SUTURE WORKSHOP Heather Onoday, RN, MN, FNP-C Assistant Professor - - PowerPoint PPT Presentation

Heather Onoday, RN, MN, FNP-C Assistant Professor Department of Dermatology Oregon Health and Science University

SUTURE WORKSHOP

Objectives

• Discuss skin biopsy; purpose, selection,

handling, and techniques

• Discuss punch biopsy
• Discuss basic excisional surgery; incision,

undermining, simple interrupted sutures, buried interrupted sutures

• Discuss suturing materials for biopsies and

wound closure

Objectives

• Discuss cosmetic considerations of biopsy and

excisional surgery

• Discuss the importance of the preoperative

assessment

• Review post-operative wound care and

bandaging

• Consider surgical complications; hematoma,

infection, nerve damage

The Skin Biopsy: Purpose

• Histology, to obtain diagnosis
• Determine extent of involvement
• Assess efficacy of therapy
• Provide tissue to clarify diagnosis process

The Skin Biopsy: Selection of Site

• If solitary lesion, problem of selection does not

exist

• Presentation of several lesions can lead to

erroneous conclusion or non-helpful if wrong region is biopsied

• Best if fully developed and untreated
• If heterogeneous lesions, best to perform

multiple biopsies of different stages of lesion

The Skin Biopsy: Handling specimens

• You are the gross pathologist
• Handle specimen carefully
• Select appropriate lesion
• Work cooperatively with the

dermatopathologist to get most knowledge of the biopsy

The Skin Biopsy: Provider’s responsibilities

• Atraumatic biopsy
• Consider need for some normal tissue to be included
• If checking for clear margin, may wish to mark one end

with dye or suture for orientation

• Multiple specimens, consider need for separate bottles
• Amount of formalin should be 20 times that of

specimen

• Fill requisition with tentative diagnoses, clear

description of lesion.

• “The possession of a microscope does not endow the

pathologist with supernatural powers” (Highman)

Skin Biopsy Types

• Needle (rare)
• Incisional
• Punch
• Shave
• Excisional

The Skin Biopsy: Risks

• Bleeding
• Infection
• Scar
• Recurrence
• Nerve damage
• Incomplete treatment
• Pigmentation changes

Incisional Biopsy

– Used to remove one portion of the lesion – Cosmetic consideration – Prone to local recurrence despite total excision in instances of psoriasis, inflammatory processes – Must be deep enough – May need incisional wedge for normal plus involved skin – If suspecting melanoma and feel unable to take full lesion, ensure you take appropriate depth to reveal true Breslow thickness and remove darkest portion – Excision in toto is preferred

Wedge into lesion

Lesion Normal skin

Excisional Biopsy

–Remove the lesion in whole –Diagnostic in most cases –Sometimes therapeutic if removing entire lesion, such as tumor –Results in more scarring

The Skin Biopsy: Punch Biopsy

• Goal of punch biopsy

– Obtain adequate amount of tissue – Cause least amount of cosmetic disfigurement

• History of punch biopsies

– Was used to remove gun powder pigmentation from patients faces in the late 1800s

The Skin Biopsy: Punch Biopsy

• Advantages to punch biopsy

– Rapid – Convenient – Easy removal of tissue – Rapid healing

• Disadvantages to punch biopsy

– Poor when needing depth, fat (erythema nodosum) – Requires suture removal – Size limitations

The Skin Biopsy: Punch Biopsy

• Technique

– Cleanse skin – Hold punch vertically – Push and turn in one direction; back and forth motion can distort tissue – Maintain pressure until just down to fat – Remove cylindrical column, usually with scissor, Sharp! – Should contain epidermis, dermis, and some fat – Close defect with appropriate suture

The Skin Biopsy: Punch Biopsy

The Skin Biopsy: Punch Biopsy

The Skin Biopsy: Punch Biopsy

• Traction for orientation

– Lateral traction should be performed, perpendicular to maximal tension line – Tension pulled in one direction results in more narrow amount of tissue removed – At same time, lengthens the wound in the opposite direction – Results in an elliptical wound

