This document provides a summary of key principles for optimal surgical technique when performing cutaneous surgery. It discusses important considerations for each step of the procedure, including incising, excising, and undermining tissue.
The summary focuses on achieving uniform incisions to the desired depth without beveled edges in order to allow for precise wound edge apposition during suturing. It also emphasizes removing lesions or excess skin during excision with minimal damage and in the intended anatomical plane corresponding to the incision depth. Quality control checkpoints are proposed to objectively assess technique and identify areas for improvement.
Surgical technique for optimal outcomes2Nhat Nguyen
This document discusses techniques for suturing tissue after cutting procedures in cutaneous surgery. It focuses on the buried vertical mattress suture technique. Key points covered include:
1) Proper suture material and needle size depends on the location and thickness of skin. A dissolving suture is ideal for buried sutures.
2) Suture sequence matters - high tension areas should be sutured first to allow for tissue creep.
3) Positioning oneself so the dominant hand is on the side of looser skin allows for easier suturing in tight spaces.
4) Countertraction is needed to evert the skin edge for accurate suturing, and can be done with
This document discusses the assessment and surgical repair of traumatic corneal and scleral wounds. It begins with the assessment of the wound, including the zone of injury, extent of damage to the cornea and sclera, and evaluation of intraocular structures. Classification systems for open globe injuries are described. Surgical indications and goals for repair are provided. The techniques for corneal suturing, management of tissue loss, and repair of different wound configurations are outlined. Post-operative care and potential complications are also summarized.
1. Local flap surgery is essential for plastic surgeons to consistently produce excellent reconstructive results for skin cancer defects.
2. While direct closure and skin grafts can sometimes provide good outcomes, only flap surgery guarantees results that meet reconstructive aims.
3. It is important for surgeons to clearly define the aesthetic and functional aims of each reconstruction with the patient, and to select the flap that best achieves these aims rather than simply closing the wound.
This document discusses various techniques for surface reconstruction and wound closure. It describes different types of sutures and skin grafts that can be used. For skin grafts, it distinguishes between split-thickness and full-thickness grafts. Split-thickness grafts can be further divided into thin and thick grafts. The document provides details on harvesting and applying both types of skin grafts, including the use of dermatomes and meshing grafts.
The Use of Three Different Suturing Techniques for Wound Closure of Mucoperio...Ziad Hazim Delemi
The Use of Three Different Suturing Techniques for Wound Closure of Mucoperiosteal Flaps After Surgical Removal of Impacted Lower Wisdom Teeth (Comparative Study)
1. Periodontal microsurgery utilizes magnification, improved illumination and specialized instruments to perform periodontal procedures with greater precision and less tissue trauma compared to conventional techniques.
2. The principles of microsurgery include improving fine motor skills, achieving exact wound apposition through passive closure, and use of microinstruments to minimize tissue damage during incision and suturing.
3. Periodontal microsurgery has applications in various periodontal plastic and regenerative procedures and can provide benefits like faster healing and less post-operative discomfort for patients.
Microsurgery is surgery performed under an operating microscope that allows surgeons to reconnect small blood vessels, nerves, and tissues less than 1 mm in diameter. It is used in free tissue transfer to move composite tissues from one part of the body to another for reconstruction, in replantation to reattach severed body parts by restoring blood flow and connecting tissues, and in transplantation research. Microsurgery techniques are also used to treat infertility and perform lumbar discectomies to remove herniated discs through small incisions. Kharghar Medicity Multispecialty Hospital in Navi Mumbai offers microsurgery and other super specialty services along with 24/7 emergency care.
1. The document discusses negative pressure wound therapy (NPWT), including its history, mechanisms of action, clinical applications, and future perspectives.
2. NPWT uses subatmospheric pressure to promote wound healing through mechanisms like hemostasis, modulation of inflammation, angiogenesis, and granulation tissue formation.
3. Studies show NPWT can effectively treat wounds in complex areas like the head and neck region, and may help close submandibular fistulas. However, wounds with pockets or deep shapes are more prone to infection with NPWT.
Surgical technique for optimal outcomes2Nhat Nguyen
This document discusses techniques for suturing tissue after cutting procedures in cutaneous surgery. It focuses on the buried vertical mattress suture technique. Key points covered include:
1) Proper suture material and needle size depends on the location and thickness of skin. A dissolving suture is ideal for buried sutures.
2) Suture sequence matters - high tension areas should be sutured first to allow for tissue creep.
3) Positioning oneself so the dominant hand is on the side of looser skin allows for easier suturing in tight spaces.
4) Countertraction is needed to evert the skin edge for accurate suturing, and can be done with
This document discusses the assessment and surgical repair of traumatic corneal and scleral wounds. It begins with the assessment of the wound, including the zone of injury, extent of damage to the cornea and sclera, and evaluation of intraocular structures. Classification systems for open globe injuries are described. Surgical indications and goals for repair are provided. The techniques for corneal suturing, management of tissue loss, and repair of different wound configurations are outlined. Post-operative care and potential complications are also summarized.
1. Local flap surgery is essential for plastic surgeons to consistently produce excellent reconstructive results for skin cancer defects.
2. While direct closure and skin grafts can sometimes provide good outcomes, only flap surgery guarantees results that meet reconstructive aims.
3. It is important for surgeons to clearly define the aesthetic and functional aims of each reconstruction with the patient, and to select the flap that best achieves these aims rather than simply closing the wound.
This document discusses various techniques for surface reconstruction and wound closure. It describes different types of sutures and skin grafts that can be used. For skin grafts, it distinguishes between split-thickness and full-thickness grafts. Split-thickness grafts can be further divided into thin and thick grafts. The document provides details on harvesting and applying both types of skin grafts, including the use of dermatomes and meshing grafts.
The Use of Three Different Suturing Techniques for Wound Closure of Mucoperio...Ziad Hazim Delemi
The Use of Three Different Suturing Techniques for Wound Closure of Mucoperiosteal Flaps After Surgical Removal of Impacted Lower Wisdom Teeth (Comparative Study)
1. Periodontal microsurgery utilizes magnification, improved illumination and specialized instruments to perform periodontal procedures with greater precision and less tissue trauma compared to conventional techniques.
2. The principles of microsurgery include improving fine motor skills, achieving exact wound apposition through passive closure, and use of microinstruments to minimize tissue damage during incision and suturing.
3. Periodontal microsurgery has applications in various periodontal plastic and regenerative procedures and can provide benefits like faster healing and less post-operative discomfort for patients.
Microsurgery is surgery performed under an operating microscope that allows surgeons to reconnect small blood vessels, nerves, and tissues less than 1 mm in diameter. It is used in free tissue transfer to move composite tissues from one part of the body to another for reconstruction, in replantation to reattach severed body parts by restoring blood flow and connecting tissues, and in transplantation research. Microsurgery techniques are also used to treat infertility and perform lumbar discectomies to remove herniated discs through small incisions. Kharghar Medicity Multispecialty Hospital in Navi Mumbai offers microsurgery and other super specialty services along with 24/7 emergency care.
1. The document discusses negative pressure wound therapy (NPWT), including its history, mechanisms of action, clinical applications, and future perspectives.
2. NPWT uses subatmospheric pressure to promote wound healing through mechanisms like hemostasis, modulation of inflammation, angiogenesis, and granulation tissue formation.
3. Studies show NPWT can effectively treat wounds in complex areas like the head and neck region, and may help close submandibular fistulas. However, wounds with pockets or deep shapes are more prone to infection with NPWT.
1) The document describes an innovative technique called the "anteriorly pedicled retroauricular flap" for reconstructing auricular defects.
2) This technique uses a skin flap from behind the ear that is initially pedicled in an anterior direction, allowing for easy wound access and dressing.
3) In three cases, the technique successfully reconstructed large ear defects, with good aesthetic outcomes and no complications.
1) The document discusses the decline in use of free flap surgery for lower limb reconstruction and presents alternatives such as local flaps.
2) It then presents a case study of a 43-year-old man with an open tibia fracture and skin loss on his lower leg treated with reverse soleus flap reconstruction.
3) Outcomes of the case study showed healthy wound healing with the reverse soleus flap providing soft tissue coverage and allowing for definitive fracture treatment.
This document discusses the management of open fractures. It begins by defining an open fracture and classifying open fractures using the Gustilo and Tscherne systems. It then outlines the treatment principles of open fractures which include antibiotic prophylaxis, wound debridement, and fracture stabilization. The initial management, primary surgery including further debridement, irrigation, and skeletal stabilization are described. Factors determining limb salvage versus amputation are provided. The document concludes with discussions on external fixation, internal fixation, and wound closure approaches.
Journal Club Bad splits in bilateral sagittal split osteotomy: systematic rev...Dr Bhavik Miyani
This journal club presentation summarizes a systematic review on unfavorable fracture patterns (known as "bad splits") that can occur during bilateral sagittal split osteotomy (BSSO) procedures. The review identified 33 studies from 1971-2015 reporting on 458 cases of bad splits among 19,527 BSSO procedures. The review developed a classification system for different types of bad splits and proposed salvage approaches for managing each type. Type 1 fractures involved the proximal segment, type 2 the distal segment, type 3 the coronoid process, and type 4 the condylar neck. The discussion analyzed factors that may contribute to different split types and emphasized the importance of proper fixation and positioning of segments. The conclusion was that most bad
This document provides information on microsurgery and microsurgical instruments. It discusses the history of magnification in surgery and introduces microsurgery. Key aspects of microsurgery include enhanced visualization through a microscope and less traumatic tissue handling. The document then describes different types of magnification systems used, including loupes and surgical microscopes. It outlines the benefits of microscopes and characteristics of ideal surgical loupes. Microsurgical instruments are also introduced, including scalpels, needles, sutures, needle holders, and forceps. Proper storage of microinstruments is also mentioned.
