PLASTIC SURGERY…for Neurosurgeons

on


Dr. Joel Aronowitz

CSMC Div. Plastic Surgery


Sutures are as old as creation


“And they knew they were naked and SEWED fig leaves to cover themselves” Genesis

A Brief Suture History




  • 30,000 BC Neolithic eyed needles
  • 3,500 BC Edwin Smith Papyrus
  • 210 AD Galen sewed gladiators w/gut
  • 1887 sterile sutures introduced
  • 1920 Merson invents the Swage

Classification of Sutures






Absorbable vs. Permanent

  • Natural vs. Synthetic
  • Tensile strength loss over time

Braided vs. Monofilament


BRAIDED VS MONOFILAMENT SUTURE

BRAIDED
  • Handling better
  • Knots more secure
  • Softer
  • No snitching, Clinching
  • Infection risk hi, 10,000X less bact innoculum
  • Freq spitting

MONOFILAMENT
  • Lower infection risk
  • Snitches easily
  • Stiffer
  • Less spitting

ABSORBABLE VS NON-ABSORBABLE

ABSORBABLE
  • No retained foreign body
  • No late suture reaction
  • Risk of premature tensile strength failure
  • Elicits cellular response, ie wbc
NON-ABSORBABLE
  • Permanent strength
  • Useful anatomic marker
  • Min inflamm response, monofil., relatively inert
  • Long term FB effects, esp braided sutures
  • Poor handling may cause loss of strength, eg instrument grasping, over stretch etc.

Absorption of Non-Permanent Sutures



Absorbable suture strength vs time



Absorbable suture strength loss
  • Vicryl and Vicryl rapide, coated (polyglactin)
    • 3 wks
  • Monocryl (poliglecaprone)
    • 2 wks
  • PDS (polydioanone)
    • 4 wks
  • Gut; fast and chromic (collagen)
    • 1 wk

Natural material: Enzymatic Absorption w/ WBC response

Synthetic material: Hydrolysis with less WBC response


TYPES of ABSORBABLE SUTURE

MONOFILAMENT
  • Monocryl (plus)
  • PDS (plus)
  • Gut
    • Plain, fast, chromic
  • Dyed vs Undyed
  • Barbed (Stratafix)
BRAIDED
  • Vicryl
  • Vicryl rapide
  • Dyed vs undyed
TYPES of NONABSORBABLE SUTURE

MONOFILAMENT
  • Ethilon (nylon)
  • Prolene (polypropylene)
  • Pronova (blue)
  • Steel

BRAIDED
  • Nurolon (nylon)
  • Mersilene (polyethylene)
  • Ethibond (polyprop. green) 
  • Silk

SURGICAL NEEDLES




TAPER
  • Useful for vessels, delicate tissues, prone to propagating a tear
  • Dull easily

CUTTING
  • Many cutting tips
  • Needle creates a small laceration in tissue
  • Spatulated, Straight


SURGICAL NEEDLES


Needle Point Type

  1. TAPER POINT
  2. TAPERCUT
  3. TAPERCUT CARDIO
  4. PRIME CONVENTIONAL CUTTING
  5. PRIME REVERSE CUTTING
  6. REVERSE CUTTING
  7. BLUNT POINT
  8. BLUNT POINT ETHIGUARD
  9. TROCAR ,(straight)
  10. CUTTING EDGE PRIME CONVENTIONAL
  11. CUTTING EDGE PRIME REVERSE
  12. CUTTING EDGE REVERSE
  13. CUTTING EDGE SPATULA REVERSE
  14. LIGAPAK Reel
  15. NO NEEDLE
  16. EYED (FREE) NEEDLES


WHAT SUTURE TO USE

SKIN of SCALP
  • 3–0 Prolene simple or vert.mattress as needed to evert
  • Staples
  • 3–0 Monocryl Subcuticular
  • Prineo System and Dermabond rare cases

SUBCUTANEOUS FAT LAYER and GALEA
  • 3–0 Monocryl buried in adipose
  • 2–0 Monocryl in Galea
  • 6–0 Prolene in face (forehead, brow, preauricular)

SOME TISSUE HANDLING TIPS
  • Envision surgical tissue handling on a histologic level.
  • Avoid crushing tissue, avoid excess or prolonged stretch
  • Respect the cutaneous blood supply, cauterize judiciously
  • Radiated tissue is anoxic on a cellular level due to obliterative arteritis, thus radiation injury worsens over time. Surgeon Beware!
  • Place sutures evenly, without xs tension
  • Minimize FB present in wound and hardware profile on overlying skin flap

SOME (extracranial) SURGICAL TECHNIQUE TIPS
  • Recognize and use old scars if possible, no signif. blood supply across the old scar. Keep Nitrobid close by…
  • Err on side of larger flap design, not smaller.
  • Protect scalp flap in long cases, keep moist, avoid excess tension in retraction, allow 5 min restoration of blood flow if flap is ischemic for >6 hrs.
  • Undermine scalp at subperiosteal level to recruit laxity if needed. OK to undermine forehead to sup orbit and nasal root, cheek to zygoma, and occiput to nape of neck if SO, ST, Occip vessels are preserved.

Skin Anatomy

Suture Technique



WHEN TO REMOVE SUTURES

Suture scars result from epithelialization of suture tract, ie sutures in too long, or strangulation of tissue within suture loop, suture pulled too tight or excess po swelling.

SUTURE REMOVAL SCHEDULE
  • Face; 5 days
  • Scalp; 14 days
  • Radiated scalp; 28 days

Scalp flaps; go large or go home!



Skin grafting the periosteum




Finale


dr-joel-aronowitz
Dr. Joel Aronowitz

Originally published at https://medium.com/@drjoelaronowitz on May 21, 2024.

Location: Beverly Hills, CA, USA

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