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The recovery suture
British Journal of Plastic Surgery (2002) 55, 588–599 © 2002 The British Association of Plastic Surgeons. Published by Elsevier Science Ltd. All rights reserved.
Short reports and correspondence doi:10.1054/bjps.2002.3921
The recovery suture Sir, Continuous subcuticular sutures are commonly used to close wounds of varying lengths, providing accurate approximation of the skin edges without the risk of stitch marks. The suture material can be either non-absorbable, requiring removal, or absorbable. Removal of a non-absorbable subcuticular suture is not usually a problem in small wounds. When, however, a nonabsorbable suture material is selected for subcuticular suturing of a lengthy wound, removal of the suture can be difficult and painful, even when a low-friction monofilament suture is used. As a result, the suture can snap, and part of it may be retained in the wound. A method often used to ease suture removal is to interrupt the subcuticular suture by looping the suture through the skin at one or more points along its length (Fig. 1).1 Traction on these exposed loops can assist in subsequent suture removal. Wound oedema and tension can, however, cause such loops to become depressed below the skin surface, and, in some cases, to become completely buried. This can also cause problems at the time of suture removal. These problems can be avoided by using a technique called the ‘recovery suture’. After inserting the subcuticular suture, the surgeon gently separates the skin edges at one or more points along the length of the wound in order to visualise the suture (Fig. 2). A simple loop of the same suture material is then tied around the exposed suture at these points, and left long. There is, therefore, minimal risk of each loop becoming depressed or buried. Traction on each recovery suture (Fig. 3) allows the subcuticular suture to be visualised and divided at the relevant points. The suture material can then be easily removed in smaller segments without friction. The recovery suture has previously been described in relation to the removal of continuous horizontal mattress sutures,2
Figure 2—Insertion of a ‘recovery suture’ around the exposed loop of a subcuticular suture.
Figure 3—Traction on the ‘recovery suture’ exposes the subcuticular suture at the time of removal.
but not subcuticular sutures. Although it is probably not a new technique, it has not previously been described in the plastic surgery literature. We recommend it as a useful aid in the removal of subcuticular sutures. Yours faithfully, Omar A. Ahmed FRCSEd(Plast), Registrar in Plastic and Reconstructive Surgery St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK.
Figure 1—The traditional method used to ease subcuticular suture removal.
588
Short reports and correspondence Amna O. Ahmed MBBS, Senior House Officer in Obstetrics and Gynaecology Horton General Hospital, Oxford Road, Banbury, Oxfordshire OX16 9AL, UK.
References 1. McCarthy JG. Introduction to plastic surgery. In McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders Co, 1990: 51. 2. Leslie D. The recovery suture. Australasian J Dermatol 1995; 36: 169–70.
doi:10.1054/bjps.2002.3907
Titanium clips: a simple technique for the excision of accessory tragi and digits Sir, We read with interest the paper by Stewart et al on the excision of accessory auricles and accessory digits in newborn babies.1 They describe a protocol in which the accessory tags are surgically excised after application of a topical local anaesthetic, usually within 7 days of birth. In our region, all maternity units and paediatricians have been sent an information sheet explaining our protocol, with illustrations of appropriate cases. Those that are considered appropriate are referred for early assessment by the plastic surgery team. If the pedicle of the accessory part is suitable, a
589 titanium clip is applied. If the accessory digit or auricle is not suitable for the application of a titanium clip, it is excised under local anaesthetic. Informed consent is obtained, and the procedure is performed under topical (EMLA or Ametop) or infiltrated local anaesthetic (0.5% lignocaine with adrenaline) in the paediatric facility. It is important to tent the accessory part so that the clip can be applied flush to the skin, thereby avoiding a residual nubbin (Fig. 1).2 The extra tissue can then be trimmed or left to drop off after a few days. Good results have been obtained 3 months postoperatively (Fig. 2). The same procedure is followed for accessory digits. The advantages of titanium clips are that they are fast to apply and that they can be applied in children who are hours or days old. Carers report that the children suffer no discomfort, usually crying for just a few seconds when the local anaesthetic is infiltrated. It may be possible to train nurse specialists in the method, potentially reducing delay for the patient and family. It allows parents to take their children home immediately, and avoids the need for sutures or the reaction to dissolvable sutures as well as additional outpatient visits. Parental satisfaction is high, because the child’s anomaly is treated before they leave hospital. Yours faithfully, J. Skillman MRCS, Senior House Officer in Plastic Surgery S. Cerovac FRCS, Locum Appointment for Training in Plastic Surgery A. Fleming FRCS(Plast), Consultant Plastic and Reconstructive Surgeon A. L. H. Moss FRACS(Plast), FRCS, Consultant Paediatric Plastic and Reconstructive Surgeon Department of Plastic Surgery, St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK.