The Skin Biopsy: Punch Biopsy Traction

The Skin Biopsy: Punch Biopsy

• Direction that is

pulled will be the shorter axis

• Traction should

be perpendicular to maximal tension line

The Skin Biopsy: Punch Biopsy

• Helpful hints

– Always mark lesion – Anesthetic may obscure lesion due to tissue expansion – Pictures help tremendously for those that may need future surgery for skin cancer – Patients may be poor historian and sites heal too well sometimes

The Skin Biopsy: Punch Biopsy

• Helpful hints

– Pinching the specimen with forceps can cause artifact on histology – Some use needle to grab before cutting – Bleeding is uncommon, often stopped with suturing. – Aluminum chloride – Monsel’s (ferrous subsulfate) can cause pigment and is destructive – Uncommon, but may need electrocautery or gelfoam

Excisional Surgery

• Methods of closure are dependent on provider’s

choice-individual

• Scar reflects the provider’s skills
• Patient judges your performance based on this
• Excellent results are usually obtained, though some

technique increase probability of such an outcome

• All scars are permanent-goal is to make a good scar
• Not chance, rather, it is good planning

Excisional Surgery

• Good scar requires:

– Correct design of wound – Incision of tissue with appropriate tension – Minimal injury to surrounding skin – Good postop management – Learn from previous mistakes, constantly re- evaluate – Attention to detail

Excisional Surgery

• Atraumatic technique

– Minimal handling of tissue, “delicate fabric” – Fibrous tissue (scar) and infection risk are directly correlated to devitalized tissue – Rough treatment results in increased fluid accumulation and edema – Edema interferes with wound healing by separating tissue, impairing venous return, and inters with tissue metabolism – Tissue debris divert energy of cells

Excisional Surgery

• Methods to minimize damage

– Sharp instruments, prevent compression of tissue – Skin hooks instead of forceps – Prudent hemostasis – Avoid heat from operating lights – Use deliberate movements and efforts-concentrate

Excisional Surgery

• Planning lines for excision

– Before injection – Plan direction, shape and length – Most appropriate for lines of excision to produce least amount of scarring possible – Follow maximal tension lines/ relaxed skin tension lines (RSTL) whenever possible

Excisional Surgery

• RSTL

– Originated as early as 1831-Depuytren noted round piercings on skin created ellipse – Studied by many, Malgaigne, Langer, Kocher, Webster, Cox-many with cadavers, unclaimed bodies

Excisional Surgery

• Benefits of RSTL

– Heal with minimal problems – Improved cosmesis – Produce scars with less spread – Scars are stronger

Excisional Surgery

• RSTL of the face

– Have patient grimace, whistle, raise brow, smile,

• r make exaggerated movements to help determine

RSTL – Especially important in the young who do not yet have wrinkles – Lines from sun damage that are perpendicular to RSTL should not be used, more noticeable

Excisional Surgery

• RSTL

– If unsure of line and appropriate, may excise circle then follow the line that appears naturally – May result in less skin being removed – Orientation may be more favorable when taking away the guesswork – Probably not helpful in areas of the scapula, anterior chest, lateral malar prominences

Relaxed Skin Tension Lines

[Salasche, et. al., 1988]

Relaxed Skin Tension Lines

Excisional Surgery

• Size and shape of excision

– Mark patient before anesthetizing – Most favorable method is tangent to circle method – Draw margin, variation of circle – Extend straight line tangent from the borders of margin defect to intersect on the skin tension line – 3:1 to 4:1 length to width ration – Angle of tangent should be ~30 degrees

Excisional Surgery

• Size and shape

– After creating tangents on each side, softening to more rounded edges will create “fusiform” excision – Straight line of tangent are shorter – The longer the line of the fusiform, the more straight the sides, the smaller the angle of the apices – Less angle, equals less pucker, less dog ear