Reconstructive surgery aims to restore function and appearance after injuries and abnormalities. It involves techniques like skin grafts, flaps, and tissue expansion to close wounds and reconstruct damaged areas following burn injuries. Nursing care after reconstructive procedures focuses on monitoring the transplanted tissues and keeping them well-perfused to ensure viability.
This article analyzes 175 mandibular condyle fractures treated over 4 years at a hospital in southern India. It finds that condyle fractures made up 18.39% of all mandibular fractures and were most common in patients over 16 years old. Most condyle fractures were unilateral and associated with other mandible fractures. Non-surgical treatment was used for undisplaced fractures in younger patients, while open reduction and internal fixation was performed for displaced fractures in older patients. The study aims to establish treatment guidelines for condyle fractures based on a patient's age, fracture pattern, and level of displacement.
This document discusses oral cancer from an international perspective. It notes that oral cancer rates and outcomes vary significantly between countries due to differences in etiological factors, socioeconomic conditions, awareness, expertise, resources and prevention strategies. While survival rates have improved in developed countries through early detection and treatment, survival remains poor in developing nations where most cases are diagnosed at advanced stages. Reducing tobacco use through education and lifestyle changes could help lower oral cancer rates globally.
1. Introduction to surgery Abdominal incision and suturing.pptxmohammed284870
This document provides an overview of abdominal incision and suturing in surgery. It discusses the key steps which include making a skin incision with a scalpel at a right angle to the skin and considering factors like skin tension lines and anatomical structures when planning the incision. It also describes various types of incisions and suturing techniques as well as factors to consider for wound closure like suture material, strength, and wound conditions.
This document describes a study evaluating the use of dynamic dermal approximation sutures for closing wounds following fasciotomy to treat compartment syndrome. The technique was applied to 12 patients and achieved wound closure in 75% of cases without need for skin grafting. Specifically, it closed all wounds in 6 patients who developed compartment syndrome due to contrast extravasation. The technique aims to provide early wound closure following fasciotomy in order to reduce complications compared to delayed closure or skin grafting. The results suggest this technique can successfully close uncomplicated fasciotomy wounds with minimal risk and good cosmetic outcomes.
Features of surgical treatment of wounds of the maxillofacial region Features...KritzSingh
This document outlines key features of surgical treatment for wounds in the maxillofacial region. It discusses developing a surgical diagnosis, maintaining aseptic technique, proper incision making and flap design to prevent complications like necrosis and dehiscence. It also covers tissue handling, hemostasis, dead space management, decontamination, debridement, controlling inflammation, and the importance of a patient's general health for wound healing.
The document discusses principles of surgical techniques including patient positioning and safety, skin and abdominal incisions, wound closure, and anastomoses. It covers proper patient transfer and positioning to prevent injury, factors to consider for incision planning like skin tension lines and access needs, techniques for skin and abdominal incisions, desired characteristics and types of suture materials and closure techniques, and examples of specific incisions like midline and Pfannenstiel. Safety is emphasized including use of universal precautions and checklists.
Smith and nesis ophthalmic plastic and reconstructive surgerySpringer
Ophthalmic plastic and reconstructive surgery combines ophthalmic microsurgery techniques with plastic surgery principles to specialize in care of the eyelid, orbit, and lacrimal system. Proper preoperative preparation and evaluation of the patient is important to achieve consistent surgical outcomes. Key considerations for oculoplastic surgery procedures include appropriate use of perioperative antibiotics and hemostasis techniques, proper tissue manipulation and wound closure methods using the correct suture materials and placement.
This document outlines principles of incision and wound closure in surgery. It discusses pre-operative planning, goals of re-establishing structure and giving a natural appearance. Key principles covered include following relaxed skin tension lines for scarring, maintaining hemostasis to allow a clear field, and approximating tissues without strangulation using appropriate suturing techniques and materials to eliminate dead space and properly tension the wound for healing. Systemic and local factors that can influence wound closure outcomes are also addressed.
Residual Deformity in oral and maxillofacial surgerydr.nikil נαιη
Dr. Nikil Jain discusses nasal deformities resulting from trauma and their surgical correction. Nasal fractures can cause deviations of the nasal bridge and septum. Repositioning requires an intranasal approach to mobilize the septal cartilage and reduce displaced bone through osteotomies and chondrotomies. The nasal skeleton must be precisely realigned and immobilized internally and externally until healing is complete to avoid relapse of the deformity.
Combined Tissue and Mesh repair for Midline Incisional HerniaKETAN VAGHOLKAR
Repair of incisional hernia continues to pose a challenge to the general surgeon. A combination technique best suited for mid line incisional hernias with loss of domain is presented.
Plastic surgery involves reshaping or reconstructing parts of the body for either cosmetic or reconstructive purposes. There are two main types - cosmetic surgery which enhances appearance without correcting impairments, and reconstructive surgery which repairs abnormal structures. Cosmetic procedures include face lifts, breast augmentations, and tummy tucks. Reconstructive surgery restores function and appearance of damaged body parts like the nose, ears, or fingers. The outcome of plastic surgery depends on factors like the skin type, location on the body, tension during closure, and individual health conditions. Proper surgical techniques help achieve a fine, inconspicuous scar.
Management of soft tissue injuries in facial traumaAhmed Adawy
Management of soft tissue injuries in facial trauma
Dr. Ahmed M. Adawy.
Professor Emeritus, Dept. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine, Al-Azhar University.
Soft-tissue injuries are the most common presentation following maxillofacial trauma. In general, injuries can initially be classified as open or closed wounds. A closed wound is one that damages underlying tissue and/or structures without breaking the skin. Examples of closed wounds include hematomas, contusions, and crush injuries. In contrast, open wounds involve a break in the skin, which exposes the underlying structures to the external environment. Open wounds include simple and complex lacerations, avulsions, punctures, abrasions, accidental tattooing, and retained foreign body. Detailed description of management is presented. The principles of repair is discussed.
This document presents a case series of two patients who presented with facial soft tissue injuries from road traffic accidents. The first case involved laceration of the upper and lower lip, which was debrided and closed in layers. The second case involved a deep laceration from the nose to the orbit, which was also debrided and closed in layers. The document then reviews principles of managing facial soft tissue injuries, including goals of preserving form and function, considerations for injuries involving structures like nerves or ducts, and various closure techniques. Primary closure is preferred for isolated injuries within 8 hours when possible to reduce risks of infection and contracture.
1) The document describes an innovative technique called the "anteriorly pedicled retroauricular flap" for reconstructing auricular defects.
2) This technique uses a skin flap from behind the ear that is initially pedicled in an anterior direction, allowing for easy wound access and dressing.
3) In three cases, the technique successfully reconstructed large ear defects, with good aesthetic outcomes and no complications.
1) The document discusses the decline in use of free flap surgery for lower limb reconstruction and presents alternatives such as local flaps.
2) It then presents a case study of a 43-year-old man with an open tibia fracture and skin loss on his lower leg treated with reverse soleus flap reconstruction.
3) Outcomes of the case study showed healthy wound healing with the reverse soleus flap providing soft tissue coverage and allowing for definitive fracture treatment.
This document discusses the management of open fractures. It begins by defining an open fracture and classifying open fractures using the Gustilo and Tscherne systems. It then outlines the treatment principles of open fractures which include antibiotic prophylaxis, wound debridement, and fracture stabilization. The initial management, primary surgery including further debridement, irrigation, and skeletal stabilization are described. Factors determining limb salvage versus amputation are provided. The document concludes with discussions on external fixation, internal fixation, and wound closure approaches.
Journal Club Bad splits in bilateral sagittal split osteotomy: systematic rev...Dr Bhavik Miyani
This journal club presentation summarizes a systematic review on unfavorable fracture patterns (known as "bad splits") that can occur during bilateral sagittal split osteotomy (BSSO) procedures. The review identified 33 studies from 1971-2015 reporting on 458 cases of bad splits among 19,527 BSSO procedures. The review developed a classification system for different types of bad splits and proposed salvage approaches for managing each type. Type 1 fractures involved the proximal segment, type 2 the distal segment, type 3 the coronoid process, and type 4 the condylar neck. The discussion analyzed factors that may contribute to different split types and emphasized the importance of proper fixation and positioning of segments. The conclusion was that most bad
This document provides information on microsurgery and microsurgical instruments. It discusses the history of magnification in surgery and introduces microsurgery. Key aspects of microsurgery include enhanced visualization through a microscope and less traumatic tissue handling. The document then describes different types of magnification systems used, including loupes and surgical microscopes. It outlines the benefits of microscopes and characteristics of ideal surgical loupes. Microsurgical instruments are also introduced, including scalpels, needles, sutures, needle holders, and forceps. Proper storage of microinstruments is also mentioned.
Reconstructive surgery aims to restore function and appearance after injuries and abnormalities. It involves techniques like skin grafts, flaps, and tissue expansion to close wounds and reconstruct damaged areas following burn injuries. Nursing care after reconstructive procedures focuses on monitoring the transplanted tissues and keeping them well-perfused to ensure viability.
