Basic Surgical Principles

Author Credentials 

Anita Sethna, MD, FACS
Associate Professor 
Division of Facial Plastic & Reconstructive Surgery
Department of Otolaryngology – Head & Neck Surgery
Emory University
Email: asethna@emory.edu

 

Pedram Daraei, MD
Resident Physician
Division of Facial Plastic & Reconstructive Surgery
Department of Otolaryngology – Head & Neck Surgery
Emory University

Module Summary

The surgeon should be facile with knowledge of facial anatomy prior to surgical intervention. Facial subunits, vascular supply, sensory and motor innervation, and adjacent structures of importance should be evaluated pre-operatively and identified intraoperatively for safe and reproducible surgical outcomes. Surgical planning is imperative – intraoperative adjustments of the plan can be made as needed based on surgical findings. The surgeon should master basic surgical skills such as tissue handling, undermining, wound edge apposition, and suture techniques for all wound types in the head and neck. Suture technique, although basic, should be emphasized during closure to promote eversion of skin edges and optimal cosmetic outcome.

Module Learning Objectives 
  1. Explain the relationship between vascular supply and depth of dissection.
  2. Summarize basic soft tissue techniques.
  3. Plan incisions and excisions in relation to facial anatomy.
  4. Describe the basic suture techniques.

 

Basic Soft Tissue Techniques

General Principles

  • Vascular Supply1,2
    • Excellent head and neck bloody supply allows for flexibility in surgical technique
    • Blood vessels travel by two main routes
      • Musculocutaneous
        • Pass through overlying muscle to which they provided nutrition
        • Enter the subcutaneous tissue to supply a small area of skin
      • Septocutaneous
        • Pass through fascial septa that divide muscles
        • Travel parallel to the skin surface
        • Supply a larger area of skin
      • Musculocutaneous and septocutaneous vessels terminate into the dermal/subdermal plexus
        • The subdermal plexus should be preserved during dissection for optimal wound healing
  • Relaxed skin tension lines (RSTL)
    • Attention to relaxed tension lines and anatomical subunits is critical
    • Subunits have different thicknesses, sebaceous content, vascularity, and other skin appendages
    • Incisions that cross relaxed skin tension lines and tissue rearrangement across subunits with different characteristics may lead to poor cosmetic outcomes
  • Wound tension
    • Blood flow is indirectly proportional to wound tension
    • Exacerbated in watershed areas or at the distal tip of a flap
    • Tension should be minimized at the level of the dermis and epidermis during closure
  • Undermining3
    • Should be performed widely in the immediate subdermal/subcutaneous plane
    • Decreases tension on the incision closure at the level of the dermis/epidermis
    • Surgeon should be aware of surrounding anatomical structures to avoid while undermining
    • Most of the benefit is achieved within the first 1-2cm of undermining
      • Undermining beyond 2-4cm may paradoxically increase the force needed for closure and place unintended tension dermal/epidermal closure2
  • Patient characteristics and comorbidities must be evaluated pre-operatively in order to optimize outcome (e.g. smoking status, soft tissue and connective tissue disorders, history of hypertrophic scars or keloid, diabetes)4

 

References

  1. Cook TA, Guida RA, Burke AJ. Soft Tissue Technique. In: Papel ID, Frodel JL, Holt, GR, Larrabee, WF, Nachlas NE, Park SS, Sykes JM, Toriumi, DM. Facial Plastic and Reconstructive Surgery. 4th ed, New York, NY: Thieme; 2016.
  2. Larrabee WF, Koch CA. Biomechanics of Skin Flaps. In Baker SR. Local Flaps in Faical Reconstruction. 3rd ed, Philadelphia, PA: Elsevier Saunders; 2014.
  3. Gibson T, Kenedi RM. Biomechanical properties of skin. Surg Clin North Am. 1967 Apr;47(2):279-94. PubMed PMID: 6022234.
  4. Brissett AE, Sherris DA. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg. 2001 Nov;17(4):263-72. Review. PubMed PMID: 11735059.

 

Pre-operative Application of Local Anesthetic
  • Two subtypes of local anesthetics: amides and esters
    • Amides: lidocaine, mepivacaine, bupivacaine
      • Typically used as infiltrative local anesthetic
    • Esther: tetracaine, cocaine, benzocaine
      • Typically used as topical local anesthetic
  • Anesthetic of choice (e.g. lidocaine, bupivacaine) should be administered at least 15 minutes prior to tissue incision or manipulation
    • Onset, dose, and duration of action of amide anesthetic of choice should be known by the surgeon and injection communicated to the anesthesiology team to avoid anesthetic toxicity
  • Use of epinephrine is a common and often necessary adjunct to increase concentration of anesthetic at the injection site and improve hemostasis, typically at a concentration of 1:100,000
  • Factors that reduce patient discomfort in awake cases
    • Addition of sodium bicarbonate can be added to buffer the acidity of the anesthetic 
    • Slow injection rate
    • Use of small-bore needle
    • Room temperature fluid
    • Use of small-volume syringe (10mL or smaller)
  • When applicable, use of nerve specific blocks (e.g. infraorbital, supraorbital, mental) should be performed, in addition to diffuse local infiltration

 

Reference

  1. Mather LE, Cousins MJ. Local anaesthetics and their current clinical use. Drugs. 1979 Sep;18(3):185-205. PubMed PMID: 40784.

