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Introduction
CHAPTER 18 Layered Excisions and
Surgical Repairs
Jonathan Kantor
SUMMARY
Linear closures involve direct side-to-side closure of the surgical wound.
Layered linear closure remains the gold standard for wound closure given its
predictable outcomes, reasonable cost to the patient and healthcare system, and low risk of complications.
Even very large defects, including those on the face, can often be closed in a
linear fashion, as long as aggressive undermining and dog-ear correction are performed.
A significant advantage of linear closures is their predictability; since
outstanding blood flow is maintained to the wound edge, these closures often result in fine-line nearly imperceptible scars when carefully designed and
executed.
Beginner Pearls
Breaking down the excision and linear repair into its component parts helps
conceptualize each requisite step.
Never attempt to rush a step; most shortcuts result in the need for a far more time-
consuming correction.
Expert Pearls
Large defects on the face do not necessarily require flap repair.
Linear closures have almost no risk of flap loss, and so are particularly useful
approaches for closures in tobacco users.
Using a rhombus or tangent-to-circle closure approach may result in smaller apical
angles and less dog-ear formation.
Donโt Forget!
When deciding between a large linear closure and a flap, keep in mind that linear
closures have less of a tendency to โburn bridgesโ for future repairs, an important consideration in the patient with florid skin cancers.
If a wound closed with buried sutures alone results in significant gaping or
overhanging dermis, do not attempt to solve this with superficial suture placement. Instead, remove the excess dermis and/or replace the deep sutures.
Pitfalls and Cautions
Always carefully identify the source of any oozing and address it directly; judicious
use of electrosurgical approaches will help reduce the amount of necrotic tissue left in a wound.
Gentle tissue handling will result in improved outcomes, decreasing the risk of
necrosis and infection.
Patient Education Points
Explaining that any additional scar length will likely heal with a minimally visible line
may go a long way toward patient reassurance.
Always review the planned degree of eversion with the patient so that there is no
confusion or worry in the immediate postoperative period regarding the ridged appearance of the wound.
Billing Pearls
As a general rule, extensive undermining, dog-ear correction, or other complex steps
are needed to bill for a complex closure.
No amount of undermining shifts a linear excision and repair to a bilateral
advancement flap for billing purposes.
CHAPTER 18 Layered Excisions and