This article analyzes 175 mandibular condyle fractures treated over 4 years at a hospital in southern India. It finds that condyle fractures made up 18.39% of all mandibular fractures and were most common in patients over 16 years old. Most condyle fractures were unilateral and associated with other mandible fractures. Non-surgical treatment was used for undisplaced fractures in younger patients, while open reduction and internal fixation was performed for displaced fractures in older patients. The study aims to establish treatment guidelines for condyle fractures based on a patient's age, fracture pattern, and level of displacement.
This document discusses oral cancer from an international perspective. It notes that oral cancer rates and outcomes vary significantly between countries due to differences in etiological factors, socioeconomic conditions, awareness, expertise, resources and prevention strategies. While survival rates have improved in developed countries through early detection and treatment, survival remains poor in developing nations where most cases are diagnosed at advanced stages. Reducing tobacco use through education and lifestyle changes could help lower oral cancer rates globally.
1. Introduction to surgery Abdominal incision and suturing.pptxmohammed284870
This document provides an overview of abdominal incision and suturing in surgery. It discusses the key steps which include making a skin incision with a scalpel at a right angle to the skin and considering factors like skin tension lines and anatomical structures when planning the incision. It also describes various types of incisions and suturing techniques as well as factors to consider for wound closure like suture material, strength, and wound conditions.
This document describes a study evaluating the use of dynamic dermal approximation sutures for closing wounds following fasciotomy to treat compartment syndrome. The technique was applied to 12 patients and achieved wound closure in 75% of cases without need for skin grafting. Specifically, it closed all wounds in 6 patients who developed compartment syndrome due to contrast extravasation. The technique aims to provide early wound closure following fasciotomy in order to reduce complications compared to delayed closure or skin grafting. The results suggest this technique can successfully close uncomplicated fasciotomy wounds with minimal risk and good cosmetic outcomes.
Features of surgical treatment of wounds of the maxillofacial region Features...KritzSingh
This document outlines key features of surgical treatment for wounds in the maxillofacial region. It discusses developing a surgical diagnosis, maintaining aseptic technique, proper incision making and flap design to prevent complications like necrosis and dehiscence. It also covers tissue handling, hemostasis, dead space management, decontamination, debridement, controlling inflammation, and the importance of a patient's general health for wound healing.
The document discusses principles of surgical techniques including patient positioning and safety, skin and abdominal incisions, wound closure, and anastomoses. It covers proper patient transfer and positioning to prevent injury, factors to consider for incision planning like skin tension lines and access needs, techniques for skin and abdominal incisions, desired characteristics and types of suture materials and closure techniques, and examples of specific incisions like midline and Pfannenstiel. Safety is emphasized including use of universal precautions and checklists.
Smith and nesis ophthalmic plastic and reconstructive surgerySpringer
Ophthalmic plastic and reconstructive surgery combines ophthalmic microsurgery techniques with plastic surgery principles to specialize in care of the eyelid, orbit, and lacrimal system. Proper preoperative preparation and evaluation of the patient is important to achieve consistent surgical outcomes. Key considerations for oculoplastic surgery procedures include appropriate use of perioperative antibiotics and hemostasis techniques, proper tissue manipulation and wound closure methods using the correct suture materials and placement.
This document outlines principles of incision and wound closure in surgery. It discusses pre-operative planning, goals of re-establishing structure and giving a natural appearance. Key principles covered include following relaxed skin tension lines for scarring, maintaining hemostasis to allow a clear field, and approximating tissues without strangulation using appropriate suturing techniques and materials to eliminate dead space and properly tension the wound for healing. Systemic and local factors that can influence wound closure outcomes are also addressed.
Residual Deformity in oral and maxillofacial surgerydr.nikil נαιη
Dr. Nikil Jain discusses nasal deformities resulting from trauma and their surgical correction. Nasal fractures can cause deviations of the nasal bridge and septum. Repositioning requires an intranasal approach to mobilize the septal cartilage and reduce displaced bone through osteotomies and chondrotomies. The nasal skeleton must be precisely realigned and immobilized internally and externally until healing is complete to avoid relapse of the deformity.
Combined Tissue and Mesh repair for Midline Incisional HerniaKETAN VAGHOLKAR
Repair of incisional hernia continues to pose a challenge to the general surgeon. A combination technique best suited for mid line incisional hernias with loss of domain is presented.
Plastic surgery involves reshaping or reconstructing parts of the body for either cosmetic or reconstructive purposes. There are two main types - cosmetic surgery which enhances appearance without correcting impairments, and reconstructive surgery which repairs abnormal structures. Cosmetic procedures include face lifts, breast augmentations, and tummy tucks. Reconstructive surgery restores function and appearance of damaged body parts like the nose, ears, or fingers. The outcome of plastic surgery depends on factors like the skin type, location on the body, tension during closure, and individual health conditions. Proper surgical techniques help achieve a fine, inconspicuous scar.
Management of soft tissue injuries in facial traumaAhmed Adawy
Management of soft tissue injuries in facial trauma
Dr. Ahmed M. Adawy.
Professor Emeritus, Dept. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine, Al-Azhar University.
Soft-tissue injuries are the most common presentation following maxillofacial trauma. In general, injuries can initially be classified as open or closed wounds. A closed wound is one that damages underlying tissue and/or structures without breaking the skin. Examples of closed wounds include hematomas, contusions, and crush injuries. In contrast, open wounds involve a break in the skin, which exposes the underlying structures to the external environment. Open wounds include simple and complex lacerations, avulsions, punctures, abrasions, accidental tattooing, and retained foreign body. Detailed description of management is presented. The principles of repair is discussed.
This document presents a case series of two patients who presented with facial soft tissue injuries from road traffic accidents. The first case involved laceration of the upper and lower lip, which was debrided and closed in layers. The second case involved a deep laceration from the nose to the orbit, which was also debrided and closed in layers. The document then reviews principles of managing facial soft tissue injuries, including goals of preserving form and function, considerations for injuries involving structures like nerves or ducts, and various closure techniques. Primary closure is preferred for isolated injuries within 8 hours when possible to reduce risks of infection and contracture.
COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...KETAN VAGHOLKAR
Background: Skin approximation is a very important step in a surgical operation. The quality of skin
approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications.
Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare
traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound
complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients
are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation).
The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation)
had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction.
Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.
RECONSTRUCTIVE AND COSMETIC SURGERY.pptxSaluSunny2
Plastic surgery procedures can be divided into reconstructive and cosmetic categories. Reconstructive surgery aims to restore normal form and function after injuries, defects present from birth, or changes from aging or disease. Common reconstructive procedures include breast reconstruction after mastectomy, burn reconstruction using skin grafts and flaps, and cleft lip and palate repair. Skin grafting and flap surgery are important reconstructive techniques that transfer skin and tissue with or without its blood supply. Reconstructive surgery improves both appearance and function.
Skin grafts and flaps are used to treat wounds and provide skin coverage. There are two types of non-vascular skin transfers - split-thickness and full-thickness skin grafts. Physical therapy aims to prevent complications after grafting like infection, contractures, and impaired healing. Treatment includes exercises, splinting and compression to promote mobility and graft adherence while avoiding shearing forces. Goals are wound healing, edema reduction, and regaining function.
1. The document summarizes the principles and practice of open fracture care, including debridement and lavage of the wound, early stable internal fixation of the bone, and reconstruction of soft tissues to prevent infection.
2. It discusses that open fractures expose the bone to contamination and complicate reconstruction with soft tissue injury as well, requiring specialists. The goal of treatment is to prevent contamination from developing into infection through proper surgical management.
3. Key aspects of surgical management are thorough debridement to remove non-viable tissue, profuse lavage to reduce bacteria, stable fixation to allow soft tissue healing, and reconstructing soft tissues to protect the injury from infection.
Single staged surgical procedure for recurrent incisional hernia with trophic...KETAN VAGHOLKAR
Incisional hernia by itself is a very challenging surgical disease to treat. Recurrent incisional hernia with trophic ulceration adds to the complexity of the problem making surgical treatment more difficult. A case of a recurrent incisional hernia with trophic ulceration treated by a single staged procedure comprising of wide excision of the trophic ulcer with repair of the incisional hernia is presented to highlight the applicability of a single staged procedure as a viable option for managing such complex hernias.
This document describes the lip repositioning flap procedure to treat excessive gingival display or "gummy smile". The procedure involves making elliptical incisions in the upper lip mucosa and removing a section of tissue to reposition the lip and limit gingival exposure during smiling. Post-operatively, patients experience mild pain and swelling that subsides after 2 weeks of healing. The results of lip repositioning are stable after 1 year and it provides an effective yet minimally invasive solution for correcting gummy smiles compared to more complex alternatives.
This document describes the technique of a Z-plasty, which is used in scar revision and correction of free margin distortion. A Z-plasty involves making triangular flaps to lengthen or change the direction of a scar. The key steps are carefully planning and drawing the Z-plasty, making precise incisions, widely undermining the tissue, and transposing the flaps. The degree of scar lengthening and directional change depends on the angle of the flaps, with larger angles resulting in greater effects. Z-plasties must be carefully designed to align with skin tension lines for optimal results. Case examples demonstrate how Z-plasties can correct problems like scar contractures and alar retraction.
