SurgDerm Case Study: Avoid These Poor Suturing Techniques to Prevent Scarring

SURGICAL CASE STUDY

This week we are going to discuss how to prevent those ugly scars and postoperative complications related to poor suturing technique. 

This week's case study is a Mohs patient that was diagnosed with a BCC to the right preauricular cheek (see pic below).

As dermatology NPs/PAs performing surgical procedures, being mindful of your technique will help improve how your patients heal. 

Let's review the case study below:

  • What kind of poor suturing technique can you identify in the left picture?
  • What kind of complication can you identify in the middle picture?
  • On the right picture, can you see how the patient healed with a widened, more noticeable scar resulting from these poor suturing techniques?

Take note of how the wound edges are not approximated well in the left picture, leaving a "step-off", where one side of the wound edge is elevated higher than the left.  Wound edges need to be leveled evenly and everted to minimize scarring.

In the middle picture, take note of the suture reaction in the middle picture as well (ulcerations caused by spitting sutures). Subsequently, 2 months later at her postoperative visit, you can see how she healed with a noticeable, widened scar that could have been prevented. 

 

CAUSES OF SUTURE REACTIONS

When you see a patient having a suture reaction, it is most likely caused by these things:

  • Suture material choice
  • Excess suture material
  • Sutures placed too close to the skin surface
  • Patient sensitivity

PREVENTION

To prevent suture reactions, here are some pearls to remember next time you perform surgery on your patient:

  • Pick appropriate suture size
  • Do not leave any suture material in incised wound edge
  • Ensure correct placement of deep suture and surgical knot in subdermal, subcuticular plane
  • Place the minimal amount of deep sutures necessary to serve its purpose
  • Place the minimal amount of throws for knot security 

METICULOUS SUTURE TECHNIQUE

It's critical to remember that leaving unnecessary excess suture material in a wound should be avoided.

Overall, the quality of your technique in your suturing skills will directly impact the outcome of your patient.  So do not rush through your procedures and suturing. 

Be mindful on “how” and “why” you are performing each step in the process of your closures.

Always think in your mind throughout the procedure:

  • "How am I going to minimize complications on this specific patient?" as each patient is like a snowflake, each coming with their own medical history and social factors we have to consider.
  •  "How am I going to help this patient obtain the best surgical outcome?". Realistically, you will have a complication inevitably, but at least you know you were thoughtful in your closure thought process and other factors, out of your control, may have been the culprit that may have caused the poor outcome.  

EDUCATE AND SET EXPECTATIONS

After any type of dermatologic surgery, setting patient expectations and expected outcomes will produce a happier, less concerned patient.

Reminding the patient a patient patient is key. With time, the wound will heal. 

Having an educated patient also improves adherence to therapy. Improved results. 

Inform them that scar maturity can occur even after 1 year. Wound eversion can take weeks to months to resolve.

These reminders can lead to less headaches for everyone involved!

WATCH VIDEO TO LEARN MORE ABOUT SCAR TREATMENT OPTIONS

I also included a quick video you can watch (above article). I discuss another case study where you can notice a gradual improvement with scarring from the patient's 3 to 4 weeks postoperative appointment.  

We discuss treatment options if puckering does persists with intralesional Kenalog injection. This is a conservative, first line therapy commonly used post surgically. 

I usually wait 3 months post surgery to allow the patient to heal naturally prior to any Kenalog treatment . However, in my experience, time and scar massage alone often works with no additional treatment necessary.

Also, if the patient has a history of hypertrophic scarring/keloid formation, I would treat sooner for prevention. 

At that point, silicone gel and sheeting can be added for prevention of hypertrophic scarring once patient becomes symptomatic (pruritic, pain, hypertrophy).

If conservative approaches and time has not improved, surgical intervention would be my last option due to the invasiveness of the procedure.

A partial removal fusiform excision would be the best technique, excising only the persistent pucker with as narrow a margin as possible (similar to a “standing cone" revision).

KEY TAKEAWAYS

Take home points to remember:

✅ Educate your patient and set those expectations early

✅ It can take even after a year for scar maturity to occur

✅ Allow wound to heal naturally > Treat conservatively as needed > Surgical intervention is last option

✅ If pt has a history of hypertrophic scarring/keloid formation, may want to consider earlier treatment for prevention

LEVERAGE YOUR SKILLS

As dermatology NPs/PAs, I hope this article helped you better understand surgical pearls to be mindful of when performing surgery.  Also, techniques to use to achieve the best aesthetic results for your patient.

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!

Until next time...

Serving with GRATITUDE,

Theresa (TheresaSurgDermNP) 

 P.U.L.S.E. Dermatology & Procedures

Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.