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Assisted Instrument Tie to Close Scalp Wounds

Assisted Instrument Tie to Close Scalp Wounds Performing closures of scalp wounds can be challenging, especially when patients are unwilling to undergo hair clipping at the operative site. Report of a Case A 60-year-old white man presented for removal of a 1.2-mm mobile, noninflamed keratinous cyst of the right scalp present for several weeks. It was tender when struck with a comb. Hair-bearing skin covered the cyst. The patient was anxious about having his hair clipped. Video View LargeDownload Figure 1. The tail end of the dark suture is quickly identified against the light-colored glove of the assistant. Comment Performing closures of scalp wounds can be challenging, especially when patients are unwilling to undergo clipping of hair. The hair obscures visualization of the scalp and gets into the knots and/or the wound. The tail end of the suture blends in with hair and can be difficult to find (Figure 2). Attempts to grasp the tail with a needle holder often result in hair being picked up with the suture and becoming entangled in the knot. It is challenging to identify the end of the suture and tie a square knot without intertwining the hair. View LargeDownload Figure 2. The dark suture blends in with the patient's hair. Prior literature has demonstrated proper technique for closures in a hairless field, including proper orientation of square knots.1 However, the efficient use of a medical assistant to manage a hairy field during closures has not been described.2-4 Furthermore, data suggest that preoperative hair removal does not decrease the chance of wound infections.5 To easily place and tie sutures without preoperative shaving, an assistant holds the tail of the suture with the distal 3 to 6 mm exposed while the dermatologic surgeon ties a square knot using an instrument tie. The tail of the dark suture is identified by the surgeon against the light-colored glove of the assistant. The gloved finger provides a barrier so that the suture tail can be grasped without including hairs. Care still must be taken to avoid trapping hair in the knot. By avoiding clipping hair, patient satisfaction is increased because the adjacent hair hides the healing wound. In addition, if the closure is performed under tension, the wound may slightly separate between the first and second throws of the knot. Traction provided by the assistant helps avoid separation. This novel instrument tie method uses the dermatologic surgeon's greatest asset: the surgical assistant. This allows the physician to more quickly and easily instrument tie knots when closing scalp wounds. Not only is this method faster and more efficient, but it also increases patient satisfaction by eliminating the need for preoperative clipping of hair. Back to top Article Information Correspondence: Dr Bhatia, 2155 CityGate Lane, Ste 225, Naperville, IL 60563 (ashish@derm.md). Conflict of Interest Disclosures: Dr Brodell has served as a consultant to Galderma, Sirius Laboratories, Medicis, and Genentech; he has conducted or participated in clinical trials for Galderma, Genentech, Allergan, and Dow; and he has served on speakers' bureaus for Allergan, Sandoz-Novartis, Galderma, GlaxoSmithKline, Dermik, and Genentech. Dr Bhatia has served as a consultant for Ethicon and SimSkin; he has received honoraria from Ethicon and owns stock in SimSkin. Additional Contributions: We thank Sarah Ahearn, RN, and Rachel Seacrest, MA, for their excellent assistance in the filming and photography for this manuscript. References 1. Weng R, Li Q, Zheng Y. Reduce suture complications by applying proper knot tying techniques. Dermatol Surg. 2010;36(8):1314-131820573169PubMedGoogle ScholarCrossref 2. Bolognia JL, ed, Jorizzo JL, ed, Rapini RP, ed. Dermatology. 2nd ed. St Louis, MO: Mosby; 2007 3. Wolff K, ed, Goldsmith LA, ed, Katz SI, ed, Gilchrest BA, ed, Paller AS, ed, Leffell DJ, ed. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008 4. Brunicardi F, ed, Anderson DK, ed, Billiar TR, ed, et al. Schwartz's Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010 5. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011;(11):CD00412222071812PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Assisted Instrument Tie to Close Scalp Wounds

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References (5)

Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2013.1067
Publisher site
See Article on Publisher Site

Abstract

Performing closures of scalp wounds can be challenging, especially when patients are unwilling to undergo hair clipping at the operative site. Report of a Case A 60-year-old white man presented for removal of a 1.2-mm mobile, noninflamed keratinous cyst of the right scalp present for several weeks. It was tender when struck with a comb. Hair-bearing skin covered the cyst. The patient was anxious about having his hair clipped. Video View LargeDownload Figure 1. The tail end of the dark suture is quickly identified against the light-colored glove of the assistant. Comment Performing closures of scalp wounds can be challenging, especially when patients are unwilling to undergo clipping of hair. The hair obscures visualization of the scalp and gets into the knots and/or the wound. The tail end of the suture blends in with hair and can be difficult to find (Figure 2). Attempts to grasp the tail with a needle holder often result in hair being picked up with the suture and becoming entangled in the knot. It is challenging to identify the end of the suture and tie a square knot without intertwining the hair. View LargeDownload Figure 2. The dark suture blends in with the patient's hair. Prior literature has demonstrated proper technique for closures in a hairless field, including proper orientation of square knots.1 However, the efficient use of a medical assistant to manage a hairy field during closures has not been described.2-4 Furthermore, data suggest that preoperative hair removal does not decrease the chance of wound infections.5 To easily place and tie sutures without preoperative shaving, an assistant holds the tail of the suture with the distal 3 to 6 mm exposed while the dermatologic surgeon ties a square knot using an instrument tie. The tail of the dark suture is identified by the surgeon against the light-colored glove of the assistant. The gloved finger provides a barrier so that the suture tail can be grasped without including hairs. Care still must be taken to avoid trapping hair in the knot. By avoiding clipping hair, patient satisfaction is increased because the adjacent hair hides the healing wound. In addition, if the closure is performed under tension, the wound may slightly separate between the first and second throws of the knot. Traction provided by the assistant helps avoid separation. This novel instrument tie method uses the dermatologic surgeon's greatest asset: the surgical assistant. This allows the physician to more quickly and easily instrument tie knots when closing scalp wounds. Not only is this method faster and more efficient, but it also increases patient satisfaction by eliminating the need for preoperative clipping of hair. Back to top Article Information Correspondence: Dr Bhatia, 2155 CityGate Lane, Ste 225, Naperville, IL 60563 (ashish@derm.md). Conflict of Interest Disclosures: Dr Brodell has served as a consultant to Galderma, Sirius Laboratories, Medicis, and Genentech; he has conducted or participated in clinical trials for Galderma, Genentech, Allergan, and Dow; and he has served on speakers' bureaus for Allergan, Sandoz-Novartis, Galderma, GlaxoSmithKline, Dermik, and Genentech. Dr Bhatia has served as a consultant for Ethicon and SimSkin; he has received honoraria from Ethicon and owns stock in SimSkin. Additional Contributions: We thank Sarah Ahearn, RN, and Rachel Seacrest, MA, for their excellent assistance in the filming and photography for this manuscript. References 1. Weng R, Li Q, Zheng Y. Reduce suture complications by applying proper knot tying techniques. Dermatol Surg. 2010;36(8):1314-131820573169PubMedGoogle ScholarCrossref 2. Bolognia JL, ed, Jorizzo JL, ed, Rapini RP, ed. Dermatology. 2nd ed. St Louis, MO: Mosby; 2007 3. Wolff K, ed, Goldsmith LA, ed, Katz SI, ed, Gilchrest BA, ed, Paller AS, ed, Leffell DJ, ed. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008 4. Brunicardi F, ed, Anderson DK, ed, Billiar TR, ed, et al. Schwartz's Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010 5. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011;(11):CD00412222071812PubMedGoogle Scholar

Journal

JAMA DermatologyAmerican Medical Association

Published: Jan 1, 2013

Keywords: scalp injuries

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