This document describes the Park Z-epicanthoplasty technique for modifying the epicanthal fold in Asian patients undergoing double eyelid surgery. Key points:
- The epicanthal fold is a skin flap covering part or all of the lacrimal lake. It is a distinguishing feature in many East Asian populations.
- The Park Z-epicanthoplasty involves making incisions within the eyelid skin to elevate and transpose the epicanthal flap, avoiding tension and visible scarring compared to other techniques.
- It is most useful for type II and III epicanthal folds in patients seeking a higher or outer-type double eyelid. Careful preoperative marking and precision inc
Facial danger zones techniques to maximize safety during soft tissue filler i...Nhat Nguyen
Given the popularity of facial fillers as a nonsurgical alternative to rejuvenation, the authors describe techniques to maximize safety when injecting in facial danger zones. Reported complications can include blindness, stroke or death from inadvertent damage or cannulation of vasculature. The authors outline preferred injection methods in areas like the glabella/brow, temporal region, lips and nasolabial folds with respect to pertinent anatomy. The goal is to minimize risk by using reversible fillers, small needles and cannulas, and avoiding direct injections near vulnerable arteries. Practitioners must recognize complications and address them immediately.
Identifying a safe zone for midface augmentation using anatomic landmarks for...Nhat Nguyen
The study identifies a safe zone for dissection during midface augmentation to avoid injury to the infraorbital nerve. Measurements were taken on 44 CT scans of adult faces to determine the average distance between the infraorbital foramen and nearby bony landmarks. For men, the average distances were 8.61 mm from the infraorbital rim, 17.43 mm from the piriform aperture, 41.81 mm from the second premolar tip, and 25.93 mm from the lateral orbital rim. For women, the averages were 8.25 mm, 15.69 mm, 37.33 mm, and 24.21 mm, respectively. Defining this safe zone can help clinicians locate the infraorbital for
The fat compartments of the face- anatomy and clinical implications for cosme...Nhat Nguyen
The document summarizes the results of a cadaver study investigating the anatomical compartments of subcutaneous fat in the face. The study found that the fat is partitioned into multiple, independent compartments rather than existing as a single confluent mass. Key findings include:
- The nasolabial fold, cheeks, forehead, and periorbital region each contain three distinct fat compartments.
- Compartments are separated by septal barriers that can fuse, forming ligament-like structures.
- Understanding the compartmentalization provides insights into how aging affects the face and considerations for cosmetic surgery.
An anantomically based of the mecanicism of eyebrow ptosisNhat Nguyen
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Update in alar base reduction in rhinoplastyNhat Nguyen
This document summarizes techniques for alar base reduction in rhinoplasty. It discusses three main techniques: 1) cinching sutures to pull the alae together, 2) alar base excisions to remove tissue and decrease flare/width, and 3) flap advancement without tissue removal. It notes surgical modification of the nasal base should be conservative to prevent complications like stenosis. The techniques aim to achieve a triangular nasal base with defined anatomy. Factors like nasal tip changes, septal deviations, and preexisting asymmetries can influence outcomes.
Preventing elevated radix deformity in asianNhat Nguyen
The Chimeric technique for Asian rhinoplasty aims to control final radix position and preserve the nasal profile. It involves using a composite silicone-PTFE implant with a glabellar component made of cartilage or PTFE. 49 patients underwent rhinoplasty with or without the Chimeric technique. Those who received the Chimeric technique had a more favorable horizontal vector of radix position change compared to the traditional technique, which resulted in a more vertical vector and potential for an elevated radix deformity. The Chimeric technique helps maintain a natural nasal profile during augmentation rhinoplasty.
This document discusses different incision techniques for rhinoplasty surgery. There are three main incision types: 1) Transcartilaginous incisions are made within the nasal cartilage. 2) Intercartilaginous incisions are made between the upper and lower nasal cartilages. 3) Marginal incisions are made along the outer edge of the nasal cartilage. The document also describes four surgical approaches - delivery, cartilage splitting, retrograde, and open - and provides details on transfixion, intercartilaginous, intracartilaginous, and transcolumellar incision techniques.
There has been tremendous growth in cosmetic surgery among Asians worldwide, with rhinoplasty being one of the most common procedures to refine Asian facial features while maintaining ethnic identity. Successful rhinoplasty in Asians requires consideration of underlying anatomic differences compared to whites, such as thinner nasal bones and thicker skin. Due to ethnic variations and cultural norms, careful preoperative counseling is important to ensure patient expectations align with the limitations and goals of the procedure.
Synthetic fillers for facial rejuvenationNhat Nguyen
This document discusses synthetic fillers used for facial rejuvenation. It begins by providing statistics on the popularity and growth of soft tissue filler procedures. It then discusses several synthetic fillers - calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), polymethyl methacrylate (PMMA), and silicone. Specifically, it outlines the composition, FDA approval history, injection techniques, and benefits of CaHA and PLLA, which provide long-lasting volume replacement through biostimulation of collagen production. Complications are rare but can include nodules, which can be treated through massage or injection of other substances.
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...Nursing Mastery
Title: Unlocking the Wonders of the Special Senses: Sight, Sound, Smell, Taste, and Balance
Introduction:
Welcome to our captivating SlideShare presentation on the Special Senses, where we delve into the extraordinary capabilities that allow us to perceive and interact with the world around us. Join us on a sensory journey as we explore the intricate structures and functions of sight, sound, smell, taste, and balance.
The special senses are our primary means of experiencing and interpreting the environment, each sense providing unique and vital information that shapes our perceptions and responses. These senses are facilitated by highly specialized organs and complex neural pathways, enabling us to see a vibrant sunset, hear a symphony, savor a delicious meal, detect a fragrant flower, and maintain our equilibrium.
In this presentation, we will:
Visual System (Sight): Dive into the anatomy and physiology of the eye, exploring how light is converted into electrical signals and processed by the brain to create the images we see. Understand common vision disorders and the mechanisms behind corrective measures like glasses and contact lenses.
Auditory System (Hearing): Examine the structures of the ear and the process of sound wave transduction, from the outer ear to the cochlea and auditory nerve. Learn about hearing loss, auditory processing, and the advances in hearing aid technology.
Olfactory System (Smell): Discover the olfactory receptors and pathways that enable the detection of thousands of different odors. Explore the connection between smell and memory and the impact of olfactory disorders on quality of life.
Gustatory System (Taste): Uncover the taste buds and the five basic tastes – sweet, salty, sour, bitter, and umami. Delve into the interplay between taste and smell and the factors influencing our food preferences and eating habits.
Vestibular System (Balance): Investigate the inner ear structures responsible for balance and spatial orientation. Understand how the vestibular system helps maintain posture and coordination, and explore common vestibular disorders and their effects.
Through engaging visuals, interactive diagrams, and insightful explanations, we aim to illuminate the complexities of the special senses and their profound impact on our daily lives. Whether you're a student, educator, or simply curious about how we perceive the world, this presentation will provide valuable insights into the remarkable capabilities of the human sensory system.
Join us as we unlock the wonders of the special senses and gain a deeper appreciation for the intricate mechanisms that allow us to experience the richness of our environment.
The Ultimate Guide in Setting Up Market Research System in Health-TechGokul Rangarajan
How to effectively start market research in the health tech industry by defining objectives, crafting problem statements, selecting methods, identifying data collection sources, and setting clear timelines. This guide covers all the preliminary steps needed to lay a strong foundation for your research.
"Market Research it too text-booky, I am in the market for a decade, I am living research book" this is what the founder I met on the event claimed, few of my colleagues rolled their eyes. Its true that one cannot over look the real life experience, but one cannot out beat structured gold mine of market research.
Many 0 to 1 startup founders often overlook market research, but this critical step can make or break a venture, especially in health tech.
But Why do they skip it?
Limited resources—time, money, and manpower—are common culprits.
"In fact, a survey by CB Insights found that 42% of startups fail due to no market need, which is like building a spaceship to Mars only to realise you forgot the fuel."
Sudharsan Srinivasan
Operational Partner Pitchworks VC Studio
Overconfidence in their product’s success leads founders to assume it will naturally find its market, especially in health tech where patient needs, entire system issues and regulatory requirements are as complex as trying to perform brain surgery with a butter knife. Additionally, the pressure to launch quickly and the belief in their own intuition further contribute to this oversight. Yet, thorough market research in health tech could be the key to transforming a startup's vision into a life-saving reality, instead of a medical mishap waiting to happen.
Example of Market Research working
Innovaccer, founded by Abhinav Shashank in 2014, focuses on improving healthcare delivery through data-driven insights and interoperability solutions. Before launching their platform, Innovaccer conducted extensive market research to understand the challenges faced by healthcare organizations and the potential for innovation in healthcare IT.
Identifying Pain Points: Innovaccer surveyed healthcare providers to understand their difficulties with data integration, care coordination, and patient engagement. They found widespread frustration with siloed systems and inefficient workflows.
Competitive Analysis: Analyzed competitors offering similar solutions in healthcare analytics and interoperability. Identified gaps in comprehensive data aggregation, real-time analytics, and actionable insights.
Regulatory Compliance: Ensured their platform complied with HIPAA and other healthcare data privacy regulations. This compliance was crucial to gaining trust from healthcare providers wary of data security issues.
Customer Validation: Conducted pilot programs with several healthcare organizations to validate the platform's effectiveness in improving care outcomes and operational efficiency. Gathered feedback to refine features and user interface.
