2 Common Surgical Mistakes to Avoid for Optimal Healing During Excisions
2 Common Surgical Mistakes to Avoid for Optimal Healing During Excisions
- Not Debeveling Incised Wound Edges
- Excessive Cauterization
Debeveled Edges
What are “debeveled edges”? This is a well executed technique to perform when performing excisions on your dermatology patients. When making linear incisions, ensure you are cutting at 90 degrees (“debeveled edges”). This produces a better closure with clean, perpendicular edges approximating the wound more meticulously. Think of your edges like the edges of a brick block (see pic below).
In practice, the tendency to not debevel your incised wound edges during an excision is common. This imprecise technique causes a physical impediment to wound closure, not allowing the wound to close with approximation, increasing the likelihood of a widened scar, and poorer aesthetic outcomes.
When working on thicker skin (e.g. back, trunk), residual overhanging dermis may inevitably result due to the robustness, so removal of any residual overhanging dermis will need to be made (see pic below).
Pencil Grip vs Overhand Grip
Some resources call for the tip of the scalpel to be used initially, holding the surgical blade like a “Pencil Grip Position”, followed by the belly of the blade. However, I find in practice, that because the belly of the blade is sharper, I tend to prefer to hold the scalpel at an “Overhand Grip Position” so the belly of the blade is what is initially used, cutting at a more precise line (see pic below).
In the “Overhand Grip Position”, place your index finger on the spine of blade, and that allows you to stabilize the scalpel while applying downward pressure. This technique is good for larger incisions, and thick skin, and will provide you a precise linear cut.
In the “Pencil Grip Position”, the weight of the hand can be supported by the medial fingers and wrist for light pressure, and this grip is used for smaller delicate incisions, and round incisions.
Performing Meticulous Hemostasis
When performing skin surgery on patients, ensuring you are providing meticulous hemostasis prior to suturing is paramount to visualize your surgical field and help your patients heal well. When you cauterize, pay special attention to “how” you cauterize and not overdue it. Meticulous pinpoint cautery is what is recommended opposed to over cauterizing because that excessive thermal damage will lead to these complications:
- Infection
- Excessive Inflammation
- Necrosis
It is best practice to have an assistant, with optimal lighting, to help locate the source of the bleeders and identify where you need to appropriately begin to cauterize.
Questions to Ask Yourself Prior to Cauterizing
Questions 1: Is cautery even needed?
For example, when working in areas where pronounced tension is present (e.g. scalp, lower legs), I already know through experience that when sutures are positioned in these very tight spaces the pressure, alone, after tying off my sutures will stop the wound from bleeding. It would be, often times, unnecessary to cauterize in this scenario.
This also can be applied to the small bleeding vessels located in the skin edges. These are delicate places to avoid cauterizing because once you close the wound, the pressure alone from bringing the wound edges together will stop the bleeding. There is no need to cauterize.
A consideration to remember is that, in most cases, a pressure bandage should be applied after surgery to prevent postoperative bleeding. This pressure bandage is essential as we anticipate the epinephrine to wear off and many of our patients are on blood thinners.
Question 2: What level cautery is needed?
In delicate areas with thin skin - such as the lips, ears, and eyelids - use a low level cautery.
This, of course, is different when working in more robust, vascular places like the scalp, trunk, and extremities where it may be required to use a higher level cautery to achieve appropriate hemostasis.
Watch Video
To help summarize this article, watch this quick VIDEO I created to help illustrate these 2 surgical techniques to remember - DEBEVELING and METICULOUS CAUTERIZATION!
Leverage Your Skills
If you found this article helpful and want to dive deeper into building your confidence in your surgical skills, I created an advanced suturing course tailored specifically for dermatology NPs/PAs that will break down how to perform these suture techniques, step-by-step.
The course will help you minimize scarring and improve your patients’ outcomes. If this sounds like a course that will help leverage your skills, click HERE to learn more!
Serving with GRATITUDE,
Theresa Talens DNP, FNP-C (TheresaSurgDermNP)
P.U.L.S.E. Dermatology & Procedures, Inc.
Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.
