Patients often present with lesions that must be removed on areas of the body where the skin does not provide a great deal of laxity, such as on the hands and feet. Thus, closure of the secondary defect resulting from removal of the lesion is difficult. Due to the elasticity of skin on these areas, the defect can expand up to 25% after excision of the primary lesion, which can complicate the closure even further.1
This article will attempt to summarize some practical points for repairs of defects on the distal-most extremities.
CLOSURE DEFECT REPAIR
Due to the repetitive and delicate movements on the hands and feet, lesions on these areas are particularly challenging to repair. Relaxed skin tension lines are both horizontally and obliquely oriented. Due to this fact, a ‘lazy S’ repair is commonly a practical approach for closing most defects on these areas.2
Redundancies of skin, i.e., dog repairs, are typical of closures of defects on the dorsal surfaces of the hands and feet.3 However, these are not usually repaired, and patients are reassured that the redundancies usually self-resolve over time, unlike what one would expect on other areas of the body.
In reference to closures on the palms and soles, primary closures should be attempted along the longitudinal axis after extensive undermining. Although excisions on the heel or arch can be made at right angles or at an acute angle to the length of the palm or sole, these scars seem to heal poorly and are more prone to problems.
When suturing wounds on the sole, softer and heavier sutures, such as Ethibond or silk, are encouraged,4 as is leaving the sutures in for as long as 4 weeks. Although these marks do occur, they do not represent a major cosmetic liability on the bottom of the sole. Patients should also be advised to stay off their feet and to use medical footgear for as long as the sutures are retained. If painful scars develop on the sole, triamcinolone acetonide injections help resolve this issue.
Due to the proximity of delicate underlying structures, such as large vessels, fascial aponeuroses, tendons, and ligaments, incisions and undermining should be kept as superficial as possible. (See Figure 1.) For this reason, the ideal undermining depth is in the immediately subdermal plane of tissue on the hands and feet.5
NEEDLE CONSIDERATIONS
Attention should be drawn to the type of needle used to repair the defect. For example, reverse cutting needles have their cutting point on the outside of the needle arc to minimize the risk of tearing through tissue. Round-tipped needles have no cutting edges and are therefore less likely to tear tissue. This latter consideration is particularly important when repairing defects on the palmar and plantar skin surfaces. When suturing, one must take care to stay superficial to avoid inadvertently trapping a tendon, which can lead to potentially significant physical impairment and pain.1,6 Informed consent for repair of defects on the extremities should take into consideration the aforementioned complication.
ANESTHESIA CONSIDERATIONS
It is encouraged to use 1% lidocaine without epinephrine to avoid end artery ischemia. It is also encouraged to introduce small aliquots of local anesthetic. Since the distal digits have a small area, adding high volumes of local anesthetic can potentially cause neurovascular bundle compression.
SUTURE SELECTION
In addition to approximating the wound edges with a buried simple suture or a buried vertical mattress suture to have excellent wound edge eversion, you must close the superficial skin with a running nonabsorbable suture as well as an additional simple interrupted nonabsorbable suture in the middle of the closure with 2.0 or 3.0 prolene or Ethibond. The buried absorbable sutures should be placed obliquely rather than vertically to increase the surface area of the dermis that comes into contact with the suture. Due to the mobility of these tissues, the likelihood of the running suture breaking is higher as compared to other sites on the body. Therefore, one or two simple interrupted non-absorbable sutures are necessary to place in the middle of the closure to counteract this potential complication of wound dehiscence (Figure 2).1
POST-OP
Patients should strictly avoid unnecessary and sudden movements post-operatively due to the increased risk of dehiscence on these delicate areas. Soft casting or splinting the extremity may be necessary to immobilize the repaired site and allow for optimal wound recovery.6
Since the areas below the elbows and knees are considered to be dependent areas, be sure to make a special note postoperatively to encourage elevation of the distal-most extremities to decrease hydrostatic pressure on the healing incision.
DISCUSSION
Even when treating melanoma, wide margin excisions can be limited due to the decrease in elasticity and plasticity of hand and foot skin. There is a tendency to limit marginal excision of lesions on these locations to avoid potential adversarial effects on function and to avoid skin grafting.7
Also, the purse string suture technique can be used as a quick and efficient procedure after excisional biopsy of suspected pigmented lesions and in resection of a melanoma with a poorly defined border, in which the probability of additional surgery is great. Use of the purse string suture does not disturb adjacent tissue, which is advantageous if re-excision is required because of a positive margin.8 The reduction in defect size reduces the need for rearrangement of adjacent tissue.