Digital Health in India_Health Informatics Trained Manpower _DrDevTaneja_15.0...DrDevTaneja1
Digital India will need a big trained army of Health Informatics educated & trained manpower in India.
Presently, generalist IT manpower does most of the work in the healthcare industry in India. Academic Health Informatics education is not readily available at school & health university level or IT education institutions in India.
We look into the evolution of health informatics and its applications in the healthcare industry.
HIMMS TIGER resources are available to assist Health Informatics education.
Indian Health universities, IT Education institutions, and the healthcare industry must proactively collaborate to start health informatics courses on a big scale. An advocacy push from various stakeholders is also needed for this goal.
Health informatics has huge employment potential and provides a big business opportunity for the healthcare industry. A big pool of trained health informatics manpower can lead to product & service innovations on a global scale in India.
Basics of Electrocardiogram
CONTENTS
●Conduction System of the Heart
●What is ECG or EKG?
●ECG Leads
●Normal waves of ECG.
●Dimensions of ECG.
● Abnormalities of ECG
CONDUCTION SYSTEM OF THE HEART
ECG:
●ECG is a graphic record of the electrical activity of the heart.
●Electrical activity precedes the mechanical activity of the heart.
●Electrical activity has two phases:
Depolarization- contraction of muscle
Repolarization- relaxation of muscle
ECG Leads:
●6 Chest leads
●6 Limb leads
1. Bipolar Limb Leads:
Lead 1- Between right arm(-ve) and left arm(+ve)
Lead 2- Between right arm(-ve) and left leg(+ve)
Lead 3- Between left arm(-ve)
and left leg(+ve)
2. Augmented unipolar Limb Leads:
AvR- Right arm
AvL- Left arm
AvF- Left leg
3.Chest Leads:
V1 : Over 4th intercostal
space near right sternal margin
V2: Over 4th intercostal space near left sternal margin
V3:In between V2 and V4
V4:Over left 5th intercostal space on the mid
clavicular line
V5:Over left 5th intercostal space on the anterior
axillary line
V6:Over left 5th intercostal space on the mid
axillary line.
Normal ECG:
Waves of ECG:
P Wave
•P Wave is a positive wave and the first wave in ECG.
•It is also called as atrial complex.
Cause: Atrial depolarisation
Duration: 0.1 sec
QRS Complex:
•QRS’ complex is also called the initial ventricular complex.
•‘Q’ wave is a small negative wave. It is continued as the tall ‘R’ wave, which is a positive wave.
‘R’ wave is followed by a small negative wave, the ‘S’ wave.
Cause:Ventricular depolarization and atrial repolarization
Duration: 0.08- 0.10 sec
T Wave:
•‘T’ wave is the final ventricular complex and is a positive wave.
Cause:Ventricular repolarization Duration: 0.2 sec
Intervals and Segments of ECG:
P-R Interval:
•‘P-R’ interval is the interval
between the onset of ‘P’wave and onset of ‘Q’ wave.
•‘P-R’ interval cause atrial depolarization and conduction of impulses through AV node.
Duration:0.18 (0.12 to 0.2) sec
Q-T Interval:
•‘Q-T’ interval is the interval between the onset of ‘Q’
wave and the end of ‘T’ wave.
•‘Q-T’ interval indicates the ventricular depolarization
and ventricular repolarization,
i.e. it signifies the
electrical activity in ventricles.
Duration:0.4-0.42sec
S-T Segment:
•‘S-T’ segment is the time interval between the end of ‘S’ wave and the onset of ‘T’ wave.
Duration: 0.08 sec
R-R Interval:
•‘R-R’ interval is the time interval between two consecutive ‘R’ waves.
•It signifies the duration of one cardiac cycle.
Duration: 0.8 sec
Dimension of ECG:
How to find heart rhytm of the heart?
Regular rhytm:
Irregular rhytm:
More than or less than 4
How to find heart rate using ECG?
If heart Rhytm is Regular :
Heart rate =
300/No.of large b/w 2 QRS complex
= 300/4
=75 beats/mins
How to find heart rate using ECG?
If heart Rhytm is irregular:
Heart rate = 10×No.of QRS complex in 6 sec 5large box = 1sec
5×6=30
10×7 = 70 Beats/min
Abnormalities of ECG:
Cardiac Arrythmias:
1.Tachycardia
Heart Rate more than 100 beats/min
Test bank advanced health assessment and differential diagnosis essentials fo...rightmanforbloodline
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About CentiUP - Introduction and Products.pdfCentiUP
A heightened child formula, with the trio of Nano Calcium, HMO, and DHA mixed in the golden ratio, combined with NANO technology to help nourish the body deeply and comprehensively, helps children increase height, boost brain power, and improve the immune system and overall well-being.
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Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...Dr. David Greene Arizona
Dr. David Greene of Arizona is at the forefront of stem cell therapy for Parkinson's Disease, focusing on innovative treatments to restore dopamine-producing neurons. His research explores the use of embryonic stem cells, induced pluripotent stem cells, and adult stem cells to replace lost neurons and potentially reverse disease progression. By transplanting differentiated cells into affected brain areas, Dr. Greene aims to address the root cause of Parkinson's. His work also investigates the neuroprotective benefits of stem cells, offering hope for effective, long-term treatments. Discover how Dr. Greene's pioneering efforts could transform Parkinson's Disease therapy.
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About CentiUP - Product Information Slide.pdfCentiUP
A heightened child formula, with the trio of Nano Calcium, HMO, and DHA mixed in the golden ratio, combined with NANO technology to help nourish the body deeply and comprehensively, helps children increase height, boost brain power, and improve the immune system and overall well-being.
English Drug and Alcohol Commissioners June 2024.pptxMatSouthwell1
Presentation made by Mat Southwell to the Harm Reduction Working Group of the English Drug and Alcohol Commissioners. Discuss stimulants, OAMT, NSP coverage and community-led approach to DCRs. Focussing on active drug user perspectives and interests
1. CONTINUING MEDICAL EDUCATION
Surgical technique for optimal outcomes
Part I. Cutting tissue: Incising, excising, and undermining
Christopher J. Miller, MD,a
Marcelo B. Antunes, MD,b
and Joseph F. Sobanko, MDa
Philadelphia, Pennsylvania, and Austin, Texas
Sound surgical technique is necessary to achieve excellent surgical outcomes. Despite the fact that
dermatologists perform more office-based cutaneous surgery than any other specialty, few dermatologists
have opportunities for practical instruction to improve surgical technique after residency and
fellowship. This 2-part continuing medical education article will address key principles of surgical
technique at each step of cutaneous reconstruction. Part I reviews incising, excising, and undermining.
Objective quality control questions are proposed to provide a framework for self-assessment and continuous
quality improvement. ( J Am Acad Dermatol 2015;72:377-87.)
Key words: excise; excision; incise; skin; surgery; suture; technique; undermine.
INTRODUCTION
Surgeons influence the aesthetics of scars from
cutaneous surgery in 2 ways: (1) surgical design and
(2) surgical technique. The principles of aesthetic
surgical design are universally accepted, and include
preserving and restoring free margins (eg, eyelids,
nasal tip and ala, lips, and helical rim), preserving
and restoring contour, and placing scars in cosmetic
subunit junction lines.1
Placing scars along
relaxed skin tension lines is also desirable, but is
less important compared to the aforementioned
principles.2
For example, it is undesirable to conform
to the horizontal relaxed skin tension lines on the
forehead if elevation of the ipsilateral eyebrow
creates asymmetry.
While surgeons nearly universally adhere to the
core principles of aesthetic surgical design, surgical
technique varies markedly. These variations can
confuse surgical trainees, who are left to struggle
by trial and error through numerous potential
approaches to execute the same surgical tech-
nique.3,4
Only after months to years of independent
practice and observation of their own postoperative
outcomes do most surgeons refine their own surgical
technique and achieve reproducibly excellent
results.5
Many practitioners desire additional
surgical coaching after their formal training.6
This 2-part continuing medical education article
proposes quality control questions for each step
of cutaneous reconstruction and provides a
Learning objectives
After completing this learning activity, participants should be able to describe common errors during the removal of tissue that lead to unaesthetic scars and delineate the steps for
proficient fusiform excisions.
Disclosures
Editors
The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with
commercial interest(s).
Authors
The authors involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).
Planners
The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved
with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).
From the Department of Dermatology,a
University of Pennsylva-
nia, Philadelphia, and Private practice,b
Austin.
Video available at http://www.jaad.org.
Funding sources: None.
Conflicts of interest: None declared.
Accepted for publication June 17, 2014.
Correspondence to: Joseph F. Sobanko, MD, Edwin & Fannie Gray
Hall Center for Human Appearance, University of Pennsylvania,
3400 Civic Center Blvd, Rm 1-330S, Philadelphia, PA 19104.
E-mail: Joseph.Sobanko@uphs.upenn.edu.
0190-9622/$36.00
Ó 2014 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2014.06.048
Date of release: March 2015
Expiration date: March 2018
377
2. framework for self-assessment and continuous qual-
ity improvement.
STEPS OF SURGICAL RECONSTRUCTION
Surgical techniques fall into 2 broad categories:
cutting and suturing. Cutting techniques include
incising, excising, and undermining. Suturing
techniques include placing deep and top sutures.
Most reconstructive surgery involves the stepwise
execution of these cutting and suturing techniques.
Each step influences the success of subsequent
steps; errors early in the process make the precise
execution of subsequent steps either more difficult
or impossible.