Tangent to Circle

30º 3:1 to 4:1 Ratio

Fusiform Excision

Excisional Surgery

• Other factors to consider

– Preserve boundaries of areas such as the nose, lips, ears, hairline, eyebrows, and eyelids – Pick simple excisions if possible – Know your limitations

Excisional Surgery

• Incising/cutting

– For most skin excisions, a #15 scalpel blade is preferred – Cosmetic 15c blade available – Hold scalpel handle like a pencil – Light traction with non-scalpel hand – Stabilize blade hand with fifth finger on patient, also giving 2-3 point traction

Excisional Surgery

• Importance of traction

– Given more control – Tension helps achieve clean, sharp straight edges – Prevents beveled edges – Cutting lax tissue results in scalpel itself creating tension, pushing rather than cutting. – Does not allow for fine dissection

Excisional Surgery

• Incising/cutting

– Hold at 90 degree angle to skin surface and cut toward yourself – Need only cut lightly at first, then press more firmly – Cut with the belly of the blade, not the tip – Penetrate as appropriate for wound to achieve necessary depth – Be uniform to minimize repeat cutting

Excisional Surgery

• Incising/cutting

– Ensure shortest incision through tissue and you will obtain minimal distortion of wound edges – Tendency is to slant blade toward the lesion, rather that hold perpendicular to skin – This causes beveling and poor approximation of the skin edges

Excisional Surgery

• Incising/cutting

– When beginning or ending incision, avoid carless extension of incisions “fish-tailing” and avoid nicking lateral edges

Excisional Surgery

• Excision of tissue

– After proper incision made, pick up is used, or skin hook to grasp the lesion – Scissor or scalpel may be used to remove the specimen – Tissue draped over the blade will yield shallow depth, tissue pulled back will be deeper – Once removed, even the fat or dermis at base

Excisional Surgery

• Undermining

– Generally good to undermine – Takes tension off of wound edges laterally and vertically – Removes fibrous bands – Mobilizes the area – Reveals tension lines – Creates scar at regions of undermining, which contracts and holds wound margin more securely – If little or not tension, no need to undermine

Excisional Surgery

• Disadvantages to undermining

– Tissue relationship changes, no longer lined up for repair – Changes plane if malignancy, which might need re-excision-lose orientation – Increased dead space, bleeding risk

Excisional Surgery

• Suggested level of undermining

– Difficult to make universal – Follow least resistance – Try for more superficial when possible – Most of the time, plane is somewhere in the superficial fat – Thin areas like eyelid are more superficial – Scalp is typically quite deep, even to subgalea – Differing opinions about apices

Suggest Levels of Undermining

Scalp Below hair follicles or below galea Forehead Low subcutaneous tissue Temple, cheeks, chin High subcutaneous tissue Lips Beneath mucosa Nose Mild or low subcutaneous tissue Neck Mid or high subcutaneous tissue Trunk, extremities Any level above muscle fascia Hands, feet Below dermis

Excisional Surgery

• Hemostasis

– Spot coagulation with electrocautery – Must be dry field for electrocautery – Wipe tip, as needed – Avoid wound edges – Ground patient with certain units, no metal contact – Cotton tip applicators make more precise

Excisional Surgery

• Ligation for hemostasis

– Tie vessels only when profusely bleeding – High pressure vessels have potential to bleed despite ligation, if only the vessel alone is tied – Insert needle into small amount of supporting structure to anchor and tie vessel – Pressure bandages are very effective, no need to char wound bed or tie all vessels – Suturing wound edges may tamponade – Cellulose/ Oxycel when needed

Excisional Surgery: Technique for Wound Closure

– Holding needle

• Placement of needle is most commonly midway

between tip and the swage

• Some recommend 3/4th from tip
• Halfway point may have less tendency to bend and one

may need to pronate less to achieve 90 degree angle

• Thumb near spring , index finger near jaw
• Don’t necessarily need to have fingers in the loops of

the needle holder

Needle Anatomy

Placement of Needle

Holding the Needle Holder

Holding Needle Holder

Holding Needle Holder

Holding Needle Holder

Excisional Surgery

• Simple interrupted sutures

– For wounds extending only to dermal-subdermal junction – Little to no tension – No dead space – No significant tissue loss