Acknowledgement We acknowledge David Evans, who first used this technique for the excision of accessory digits.
References
Figure 1—The titanium clip is applied flush to the skin.
1. Stewart KJ, Holmes JD, Kolhe PS. Neonatal excision of minor congenital anomalies under local anaesthetic. Br J Plast Surg 2002; 55: 170. 2. Frieden IJ, Chang MW, Lee I. Suture ligation of supernumerary digits and ‘tags’: an outmoded practice? Arch Pediatr Adolesc Med 1995; 149: 1284. 3. Sebben JE. The accessory tragus – no ordinary skin tag. J Dermatol Surg Oncol 1989; 15: 304–7.
doi:10.1054/bjps.2002.3924
Ear reconstruction in elderly patients: a two-part helix method in a framework
Figure 2—Appearance 3 months postoperatively: a good result has been achieved.
Sir, In aged patients the costal cartilage is often calcified or fused into a solid block. Ear reconstruction using costal cartilage in elderly patients is rarely reported because of the difficulty of fabricating the framework. We report the case of a 62-year-old female with microtia who underwent an autogenous costalcartilage graft. The patient’s condition had not been previously treated (Fig. 1); she sought medical advice because her glasses repeatedly slipped off while playing golf. After examining her at our
Short reports and correspondence doi:10.1054/bjps.2002.3921
The recovery suture Sir, Continuous subcuticular sutures are commonly used to close wounds of varying lengths, providing accurate approximation of the skin edges without the risk of stitch marks. The suture material can be either non-absorbable, requiring removal, or absorbable. Removal of a non-absorbable subcuticular suture is not usually a problem in small wounds. When, however, a nonabsorbable suture material is selected for subcuticular suturing of a lengthy wound, removal of the suture can be difficult and painful, even when a low-friction monofilament suture is used. As a result, the suture can snap, and part of it may be retained in the wound. A method often used to ease suture removal is to interrupt the subcuticular suture by looping the suture through the skin at one or more points along its length (Fig. 1).1 Traction on these exposed loops can assist in subsequent suture removal. Wound oedema and tension can, however, cause such loops to become depressed below the skin surface, and, in some cases, to become completely buried. This can also cause problems at the time of suture removal. These problems can be avoided by using a technique called the ‘recovery suture’. After inserting the subcuticular suture, the surgeon gently separates the skin edges at one or more points along the length of the wound in order to visualise the suture (Fig. 2). A simple loop of the same suture material is then tied around the exposed suture at these points, and left long. There is, therefore, minimal risk of each loop becoming depressed or buried. Traction on each recovery suture (Fig. 3) allows the subcuticular suture to be visualised and divided at the relevant points. The suture material can then be easily removed in smaller segments without friction. The recovery suture has previously been described in relation to the removal of continuous horizontal mattress sutures,2
Figure 2—Insertion of a ‘recovery suture’ around the exposed loop of a subcuticular suture.
Figure 3—Traction on the ‘recovery suture’ exposes the subcuticular suture at the time of removal.
but not subcuticular sutures. Although it is probably not a new technique, it has not previously been described in the plastic surgery literature. We recommend it as a useful aid in the removal of subcuticular sutures. Yours faithfully, Omar A. Ahmed FRCSEd(Plast), Registrar in Plastic and Reconstructive Surgery St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK.
