D e r m a t o l o o i c suroery I I I I I I I I I

TIPS for a better ellipse John A. Zitelli, MD Pittsburgh, .Pennsylvania

The ellipse or fusiform closure is the simplest and most common type of excisional surgery and repair. Textbooks and review articles repeat similar traditional principles for excision and closure. In this article four additional ideas are reviewed to improve the final cosmetic result of the ellipse. (J AM ACAD DERMATOL 1990;22:101-3.)

The ellipse, or fusiform excision, is the most com- mon procedure in cutaneous surgery. Articles and textbooks expound on techniques to obtain the best cosmetic result. These include proper planning of the excision within favorable skin lines, adequate length- to-width ratio, prevention of inversion of skin edges, and good suture technique.

Other less often discussed tips can further im- prove results. These tips include consideration of to- pography of the skin, incision techniques, peripheral undermining, and advanced suture techniques (TIPS).

TOPOGRAPHY

Special consideration must be given to fusiform closures on convex surfaces; the usual design must be altered to obtain a good result. To understand the advantage of an altered design, it is important to re- member that scars contract both vertically and hor- izontally. Vertical contraction may cause a de- pressed scar, unless suture techniques evert the edges. The consequences of horizontal contraction parallel to the skin surface depend more on surface contour. On a flat surface, horizontal contraction does not adversely affect the cosmetic result; how- ever, on a convex or concave surface, horizontal contraction acts like a constricting band and con- tributes to a depressed scar on convex surfaces or an elevated scar in concave areas. To minimize this ef- fect, the excision should be lengthened so that the total scar length is greater than the distance between the two ends.

A variety of complex procedures have been de-

From the University Health Center of Pittsburgh.

Reprint requests: John A. Zitelli, MD, University Health Center of Pittsburgh, 347I Fifth Avenue, Room 10I !, Pittsburgh, PA 15213.

16/1/13766

-- j , /

Fig. 1. Topography of S-plasty variation. A, Standard fusiform excision and closure on convex surface results in straight tine that will become depressed when wound contracts. B, S-plasty variation results in double convex curve that tends to straighten before it becomes depressed with wound contraction.

scribed to lengthen scars and minimize depressions, such as Z-plasty techniques or geometric broken line closures. However, a more simple technique, the S- plasty, can often be used to minimize scar depression from a fusiform closure on convex surfaces. This double convex 8-plasty variation provides greater total wound length between the two ends of the clo- sure than the straight line of the standard ellipse. The S-plasty cannot be created merely by obliquely suturing a fusiform wound but must be designed at the time of excision to create sides whose length is significantly greater than the straight line distance between the two ends (even more so than the simple fusiform wound). Therefore, when wound contrac- tion of the S-plasty occurs, the scar will straighten before it becomes depressed and will provide a bet- ter cosmetic result (Fig. 1 ).This $-plasty variation is particularly useful on the convex surfaces of the lat- eral forehead, malar cheek, chin, or extremities, where this design will also fit in favorable lines of closure.

101

102 Zitelli

Journal of the American Academy of

Dermatology

B

- ~ - ~

Fig. 2. Incision technique. A, Fusiform excision per- formed by improperly tilting scalpel leaves excess tissue at tips, which contribute to "dog ear" formation. B, Proper incision techniques remove excess tissue with minimized dog ear formation.

Fig. 3. Peripheral undermining. A, Suturing ellipse pushes tips further apart. B, Undermining sides alone (dotted line) forces pushed tip vertically. C, Undermining tips as well as sides allows tips to be pushed horizontally rather than verticaUy.

A.

VERTICAL MATTRESS SUTURE

ADVANTAGE .DISADVANTAGE

�9 Temporary wound �9 Permanent suture edge eversion marks common

�9 Temporary dermal support

B.

BURIED INTRADERMAL SUTURE

�9 Prolonged dermal �9 No wound edge support aversion

�9 No suture marks

~ r - ~ . . . . . ~ �9 Prolonged dermal

C. / . - ~ - . r , �9 Prolonged wound edge eversion

i ' (~ " " ~ �9 NO suture marks

BURIED VERTICAL MATTRESS SUTURE

Fig. 4. Comparison of suture techniques: evolution of the buried vertical mattress suture, (From Zitelli JA. J Dermatol Surg Oncol 19 8 9; 15:18.)

