Video: 3 Must-Know Tips When Closing a Surgical Wound
Repairing a surgical wound is like an artist visualizing how to fix a broken sculpture. You must understand what pieces are missing in order to fill those gaps, cracks, and crevices to achieve the best aesthetic result.
Every reconstruction is a mix of art and science and becomes your masterpiece.
Nose reconstructions have grown to be my favorite anatomic location to reconstruct because every nose is unique.
The nose has a distinct topography filled with a myriad of convexities, concavities, creases, and textures that you have to mindfully respect in order to choose the best repair option.
3 TIPS TO REMEMBER WHEN CLOSING A SURGICAL WOUND
When approaching a surgical wound, here are 3 PEARLS TO REMEMBER when reconstructing any closure.
In this article, we are going to use a Mohs nasal defect as an example.
TIP 1: Where can you place incisions so that the scar will be less noticeable? Pay attention to preserving cosmetic subunits. Placing incisions in junction lines (borders between subunits) and natural creases leaves a less conspicuous scar.
TIP 2: Understand facial structures and landmarks to avoid tension that can lead to distortion. For a nasal defect, any subtle tension to alar rim can cause asymmetry.
TIP 3: Preserve function. Function always takes precedence over aesthetics! A beautifully repaired nose, for example, will be overshadowed if the patient's breathing is compromised. Always monitor the nasal valve when repairing nose.
THE RHOMBIC FLAP
One of my favorite Mohs repairs to perform for a nasal defect is: the Rhombic Flap.
The rhombic flap is a random-pattern, geometric, transposition flap simple to execute (opposed to the bilobed flap for example)! Very versatile and can be used for small to medium sized nasal defects that provide superior cosmesis when compared to other repair options.
WATCH VIDEO
Watch this quick video on the simple steps it took for a Rhombic Flap:
Step 1 - Designing the flap
I kept the repair on one cosmetic unit of the nose (the lateral sidewall). Usually, if the repair design is on the same unit, opposed to crossing over, better cosmesis results with time.
Step 2 - Incising the flap & dog ear removal
When incising the flap, you always want to anticipate where the dog ear is going to be removed to allow optimal movement of the flap into the defect. I appreciated the fact that the design positioned the dog ear removal at the alar crease. Incisions placed in creases will hide scars well!
The video also touches on the importance of preserving symmetry and function of the nose and what to tell your patients if there is mild distortion.
This random pattern flap relies on the blood supply through the subdermal plexus, which is located at the junction between the reticular dermis and the subcutaneous layer. I'll show you where undermining was performed to preserve this plane.
Step 3 - Transposing the flap
When transposing the flap, always anticipate how the tissue is going to move and how it is going to affect the surrounding structures of the nose.
While the goal is to have an aesthetically beautiful closure, function of the nose always takes precedence. Function first! Always ask your patients to breathe in-and-out through the side of the nose you are reconstructing, while occluding the other side, testing patency. This should be done after each key suture is placed because any subtle movement of tissue can affect the nasal valve.
I also mention how a tacking suture can be placed to help tack down the underside of the flap into the wound bed of the defect to help lift the left ala back up to preserve patency of the valve!
The tacking suture is a nice suture technique to use when you want to make sure the flap is attached to the wound bed and to help prevent dead space.
Once subcuticular sutures placed, place epidermal sutures for optimal approximation and wound edge support.
SUMMARY
When performing your repairs, always visualize all angles of whatever anatomic location to prevent distortion. Reassure your patients! Have them follow up as frequently as needed to ensure they are healing as expected. Set those patient expectations early! For intricate repairs, I usually do a follow-up at 1 month, 3 months, and a year to ensure the patient is healing well.
As a surgical dermatology NP/PA, next time you have a surgical wound to reconstruct....remember these 3 pearls!
- Respect cosmetic units. Place incisions in areas where the scar is less noticeable (e.g. creases, curves, concave areas).
- Understand structures and landmarks on anatomic location you are repairing.
- FUNCTION over AESTHETICS first!
I hope you found this information helpful and would love to know your thoughts and take-aways from this article!
ALL my best,
Theresa Talens DNP, FNP-C (TheresaSurgDermNP)
P.U.L.S.E. Dermatology & Procedures, Inc.
Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.