Scars heal with a shiny texture that reflects light
more brightly than the textured, normal surrounding
skin. Sound surgical technique must therefore aim to
diminish the contrast between scar and normal skin
by minimizing the breadth of the scar.7-9
Precise,
tension-free approximation of the skin edges allows
for prompt reepithelialization and a barely visible
scar.10,11
The appearance of scars often improves
with time, helping to disguise minor technical
deficiencies.12
The appearance of the wound 1
week after surgery gives an honest assessment
of the precision of the surgical technique.
Completely reepithelialized scars with minimal to
no inflammation signify meticulous surgical tech-
nique (Fig 1). Wounds with prominent inflammation
and focal inversion or separation of wound edges
usually result from suboptimal surgical technique
(Fig 2). In these continuing medical education
articles, we analyze each step of cutting and suturing
and propose quality control checkpoints for
objective self-evaluation. Part I reviews cutting
techniques, including incising, excising, and under-
mining. Part II reviews suturing techniques,
including placing deep and top sutures. Space
precludes a comprehensive coverage of surgical
techniques; we therefore focus on core techniques
that apply broadly to any surgeon performing
surgery of the skin.
CUTTING TECHNIQUE: INCISING
Key points
d The incision aims to achieve uniform release
of the entire skin edge to the desired
anatomic depth
d The ideal depth of the incision varies
according to the anatomic location and
intent of the procedure
d The incised wound edges should be smooth
and sharply perpendicular to the skin
surface
d Beveling of the dermis or fat toward the
center of the wound impedes the precise
approximation of wound edges
The goal of the incision is to achieve uniform
release of the entire skin edge to the desired
anatomic depth and to create smooth and
perpendicular wound edges without a bevel.13
Before beginning the procedure, the surgeon should
have a clear plan for the anatomic depth of the
incision. The desired anatomic depth will vary based
on the location and intent of the procedure. In most
cases, the depth of the incision will correspond to the
intended anatomic plane for the subsequent steps of
excision and undermining. The skin should be
released to a uniform depth along the entire incision
(Fig 3).
The incision should create wound edges that are
sharply perpendicular to the skin surface, because
any bevel of the dermis or fat will impede the direct
apposition of the epidermal edges during suturing
(Fig 4). Beveled wound edges will force the surgeon
to place excessive tension on the sutures, a practice
that increases the risk of leaving suture marks on
Fig 1. A, Ideal appearance of a wound on the forehead 1 week postsurgery, with sutures still in
place. There is minimal erythema. B, Appearance of the same wound on the forehead
immediately after removing the sutures. Precise approximation of the wound edges and
minimal inflammation reflect sound surgical technique and portend a minimally apparent scar.
J AM ACAD DERMATOL
MARCH 2015
378 Miller, Antunes, and Sobanko
3. each side of the scar (Fig 5). The angle of the scalpel
relative to the skin influences whether or not the
incision creates beveled wound edges. The scalpel
handle tends to fall toward the surgeon’s dominant
hand, similar to the eraser end of a pencil, thereby
positioning the blade in an undesirable beveled
position (Fig 6, A). The surgeon must compensate
for this natural tendency by taking care to hold the
scalpel perpendicular to the surface of the skin
throughout the entire pass of the incision (Fig 6, B).
Cleanly incised wound edges facilitate precise
approximation of the epidermis and dermis during
suturing. Jagged wound edges complicate suturing.
A sharp scalpel should incise the skin smoothly with
minimal downward pressure. If the surgeon forces
the scalpel with downward pressure in an attempt to
reach the desired depth in 1 pass, or if the scalpel
edge is dull, the scalpel may succumb to chatter,
resulting in jagged wound edges. To avoid chatter,
especially in thick or fibrotic skin, [1 pass of the
scalpel may be necessary to reach the desired
depth. If multiple passes are necessary to incise
through thick skin (eg, on the back and proximal
extremities), applying pressure of the scalpel against
the outside wound edge can decrease the risk for a
bevel on subsequent passes. Using the nondominant
Fig 5. Typical long-term appearance of a scar repaired
with excessive tension on the superficial sutures. The scar
has spread, and prominent track marks are present.
Fig 2. Suboptimal appearance of a wound 1 week
postsurgery and immediately after removing the
cutaneous sutures. Prominent inflammation and inversion
of the wound edges have resulted from imprecise surgical
technique and signal an opportunity to improve technical
skills.
Fig 3. The incision should achieve uniform release to the
desired anatomic depth. Note this fusiform incision where
the tips have not been incised to the same depth as the
sides of the specimen. The tips (black arrowheads) require
additional release.
Fig 4. Intraoperative appearance of a wound repaired
with suboptimal technique. The black arrow indicates a
prominent beveled edge of the dermis. The beveled
dermis will prevent direct approximation of the wound
edges, regardless of the quality of the buried sutures. In an
attempt to close the gap between the epidermal edges, the
superficial sutures have been placed with excessive
tension. The prominent gap at the puncture site of the
superficial sutures (black arrowhead) risks track marks.
J AM ACAD DERMATOL
VOLUME 72, NUMBER 3
Miller, Antunes, and Sobanko 379
4. hand to stabilize the skin with gentle downward
pressure (as opposed to lateral traction) also mini-
mizes a beveled dermis with each pass of the scalpel.
The epidermis and dermis have greater surface
tension compared to subcutaneous fat. After incising
through the dermis, the epidermis and dermis
immediately retract away from the incision, and the
subcutaneous fat tends to lag toward the center of
the wound (Fig 7, A). If the lagging fat obscures the
dermis or extrudes between the wound edges during
the placement of deep sutures, trimming it flush with
the dermis allows for greater visibility of the reticular
dermis for accurate placement of the buried dermal
sutures (Fig 7, B). In many cases, this is best
accomplished after undermining. Using forceps to
gently stabilize the lagging fat, the surgeon can use
tissue scissors to trim the fat flush with the dermis
and create a sharply perpendicular wound edge
along the full thickness of the skin flap. Excessive
traction should be avoided, because it frequently
causes a reverse bevel (ie, a bevel away from the
center of the wound), which makes it more difficult
to place the deep sutures without a prominent
dimple.
Goal of incision
The goal of incision is to achieve a uniform release
along the entire skin edge to the desired anatomic
depth and to create smooth and perpendicular
wound edges with no bevel.
Quality control checkpoints for incision
1. Has the incision achieved uniform release to the
desired anatomic plane?
a. Troubleshooting #1—If the incision has
not reached the desired anatomic depth,
complete the incision to get uniform release.
b. Troubleshooting #2—If the incision extends
more deeply than the intended depth of
Fig 6. A, Suboptimal surgical technique, with the scalpel handle falling toward the dominant
hand. This position predictably incises the skin with a beveled edge. B, Sound surgical
technique, with the scalpel handle and blade held perpendicular to surface of the skin. This
position will help to incise the skin with a vertical wound edge and no bevel.
Fig 7. A, Intraoperative appearance of a wound after incision, excision, and undermining. The
epidermis and dermis have retracted away from the center of the wound more than the
subcutaneous fat. The lagging fat (black arrowhead) creates a beveled edge that obscures
visualization of the reticular dermis and will obstruct direct approximation of the dermis. B,
Intraoperative appearance of the same wound showing the technique of using tissue scissors to
trim to the lagging fat bevel flush with the dermis. The fat bevel on the superior wound edge
has already been trimmed and now has an incised wound edge with a precisely vertical face.
J AM ACAD DERMATOL
MARCH 2015
380 Miller, Antunes, and Sobanko
5. the excision and undermining, be careful that
the subsequent steps of excision and under-
mining occur in the correct anatomic plane.
2. Are the incised wound edges perpendicular
without a bevel of the dermis or fat?
a. Troubleshooting #1—If the dermis is cut with
a beveled edge, ensure that the angle of the
scalpel is perpendicular to the plane of the
skin throughout the entire pass of the incision
(Fig 6, B).
b. Troubleshooting #2—If the dermis is cut
with a beveled edge, assess the method
of stabilizing the skin. The application of
downward pressure perpendicular to the
surface of the skin is less likely to produce a
beveled edge compared to stretching each
side of the skin away from the path of the
incision.
c. Troubleshooting #3—To avoid a beveled
dermal edge, consider using a no. 10 scalpel
for anatomic locations with a thick dermis.
d. Troubleshooting #4—If the dermis is cut with
a beveled edge, grip the redundant tissue
with a forceps and apply gentle traction into
the wound. Incise through the beveled
dermis to create a clean and perpendicular
edge.
e. Troubleshooting #5—If the subcutaneous fat
is lagging in the center of the wound, consider
using tissue scissors to trim the lagging fat
flush with the vertical face of the incised
dermis (Fig 7, B).
3. Are the wound edges cut cleanly without jagged
edges?
a. Troubleshooting #1—Jagged edges may occur
from excessive downward pressure or the use
of a dull scalpel. Ensure that the scalpel
is sharp and pass the scalpel lightly, allowing
[1 pass to achieve the desired depth, if
necessary.
b. Troubleshooting #2—Jagged edges may occur
if loose skin is not stabilized while incising.
Improve stabilization of the skin while
incising.