Additionally, the subcutaneous island pedicle flap is a possible choice for closure of these defects.9 Full-thickness grafts can be used for the dorsal hands and feet, while split-thickness grafts can better serve the palms and soles. Although full-thickness skin grafts are necessary to withstand normal trauma, split-thickness grafts have a greater take rate over exposed tendons.
on the palms and soles require significant skill and represent advanced dermatologic surgery. Besides having the skill to execute the flap, one must also be capable of managing the resultant scar tension. For example, due to the alternating lengthening and shortening dimensions of a Z-plasty on the digit, this may possibly lead to significant vascular compromise.3 Therefore, rather than use flaps on the digits, most cases should be closed with split-thickness skin grafts to avoid the potentially devastating outcome of vascular insult.6
With regard to closure of defects in the toe web spaces, remember that this area frequently harbors Gram-negative bacteria, as well as various yeast and fungi. Therefore, it is a good idea to prophylax with oral antibiotics as well as topical antibacterial/antifungal therapies. Excisions between the toes often require prolonged healing, and dehiscence is not uncommon.
In conclusion, the principles of good closures should be applied with special consideration to some of the practical advice that is aforementioned in this review article
Patients often present with lesions that must be removed on areas of the body where the skin does not provide a great deal of laxity, such as on the hands and feet. Thus, closure of the secondary defect resulting from removal of the lesion is difficult. Due to the elasticity of skin on these areas, the defect can expand up to 25% after excision of the primary lesion, which can complicate the closure even further.1
This article will attempt to summarize some practical points for repairs of defects on the distal-most extremities.
CLOSURE DEFECT REPAIR
Due to the repetitive and delicate movements on the hands and feet, lesions on these areas are particularly challenging to repair. Relaxed skin tension lines are both horizontally and obliquely oriented. Due to this fact, a ‘lazy S’ repair is commonly a practical approach for closing most defects on these areas.2
Redundancies of skin, i.e., dog repairs, are typical of closures of defects on the dorsal surfaces of the hands and feet.3 However, these are not usually repaired, and patients are reassured that the redundancies usually self-resolve over time, unlike what one would expect on other areas of the body.
In reference to closures on the palms and soles, primary closures should be attempted along the longitudinal axis after extensive undermining. Although excisions on the heel or arch can be made at right angles or at an acute angle to the length of the palm or sole, these scars seem to heal poorly and are more prone to problems.
When suturing wounds on the sole, softer and heavier sutures, such as Ethibond or silk, are encouraged,4 as is leaving the sutures in for as long as 4 weeks. Although these marks do occur, they do not represent a major cosmetic liability on the bottom of the sole. Patients should also be advised to stay off their feet and to use medical footgear for as long as the sutures are retained. If painful scars develop on the sole, triamcinolone acetonide injections help resolve this issue.
Due to the proximity of delicate underlying structures, such as large vessels, fascial aponeuroses, tendons, and ligaments, incisions and undermining should be kept as superficial as possible. (See Figure 1.) For this reason, the ideal undermining depth is in the immediately subdermal plane of tissue on the hands and feet.5
NEEDLE CONSIDERATIONS
Attention should be drawn to the type of needle used to repair the defect. For example, reverse cutting needles have their cutting point on the outside of the needle arc to minimize the risk of tearing through tissue. Round-tipped needles have no cutting edges and are therefore less likely to tear tissue. This latter consideration is particularly important when repairing defects on the palmar and plantar skin surfaces. When suturing, one must take care to stay superficial to avoid inadvertently trapping a tendon, which can lead to potentially significant physical impairment and pain.1,6 Informed consent for repair of defects on the extremities should take into consideration the aforementioned complication.
ANESTHESIA CONSIDERATIONS
It is encouraged to use 1% lidocaine without epinephrine to avoid end artery ischemia. It is also encouraged to introduce small aliquots of local anesthetic. Since the distal digits have a small area, adding high volumes of local anesthetic can potentially cause neurovascular bundle compression.
