DOG - EARS

• Dog-ears are tissue redundancies that may appear at the end of a closed wound • Bunched-up or elevated areas may appear in properly or improperly closed wounds • Tissue rotation or compression always produces some degree of redundancy • Dog-ears relate to degree of tissue elasticity, excess SQ fat at end of the wound, and the natural convexity of extremity promoting effect

BUROW’S WEDGE TRIANGLES

• Closing defects with wound edges of unequal length can result in conical tissue elevations known as dog-ears • One method to avoid dog-ear formation is removal of a triangular piece of tissue on the longer side, effectively shortening that side • Triang. pieces of tis. known as Burow’s triangle • Some suggest fusiform excision represents a circular defect with 2 Burow’s triangles at ends BUROW’S WEDGE TRIANGLES

• Some believe that skin flaps are geometric configurations that allow for Burow’s wedge triangles to be placed in more convenient loc. • Most flap designs include Burow’s wedge triangles at the distal end of the flap • Distal Burow’s triangles often are smaller than they would be if performed next to skin defect, as the tissue redundancy is spread out over the distance of the flap edge

Burrows Triangle Exercise • Create a half moon shaped lesion • Undermine the wound edges • Remove a burrows wedge triangle • No need to suture BUROW’S WEDGE TRIANGLES ALONG A STRAIGHT LINE • Skin moved along a line to closed a triangular defect requires a Burow’s wedge triangle on the opposite side of the line • Adjacent Burow’s wedges generally are similar in size to the original defect • Burow’s wedges that are created some distance away down a long line allow for more redundant tissue to be “borrowed” to close the skin defect

INDICATIONS FOR BUROW’S WEDGE TRIANGLES • Removal of redundant tissue at distal edge of a rotation or advancement flap • Closure of a half-moon defect with wound edges of unequal length • Closure of defects near vital facial structures that prevent primary fusiform closure • Excision of lesions of eyebrow, carrying the wound laterally to avoid hair-bearing tissue THE SINGLE V-Y PLASTY

• Island pedicle flap technique • Variation of the fusiform excision technique, and is used when a full fusiform exc. cannot be perf. due to nearby fixed obstruction (nose) • Best used with rich blood supply (face, hand) • Not the same as V-Y advancement flap • Do not undermine the flap, as this is the source of blood flow and oxygenation • Final wound closed in a Y-shape

THE SINGLE V-Y PLASTY: INDICATIONS • Closure of a cheek defect next to nostril • Closure of a defect near the angle of the mouth • Closure of a defect near the lateral edge of the eyebrow • V-Y pulp flap closure of a fingertip amputation

Single V-Y Plasty • Create a single V-Y Plasty • Careful not to undermine! THE DOUBLE V-Y PLASTY

• Two island pedicle flaps are used to close a wound with less central tension • Technique is a variation of the fusiform exc. • Main indication for this technique is to reduce cosmetic def. created by pull on tissues lateral to the largest, central portion of the wound • Small island flaps are nourished by intact vessels beneath, & should not be undermined • Only used where good perfusion (face)

Courtesy of Thomas Zuber THE DOUBLE V-Y PLASTY: INDICATIONS • Excision of lesions just above eyebrows • Closure of a defect just above nares • Closure of a defect on the upper lip • Closure of a defect in the chin crease THE SINGLE ADVANCEMENT FLAP • Advancement flaps move adjacent tissue into a defect without rotation or lateral movement • Inferior and superior dimensions of the advancement flap are equal • Tissue in the flap is stretched more than surrounding skin, creating dog-ears at ends • Advancement flaps in areas of low skin elasticity req. Burow’s triangles at distal ends • Nonfacial adv. flaps length to width ratio < 3:1

THE SINGLE ADVANCEMENT FLAP: INDICATIONS

• Remedy lateral eyebrow defects • Repair defects in the temple area • Closure of forehead defects • Closure of defects in the tip of the nose THE SINGLE ADVANCEMENT FLAP: INDICATIONS

• Remedy lateral eyebrow defects • Repair defects in the temple area • Closure of forehead defects • Closure of defects in the tip of the nose