Common errors to avoid during incision
1. Failure to incise to the desired anatomic depth
(ie, either too superficial, leading to no release,
or too deep, leading to bleeding through the
gulley from the incision)
2. Holding the scalpel at an angle that creates a
beveled edge
3. Jagged wound edges resulting from chatter
caused by excessive downward pressure on the
scalpel, from a dull blade, or from a failure to
stabilize the skin while incising
CUTTING TECHNIQUE: EXCISING
Key points
d Excision should remove the lesion or excess
skin during the reconstruction with minimal
collateral damage to important anatomic
structures
d The anatomic plane of the excision ideally
corresponds to the depth of initial skin
incision; otherwise, hemostasis may be
more challenging or bulky soft tissue in the
central wound may impede apposition of
wound edges
d The ideal anatomic plane of excision varies
by location on the body
d Ideal planes of excision are characterized by
the effortless release of tissue and minimal
bleeding
Excision has 2 purposes: either to (1) ensure
complete removal of a lesion or to (2) restore
contour by removing the standing cone or excess
tissue during the reconstruction. Based on the
clinical examination and pathology of the preoper-
ative biopsy specimen, the surgeon must determine
the anatomic depth of the excision. The excision
should remove the lesion or excess skin with
minimal collateral damage to important anatomic
structures. Deeply infiltrating tumors may require
excision to a depth that causes predictable
morbidity. For example, a tumor that invades
the deep fat on the temple may require excision of
the temporoparietal fascia and may sacrifice the
temporal branch of the facial nerve. By contrast,
the surgeon can almost always dictate the anatomic
plane when excising standing cones or excess tissue
during the reconstruction. The ideal anatomic planes
for different anatomic locations can be found in
Table I.
Ideally, the preceding incision has released the
skin to the desired anatomic depth and the excision
continues a clean lift of tissue in the same surgical
plane. In areas with thick subcutaneous fat, a
disparity between the depths of the incision and
excision may create unnecessary challenges during
the closure. For example, if the incision extends to
the fascia, but the tissue is excised at the level of the
superficial subcutaneous fat, then the island of
subcutaneous fat at the base of the wound can
impede advancement of the wound edges during
J AM ACAD DERMATOL
VOLUME 72, NUMBER 3
Miller, Antunes, and Sobanko 381
6. the closure and complicate hemostasis by obscuring
blood vessels (Fig 8).
On the scalp, central face and temples, hands and
feet, and male genitalia, the subcutaneous fat is
either thin or indistinct (eg, on the mid-chin, the
mentalis muscle inserts directly into the dermis and
there is not a distinct layer of fat), so the surgeon
encounters the underlying muscle or fascia
immediately after release of the dermis. In the medial
aspect of the cheek, neck, trunk, proximal
extremities, and female genitalia, there is frequently
a thicker layer of subcutaneous fat. In these loca-
tions, a layer of columnar, compact, and tightly
organized fat lobules adheres to the underside of
the dermis. A surgical plane separates these tightly
organized columnar lobules from a deeper layer of
larger, more loosely organized fat lobules that invest
the fascia (Fig 9). Vigorous scrubbing with gauze can
often dislodge these deeper, loosely organized,
larger fat lobules from the fascia. The junction of
Table I. Ideal surgical planes for incising, excising, and undermining
Anatomic location Preferred anatomic plane Comments/critical structures to consider
Trunk and extremities Junction of subcutaneous fat
and deep fascia
In areas on the trunk and proximal extremities, with a thicker
layer of subcutaneous fat, the ideal surgical plane is the
junction between the tightly organized, compact, columnar
fat lobules adherent the underside of the dermis and the
underlying, looser, larger, and more disorganized fat lobules
that invest and obscure the fascia
Lateral aspect of the
face and neck
Junction of the subcutaneous
fat and SMAS
The motor branches from the facial nerve always lie deep to
the most superficial layer of SMAS (in areas where the
muscles of facial expression are layered [eg, lip depressors
and elevators], the motor nerves innervate the deepest
muscles from their superficial surface); excision at the
junction of the subcutaneous fat and SMAS will always
protect the motor nerves
Central third of face
and scalp
At the junction of subcutaneous
fat and SMAS or deep to the
muscles of the SMAS or galea
(on scalp)
Because the branches of the facial nerve have arborized before
reaching the central third of the face, excision deep to the
SMAS is less likely to cause motor deficits (eg, excision of
midline and paramedian frontalis muscle does not leave
motor deficit on the forehead); on the midline nose,
forehead, and scalp, undermining deep to the SMAS is
frequently desirable
SMAS, Superficial musculoaponeurotic system.
Fig 8. This intraoperative photograph shows a
discrepancy between the anatomic depths of the incision
and excision. The incision has released to the fascia. The
central island of tissue is being excised in the superficial
subcutaneous fat. A gully (arrowhead) left by the deeper
incision often creates challenges for hemostasis, and the
central island of fat can impede advancement of the
wound edges. Excising the specimen with tissue scissors
reduces the likelihood of this error by providing improved
tactile feedback from the release of the anatomic planes.
Fig 9. On the trunk and extremities, the ideal surgical
plane is at the junction of the tightly organized, columnar
fat adherent to the dermis and the larger, loosely organized
fat lobules that invest the deep muscular fascia.
J AM ACAD DERMATOL
MARCH 2015
382 Miller, Antunes, and Sobanko
7. these 2 layers of fat provides a natural and efficient
surgical plane that releases effortlessly. Optimal
planes for excision vary by location (Table I).
Excising at the junctions of tissue planes minimizes
bleeding and allows for effortless dissection. On the
trunk and extremities, the junction of the subcutane-
ous fat and deep muscular fascia provides an ideal
surgical plane (Fig 9). In order to preserve the
underlying branches of the facial nerve on the lateral
aspect of the face and the spinal accessory nerve in
the posterior triangle of the neck, the surgeon
excises at the junction of the subcutaneous fat and
fascia of the superficial musculoaponeurotic system
(SMAS; Fig 10). On the central face, excising deep to
the muscles of facial expression/SMAS poses a
minimal risk for motor deficits (Fig 11). Whereas
the most common surgical plane on the nose and
central forehead is deep to the SMAS, it is more
common to work superficial to the orbicularis oris
muscle around the mouth. For smaller procedures in
the central face, the surgeon may choose a
surgical plane superficial to the SMAS. In the midline
forehead, for example, the surgeon may choose to
stay above the frontalis for a small horizontal
excision in order to minimize postoperative sensory
deficits, but may excise deep to the frontalis to
remove bulk and facilitate tissue advancement for a
large excision. On the scalp, the anatomic plane of
the excision is usually deep to the galea apo-
neurotica (Fig 12).
The surgeon can use either scissors or a scalpel for
excision. Scissors have some advantages over
scalpels, especially when the surgeon does not
have intimate knowledge of the surgical planes.
Compared to the scalpel, scissors provide more
tactile feedback, which helps the surgeon feel the
release of tissue and maintain a uniform anatomic
plane. Scissors should split the anatomic plane with
ease, especially in healthy skin without fibrosis from
a previous scar. Undue resistance during excision
should prompt the surgeon to reevaluate the
accuracy of the anatomic plane. In contrast to
scissors, the blind, sharp edge of the scalpel more
easily breaches tissue planes. Especially in areas with
thick subcutaneous fat, such as the abdomen or
Fig 10. Excising and undermining superficial to the
superficial musculoaponeurotic system of the face and
investing cervical fascia of the neck preserves the
underlying branches of the facial nerve on the lateral
face and the spinal accessory nerve in the posterior
triangle of the neck.
Fig 11. On the central face, where there is minimal risk
for motor deficits from working in a deep surgical plane,
the anatomic plane of excision is usually deep to the
muscles of facial expression/superficial musculoaponeur-
otic system. For smaller procedures, the surgeon may
choose a surgical plane superficial to the superficial
musculoaponeurotic system.
Fig 12. On the scalp, the anatomic plane of the excision is
usually deep to the galea aponeurotica.
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Miller, Antunes, and Sobanko 383
8. proximal thigh, there is a tendency for the scalpel to
cut progressively deeper during the excision and for
the underside of the specimen to have scalloped
incisions. The surgeon should aim for a clean
separation of anatomic planes and an excision
specimen with a uniform thickness in profile that
reflects the accuracy of the plane of excision (Fig 13).
Goal of excision
The goal of excision is to remove the skin in a
uniform and efficient anatomic plane with minimal
morbidity to the underlying structures.
Quality control checkpoints for excision
1. Is the excision effortless and does it cause
minimal bleeding?
a. Troubleshooting—Undue resistance or exces-
sive and diffuse bleeding from small vessels
frequently signifies an inefficient plane of
excision. Reevaluate the plane of excision
and aim for the junction of tissue planes,
where excision usually occurs effortlessly and
with less bleeding (Figs 9-12).
2. Does the excision specimen have a uniform
thickness (Fig 13)?
a. Troubleshooting—If the profile view of the
excised specimen has varying thicknesses,
then consider using scissors, rather than a
scalpel, to gain the tactile feedback that helps
maintain a uniform anatomic plane during
excision.
3. Does the base of the wound have a uniform
depth at the desired anatomic plane (Fig 14)?
a. Troubleshooting—If the base of the wound
does not have a uniform anatomic depth
because of a partially shallow excision, then
complete the excision of the remaining
superficial tissue to the desired anatomic
plane. If portions of the wound have been
excised more deeply than the preferred
anatomic depth, be careful that undermining
occurs more superficially at the preferred
anatomic plane.