SUTURE SELECTION
In addition to approximating the wound edges with a buried simple suture or a buried vertical mattress suture to have excellent wound edge eversion, you must close the superficial skin with a running nonabsorbable suture as well as an additional simple interrupted nonabsorbable suture in the middle of the closure with 2.0 or 3.0 prolene or Ethibond. The buried absorbable sutures should be placed obliquely rather than vertically to increase the surface area of the dermis that comes into contact with the suture. Due to the mobility of these tissues, the likelihood of the running suture breaking is higher as compared to other sites on the body. Therefore, one or two simple interrupted non-absorbable sutures are necessary to place in the middle of the closure to counteract this potential complication of wound dehiscence (Figure 2).1
POST-OP
Patients should strictly avoid unnecessary and sudden movements post-operatively due to the increased risk of dehiscence on these delicate areas. Soft casting or splinting the extremity may be necessary to immobilize the repaired site and allow for optimal wound recovery.6
Since the areas below the elbows and knees are considered to be dependent areas, be sure to make a special note postoperatively to encourage elevation of the distal-most extremities to decrease hydrostatic pressure on the healing incision.
DISCUSSION
Even when treating melanoma, wide margin excisions can be limited due to the decrease in elasticity and plasticity of hand and foot skin. There is a tendency to limit marginal excision of lesions on these locations to avoid potential adversarial effects on function and to avoid skin grafting.7
Also, the purse string suture technique can be used as a quick and efficient procedure after excisional biopsy of suspected pigmented lesions and in resection of a melanoma with a poorly defined border, in which the probability of additional surgery is great. Use of the purse string suture does not disturb adjacent tissue, which is advantageous if re-excision is required because of a positive margin.8 The reduction in defect size reduces the need for rearrangement of adjacent tissue.
Additionally, the subcutaneous island pedicle flap is a possible choice for closure of these defects.9 Full-thickness grafts can be used for the dorsal hands and feet, while split-thickness grafts can better serve the palms and soles. Although full-thickness skin grafts are necessary to withstand normal trauma, split-thickness grafts have a greater take rate over exposed tendons.
on the palms and soles require significant skill and represent advanced dermatologic surgery. Besides having the skill to execute the flap, one must also be capable of managing the resultant scar tension. For example, due to the alternating lengthening and shortening dimensions of a Z-plasty on the digit, this may possibly lead to significant vascular compromise.3 Therefore, rather than use flaps on the digits, most cases should be closed with split-thickness skin grafts to avoid the potentially devastating outcome of vascular insult.6
With regard to closure of defects in the toe web spaces, remember that this area frequently harbors Gram-negative bacteria, as well as various yeast and fungi. Therefore, it is a good idea to prophylax with oral antibiotics as well as topical antibacterial/antifungal therapies. Excisions between the toes often require prolonged healing, and dehiscence is not uncommon.
In conclusion, the principles of good closures should be applied with special consideration to some of the practical advice that is aforementioned in this review article
Patients often present with lesions that must be removed on areas of the body where the skin does not provide a great deal of laxity, such as on the hands and feet. Thus, closure of the secondary defect resulting from removal of the lesion is difficult. Due to the elasticity of skin on these areas, the defect can expand up to 25% after excision of the primary lesion, which can complicate the closure even further.1
This article will attempt to summarize some practical points for repairs of defects on the distal-most extremities.
CLOSURE DEFECT REPAIR
Due to the repetitive and delicate movements on the hands and feet, lesions on these areas are particularly challenging to repair. Relaxed skin tension lines are both horizontally and obliquely oriented. Due to this fact, a ‘lazy S’ repair is commonly a practical approach for closing most defects on these areas.2
Redundancies of skin, i.e., dog repairs, are typical of closures of defects on the dorsal surfaces of the hands and feet.3 However, these are not usually repaired, and patients are reassured that the redundancies usually self-resolve over time, unlike what one would expect on other areas of the body.
In reference to closures on the palms and soles, primary closures should be attempted along the longitudinal axis after extensive undermining. Although excisions on the heel or arch can be made at right angles or at an acute angle to the length of the palm or sole, these scars seem to heal poorly and are more prone to problems.
When suturing wounds on the sole, softer and heavier sutures, such as Ethibond or silk, are encouraged,4 as is leaving the sutures in for as long as 4 weeks. Although these marks do occur, they do not represent a major cosmetic liability on the bottom of the sole. Patients should also be advised to stay off their feet and to use medical footgear for as long as the sutures are retained. If painful scars develop on the sole, triamcinolone acetonide injections help resolve this issue.