Single Advancement Flap • Plan and cut a single advancement flap using a square removal of tissue • Try to allow enough skin on the opposite side of the flap to use later THE BILATERAL ADVANCEMENT FLAP

• Often created when single advancement flap fails to create enough laxity to close • Bilateral advancement flap stretches skin from two directions • Allows flap length to be less than with a single advancement flap • Adequate undermining needed, and often Burow’s wedges not necessary

THE BILATERAL ADVANCEMENT FLAP: INDICATIONS

• Closure of skin defects on the trunk and abdomen (ideal for lax abdominal skin) • Closure of a defect in the middle of the eyebrow • Closure of forehead defects Double Advancement Flap Practice • Use the single advancement flap and create a double by cutting on the opposite side of the single or create a new flap THE ROTATION FLAP

• One of simplest and safest flaps to perform • Undermined semicircular flap of skin is rotated around a pivot point close to triangular defect • Often used when lax donor skin is a distance from the original defect • Incisions designed to hide within creases • Flap is often 4x the original defect, and large base of pedicle allows for good blood flow • Burow’s triangle needed at distal end of flap THE ROTATION FLAP

• If the pedicle of the flap is placed inferiorly, gravity aids in lymphatic/venous drainage • Because the flap becomes effectively shorter the more it is rotated, a back cut sometimes is performed to reduce tension across the flap • This is a transposition flap: combining rotation of skin with direct advancement of skin to cover a defect • Double rotation flaps in the A to T plasty

Courtesy of Thomas Zuber Courtesy of Thomas Zuber Courtesy of Thomas Zuber Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD Courtesy of Edward Jackson MD THE ROTATION FLAP

• Coverage of a defect over the temple • Large chin or cheek defects can be closed with rotation flaps • Large defects on the scalp • Defects in the inelastic skin of the back, trunk, or extremities

Rotation Flap Practice • Plan and cut a simple rotation flap

THE A TO T FLAP

• T-shaped closure may be needed if excision cannot proceed into surrounding structures • A to T is a bilateral advancement flap, closing a triangular defect on one side of a line • The incision line is extended out in both directions from the defect • Large pedicles created permit good blood flow • Two pedicles slide along incision line to close into T-shaped wound

THE A TO T FLAP: INDICATIONS

• Closure of defects on the lower eyelid • Closure of defects in preauricular area • Closure of a wound on the upper lip • Closure of a defect just lateral to the nasal ala • Closure of a defect just above the eyebrow DOG-EARS AND THE A TO T FLAP • Dog-ears frequently encountered after closure of the triangular defect • Burow’s wedges needed on opposite sides of the original defect at the ends of the line • Burow’s wedges are not incised until after the flaps have been advanced to prevent unnecessary tissue removal • Dog-ear can appear at apex of triangular defect, and tissue may need to be excised THE BASIC Z-PLASTY

• Commonly used tech. in plas. surg. to change wound direc., aligning it with lines of least ten. • Transposition of 2 triangular flaps that creates a final Z-shaped wound • Mult. var. exist in angles and length of arms • Improves the appearance of scars and corrects scar webs and contractures • Can reorient a scar so that it conforms to naturally occurring concavities or depressions THE BASIC Z-PLASTY

• Z-plasty increases the length of skin available in a desired direction • Increases skin available across a defect by 50% for a 45 degree Z-plasty, and by 75% for a 60 degree Z-plasty • This lengthening reduces the tension across the flexor crease (site of flexion contracture) • The increase in skin length in one direction is at the expense of tissue to the sides

SIMPLE Z-PLASTY TECHNIQUE

• Two side arms equal length to center wound • Draw & measure lat. arms on opposite sides of the center wound, at 60 degrees to center wound • Incise center wound and side arms • Undermine the flaps and surrounding skin • Transpose flaps and anchor each flap in place • Corner stitches advocated for flap tips • Limit no. of sutures between flaps (1-3 only)

Z Plasty Practice • Draw and cut a 60 degree Z plasty • Rearrange the tissue to observe how the center line moves MULTIPLE Z-PLASTIES

