Continuing medical education
Surgical technique for optimal outcomes: Part I. Cutting tissue: Incising, excising, and undermining

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Sound surgical technique is necessary to achieve excellent surgical outcomes. Despite the fact that dermatologists perform more office-based cutaneous surgery than any other specialty, few dermatologists have opportunities for practical instruction to improve surgical technique after residency and fellowship. This 2-part continuing medical education article will address key principles of surgical technique at each step of cutaneous reconstruction. Part I reviews incising, excising, and undermining. Objective quality control questions are proposed to provide a framework for self-assessment and continuous quality improvement.

Introduction

Surgeons influence the aesthetics of scars from cutaneous surgery in 2 ways: (1) surgical design and (2) surgical technique. The principles of aesthetic surgical design are universally accepted, and include preserving and restoring free margins (eg, eyelids, nasal tip and ala, lips, and helical rim), preserving and restoring contour, and placing scars in cosmetic subunit junction lines.1 Placing scars along relaxed skin tension lines is also desirable, but is less important compared to the aforementioned principles.2 For example, it is undesirable to conform to the horizontal relaxed skin tension lines on the forehead if elevation of the ipsilateral eyebrow creates asymmetry.

While surgeons nearly universally adhere to the core principles of aesthetic surgical design, surgical technique varies markedly. These variations can confuse surgical trainees, who are left to struggle by trial and error through numerous potential approaches to execute the same surgical technique.3, 4 Only after months to years of independent practice and observation of their own postoperative outcomes do most surgeons refine their own surgical technique and achieve reproducibly excellent results.5 Many practitioners desire additional surgical coaching after their formal training.6 This 2-part continuing medical education article proposes quality control questions for each step of cutaneous reconstruction and provides a framework for self-assessment and continuous quality improvement.

Section snippets

Steps of surgical reconstruction

Surgical techniques fall into 2 broad categories: cutting and suturing. Cutting techniques include incising, excising, and undermining. Suturing techniques include placing deep and top sutures. Most reconstructive surgery involves the stepwise execution of these cutting and suturing techniques. Each step influences the success of subsequent steps; errors early in the process make the precise execution of subsequent steps either more difficult or impossible.

Scars heal with a shiny texture that

Cutting technique: Incising

Key points

  1. The incision aims to achieve uniform release of the entire skin edge to the desired anatomic depth

  2. The ideal depth of the incision varies according to the anatomic location and intent of the procedure

  3. The incised wound edges should be smooth and sharply perpendicular to the skin surface

  4. Beveling of the dermis or fat toward the center of the wound impedes the precise approximation of wound edges

The goal of the incision is to achieve uniform release of the entire skin edge to the desired anatomic

Cutting technique: Excising

Key points

  1. Excision should remove the lesion or excess skin during the reconstruction with minimal collateral damage to important anatomic structures

  2. The anatomic plane of the excision ideally corresponds to the depth of initial skin incision; otherwise, hemostasis may be more challenging or bulky soft tissue in the central wound may impede apposition of wound edges

  3. The ideal anatomic plane of excision varies by location on the body

  4. Ideal planes of excision are characterized by the effortless release of

Cutting technique: Undermining

Key points

  1. Undermining may facilitate advancement of the wound edges and eversion when suturing

  2. Wounds at anatomic sites where the fascia is adherent to the overlying dermis benefit most from undermining

  3. Excessive undermining can threaten the blood supply of the flap and rarely provides a mechanical advantage

  4. The plane of undermining frequently corresponds to the plane of excision

  5. An efficient plane of undermining is characterized by effortless release of the tissue and minimal bleeding

  6. Efficient undermining

Conclusion

The initial steps to cutaneous surgery require cutting, including incising, excising, and undermining. After the cutting steps, the ideal wound has cleanly incised, vertical wound edges, a base at a uniform anatomic plane, and precisely undermined skin edges (Fig 16, Fig 17). Part I of this continuing medical education article provided quality control checkpoints and troubleshooting solutions to address common challenges during incision, excision, and undermining to help surgeons create wounds

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Funding sources: None.

Conflicts of interest: None declared.

Date of release: March 2015

Expiration date: March 2018

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