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Pearls for Mastering Surgical Procedures

Michael Swann, MD, presented “Mastering Surgical Procedures” early Friday morning at the 2019 Fall Society of Dermatology Physician Assistants Conference in Scottsdale, AZ. Dr Swann is in private practice in Springfield, MO.

According to Dr Swann, there are 5 risks for performing any kind of surgery, which include bleeding, infection, scarring, incomplete removal, and complications such as bruising. He reviewed the superficial anatomy of the face, eyes, nose, and lips, as well as the subunits of these areas. It is important to name these areas appropriately when performing biopsies, he said, to help designate the area from which a lesion originates and communicate what was biopsied with other providers and pathologists. As a general rule, if a provider is not sure about anatomy, they should study it more, he added.

Dr Swann also discussed relaxed tension lines. When closing on the face, a straight line is not the best idea because it turns the curved lines into straight ones, he said. He discussed deep facial anatomy and facial nerves, noting that staying in the subcutis and superficial fat is important to avoid the facial nerve. Other danger zones Dr Swann discussed included the temporal branch, zygomatic branch, marginal mandibular, depressor anguli oris, and spinal accessory nerve. In addition, he reviewed important bone anatomy, such as the super orbital nerve, and noted that understanding the anatomy of the nerve can be used to regionally block patients.

“Stay in the subcutis and stay out of trouble,” he recommended, as most nerves are located beneath the subcutis.

Dr Swann recommended using an elegant ellipse design of 3:1 or 4:1, using the widest area of the tumor with the margin to create a 30-degree angle. In areas that are thick and more prone to dog ears, on the scalp, larger tumors, or on the extremities, Dr Swann suggested making convex ellipses longer.

He said he teaches to incise more perpendicular to avoid bevel wound edges or going down into the fat. Patient positioning is very important for this, he said. Bevel wound edges prevent precise wound apposition and causes bad scarring, he added. For vertical wound edges, he added, he likes to have a little bit of a reverse bevel. When the dermis is cut it retracts and the vessels are at the subcutaneous fat dermal junction. He said he preferred to take the tips last when doing ellipses.

For providers who are starting surgical procedures, he encouraged them to use scissors because it is difficult to undermine properly with a scalpel. The scissors create a more horizontal plane that is parallel to the dermis and helps remove the skin evenly, he said.

There are a lot of ways to undermine and there is an art to closing wounds, he said. He preferred to use scissors to undermine because it will maintain an even plane. It is really important when undermining to stay in the same plane on each side, he reiterated, regardless of whether one uses a scalpel or scissors. He added that he liked vertical undermining in areas where he would worry about hemostasis.

Dr Swann undermines predominantly to the superficial fat. The deep fascia, also known as superficial musculoaponeurotic system (SMAS), is where the nerves are, he said. Undermining to right above the SMAS is ideal. However, the scalp requires undermining to under the galea, he added. In addition, he noted that he liked to undermine deeper on the face.

When undermining, Dr Swann recommended providers slide and divide, using sharp scissors to help slide through. He said providers need to be able to visualize how far part the area being undermined is, because it will be difficult to get an even dermis if blinding undermining. A skin hook is helpful, but not if held over the point of undermining. He also recommended having counter tension, such as a stabilizing finger. He uses a “smart finger” behind to hook so he can feel and press while undermining.

In addition, he recommended undermining everything including the tips to prevent buckling and bunching. Be meticulous to achieve a uniform surgical plane, he said. He stressed to providers the importance of being able to perform the simple things really well to achieve the best results, as well as avoid using heavy-handed forceps.

His hemostasis technique included using a “smart finger” to apply pressure to the area. Fat bevel is caused by not completely undermining and requires resection, he said.

The most important stitch, according to Dr Swann, is the deep suture because it takes tension off the epidermis. He recommended a buried vertical mattress suture. The superficial vertical mattress, which can be either stitched far-to-far or near-to-near, should create epidermal eversion, he said. One does not want the epidermis to fold over, he said. The skin should come together to be everted.

According to Dr Swann, most patients need a buried vertical mattress for good scars. The buried vertical mattress is a heart-shaped shaped stitch, he said, adding that he liked everting the dermis with this stitch. Dr Swann recommended providers aim small and miss small. Patient positioning is important, he stated. He recommended grabbing tissue at the same height. If the tissue is grabbed down on the subcutis it squishes and does a disservice to the patient, he said, and grabbing too large a piece of tissue creates a small window to throw the mattress.

The first step Dr Swann recommended was to start shallow. Skin dimpling can occur, but can be removed. On the nose and cheek, the dimpling will not go away, but he noted he does not worry about it as much on the trunk. In addition, he tries to avoid dermis denting with thinner areas.

When doing stitches, enter at the same level, and create the same exact same look as the first throw when performing superficial stitches, he said. The second step is difficult because it is a little harder to see, but second half should be at same depth, he added. It is important providers grab the dermis high so they can see the tissue, Dr Swann reiterated.

For step 3, Dr Swann recommended providers visualize where the knot is. “I cannot overstate the importance of training nurses to cut stitches,” he emphasized. He teaches his nurses to feel for the knot with scissors instead of looking into the wound.

For thick and heavy skin, he recommended using wide throws in the dermis to spread the tension. “For the first stitch, I am mostly superficial because the first throw sets you up,” he said. He places the first stitch in the middle of the wound, shallow, and deliberately. He also recommended using smaller thread so that if there is tension, it will break.

Height discrepancy is caused by imprecise buried vertical mattress sutures, he noted. In addition, he suggested investing in loops because the lighting in these devices can help with positioning while performing sutures.

According to Dr Swann, the goal of the top stitch is to approximate the tissue. As a rule, eversion is architecture, he said. When talking about the epidermis with shallow stitches, the skin should together under very little tension and approximated. He reiterated to minimize the tension of top stitches. 

Dr Swann concluded his presentation by discussing the differences between dermatologists and family medicine or primary care providers. What separates the fields is the details, he said, encouraging all providers to educate themselves on anatomy and complications associated with surgical procedures. It is important to go the extra mile and talk about risks and benefits with every patient, he added, noting that providers should be comfortable in their own skillset and seek out more training if they feel they need it to improve their skills.


Swann M. Mastering Surgical Procedures. Presented at: 2019 Fall Society of Dermatology Physician Assistants Conference; November 22, 2019; Scottsdale, AZ.

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