Figure 1—The traditional method used to ease subcuticular suture removal.
588
Short reports and correspondence Amna O. Ahmed MBBS, Senior House Officer in Obstetrics and Gynaecology Horton General Hospital, Oxford Road, Banbury, Oxfordshire OX16 9AL, UK.
References 1. McCarthy JG. Introduction to plastic surgery. In McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders Co, 1990: 51. 2. Leslie D. The recovery suture. Australasian J Dermatol 1995; 36: 169–70.
doi:10.1054/bjps.2002.3907
Titanium clips: a simple technique for the excision of accessory tragi and digits Sir, We read with interest the paper by Stewart et al on the excision of accessory auricles and accessory digits in newborn babies.1 They describe a protocol in which the accessory tags are surgically excised after application of a topical local anaesthetic, usually within 7 days of birth. In our region, all maternity units and paediatricians have been sent an information sheet explaining our protocol, with illustrations of appropriate cases. Those that are considered appropriate are referred for early assessment by the plastic surgery team. If the pedicle of the accessory part is suitable, a
589 titanium clip is applied. If the accessory digit or auricle is not suitable for the application of a titanium clip, it is excised under local anaesthetic. Informed consent is obtained, and the procedure is performed under topical (EMLA or Ametop) or infiltrated local anaesthetic (0.5% lignocaine with adrenaline) in the paediatric facility. It is important to tent the accessory part so that the clip can be applied flush to the skin, thereby avoiding a residual nubbin (Fig. 1).2 The extra tissue can then be trimmed or left to drop off after a few days. Good results have been obtained 3 months postoperatively (Fig. 2). The same procedure is followed for accessory digits. The advantages of titanium clips are that they are fast to apply and that they can be applied in children who are hours or days old. Carers report that the children suffer no discomfort, usually crying for just a few seconds when the local anaesthetic is infiltrated. It may be possible to train nurse specialists in the method, potentially reducing delay for the patient and family. It allows parents to take their children home immediately, and avoids the need for sutures or the reaction to dissolvable sutures as well as additional outpatient visits. Parental satisfaction is high, because the child’s anomaly is treated before they leave hospital. Yours faithfully, J. Skillman MRCS, Senior House Officer in Plastic Surgery S. Cerovac FRCS, Locum Appointment for Training in Plastic Surgery A. Fleming FRCS(Plast), Consultant Plastic and Reconstructive Surgeon A. L. H. Moss FRACS(Plast), FRCS, Consultant Paediatric Plastic and Reconstructive Surgeon Department of Plastic Surgery, St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK.
Acknowledgement We acknowledge David Evans, who first used this technique for the excision of accessory digits.
References
Figure 1—The titanium clip is applied flush to the skin.
1. Stewart KJ, Holmes JD, Kolhe PS. Neonatal excision of minor congenital anomalies under local anaesthetic. Br J Plast Surg 2002; 55: 170. 2. Frieden IJ, Chang MW, Lee I. Suture ligation of supernumerary digits and ‘tags’: an outmoded practice? Arch Pediatr Adolesc Med 1995; 149: 1284. 3. Sebben JE. The accessory tragus – no ordinary skin tag. J Dermatol Surg Oncol 1989; 15: 304–7.
doi:10.1054/bjps.2002.3924
Ear reconstruction in elderly patients: a two-part helix method in a framework
Figure 2—Appearance 3 months postoperatively: a good result has been achieved.
Sir, In aged patients the costal cartilage is often calcified or fused into a solid block. Ear reconstruction using costal cartilage in elderly patients is rarely reported because of the difficulty of fabricating the framework. We report the case of a 62-year-old female with microtia who underwent an autogenous costalcartilage graft. The patient’s condition had not been previously treated (Fig. 1); she sought medical advice because her glasses repeatedly slipped off while playing golf. After examining her at our