PRACTICE RECOMMENDATIONS
› If the skin edges of a wound require pressure to approximate, consider undermining the edges. C
› When removing a cutaneous neoplasm, avoid resecting excessive tissue. A
› For deep lacerations with potential “dead space,” use vertical mattress sutures to approximate the wound edges. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Skin procedures such as closing wounds and removing neoplasms are an integral part of most family medicine practices. While closure of simple lacerations and small surgical procedures are relatively straightforward, some lesions require extra techniques and attention to achieve the best outcomes.
This article describes some steps you can take to achieve the best outcomes for wound healing and cosmesis. Although suturing basics are important for successful wound closure, that information is not covered in this article. Forsch,1 however, provides an excellent discussion of basic wound skin preparation and suturing techniques.
Before beginning, visualize the ending
Before beginning any skin repair—whether it is a planned surgical procedure or a more urgent wound closure—review the patient’s medical record for conditions or medications that may adversely affect wound healing. Key in on patients with poorly controlled diabetes or those taking anticoagulants or antiplatelet drugs. Good diabetes control before surgery improves healing2 and drugs that promote bleeding sometimes may be temporarily discontinued before a procedure. If a patient’s diabetes is poorly controlled, an elective procedure can be postponed. If a patient is taking an anticoagulant and the international normalized ratio is within the therapeutic window, the procedure can be performed, but the physician must be ready to address bleeding by having electrical or chemical cautery available.
During your initial evaluation of the patient, assess and document the condition of the joints, muscles, tendons, and ligaments in the area in question before the procedure. Being aware of the local anatomy will help you avoid inadvertently damaging nerves, tendons, vessels, and other vital structures. Also, any time a procedure is beyond your comfort level, ask for help or refer the patient to a subspecialist. For example, if a lesion is on a patient’s neck near the carotid artery, the procedure is better left to an ear, nose, and throat specialist.
On the day of the procedure, plan how you will close the wound before you make the first cut, and include this information in your informed consent. Mentally review the anatomy of the area before starting a procedure to anticipate obstacles or structures that may be inadvertently injured. Visualize how the skin will fit together and how it will heal before making an incision. Reassure the patient that you will use techniques to minimize pain and scarring. Consider taking photos both before and after the procedure for documentation.
The best cosmetic results usually are achieved when the final closure line (and therefore the scar) lies parallel to the lines of least skin tension. When doing an excision, start choosing possible closures by considering layouts that produce this result. Eliminate from consideration any closures that would pull skin tension from areas that are immobile or that would cause cosmetic problems (such as a closure on or near the eyebrows or mouth, since this would change the contours of these structures). For such closures, a skin rearrangement flap may offer a cosmetically better outcome, especially on the face.
Tips for irrigating the wound and prepping the skin
If you are repairing a wound that is the result of an injury, you will need to clean the laceration gently but thoroughly. Avoid using products on open wounds that can damage regenerative tissue, such as organified iodines or hydrogen peroxide.3,4 Before irrigating a wound with normal saline, thoroughly examine it for foreign bodies, which may promote infection and impede healing. Consider giving local anesthesia before irrigation. Typically, irrigation pressure of approximately 8 pounds per square inch (psi) is considered ideal.5 Using irrigation pressures of <4 psi only moistens the wound, and >15 psi can damage the wound and drive bacteria deeper into tissue.6 Pressures of 8 to 11 psi can be achieved using a 18- to 19-gauge needle or angiocatheter with a 30 cc to 35 cc syringe.
Consider snipping off the tip of the cap and leaving it snugly on the needle. This will help prevent needle sticks and allow for thorough and safer irrigation. If commercial irrigation equipment is available, use it as directed by the manufacturer. Always be aware of potential splashback while irrigating and use appropriate personal protective equipment.