sutures cutting through subq fat

[sonofva]

so i am an FP type of person. was doing an excisional biopsy on a patient's calf. was probably a 3-4 cm long ellipse, removing a sizable BCC with margins leftover. did the usual thing, excised, undermined, started to do a subq layer of sutures for initial closing. for some reason i couldn't get any kind of bite to take. it was like this person had no good tissue to tie with. my suture material would cut through whatever i was trying to close on. eventually got it closed, but damn... suture was 4-0 monocryl. any tips? thx.

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[asmallchild]

so i am an FP type of person. was doing an excisional biopsy on a patient's calf. was probably a 3-4 cm long ellipse, removing a sizable BCC with margins leftover. did the usual thing, excised, undermined, started to do a subq layer of sutures for initial closing. for some reason i couldn't get any kind of bite to take. it was like this person had no good tissue to tie with. my suture material would cut through whatever i was trying to close on. eventually got it closed, but damn... suture was 4-0 monocryl. any tips? thx.

Common on the lower extremities unfortunately. The dermis is often thin, couple that with a higher tension wound and it can make for a tricky closure

I will often use 3-0 suture or just minimize my subQ sutures and use larger bites for the top layer (this will come at the expense of cosmesis unfortunately )

 

[Dral]

Common on the lower extremities unfortunately. The dermis is often thin, couple that with a higher tension wound and it can make for a tricky closure

I will often use 3-0 suture or just minimize my subQ sutures and use larger bites for the top layer (this will come at the expense of cosmesis unfortunately )

Agree. Pulley stitches can be helpful too.

http://www.acssurgerynews.com/speci...tension/dc223352d3d31bb2e218403570fc473c.html

 

[sonofva]

Thanks y'all!

 

[doctalaughs]

Thanks y'all!

Also make sure you are using a reverse cutting needle.

 

[MOHS_01]

Sounds like a missed opportunity at tissue conservation.



In all seriousness, it wasn't a suture selection problem. The area is notoriously difficult; it is (generally) relatively inelastic skin with little redundancy -- so you are hit with a double whammy -- not only will the tissue not stretch, it won't move either as you have little to no excess to recruit from. Throw in aged atrophic skin and you're just hosed before you ever get started.

If the skin is that atrophic -- and the tension is that great -- pulley stitches may not really be your friend in the long term as they are locally strangulating and concentrate the tension in one focal area. They can be useful in holding tension temporarily while allowing you to distribute the tension more uniformly, but you probably want to remove them before letting the person leave the room. You don't have to, but you probably should.

What I like to do in areas of atrophic skin (tension is a problem that I just avoid -- excess tension is a common culprit for unnecessary complications) is some form of stent suture technique, whether it is a simple horizontal mattress through rolled xeroform or multiple vertical mattresses (quilled) through / over a stent to relieve tension directly at the wound edge.

The best thing to do is to consider the lower leg (and the bald atrophic scalp) just like herpes -- don't touch it unless you absolutely have to. 😱

 

[MOHS_01]

Common on the lower extremities unfortunately. The dermis is often thin, couple that with a higher tension wound and it can make for a tricky closure

I will often use 3-0 suture or just minimize my subQ sutures and use larger bites for the top layer (this will come at the expense of cosmesis unfortunately )

Yeah -- lower legs just suck. They are the anti-face; they make heroes look like chumps. Ha.

 

[doctalaughs]

Yeah -- lower legs just suck. They are the anti-face; they make heroes look like chumps. Ha.

While you (and other mohs people) are dispensing advice, any tips on orienting larger excisions on arms (or calves) in young elastic skin? I know some dog ears are inevitable in elastic convex surfaces (and they usually flatten out) but is there a optimal rule besides lazy S or just disc excision then correcting dog ears where they best seem to lie?

 

[MOHS_01]

Yeah -- forget the hard rules of orientation; just pinch the skin and follow the lines (run with the many small lines, not the few large ones). Hopefully they will have some -- ha.

 

[username456789]

Agree with avoiding the lower leg when possible.

When not possible, consider a disc excision and purse string it, although you still may end up SOL.

 

[MOHS_01]

Do you really like purse stringing the lower leg? My luck with them has sucked... I've never found that they provide any more movement than side to side... plus they are either likely to hurt due to tension or pull through when they walk on it.

Here's what I do if it is too tight to close primarily:

1. Partial closure, stented, plus second intention.
2. Partial closure plus Burrow's graft. Immediate FTSG on lower extremities often struggle, but there is little harm in trying. Be sure to really thin down and don't strangulate with your primary.
3. Suture in a xeroform covered restone bolster and consider delayed grafting at 1-3 weeks. Granulation is a wonderful thing.

