• Scalpel handles

■ Bard-Parker standard handle (most common): flat; holds common blades such as the #15, #11, and #10

■ Beaver handle: round or hexagonal; holds smaller, sharper blades; useful for confined spaces or delicate tissue

• Scissors

■ Basics

○ Short-handled scissors useful for delicate work

○ Long-handled scissors extend the surgeons reach and are useful for undermining

○ Curved blades useful for undermining cysts

○ Straight blades useful for trimming tissue and cutting sutures

○ Serrated blades grab tissue better

○ Sharp-tipped scissors puncture tissue easily and are best for dissection

○ Blunt-tipped scissors are best for delicate undermining

■ Scissor types

○ Iris scissors: sharp-tipped and short-handled; blades may be straight or curved; best for sharp dissection

○ Gradle scissors: similar to iris but blades curved and tapered to a fine point at tip; best for dissection of delicate tissue such as periorbital skin

○ Westcott scissors: spring-loaded instrument similar in appearance to Castro-Viejo; good for delicate eyelid dissection

○ Mayo scissors: characterized by its ~1 : 1 handle-to-blade ratio; primary purpose is coarse dissection

○ Metzenbaum scissor: long handles with blunt tips ➔ useful for blunt dissection in areas that require long reach

○ Supercut scissors: one blade has a razor edge; “supercut” blades are available on most scissor types listed above and often are denoted with black handles

• Needle drivers

■ Basics

○ Smaller needle drivers with smooth jaws

♦ Ideal for small, delicate needles

♦ Advantages: smooth jaws have ↓risk of tearing small sutures (6-0 and smaller) and are less damaging to fine needles (P-3 and smaller)

♦ Disadvantages: needles not grasped as tightly as with serrated needle drivers ➔ ↑needle twisting

♦ Caution: larger needles will ruin small needle drivers

○ Larger, serrated jaws

♦ Ideal for larger needles and work on trunk

♦ Advantages: serrated jaws hold needles more securely (prevents twisting)

♦ Disadvantage: damages delicate needles, shreds small sutures

• Forceps

■ Basics

○ Serrated forceps: easier to grab needle, but results in ↑tissue crush injury

○ Toothed forceps: harder to grasp needle, but handles tissue gently (↓crush injury)

○ Combination forceps: have both teeth as well as serrated platforms ➔ allows for gentle tissue handling and easier grasping of needle

■ Types

○ Adson: relatively large forceps; useful for trunk and extremities

○ Bishop-Harmon forceps: small, fine-tipped instruments; most useful for delicate tissues such as the eyelids; always have 3 holes in handles to make them lighter in weight and easier to grip

○ Jeweler’s forceps: have very pointy ends; most useful for suture removal

• Other instruments

■ Hemostats: used to grasp bleeding vessels before ligation

■ Skin hooks: available in many forms;

○ “Skin rake”: a skin hook with multiple hooks

○ Hooks are the least traumatic way to handle tissue (during electrosurgery and suturing), but are a sharps hazard

■ Periosteal elevator: used to remove periosteum or separate nail plate from nail bed

■ Chalazion clamp: useful for eyelid surgery or on the lip to stop bleeding needles

• Surgical needles

■ Needle is composed of three parts:

○ Shank (swage): swaged portion that attaches to suture; weakest part of needle ➔ do NOT grasp here, it will bend or break the needle

♦ Size of suture track is determined by shank size, not suture size

○ Body: middle part; strongest portion of needle ➔ always grasp here with needle driver; comes in various curvatures (most common is 3/8 circle)

○ Tip: sharp tip that may be round (tapered) or cutting; minimize grasping of tip ➔ contact w/ other instruments quickly dulls the tip

■ Three types of needle tips:

○ Round (tapered): only the tip pierces tissue (no sharp edges along arc of needle); is less likely than cutting needles to tear tissues; used for deep soft tissues (fat and muscle); difficult to pass through skin

○ Cutting: triangular-shaped needle point; preferred for skin because it easily passes through tissue; two types:

♦ Conventional cutting: cutting surface is on inner portion of needle arc; ↑risk of sutures tearing through wound edge (this is because the cutting edge of needle faces toward the wound edge)

♦ Reverse cutting: cutting surface is on outer portion of needle arc; ↓risk of sutures tearing through wound edge

• Knots

■ Surgeon’s knot: most commonly used; essentially a square knot; first knot is double thrown to prevent slippage

■ Aberdeen hitch knot: used to tie the end of a running subcutaneous suture; is more compact, more secure, and uses less material than surgeon’s knot

• Cuticular/epidermal suturing

■ Simple interrupted: used for wounds under moderate to high tension; directing the needle away from the wound results in ↑eversion and less frequent sunken scars

■ Simple running: used for wounds under minimal tension; faster to place than interrupted sutures; ↑risk of wound dehiscence

■ Running locked sutures: provides hemostasis, but has risk of strangulation

■ Vertical mattress: strongly everts (Vertical = eVert) wound edges, eliminates dead space, and decreases wound edge tension

■ Horizontal mattress: provides hemostasis (Horizontal = Hemostasis), eliminates dead space, and decreases wound edge tension; significant strangulation risk ➔ do not use in poorly vascularized areas

■ Pulley suture: modified vertical mattress suture; used for wounds under high tension

■ Running horizontal mattress: same benefits as simple horizontal mattress, but is faster, provides ↑eversion, and ↓strangulation risk; improved outcomes relative to simple running sutures, but takes longer

■ Tip stitch: best stitch for flap and M-plasty tips; is a half-buried horizontal mattress suture

■ High-low (step-off stitch): used to correct imprecise dermal/subcuticular suturing, where one side of the wound edge is higher than the other (“step-off”)

• Subcuticular/dermal suturing

■ Simple buried suture: traditional intradermal suture; results in minimal wound eversion and high rate of spitting sutures

■ Buried vertical mattress: has one exit point in the subcutaneous plane; everts tissue more than a simple buried suture

■ Set-back suture (“buried butterfly”): suture entry and exit points are both underneath the undermined wound surface; everts tissue maximally; results in ↓spitting sutures and ↑cosmetic outcomes than the buried vertical mattress technique

■ Running subcuticular: running sutures in superficial dermis, instead of along epidermal surface; primary advantage = lack of track marks; however, ↑rate of spitting sutures; typically used in combination w/ buried vertical mattress sutures

■ Purse-string: traditionally used to ↓wound size and ↓healing time, relative to second intention; a recent RCT study did not demonstrate any difference in cosmetic appearance or scar size, but there was a trend toward faster healing time

■ Pulley suture: buried (subcuticular) pulley suture is essentially just a series of two or more simple buried subcuticular sutures; primary advantage = permits wound closure under high tension; disadvantage = tissue strangulation

■ “Figure of 8”: main suturing method used to tie off bleeding vessels

• Suture removal recommendations (largely anecdotal): head/neck ≤7 days, extremities/torso = 10 to 14 days; the longer the sutures remain in place ➔ ↓likelihood of dehiscence, but ↑cutaneous track-marks

• Suspension sutures: anchor the overlying tissue to periosteum ➔ removes tension from leading edge of flaps; prevents distortion of a free margin (especially eyelid), also prevents flap “tenting” across a concavity

• Suture types and properties (Tables 8-5 through 8-9)

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