Excisional Surgery

• Placement of interrupted sutures

– Insert needle at 90 degree angle – Slight hyperpronation of wrist is necessary – Bring through opposite side and grasp with forceps – Minimize use of needle holder to grasp needle point, can injure needle – May need to pick up skin edge to ensure proper placement of suture (thin skin, curling edge)

Excisional Surgery

• Simple interrupted suture

– Skin hook can be useful , as toothed forceps and crimp or tear wound edges, enhancing infection risk – Should produce slight eversion of wound edges – Eversion counteracts the tendency of wound edges to contract and invert – Proper path of suture: perpendicular 90 degrees, then laterally as it descends

Excisional Surgery

• Simple interrupted suture

– Good technique to exit at wound center – Re-enter the skin at opposite site – Ensures the loop is broad enough and aids in approximation of wound edges – Avoid ‘one turn’ of the needle to prevent

• verlapping of the wound edges

Suture Placement

Excisional Surgery

• Suture tying

– Loop, knot, and tail – Tying with needle holder is preferred – First loop is teased town to coapt with wound edges – Second loop sets the knot – Generally 4 throws to secure for percutaneous suture – Do not tie so tight as to strangulate

Excisional Surgery

• Suture tying

– Attempting to remove lateral tension with just simple interrupted suture to make up for buried suture, will result in spread scar and/or hypertrophy – Additional throws should alternate opposite directions to increase security of “square” knot – Our tendency is to tie in the same direction, so must use conscious effort

Excisional Surgery

• Steps to tie square knot

– Loop suture over needle holder or circle needle holder tip around suture material – Grasp free end of suture with needle holder and pull through the created loop – Ease knot down to skin edge – Loop suture on opposite side of wound – Grasp free end of suture with needle holder, and pull through created loop – Repeat 3-4 total created loops, alternating direction

Excisional Surgery

• Suture tying

– May let needle dangle – Some grasp at swage/suture junction – Double loop for first throw may temporarily hold wound together, though may not allow for adjustments after second throw – Allow room for swelling – Silk, 2-3 throws, nylon, 4 throws recommended

Excisional Surgery

• Size of loop

– Smallest bit for the job (depth, width) – One that doesn’t cause crimping or tearing – ~1-3 mm of wound edge – Thin tissue, closer to wound – Thicker tissue, may require wider bit – Larger bites, one tends to tie tighter-necrosis – Increased bite does not equal increased strength

Excisional Surgery

• Suture tying

– In general, the greater the wound tension, the farther the suture should be placed from the edges – Typically the suture loop is slight larger in horizontal directions, compared to vertical/deep direction

Excisional Surgery

• Suture spacing

– Wound strength is partially determined by number

• f sutures

– Use the minimum needed to hold wound edges exactly without crimping – In general, greater tension requires sutures to be placed closer together – However, very closely spaced sutures can impede blood flow, be prudent

Excisional Surgery

• Suture spacing

– Uniformity isn’t always necessary – Higher tension areas may require more closely spaced, such as center of wound. Fewer sutures may be needed at apices, where there might be less tension

Excisional Surgery

• Sequence of placing sutures
• Some recommend best to start in center and place

by rule of halves

• Minimize dog ear potential
• Evenly distributes length of the sides
• Tension reduced if sutures are place at ends first,

thereby reducing tension in center-may be better in some instances

Excisional Surgery

• Buried interrupted

– Can include dermal, dermal-subdermal, and subcutaneous – Purpose

• Realign deep tissues to normal position
• Help coapt the overlying epidermis
• Fewer percutaneous suture needed
• Finer more inconspicuous scar
• Closes dead space

Excisional Surgery

• Buried interrupted

– Stitch begins deep in wound and passes to the superficial aspect of one side – The needle is remounted, then enters at superficial aspect of opposite side and exits in the deep portion of wound – The suture does not pierce the epidermis – When tied, the knot is buried deep in the deep dermis or subdermis – Does not get in way of percutaneous sutures