Common errors to avoid during excision
1. Failure to excise the specimen in a uniform
anatomic plane
2. Mismatch between the anatomic depths of the
incision and excision
3. Failure to excise the tissue at the junction of
tissue planes
CUTTING TECHNIQUE: UNDERMINING
Key points
d Undermining may facilitate advancement of
the wound edges and eversion when
suturing
d Wounds at anatomic sites where the fascia is
adherent to the overlying dermis benefit
most from undermining
d Excessive undermining can threaten the
blood supply of the flap and rarely provides
a mechanical advantage
d The plane of undermining frequently
corresponds to the plane of excision
Fig 14. Examining the base of the wound for a uniform
surgical plane serves as a quality control checkpoint. The
plane of excision on the anterior surface of the neck seen
in this photograph is immediately superficial to the
platysma muscle, providing a relatively bloodless and
efficient surgical plane.
Fig 13. Assessing the excision specimen for uniform
thickness serves as a quality control checkpoint. The
fusiform excision specimen in the photograph has a
uniform thickness in profile. In this case, the small excision
specimen was removed in plane of the superficial
subcutaneous fat. Excising the specimen at the junction
of the subcutaneous fat and fascia is usually a more
efficient surgical plane that allows for easier isolation of
vessels for hemostasis.
J AM ACAD DERMATOL
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384 Miller, Antunes, and Sobanko
9. d An efficient plane of undermining is charac-
terized by effortless release of the tissue and
minimal bleeding
d Efficient undermining requires effective
countertraction, most frequently applied
with a skin hook, directly over the point of
release
The goals of undermining are to (1) facilitate
tissue advancement by releasing either the skin
edges or flap from underlying adhesions and to
(2) facilitate eversion of the wound edges during
suturing. The surgeon must make 2 key decisions
when undermining: (1) the ideal anatomic plane for
undermining and (2) the extent of undermining
(ie, how widely to undermine). In most cases, the
anatomic plane for undermining coincides with the
depth of the incision and the plane of the excision.
If the surgeon is working in an efficient surgical
plane, undermining should occur with ease. Undue
resistance while undermining usually signifies an
inefficient anatomic plane (eg, most commonly
splitting the subcutaneous fat rather than working
at the junction of the fat and fascia). The ideal surgical
plane varies based on the location (Table I and Figs 9-
12). In some instances, undermining at a more
superficial anatomic depth than the excision can
minimize morbidity. For example, if excision of the
temporoparietal fascia is necessary to clear a tumor
on the temple, the surgeon may decrease morbidity
to the underlying temporal branches of the facial
nerve by undermining the edges of the reconstruc-
tion superficial to the temporoparietal fascia.
The extent of undermining varies according to the
procedure. For primary closures, wide undermining
rarely increases mobility of the skin edges. Minimal
undermining (ie, 0.5-1.0 cm) will usually suffice.
For deep wounds or very loose skin (eg, on the
forearm or lateral aspect of the neck), undermining
may not be necessary. Fascial plication sutures
can advance tissue and decrease undermining re-
quirements.14
To decide whether undermining is
necessary, the surgeon can use a skin hook to pull
the incised wound edge to its desired position.
If underlying adhesions restrict mobility or fix
the skin in an inverted position, undermining will
help. Undermining is most beneficial in areas
where the fascia and the underlying dermis have
dense connections (eg, the muscles of facial expres-
sion inserting in the dermis at the apical triangle of
the lip).
Undermining influences the vascular supply and
mobility of the flap. The vascular supply to the flap
varies according to anatomic plane and the extent
of undermining. Flaps elevated too superficially
(eg, immediately subdermal) may not have adequate
blood supply.15
To optimize blood supply, local
flaps should contain at least the epidermis, dermis,
and the tight columnar cells of subcutaneous
fat immediately adherent to the dermis (Fig 9).
Undermining deep to muscle or fascia improves
flap blood supply but may increase morbidity,
depending on the anatomic location of the surgery
(Table I). For example, in the central face (eg, the
nose and central forehead) and scalp, undermining
deep to the muscles of facial expression or galea,
respectively, is desirable in most cases (Figs 11 and
12). By contrast, on the lateral aspect of the face,
temple, and posterior triangle of the neck,
undermining superficial to the SMAS and investing
fascia of the neck, respectively, preserves function of
the underlying motor nerves (Fig 10).
Undermining too widely can threaten a flap’s
blood supply or increase the possibility of
postoperative bleeding and hematoma forma-
tion.16-18
In general, the surgeon should aim to
undermine just enough to move the flap into place.
Frequent assessment of skin edge mobility while
undermining helps to avoid unnecessarily wide
undermining. When the skin edges comfortably
stretch to their desired target, additional undermin-
ing is rarely helpful or necessary.
Sharp undermining improves efficiency. With a
thorough knowledge of anatomy, the surgeon can
undermine sharply and with confidence. Compared
to the scalpel, scissors allow sharp undermining with
better tactile feedback. The scissors precisely release
the skin at the desired surgical plane. After the initial
releasing cut, the surgeon can efficiently undermine
the remaining skin by sliding 1 blade of the scissors
in the newly released space and by using the second
blade to complete the cut (Fig 15). Using this slide
Fig 15. Sharp undermining improves operative efficiency.
When working in efficient surgical planes, sharp under-
mining occurs with ease. This photograph shows the
practice of sliding 1 blade of the tissue scissors in the
desired surgical plane, then using the second blade to
complete the release. Using this slide and divide technique
of undermining, the surgeon does not have to rediscover
the preferred undermining plane with each new cut.
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Miller, Antunes, and Sobanko 385
10. and divide technique,19,20
the surgeon does not have
to rediscover the preferred undermining plane with
each new cut. Blunt undermining may be preferred
where fascial planes are being separated, such as on
the dorsal surface of the hand or under the galea of
the scalp. These avascular planes may be split simply
by inserting the closed tips of the scissors in the
desired plane of undermining then spreading the
instrument.
Countertraction with skin hooks greatly facilitates
undermining. Compared to forceps, skin hooks
allow forceful countertraction of the skin without
epidermal trauma. The skin hook should be placed
firmly at the desired depth of undermining (usually
firmly under the dermis) immediately over the point
of undermining. If the skin hook is placed too
superficially (eg, in the mid-dermis), the instrument
tends to slip from the skin. If the skin hook is placed
remotely from the point of undermining with the
scissors, the forces of countertraction diminish and
undermining is more difficult. Therefore, as the
scissors progress to a new spot, the retracting skin
hook should follow. When undermining is
complete, there is often a bevel of subcutaneous fat
along the incised face of the skin edge. Tissue
scissors can be used to trim this fat bevel flush with
the dermis (Fig 7, B).
Goal of undermining
The goal of undermining is to facilitate
advancement of skin edges by releasing the skin
edges from underlying adhesions and to facilitate
eversion of the wound edges during suturing.
Quality control checkpoints for undermining
1. Is undermining effortless, and does it cause
minimal bleeding?
a. Troubleshooting #1—If undermining is
difficult, reassess the surgical plane (Table I).
Resistance during undermining frequently
occurs from working in a suboptimal surgical
plane.
b. Troubleshooting #2—If undermining is
difficult, evaluate whether countertraction
was performed effectively. Efficient under-
mining requires forceful countertraction
directly over the point release. Undermining
will feel difficult if countertraction is either
absent or remote from the exact point of
undermining.
2. Can the incised skin edge be retracted in an
everted position?
a. Troubleshooting—If a skin hook cannot
retract the skin edge in an everted position,
then connective tissue adhesions will likely
force the wound edge in an inverted position.
The wound edge may need additional
undermining before suturing. Wide under-
mining rarely facilitates eversion.
3. Are the wound edges sharply perpendicular from
the epidermis to the plane of undermining?
b. Troubleshooting—After undermining, there is
often a bevel of subcutaneous fat along the
incised face of the skin edge. Tissue scissors
can be used to trim this fat bevel flush with
the dermis (Fig 7, B).
Common errors in undermining
1. Undermining in a suboptimal surgical plane
2. Undermining without effective countertraction
3. Insufficient undermining that restricts eversion of
the incised wound edge
4. Failure to trim the fat bevel to create sharply
perpendicular wound edges after undermining
Fig 16. The wound edges have been undermined in the
same surgical plane as the base of the excision. In this case
on the temple, the surgical plane is at the junction of the
subcutaneous fat and the superficial musculoaponeurotic
system.
Fig 17. Upon final inspection from the cutting steps, the
surgeon should observe a wound with cleanly incised,
vertical wound edges, a wound base uniformly located at
the preferred anatomic plane, and skin flaps undermined
enough to allow advancement and eversion of the wound
edges.
J AM ACAD DERMATOL
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386 Miller, Antunes, and Sobanko
11. CONCLUSION
The initial steps to cutaneous surgery require
cutting, including incising, excising, and under-
mining. After the cutting steps, the ideal wound has
cleanly incised, vertical wound edges, a base at a
uniform anatomic plane, and precisely undermined
skin edges (Figs 16 and 17). Part I of this continuing
medical education article provided quality
control checkpoints and troubleshooting solutions
to address common challenges during incision,
excision, and undermining to help surgeons create
wounds ideally suited for repair with precise and
efficient buried and superficial sutures.
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Answers to CME examination
Identification No. JA0315
March 2015 issue of the Journal of the American Academy of Dermatology.
Miller CJ, Antunes MB, Sobanko JF. J Am Acad Dermatol 2015;72:388.
1. c
2. b
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