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When visualizing how a closure ultimately will appear, the wound may throat big temporarily closed by grasping the subcutaneous tissue instead of the epidermis and approximating together the wound margins.

This minimizes the crushing trauma to the wound, yet allows an adequate preview of how the revision will appear when the epidermis finally is closed.

Often overlooked is the value of using saline-dampened sponges intraoperatively during scar revision procedures. Moreover, damp sponges allow, by virtue of their ability to destain the tissue, a better differentiation of important adjacent anatomic structures (ie, preferred planes of dissection and neurovascular anatomy).

Proper incisions in scar revision are the foundation of superior results and must be precise. While vertical incisions offer the greatest usefulness in scar revision, conditions exist in which a slightly beveled incision is desirable. Hair follicles rarely are oriented perpendicular to the skin surface, and thus the hair shaft lies in the same direction.

Incisions made perpendicular to the skin in hair-bearing areas are at greater risk of irreversibly damaging the follicle, with resulting alopecia adjacent to the healing incision. This type of iatrogenic scar is particularly visible as a well-defined hypopigmented line lying adjacent to or within a hair-bearing surface. This may be overcome by beveling the incision parallel to the hair care your eyes, thereby preserving hair growth in the tissue adjacent to the incision line (see image below).

Beveling the incision also plays an important role in the formation of an everted wound closure. To fully understand the importance hiaa this technical concept, remember that as scars heal, forces of contracture pull the wound centripetally, including from a deep to superficial direction.

Even if wounds are closed using deep subcutaneous suture technique to minimize tension across the margins, scar contracture probably causes retraction of these same margins, resulting in a depressed scar. To minimize this problem, incision and suturing techniques have been developed (eversion by design) to produce wound eversion that over Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA results in a less visible planar scar.

While it may appear less aesthetic to both physician and patient, the initial heaped-up wound flattens out remarkably over 6 months to a year as the Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA of scar contracture pull the healing margins inward and downward. Preoperatively counsel patients that initial results seem unsatisfactory but improve dramatically over time. Invariably, this concept needs reinforcement during the ensuing months.

Dermabrasion or laser resurfacing may be used adjunctively if the scar appears unaesthetic and unlikely to improve to an acceptable state after 6 months. An essential component Vigabatrin for Oral Solution (Vigadrone)- Multum any scar revision technique is judicious subdermal Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA lateral to the wound margins.

This technique permits a more tension-free closure on the epidermal surface, resulting in a superior revision. The amount of undermining in any particular Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA is dictated by the surgeon's experience. Skin flap undermining can be achieved with a No.

Elevation Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA the flap during undermining is achieved atraumatically with skin hooks or toothed forceps. Adequate hemostasis is of paramount importance in all surgical wounds. Localized collections of blood under the flap or Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA coagulum that separates wound margins can predispose the wound to infection and more visible scar between approximated margins.

After all preoperative precautions are undertaken to ensure hemostasis, proper planar tissue dissection and judicious electrocautery remain the mainstays of superior wound hemostasis. While monopolar cautery with a needle-tip attachment is probably the more popular instrument used, a strong supportive argument can be made for bipolar cautery. Bipolar cautery has the distinct advantage because the cauterizing electric current passes only between the instrument tips, thus minimizing any unintended lateral thermal trauma.

This is particularly important if any cautery is performed near the dermoepidermal junction, in the subdermal vascular plexus of a particularly thin flap, or near hair follicles. Proper closure of the deeper subcutaneous layers is of critical importance in any scar revision. No amount of carefully planned and executed incisions or meticulous epidermal closure yields a superior result if the subcutaneous layer is not closed in the appropriate manner. One method of placing subcutaneous sutures is described.

While gently everting the deep subcutaneous tissues with either a skin hook or minimally traumatic toothed forceps, the needle is placed 5-10 mm distal to Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA wound margin.

The suture passes through the dermis and the opposite side in the reverse order. This sequence of suturing places the knot deepest in the wound, decreasing the likelihood of future suture extrusion.

Alternative means are used in closing triangular flaps such as in geometric broken line closure (GBLC) and M-plasty. In this instance, a horizontal mattress suture is Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA midway through Alrex (Loteprednol Etabonate Ophthalmic Suspension)- FDA full thickness of the flap, and then, by placing the suture at a corresponding similar level, the angulated tip is advanced into the wound.

This advancement is critical because it closes the potential dead space between the flap and recipient site and everts the wound edges (see image below). Closure of the subcutaneous layer most often is performed with a synthetic absorbable suture. Although nonabsorbable sutures retain tensile strength over an extended period, many surgeons believe that these sutures have little utility in chlorhexidine acetate surgery and specifically in cosmetically sensitive areas, because of their higher likelihood of later rejection.

However, nonabsorbable suture elicits significantly less inflammation than its absorbable counterpart. Absorbable sutures eventually dissolve, losing tensile strength according to known time parameters and wound characteristics. This can lead to a loss of support in the subcutaneous layer and greater tension across the overlying epidermal layer, with an increased likelihood of a more prominent scar.

For these reasons, surgeons must use judicious undermining to decrease wound tension and must choose the proper absorbable suture. This ensures that the wound is healed sufficiently by the time skin diagram absorbable suture has lost nearly all its tensile strength.



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