 

[username456789]

Well, I'm just a 3rd year resident and will defer to someone who makes a living doing surgery.

I wouldn't say I like purse stringing the lower leg, but I don't like doing much of anything on the lower leg. I remember my first lower leg SCC excision as a first year - struggled forever to put in some deeps, then managed some epidermal sutures with a combo of interrupteds and running. Looked like a mess, but it held together. Had a couple spitting sutures, and the guy was a great sport about it, but it took forever to heal up. I just saw him in clinic the other day and now, a couple years later, the scar actually looks surprisingly good.

I've done a couple lower leg pursestrings over the past year or two, with varying results. They never close completely of course. It's basically a fancy way of letting them heal by secondary intent, I suppose.

Anyway, I like your ideas - likely beyond what a FP resident would be considering, but mechanistically they're just as likely (and probably moreso) to work as anything I've got up my sleeve.

 

[Dral]

Sounds like a missed opportunity at tissue conservation.



In all seriousness, it wasn't a suture selection problem. The area is notoriously difficult; it is (generally) relatively inelastic skin with little redundancy -- so you are hit with a double whammy -- not only will the tissue not stretch, it won't move either as you have little to no excess to recruit from. Throw in aged atrophic skin and you're just hosed before you ever get started.

If the skin is that atrophic -- and the tension is that great -- pulley stitches may not really be your friend in the long term as they are locally strangulating and concentrate the tension in one focal area. They can be useful in holding tension temporarily while allowing you to distribute the tension more uniformly, but you probably want to remove them before letting the person leave the room. You don't have to, but you probably should.

What I like to do in areas of atrophic skin (tension is a problem that I just avoid -- excess tension is a common culprit for unnecessary complications) is some form of stent suture technique, whether it is a simple horizontal mattress through rolled xeroform or multiple vertical mattresses (quilled) through / over a stent to relieve tension directly at the wound edge.

The best thing to do is to consider the lower leg (and the bald atrophic scalp) just like herpes -- don't touch it unless you absolutely have to. 😱

When I've seen/used pulleys in that area, it's usually 1 to 3, mainly to get the wound edges to oppose...or at least get close. Those usually come out a few days later and the interrupteds stay in.

What types of things have you seen happen if they stay in for a longer time...anything other than tissue necrosis?

 

[MOHS_01]

When I've seen/used pulleys in that area, it's usually 1 to 3, mainly to get the wound edges to oppose...or at least get close. Those usually come out a few days later and the interrupteds stay in.

What types of things have you seen happen if they stay in for a longer time...anything other than tissue necrosis?

Necrosis and pulling through like a cheese slicer mostly, but I've also seen where they pull and cut just enough to bury the knot -- which results in more tissue trauma removing them. I guess my thought is that, if the tension is high enough that they are required, it's too tight for comfort. Infection risk goes up, necrosis risk goes up, even hematoma risk goes up (due to bleeding secondary to sutures tearing through the dermis with post op swelling). I'm quite conservative, though -- I have a significant aversion to even normal or expected complications -- so I'm probably out on the curve a bit on this one. If necrosis occurs, the sutures are not likely to hold anyway -- and your already sizable defect that caused the problem has now been unnecessarily expanded into something even more difficult to address.

my .02

 

[asmallchild]

When I've seen/used pulleys in that area, it's usually 1 to 3, mainly to get the wound edges to oppose...or at least get close. Those usually come out a few days later and the interrupteds stay in.

What types of things have you seen happen if they stay in for a longer time...anything other than tissue necrosis?

Agree with MOHS_01, I've found they will usually pull through. If the wound won't stay closed upon removal of the pulley suture, the pulley is likely to pull through anyway. If left in for 2 weeks and they happen to stay in place, there's usually a pretty terrible suture impression that's left behind. I really like secondary intention healing or xenografts when dealing with larger wounds on the lower extremities. I also agree avoidance (if possible) is the best tactic with lesions on the lower extremities.

 

[MOHS_01]

Do you get paid for xenografts?

 

[asmallchild]

Do you get paid for xenografts?

Not well, but yes 🙂

 

[Tamahawk]

Mother Nature (Granulation) is my top choice for most leg wounds. Lower infection risk relative to high-tension closures, cheaper for the patient, 100% dependable. Also, circular excision (via Mohs or other technique) is my go-to rather than elliptical excisions on the lower legs because it results in a smaller defect (especially compared to a dehisced elliptical).

Pursestring closures have not proved helpful on lower legs (in my experience), but are helpful for dorsal hands and atrophic forearms at times.

 

[sonofva]

Good news! Got the path report back and margins were clear. The scar is healing way better than I anticipated. Lessons learned though! Thanks for all the great tips y'all.