Due to the proximity of delicate underlying structures, such as large vessels, fascial aponeuroses, tendons, and ligaments, incisions and undermining should be kept as superficial as possible. (See Figure 1.) For this reason, the ideal undermining depth is in the immediately subdermal plane of tissue on the hands and feet.5
NEEDLE CONSIDERATIONS
Attention should be drawn to the type of needle used to repair the defect. For example, reverse cutting needles have their cutting point on the outside of the needle arc to minimize the risk of tearing through tissue. Round-tipped needles have no cutting edges and are therefore less likely to tear tissue. This latter consideration is particularly important when repairing defects on the palmar and plantar skin surfaces. When suturing, one must take care to stay superficial to avoid inadvertently trapping a tendon, which can lead to potentially significant physical impairment and pain.1,6 Informed consent for repair of defects on the extremities should take into consideration the aforementioned complication.
ANESTHESIA CONSIDERATIONS
It is encouraged to use 1% lidocaine without epinephrine to avoid end artery ischemia. It is also encouraged to introduce small aliquots of local anesthetic. Since the distal digits have a small area, adding high volumes of local anesthetic can potentially cause neurovascular bundle compression.
SUTURE SELECTION
In addition to approximating the wound edges with a buried simple suture or a buried vertical mattress suture to have excellent wound edge eversion, you must close the superficial skin with a running nonabsorbable suture as well as an additional simple interrupted nonabsorbable suture in the middle of the closure with 2.0 or 3.0 prolene or Ethibond. The buried absorbable sutures should be placed obliquely rather than vertically to increase the surface area of the dermis that comes into contact with the suture. Due to the mobility of these tissues, the likelihood of the running suture breaking is higher as compared to other sites on the body. Therefore, one or two simple interrupted non-absorbable sutures are necessary to place in the middle of the closure to counteract this potential complication of wound dehiscence (Figure 2).1
POST-OP
Patients should strictly avoid unnecessary and sudden movements post-operatively due to the increased risk of dehiscence on these delicate areas. Soft casting or splinting the extremity may be necessary to immobilize the repaired site and allow for optimal wound recovery.6
Since the areas below the elbows and knees are considered to be dependent areas, be sure to make a special note postoperatively to encourage elevation of the distal-most extremities to decrease hydrostatic pressure on the healing incision.
DISCUSSION
Even when treating melanoma, wide margin excisions can be limited due to the decrease in elasticity and plasticity of hand and foot skin. There is a tendency to limit marginal excision of lesions on these locations to avoid potential adversarial effects on function and to avoid skin grafting.7
Also, the purse string suture technique can be used as a quick and efficient procedure after excisional biopsy of suspected pigmented lesions and in resection of a melanoma with a poorly defined border, in which the probability of additional surgery is great. Use of the purse string suture does not disturb adjacent tissue, which is advantageous if re-excision is required because of a positive margin.8 The reduction in defect size reduces the need for rearrangement of adjacent tissue.
Additionally, the subcutaneous island pedicle flap is a possible choice for closure of these defects.9 Full-thickness grafts can be used for the dorsal hands and feet, while split-thickness grafts can better serve the palms and soles. Although full-thickness skin grafts are necessary to withstand normal trauma, split-thickness grafts have a greater take rate over exposed tendons.
on the palms and soles require significant skill and represent advanced dermatologic surgery. Besides having the skill to execute the flap, one must also be capable of managing the resultant scar tension. For example, due to the alternating lengthening and shortening dimensions of a Z-plasty on the digit, this may possibly lead to significant vascular compromise.3 Therefore, rather than use flaps on the digits, most cases should be closed with split-thickness skin grafts to avoid the potentially devastating outcome of vascular insult.6
With regard to closure of defects in the toe web spaces, remember that this area frequently harbors Gram-negative bacteria, as well as various yeast and fungi. Therefore, it is a good idea to prophylax with oral antibiotics as well as topical antibacterial/antifungal therapies. Excisions between the toes often require prolonged healing, and dehiscence is not uncommon.
In conclusion, the principles of good closures should be applied with special consideration to some of the practical advice that is aforementioned in this review article