• Z-plasty redirects wounds of modest dimen. • When a long wound needs to be redirected, multiple small Z-plasties produce a less obtrusive result • Meticulous work for multiple Z-plasty, but produces superior cosmetic results • A single large Z-plasty produces large flaps that transpose under great tension, while mult. Z-plasties can be perf. under low tension

Z-PLASTY INDICATIONS • Bowstring scars across flexion creases • Scars bridging across a concavity • U-shaped scar of the face with a trapdoor effect • A long, continuous scar that runs perpendicular to the lines of least skin tension THE RHOMBOID FLAP

• Rhomboid or Limber flap is transposition flap • Based on geometry of rhomboid or diamond: equilateral parallelogram with oblique angles • Mainly used for clos. of small to mod. defects • Utility of flap relates to ability to be created from any side of the flap • Final result is broken line which hides well • Wide undermining needed, but undermining of the flap base can compromise blood flow

Rhomboid Flap Practice

• Draw and cut a rhomboid flap THE RHOMBOID FLAP: INDICATIONS • Closure of defects around eyes/eyebrows • Closure of defects on the lips • Closure of a defect over the glabella • Closure of a large hand defect • Closure of cheek defects SCALP REPAIR TECHNIQUES • Scalp repair presents special challenges • Rich plexus of vessels in the inelastic scalp dermis, creating marked bleeding from wounds • SQ tissue has thick fibrous bands (retinacula) uniting skin to galea and supporting blood vessels (keeps vessels open when cut) • Hair follicles from skin may enter SQ layer, and must not be damaged when undermining • Best undermining at fat-galea layer EMERGENCY OR “FIRST AID” SCALP REPAIR TECHNIQUES • Physicians often asked to intervene in emergencies where scalp bleeding is profuse • Hair can be twisted together and tied across the wound, and knot placed on top of wound • Benzoin, hair spray, or tape holds the knot • Pass clean hypodermic needle through wound edges, run fishing line thru needle, remove the needle and then tie

SCALP REPAIR TECHNIQUES

• Scalp generally repaired in one layer • Closing upper scalp layers approx. lower lay. • Large needles used to grasp more tissue • Sutures can be tied tightly for hemostasis • Figure-of-8 stitch is rapid and hemostatic • Large caliber sutures (3-0) often selected • Galea defects closed with interrupted absorb. • Min. trimming wound edges to limit tissue loss

Practice Scalp Repair LIP LACERATION REPAIR

• Vermilion border of the lip is the tissue transition between the skin and oral mucosa • Any lip repair must exactly realign vermil. bor. • A 1 mm offset of vermil. bor. will be noticeable • Consider placing marking sutures at the vermilion border on each side of the wound before initiating deeper sutures • Tie the vermilion border together before placing other skin sutures LIP LACERATION REPAIR

• Lip can swell with admin. of local anesthetic • Consider mental nerve blocks, or a combination of regional and local anesthesia • Lacerations with jagged skin edges should have sharp, incised edges perpendicular to the vermilion border • Any laceration involving the orbicularis oris muscle should be repaired in layers, with separate repair of the muscle

THROUGH-AND-THROUGH LIP LACERATION REPAIR • Irrigate to limit oral bacterial contamination • Marking sutures placed in vermilion border • Oral mucosa closed first with 5-0 Vicryl up to the top of the lip • Gauze placed bet. mucosa & teeth, re-irrigate • Orbicularis oris muscle and SQ repair in layers with interrupted 5- 0 Vicryl behind vermilion border

LIP WEDGE EXCISION

• Wedge excision of lip is valuable for removing infiltrating lesions (SCC) of the lower lip • SCC margins must be clear because metast. risk • Performed in office under local anesthesia • Reapprox. of vermilion border critical • Inferior labial art. consist. landmark 2/3 way back from vermilion on posterior shelf of lip • Artery should be identified, clamped and tied • Up to 1/3 of lip can be exc. with limiting stoma

