Technique to Avoid Ugly Scars & Suture Reactions
This week's case study is a Mohs patient that was diagnosed with a BCC to her right preauricular cheek.
What kind of poor suturing technique can you identify in the left picture?
What kind of complication can you identify in the middle picture?
The poor suturing technique that you should take note of in the left picture is that the wound edges are not approximated well.
Notice the gap between the incised wound edges? There’s also no eversion present to help minimize scarring.
You also see a step-off near the inferior apex of the wound where the right side of the wound is lifted higher than the left side (HERE is an article to help you understand better placement for subcuticular sutures).
Take note of the suture reactions in the middle picture as well.
Two months later at her postoperative visit (pic to the right), you can see how she healed with a noticeable, widened scar!
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
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.
Also, "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.
EMPOWER YOURSELF WITH THE RIGHT SKILLS
I hope this case study helped give you insight. Sometimes it’s the bad surgical outcomes that become the best lessons! It’s just up to us to take notice and learn from these pitfalls to avoid it from happening again.
Coming soon, my advanced suturing course for the dermatology NP/PA is opening up for a short amount of time for enrollment. If you want to dive deeper and learn how to master your suturing skills, sign up for the waitlist below.
It is my mission to empower our community and help you feel more confident in your technique!
Serving with GRATITUDE,
Theresa Talens DNP, FNP-C
P.U.L.S.E. Dermatology & Procedures, Inc.
Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.