INCISION TECHNIQUES

Although most basic texts and courses emphasize the need for incisions to be perpendicular to the sur- face, it is a common error to forget to extend this angle to the tip. Occasionally, as the scalpel curves along the body of the ellipse toward the tip, the sur- geon mistakenly tilts the blade handle away from the center. This results in an excised specimen with a tip shaped like the bow of a boat. The tissue remaining in the wound near the tip will contribute to protru- sions, or "dog ears." Unlike most "dog ears" that

eventually resolve, those caused by excess tissue in the tip will not resolve (Fig. 2). The surgeon should take special care to maintain the scalpel perpendic- ular to the skin surface for the entire excision.

PERIPHERAL UNDERMINING

Although many fusiform excisions can be closed without undermining, the best results are obtained by total peripheral undermining. Most textbooks emphasize undermining beneath the sides of closure

Volume 22 Number 1 January 1990

that will be pulled towards the center. However, the dynamics of tissue movement necessitate undermin- ing the tips of the wound as well.

During closure of any fusi_form defect there is a tendency to formtissue protrusions at the tips. Be- cause the wound edges of a fusiform defect are curved, the total length of those edges is greater than the straight-line distance between the two tips. When the wound is closed in a straight line, this tends to push the tips apart and away from the cen- ter of the wound. Without adequate undermining the tips will be pushed up, thereby resulting in tissue protrusions. However, with peripheral undermining that includes the tips, the skin can be pushed away in a horizontal plane and the vertical tissue protru- sions at the ends will be minimized (Fig. 3).

SUTURE TECHNIQUES

One of the most important concepts of suture tech- nique is wound edge eversion. A wound sutured without eversion may look good to the inexperienced eye at the time of closure, but once wound contrac- tion pulls the edges below the level of adjacent skin, the results are poor. The simple interrupted suture can help to evert the wound temporarily, but it is re- moved before wound contraction occurs. In addition, the simple interrupted suture does not adequately evert wound edges closed under tension, particularly in the central portion of the elliptic closure.

The standard vertical mattress suture everts the wound edge but can cause permanent suture marks on the skin surface. It can only provide temporary eversion and support because the suture is usually removed in 4 to 5 days. The simple buried intrader- ma l suture provides prolonged support of the edge but it does not evert the edge.

A better suture technique is the buried vertical mattress suture. This technique combines the ad- vantages of the best of the more common suture techniques mentioned earlier. The buried vertical mattress suture is best understood by visualizing the s tandard vertical mattress suture and moving it en- tirely below the skin surface with a buried knot (Fig. 4) . t

This suture technique offers prolonged wound

TIPS for a better ellipse 103

A B

Fig. 5. Placement of buried vertical mattress suture. A, Suture is started at base of skin flaps so that the knot will be buried. Skin edge is pivoted over fingertip with a skin hook (or forcep) to facilitate suture placement. To achieve eversion it is important to place suture closest to epider- mis at a point 3 to 4 mm from skin edge, and deeper in dermis at the edge. B, Suture is placed in opposite edge in a mirror-image fashion. (2, Final appearance, with knot tied at base, everts edge and provides prolonged support without causing suture marks. (From Zite~li JA. J Der- matoI Surg Oneol 1989;15:18.)

support as well as prolonged wound eversion but be- cause it is entirely buried, it leaves no permanent su- ture marks in the skin. It is performed most com- monly with an absorbable material such as Vicryl or Dexon but a permanent clear nylon suture can also be used. The needle should be a small half circle to allow for easy turning in the limited space under the skin edge. A skin hook is helpful to lift the skin and manipulate the edge during suture placement (Fig. 5).

When properly placed, a few buried vertical mat- tress sutures will completely close the wound and evert the edges. Then a quick oontinuous running suture can be placed to adjust the skin edges and augment wound edge eversion.

REFERENCE 1. Zitelli JA. The buried vertical mattress suture. J Der-

matol Surg OncoE 1989;15:17-9.