Squamous Cell Carcinoma Keratoacanthoma Type Purse String Suture Repair by Daniel Stulberg Shave biopsy base of actinic horn-Squamous cell carcinoma Ellipse margins vs Purse string

Ellipse margins

Courtesy Daniel Stulberg, M.D. Incise circumference

Courtesy Daniel Stulberg, M.D. Remove sample

Courtesy Daniel Stulberg, M.D. Widely undermine wound margins

Courtesy Daniel Stulberg, M.D. Serpentine dermal suture 2-0 Vicryl

Courtesy Daniel Stulberg, M.D. Leave space between needle exit and entry

Courtesy Daniel Stulberg, M.D. Completing circumferential stitching

Courtesy Daniel Stulberg, M.D. Friction knot

Courtesy Daniel Stulberg, M.D. Tightening purse string

Courtesy Daniel Stulberg, M.D. Tighter

Courtesy Daniel Stulberg, M.D. Tight enough Can close as ellipse

Courtesy Daniel Stulberg, M.D. Simple suture 4-0 prolene

Courtesy Daniel Stulberg, M.D. Three interrupted sutures Adhesive strips if desired

Courtesy Daniel Stulberg, M.D. How does this look in the long run? SCC Keratoacanthoma typeSCC Keratoacanthoma type ShaveShave biopsy biopsy positive positive deepdeep margin margin

Courtesy Daniel Stulberg, M.D. Excision with margins Purse string to ellipse then Vertical mattress and 2 interrupted simple

Courtesy Daniel Stulberg, M.D. 8 weeks post op

Courtesy Daniel Stulberg, M.D.Courtesy Daniel Stulberg, M.D. 10 months post op

Courtesy Daniel Stulberg, M.D. BILOBED FLAPS

• Transposition flaps like bilobed flap are most frequently used local skin flaps on the face • Bilobed flap used when primary defect is on inelastic skin, & nearby elastic skin brought in • Main clinical application on lower 1/3 of nose • Two transposition flaps used to close 1 defect • Most bilobed flaps are rotated about 90 deg. to each other, but total rot. < 180 deg. gives the best cosmetic results BILOBED FLAP TECHNIQUE

• Circular defect has a lateral cone excised • First limb circular, approx. same diameter or slightly smaller than original defect • Second limb is cone shaped, about 2/3 of the diameter of the first limb, and should point upward (between the eyes) • First limb into orig. defect, second limb into first limb defect, 2nd defect closed primarily • Smaller the total area moved, easier the closure

Courtesy of Thomas Zuber MD Courtesy of Thomas Zuber MD Coding Flaps Practice Recommendations

• Use demonstrated advanced skin closure skills when faced with challenging closure of a laceration or excision that does not allow for a fusiform excision

• Use of an O to Z plasty is the basic flap that can be employed and it builds on a fusiform excision technique.

• Use adequate volumes of anesthesia or the use of field blocks to obtain a good area of anesthesia to preform a flap and plasty procedure Contact Information Edward A. Jackson, MD Medical Director, Florida Hospital Osteopathic Family Medicine Residency 7975 Lake Underhill Rd, Suite 200 Orlando, FL 32822 Email: [email protected] or [email protected] Thank you! Syllabus Extra – Extensor Tendon Repair EXTENSOR TENDON REPAIR

• Cut ext. tendon doesn’t retract like flexor tend. • No true capsule for extensor tendon, and adhesions can develop to SQ tissues or skin • Handle tendon gently to prevent fraying • Monofilament suture (4-0 Prolene) used • One suture adequate for repair • Mod. Bunnell tech. strong for postrep. motion • Bulky hand dress & splinting, motion in 3 weeks EXTENSOR TENDON REPAIR

• Flexor tendon inj. always referred hand surg. • Extensor tendon injuries on the dorsum of the hand can be repaired in the ED • Ext. tendon injuries most common in zones 5 and 6 (over MCP joints to wrist) • Fracture or wound contamination is excluded • Zone 6 injuries (over dorsum of hand) may be obvious if finger drooping • Partial lac. of tendons often heal well w/o suture