Buried Suture

Suture materials

• http://emedicine.medscape.com/article/884838
• overview

Suture Materials

• Lack of agreement among those performing

surgery about which material or method of suturing is best

• No one suture material is best under all

circumstances for all patients at all times by all providers

• Based often on subjectivity or prejudices of the

teacher or institutional offerings

Suture Materials

• Limitations of suture choices

– Cost – Availability of different needles, material type, colors – Too many choices and nomenclature varies

Suture Materials: Structure

• Absorbable

– Natural (plain gut, chromic gut) – Synthetic (vicryl, Polysorb, PDS, Caprosyn)

• Nonabsorbable

– Natural (silk, cotton, steel) – Synthetic (nylon-Ethilon or Monosof, polyester- Ethibond, polybutester-Novafil, polypropylene - Prolene)

• Monofilament: single strand
• Multifilament: twisted or braided

Suture Materials: Interaction with Skin

• Adverse reaction to suture materials

– Allergy (rare, chromic, cat gut) – Hypertrophic scar (improper placement) – Spitting (improper placement, usually at 14-34 days) – Nodules (usually resolve, vicryl -due to coating) – Fire (alcohol in packaging) – Tissue reactions (occurs routinely) – Milia (suture in place too long) – Infection (avenue of infection from surface)

Suture Materials: Interaction with Skin

• Tissue reaction to suture material

– All are foreign bodies – Evoke reaction to differing degrees – Want to select best material for particular task – Select least amount of material – Least number of knots should be thrown

Preoperative Evaluation

Preoperative Evaluation

• Minimize complications
• Health history
• Psychosocial history
• Consultation
• Risks
• Alternatives
• Consent
• Anxiety
• Antibiotic prophylaxis

Preoperative Evaluation

• Many complications can be avoided in the

preoperative setting

• Consultation whenever possible
• Health history, current and past
• Psychosocial History
• Patient able to provide informed consent

Consultation: Talk with the Patient

• Are the patient’s expectations appropriate?
• Do they understand the entire procedure and

possible defects or risks?

• Is the patient asking appropriate questions?

Understanding of risks of procedure

• Bleeding, infection
• Scar
• Incomplete treatment
• Recurrence
• Nerve damage
• Pain
• Bruising, swelling
• Ectropion, lid droop

Risks, cont.

• Pigment changes
• Temporary improvement
• Suture reaction

Anxiety

• Affects patient comfort and progress of

surgery

• Anti-anxiety medication
• External distracters

Antibiotic Prophylaxis in Dermatologic Surgery

• Prosthetic joint

– 1 year post surgery; previous joint infection? Ortho organizations do not all agree; immuno-compromised, IDDM, HIV infection; malignancy; malnourishment; hemophilia

• Cardiac

– High risk cardiac conditions: prosthetic cardiac valve, previous infective endocarditis; CHD including those with unrepaired cyanotic CHD, including palliative shunts and conduits; completely repaired congenital heart defects with prosthetic material or device, during the first 6 month after procedure; repaired CHD with residual defects at site or adjacent to site of prosthetic patch or prosthetic device; or cardiac transplantation recipients who develop cardiac valvulopathy (adapted from American Heart Assoc guidelines)

Antibiotic Prophylaxis in Dermatologic Surgery

• “Increased risk for surgical site infection”*

– lower extremity – groin – wedge section of lip – skin flap on nose – skin graft – extensive inflammatory disease (*”The data underlying these factors are suboptimal; therefore decisions should be individualized”, Wright, et al., 2008)

Postoperative Wound Care

Pressure Bandage

• Always apply after any excision
• An effective pressure dressing mimics the

function of normal skin

When Applying a Pressure Dressing, Remember To:

