February 22, 2018


Skin Incision Key Points (Scalpel)

  • Plan your incision!
    • Clip fur at least 15cm wide of incision
    • Permanent marker prior to prep or sterile marker after draping (if needed)
    • If possible, follow lines of tension (final closed incision will be on/parallel to a line of tension)
    • Do not create a “biological tourniquet” with closure; it is better to leave it open a centimeter or so…it is not a “failure” it is a “rational plan”.
  • Hold blade perpendicular to, not oblique to, the skin surface
  • Exert enough, but not too much, pressure
    • Use fingers to stabilize/retract the skin perpendicular to incision line, i.e. create tension that the blade “splits”.
    • Advance fingers in stages with blade stopped/in contact with skin
    • Using tension, create and watch the gapping of the incision as you cut—adjust pressure every millimeter as you go
  • Pencil grip—incisions < 3 cm
  • Finger tip grip—long incisions
  • Do not “saw” with a scalpel; do not repeatedly pickup blade.
  • Always brace hand when making a stab incision (“too deep” may be “too bad”)

Tissue handling

  • Do not touch tissue unless necessary.
  • Do not pickup tissue unless necessary.
  • Use thumb forceps on acellular tissue preferentially (fascia vs. skin).
  • Sharp dissection is less traumatic than blunt (blade < scissors < blunt dissection < gauze/finger dissection).
  • Hemorrhage higher with sharp dissection (blade > scissors > blunt dissection > gauze/finger dissection).
  • Blot with gauze—DO NOT wipe.
  • Use damp gauze (saline…ring out)

Subcutaneous dissection

  • Blade—one layer at a time; use fingers to spread perpendicular to incision, create tension.
  • Scissors
    • Scissor cut: typical cutting motion; short incisions; do not close completely with each cut; use tips only.
    • Push cut: i.e. running cut, like in material/paper; only have small opening in scissor blades; long incisions; less traumatic
    • Blunt dissection: increases caution in highly vascular/nervous/vital areas; insert closed–> open, small gap–> remove open –> close and repeat, many little spreads vs. one huge spread.

Subcutaneous closure

  • Goal to reduce dead space with minimum of foreign material (suture).
  • Bury knots routinely.
  • Simple interrupted pattern if tension relieving.
  • Simple continuous / ”Lembert” if minimal tension.
  • Tack to underlying layer to avoid pocket formation.

Skin closure

  • Avoid crushing skin; do not “oppose” needle resistance with thumb forceps pinching skin.
  • Needle passes easier when skin under tension
    • Immobilize with forceps on SQ pulling away from cut surface
    • Immobilize with fingers parallel to incision
  • Intradermal/subcuticular layer
    • Bury knot 5-10 mm from end of incision
    • Start pattern at the beginning of incision (one technique—dive under knot and come out at very beginning in dermis)
    • Pop needle in dermis, rotate through arc of needle, watch for needle bulge, “whittle” it around until bulge is within dermis, pop out of dermis
    • Dove tail to avoid gapping
    • Smaller bites (less needle arc) in thinner skin to avoid bunching appearance

No suture tract through skin (less bacterial access to incision; more cosmetic)
Better incision seal (less bacterial access to incision; more cosmetic)
Potentially no suture removal

  • Skin sutures
    • 2/3 thickness of dermis  exact apposition (better seal, more cosmetic)
    • Use smallest size suture appropriate (3-0 or 4-0 most dogs/cat wounds)
    • Use monofilament (nylon, prolene, surgilene, steel) or coated multifilament suture (Vetafil, Braunamid, Supramid) for skin (exception—silk on eyelids +/- ok; remove 5-7d)