 

Incisions Relative to Facial Anatomy
  • Aesthetic subunits of the face1
    • Forehead: central, lateral/temporal/brow
    • Periorbital: upper lid, lower lid, medial canthus, lateral canthus
    • Nasal: dorsum, lateral walls, tip, soft tissue triangle, ala, columella
    • Perioral: philtrum, upper lip (red lip, vermillion), lower lip (red lip, vermillion), commissure
    • Mental
    • Malar: infraorbital, buccal, zygomatic, parotidomasseteric
    • Auricular: helix, antihelix, concha, lobule, post-auricular
    • Cervical

 

Operative Planning

  • Surgical maneuvers and incisions must be planned ahead of time to achieve optimal cosmetic and functional outcome
    • Aesthetic subunits should be considered and maintained, if possible
      • Boundaries between aesthetic subunits can guide the surgeon for incision placement
    • Natural creases (e.g. nasolabial, post-auricular, subnasale, and alar crease) can be used to camouflage incisions
    • Relaxed skin tension lines (RSTLs) must be taken into consideration and incisions made within the RSTLs
      • Always lie perpendicular to the fiber direction of underlying musculature (e.g. procerus vertical muscle fibers create horizontal facial rhytids and RSTLs)
        • Exception to this rule is the orbicularis oculi due to the scaffold provided by the rigid tarsal plate
      • Incisions made within an RSTL will close with minimal tension2
    • Hair-bearing skin can camouflage incisions
      • Planned incisions can be made along the hair-bearing and non-hair-bearing border or within the hair-bearing tissue
      • When making incision at the junction of hair-bearing skin, the incision can be beveled perpendicular to the direction of the hair follicles. This may allow hair to grow through and further camouflage the incision
      • When making an incision within hair-bearing skin the incision should be parallel to the hair follicles
      • Care must be taken not to injure hair follicles and cautery should be minimized1

​References

  1. Cook TA, Guida RA, Burke AJ. Soft Tissue Technique. In: Papel ID, Frodel JL, Holt, GR, Larrabee, WF, Nachlas NE, Park SS, Sykes JM, Toriumi, DM. Facial Plastic and Reconstructive Surgery. 4th ed, New York, NY: Thieme; 2016
  2. Larrabee WF, Koch CA. Biomechanics of Skin Flaps. In Baker SR. Local Flaps in Faical Reconstruction. 3rd ed, Philadelphia, PA: Elsevier Saunders; 2014.

 

Basic Tissue Handling and Suture Techniques

Incisions and Closures

  • Handling of skin/mucosa edges should be minimized
    • Avoid crush injury with use of toothed-forceps (i.e. Adson or Adson-Brown) and delicate digital pressure
    • Use skin hooks to grab skin edges when possible
  • Structural and anatomical integrity should be restored
    • Wound bed should be irrigated and explored to identify underlying anatomic structures
    • All identified anatomic structures in the wound bed should be reapproximated, if possible
    • The overlying epidermis or mucosa should be re-oriented and reapproximated for improved cosmesis (i.e. the vermillion border exactly reapproximated with white and red lip closed side-by-side)6
  • Incisions
    • Should be made with a new blade of the surgeon’s choice (e.g. 10, 11, or 15-blade)
    • Incisions should be made perpendicular to the skin with exceptions detailed below
      • When creating incisions at the junction of non-hair-bearing skin and hair-bearing skin, where the incision should be beveled perpendicular to the direction of hair growth1
      • Wide local excision of a mass, where the incision should be beveled away from the mass to incorporate as much of the mass that lies underneath the epidermis as possible
      • In areas of high-tension, where the incision should be beveled outward to improve eversion of edges during skin closure5
    • Judicious hemostasis should be achieved as bleeding is identified, taking care not to injure adnexal skin appendages 
  • Closure
    • Attention should be paid to three tenets of wound closure: 1) careful handling of soft tissue free edges, 2) eversion of skin edges, 3) decrease wound tension at the level of the dermis/epidermis6
    • Suture placement
      • Deep or subcutaneous sutures should be placed first in a buried fashion
      • Once deep or subcutaneous layer is reapproximated, the skin edges should oppose one another without added manipulation by the surgeon
      • Undermining may be required, as detailed above, to decrease wound tension with closure7
    • Principle of halving
      • Can be employed with symmetric or asymmetric defects
      • Creates symmetric halves that can be sequentially closed to avoid skin edge redundancy and asymmetry
      • Equalizes load across the sutures and skin edges
    • Principle of equalizing edges
      • Employed with asymmetric defects
      • A Burrow triangle taken out from the mid-portion of the longer incision side
      • Closure of the Burrow triangle will shorten the free edge of the longer side to equal that of the shorter incision side