• Cover the entire surgical area, including

areas that have been undermined

• Keep it as small as possible to get the job

done

• It should be a aesthetically pleasing as

possible

• How a dressing is applied can greatly

influence the surgical results

Sutured Wounds

• Remove pressure bandage in 24 hours
• Leaving sutured wounds uncovered after the post-
• p pressure bandage is removed, reduces the

amount of drainage present against normal skin and can often allow for a better cosmetic result long-term

• The wound must always be moist with antibiotic
• intment or petrolatum
• When the sutured area is covered with clothing, a

non-stick bandage over the ointment will be necessary to keep from rubbing the ointment off

Surgical Complications

Postoperative Complications

• Defined as:

“Any negative outcome after surgery, whether perceived by the surgeon or patient”

Preventing Complications

• Prevention is key
• Complications must be anticipated
• Action must be taken in every surgical case
• Early recognition with prompt intervention is

the best way to avert progression of a complication

Positive Postoperative Outcome

• Thorough preoperative evaluation
• Proper surgical technique
• Appropriate choice of suture materials
• Appropriate postoperative care
• Detailed patient education
• Close follow-up

Proper Surgical Technique

One of most important factors contributing to a positive outcome after surgery is proper surgical technique Surgical technique encompasses all tasks performed during surgery Prevent vaso-vagal episode Lay flat –Ensure hydration –Anti-anxiety medication –Offer reassurance, calming voice, allow for questions

Proper Surgical Technique

• VSS

– hypertension, increased risk of hematoma – Tachycardia, epi will worsen

• Proper anesthesia

– Lidocaine – Longer lasting anesthetics, marcaine, mepivicaine – Topical anesthetic, cocaine, EMLA

Proper Surgical Technique

• Strict aseptic technique, hand-washing
• Universal precautions
• Appropriate equipment

– Masks – Gloves – scrubs, gown – eye protection

Proper Surgical Technique

• Prep skin widely with Hibliclens or povodine

solution, properly drape

• Protect patient eyes-

– Do not use scrub solution near eyes (hibiclens can cause corneal ulceration) – Drape over eyes to protect from lighting, suture materials, gauze, and instruments

• Patient should turn away from treatment site,

reduce airborne contamination

Proper Surgical Technique

• Limit traffic in room
• Provide good lighting and instrumentation
• Proficient knowledge of anatomical structures

– Important nerves – Important vessels – Parotid gland – Lymphatics

Proper Surgical Technique

• Proper handling of tissues with instruments

– Excessive tension on the wound – Excessive suturing or undermining – Poor flap design

• Always provide for a safe, confident, and well-

prepared environment

Most Common Postoperative Complications

• Bleeding
• Infection
• Suture reactions
• Dehiscence
• Necrosis
• Surface contour irregularity
• Nerve Injury

Bleeding

• Most common complication after excisions or

sometimes punch/shave biopsies

• Rarely poses life-threatening risk
• Alarming to patients
• Postoperative bleeding may lead to ‘terrible

tetrad’ of hematoma, infection, dehiscence, and necrosis.

Treatment of Bleeding

• Pressure-in some cases, patient may attempt this at

home-20 min direct pressure

• Re-open wound to identify bleeding vessels for

cautery or ligation

• Evacuation of hematoma, if present and appropriate
• Apply hemostatic product-Oxycel
• Leave hematoma to absorb
• If hematoma removed or evacuated, must replace

pressure bandage

Hematoma

Hematoma

Hematoma

Hematoma

1 Day Post Hematoma Evacuation

1Week Post-Hematoma

2 Month Post-Hematoma

Causes of Infection

• Poor aseptic technique
• Improper preparation of surgery site
• Prolonged surgery times-wound open extended

periods of time

• Excessive manipulation of wound edges
• Sutures impeding dermal capillary blood flow,

leading to ischemia

• Presence of drains

Infection

Infection

Suture Reaction

• Sutures are foreign bodies
• May cause immune response, resulting in pustules,

swelling, erythema, pain

• Must be differentiated from infection
• Larger suture material increases risk, as does braided

suture and natural materials.

