Across the board this is yet another hot topic… Closing the strip excision. As far as technique goes eeeevvveryone is so different. I can only provide information for what I know in terms of the docs I worked for, however… I hope jotronic from H & W, vehement, B spot, HLC, gillinator, someone from Brad Wolf, MD because he has spoken to no end in the gold suturing at the ISHRS conferences. and patients all provide input here please… for the sake of the ghost readers out there wanting to know. It would at extremely interesting that posters take a picture of their suture line at whatever stage it is at and the tell us with a post how it was performed. This might not be an ideal thing but for those who wish to show themselves it would be treated with the deepest respect here. This is what I know of the different clinics.
Cooley: Tight continuous running suture/ blue nylon suture/upper ledge/ Ledge Closure/ sqweezes excess blood from the suture line and compressed bandage if leaky/ picks the suture line clean of hair while suturing/ uses Bovi for vessel cautery
Rose: Somewhat tight continuous running suture/ gut dissolvable suture/lower ledge/ Ledge Closure/ compressed bandage if leaky/ picks the suture line after suturing. uses Bovi for vessel cautery
Harris: slightly larger bites when using dissolvable sutures/tighter bites with nylon/Interrupted standard running suture X 2 sutures/Uses mosquito clamps for vessels/uses a modified towel clamp with gauze as a compression technique during suturing to help proximate the borders by descreasing fluid from tumescence/picks the suture line after suturing/neosporin
PAI: Wide bites with nylon single standard running suture/Uses an Infrared (Ir) Bovi for vessel cautery/ Picking???
Bosley: Wide standard running suture with gut dissolvable/band around head and especially on suture line until case over/no picking
Here is Dr. Roses words,
"I usually use a single layer running closure with a 4-0 nylon suture. I try to avoid having tension of on the wound edge. The sutures are placed close together to allow formore exact approximation of the wound edges.I rarely need to use a two layer closure with deep suture. When I do use a deep suture it is usually a slow absorbing suture such as PDS. At times I will use Vicryl. If I use a deep suture the sutures are intermittent and placed to take tension off of the tissue and avoid damage to hair follicles.
My ledge closure technique is often copied but not always well duplicated. I use a scalpel to score th lower edge and use a scapel to cut the epidermis at about 1mm depth. With this method there is higher degree of accuracy and the scalpel can be used to pick out the hair follicles to include or exclude. A true right angle is created like a cabinet joint.
I find that other physicians use a scissor and create a slope rather than a true ledge. This produces a less secure bond.
I also find that some physicians cut too deeply in trying to create the ledge.
Paul T Rose, MD
2919 West Swann Ave
tampa, Florida 33609"