 

Basic suture technique 

  • Standard interrupted
  • Subcuticular
  • Vertical mattress
  • Horizontal mattress
  • Running intra- or subcuticular

 

References

1.  Cook TA, Guida RA, Burke AJ. Soft Tissue Technique. In: Papel ID, Frodel JL, Holt, GR, Larrabee, WF, Nachlas NE, Park SS, Sykes JM, Toriumi, DM. Facial Plastic and Reconstructive Surgery. 4th ed, New York, NY: Thieme; 2016.

5.  Mather LE, Cousins MJ. Local anaesthetics and their current clinical use. Drugs. 1979 Sep;18(3):185-205. PubMed PMID: 40784.

6.  Stell PM. The effects of varying degrees of tension on the viability of skin flaps in pigs. Br J Plast Surg. 1980 Jul;33(3):371-6. PubMed PMID: 7426816. 

7.  Larrabee WF Jr, Trachy R, Sutton D, Cox K. Rhomboid flap dynamics. Arch Otolaryngol. 1981 Dec;107(12):755-7. PubMed PMID: 7316858. 

 

 

Case Studies
  1. A 55 year old male presents for Mohs reconstruction of a left medial malar defect near the infraorbital nerve
  • Physical exam should include pre-operative sensation of the left V2 distribution
  • Anesthetic of choice with epinephrine should be used for diffuse local and infraorabital nerve block
  • A cheek advancement flap can be considered, with widespread undermining of the subcutaneous layer for advancement of the flap as well as to decrease wound tension
  1. A 52 year old female presents for Mohs reconstruction of a right lateral cutaneous nasal tip defect measuring 1cm in diameter and not including the alar rim
  • Use of adjacent nasal subunits skin will help color match and improve cosmetic outcome
  • Bilobe flap using skin from the ipsilateral lateral nasal wall is optimal
  • Widespread undermining of the reconstructive flap, both ipsilaterally and contralaterally, in a supraperichondrial and supraperiosteal plane will aid in advancement and decrease tension at closure
  • Absorbable dermal sutures should be used to reapproximate wound edges as there is very minimal subcutaneous tissue in the nasal skin 
  1. A 31 year old female with a midline mental scar presents for in-office, awake scar revision
  • Local anesthetic with 1:100,000 epinephrine should be infiltrated diffusely, in addition to bilateral mental nerve blocks (intraorally or transcutaneously)
  • Sodium bicarbonate (8.4% solution) should be added to the above anesthetic and mixed 1:10 for decreased pain with infiltration
  • Above injectable fluid should be at room temperature before injection
  • A 3-5cc syringe should be used with a 27-30 gauge needle

 

Review Questions
  1. The vascular supply plexus of the skin is located in what layer?
  2. Superficial skin rhytids will form in what orientation to underlying musculature?
  3. The orbicularis oculi create what orientation of superficial rhytids, and why is this unique?
  4. What technique can improve scar cosmesis in hair bearing skin?
  5. T/F: As wound tension decreases, blood flow to the site decreases as well.
  6. What are the nasal subunits?
  7. What are four factors that can reduce pain during awake infiltration of an anesthetic?
  8. Describe two methods of closure of unequal wound edges.
References
  1. Cook TA, Guida RA, Burke AJ. Soft Tissue Technique. In: Papel ID, Frodel JL, Holt, GR, Larrabee, WF, Nachlas NE, Park SS, Sykes JM, Toriumi, DM. Facial Plastic and Reconstructive Surgery. 4th ed, New York, NY: Thieme; 2016.
  2. Larrabee WF, Koch CA. Biomechanics of Skin Flaps. In Baker SR. Local Flaps in Faical Reconstruction. 3rd ed, Philadelphia, PA: Elsevier Saunders; 2014.
  3. Gibson T, Kenedi RM. Biomechanical properties of skin. Surg Clin North Am. 1967 Apr;47(2):279-94. PubMed PMID: 6022234.
  4. Brissett AE, Sherris DA. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg. 2001 Nov;17(4):263-72. Review. PubMed PMID: 11735059.
  5. Mather LE, Cousins MJ. Local anaesthetics and their current clinical use. Drugs. 1979 Sep;18(3):185-205. PubMed PMID: 40784.
  6. Stell PM. The effects of varying degrees of tension on the viability of skin flaps in pigs. Br J Plast Surg. 1980 Jul;33(3):371-6. PubMed PMID: 7426816. 
  7. Larrabee WF Jr, Trachy R, Sutton D, Cox K. Rhomboid flap dynamics. Arch Otolaryngol. 1981 Dec;107(12):755-7. PubMed PMID: 7316858.