• Preferred suture is monofilament, synthetic and

smaller size

• Increases risk of tracking, permanent fibrosis, poor

cosmetic result, or prolonged irritation

Dehiscence

• Results when wound edges separate
• Healing wound-3-5% at 1 week, 15% at 3

weeks, 35% at 1 month

• Most common cause, surgical error

–Excessive pull or tension, or overly tight sutures –Excessive cautery or ineffective hemostasis –Dead space-resulting in hematoma

Dehiscence

• May also be caused by

–Trauma, excessive pulling movements –Obesity –Inappropriate suture material –Infection –Tobacco use

Dehiscence

• Once wound dehisces, provider must decide to

either re-suture or allow to granulate.

• Closure may increase risk of infection
• Devitalized tissue may need to be removed and

edges refreshed

• Scar revision if granulating, when needed

Dehiscence

Necrosis

• Necrosis is the death of tissue related to ischemia
• Any condition that results in decreased flow of
• xygenated blood increases risk of necrosis

– Damage to tissue (most common cause) – Excessive tension on wound edges – Excessive suturing – Excessive undermining or superficial undermining – Poorly designed flaps (>4:1 ratio of length to base =high risk) – May be caused by hematoma

Necrosis

• Nicotine/cigarette smoking

– Causes vasoconstriction, increased blood viscosity, hypoxia, and increased platelet aggregation that promotes microvascular thrombosis – Abstain or drastically decrease amount of smoking – Preferable that patient stops 2 days before and at least one week after

Necrosis

Necrosis

Necrosis

Surface Contour Irregularity

• This is expected in wound healing
• May be purposeful-eversion, pulling, gathering
• Patients need reassurance
• May need steroid injections, massage, or

treatment for hyperpigmentation

• Scar maturation takes TIME

Nerve injury

• Inadvertent nerve damage is one of the most

dreaded complications

• Patient should always understand risk before

surgery

• High risk areas of temporal and marginal

mandibular should be explained

• Provider must have knowledge of anatomical

structures when performing surgery

Important Nerves

• Sensory Innervation
• The Facial Nerve (Motor Nerves of the Face)

Temporal Branch of Facial Nerve

[Salasche, et. al., 1988]

Nerve Damage

Marginal Mandibular Nerve

• Controls lip depressor muscles
• Ability to pull down on corners of mouth
• Uneven at rest or unequal movements

Nerve Damage

Spinal Accessory Nerve

[McMinn et. al., 1981]

Spinal accessory nerve

Erb’s point

Spinal Accessory Nerve

Let’s Practice!!

Suggested Readings

• Bertucci V: Wound Healing and Its Role in Post Surgical
• Complications. Dermatologic Surgery Core Curriculum 2001;54-63
• Breisch EA, Greenway HT: Cutaneous Surgical Anatomy of the

Head and Neck. Churchill Livingstone, New York, NY, 1992.

• Leffell DJ, Brown MD: Manual of Skin Surgery. Wiley-Liss,

New York, NY, 1997.

• McMinn RMH, Hutchings RT, Logan BM: Color Atlas of Head

and Neck Anatomy. Year Book Medical Publishers Inc., Chicago, IL, 1981.

Suggested Readings

• Salasche SJ, Bernstein G, Senkarik M: Surgical Anatomy of the
• Skin. Appleton & Lange, Norwalk, CT, 1988.
• Senchyshyn N. Sengelmann, R: Surgical Complications; Sect. 1-11

[E-medicine] www.emedicine.com/derm/topic829.htm

• Whitaker DC, Grand DJ. Johnson SS: Wound Infection Rate in

Dermatologic Surgery. J Dermatology Surg Oncol 1988 May; 14(5):[Medline]

• Wright, T.I., Baddour, L.M., Berbari, E.F., Roegnik, R.K., Phillips,

P.K..,Jacobs, A., Otley, C.C., 2008. Antibiotic prophylaxis in dermatologic surgery. Journal of the Academy of Dermatology, 59(3), 463-473.

Thank you