Objectives of the Presentation

Review the factors involved in cosmetic skin closures.

Key Points

Skin incisions should be made perpendicular to the skin surface, without any serrations or dog-ears. The keys to cosmetic skin closure, are atraumatic handling of the skin, no tension on the skin edges, perfectly apposed skin edges both vertically and horizontally, and consistent, loosely applied skin sutures.

Atraumatic Skin Handling

Avoid handling skin during subcutaneous suturing. When skin adjustment is necessary, use DeBakey thumb forceps since they force the surgeon to be delicate and handle skin gently.

Do not grab the skin edges and lift the skin while suturing, simply lightly hold the skin when driving the needle into the skin.

Try not to undermine skin edges excessively.

No Tension on the Skin Edges

A well-placed subcutaneous suture line that incorporates the hypodermis is important to reduce skin tension. Place subcutaneous sutures as close as 0.5 cm apart to bring skin edges within 0.2–0.3 mm from one another.

Pick up the same level of subcutaneous tissues with each bite to avoid vertical “stepping” of the skin.

Perfectly Apposed Skin Edges

Examine the skin edges before skin closure to determine if there will need to be adjustments.

When suturing the skin, watch to appose edges both in the vertical direction as well as between edges. If there is vertical stair stepping, drive the needle more superficial on the higher side, and deeper in the tissue on the lower side.

Needle bites should not incorporate deeper subcutaneous tissues, but strive to take only the dermal and hypodermal layers only.

Consistent Skin Sutures

Sutures should be placed identically with each tissue purchase.

The same needle direction, amount of skin, and distance between skin bites are taken.

Suture knots are pulled to the same side of the incision. Sutures are placed without causing excessive intrinsic suture tension.

Needle bites are taken perpendicular to the skin surface.

Suture Materials

A rapidly absorbable suture (no larger than 3-0; 4-0 is preferred) is used in the subcutaneous tissues. Skin sutures are nonabsorbable (no larger than 3-0; 4-0 is preferred).