Where a triangular flap has to be inset, it is often difficult to get the tip of the flap to lie in position, yet multiple sutures placed through the full thickness of the dermis are apt to strangulate the tissue at the tip and produce necrosis. In such a situation the three-point suture helps to avoid necrosis while holding the tip in place.
As frequently illustrated the suture tends to bunch the tip of the flap, and a minor variation is recommended which is theoretically sound and effective in practice in holding the tip with-out bunching.
The points to be noted in inserting the suture are to make sure that the suture leaves and enters the reception side of the wound at the same level in the dermis as its placement in the tip of the V flap and to make the suture emerge well back on the reception side of the wound. The principle of the three-point suture can be extended for use where two flaps are being approximated to the third side of a wound.
When a wound is tending to distort, and it is dif-ficult to distribute the tension evenly on both sides for suturing, it often helps to make the wound taut with a skin hook in each end so that a few key sutures can be placed accurately before inserting the intervening sutures. When distor-tion is to be expected, and especially in a curved incision, trouble will be saved by tattooing matching points with Bonney’s Blue (gentian violet, 1O g; brilliant green, 1O g; alcohol 95%, 95O ml; water to 2000 ml) on either side of the projected incision before any cut is made.
Suture materials are now routinely swaged to an atraumatic needle, and the characteristics which separate one from another concern whether the material is non-absorbable and needs to be removed, or absorbable and can be left in situ, the extent to which it causes tissue reaction, and how it handles in clinical practice. In its handling characteristics, silk remains the bench mark against which other non-absorbable suture materials are measured, but for many sur-geons synthetic materials such as nylon and pro-lene have largely replaced it, because the tissue reaction to their presence is less marked.
When the surgeon is aiming to make his scar as inconspicuous as possible suturing of the wound becomes an extremely precise procedure, prefer-ably using the instrumental method of suture tying. The necessarily small needles and fine suture materials make tying by hand clumsy and difficult.
Instrumental tying allows the tension of the suture to be regulated, and knot placement to be carried out with much greater finesse, precision and expedition. The more a wound is traumatised in the process of suturing the less good is the cosmetic result likely to be and the implements used for holding wound margins steady for suturing should be as atraumatic as possible.
When the presence of tension adds to the diffi-culty of wound closure, the use of undercutting of the wound margins to allow a degree of advancement is frequently recommended. Before this can even be considered the vascular state of the skin has to be assessed, and the potential effect of tension on its viability, particularly if the injury has involved an element of degloving. Personal experience has been that the amount of advancement achieved in practice is often disappointingly small.
The common errors made in treating facial wounds at this stage are failure to remove all dirt from the wound, creation of a scar with gross suture marks, and failure to suture the various wound edges in the precise position which they occupied relative to one another before the in}ury. The effect of failure to remove all dirt from the wound is to leave foci of tattooed scarring in the dermis.
The presence or absence of damaged tissue determines whether or not a wound needs to be excised. It is axiomatic that all dirt and other for-eign material must be removed, and when the dirt is ingrained this may entail the vigorous use of a sharp spoon or wire brush to ensure that removal is demonstrably complete. The apparent coarseness of the methods involved may seem inappropriate, but total removal of grit and dirt at this stage takes priority.
The obvious examples are inside the hairline or in the eyebrow. In these sites the incision, instead of being perpendicular to the skin surface, should be made parallel to the hair follicles. This avoids the creation of the hairless scar line which results from sectioning of the hair follicles. A practical point to note in making a scalp incision is the possibility of subsequent baldness reveal-ing a scar previously hidden.
Use of natural lines Incisions should be placed wherever possible so that the scar will lie in a line of election, or at least parallel to it , so that in the course of time it will settle in to look like another wrinkle. Even if wrinkling is not actually pres-ent, the site and line of the wrinkles likely to develop in the future can often be found by getting the patient to simulate the appropriate facial expression, e.g. smiling, frowning, closing the eyelids tightly, etc.