Surgery

Sherry H. Yu, MD

Surgical Anatomy

Basic Concepts

In-depth knowledge of surgical anatomy is fundamental to the safe execution of dermatologic procedures.
The face is divided into eight major cosmetic subunits (Figure 8.1): forehead, temples, eyelids, nose, cheeks, ears, lips, and chin. Cosmetic subunits are delineated based on similarities in topographic anatomy, texture and color, solar exposure, sebaceous features, and hair density.
Important landmarks of the face include the midline and the mid-pupillary line, on which the supraorbital foramen, infraorbital foramen, and mental foramen are located. Topography of the eyelids, nose, lips, and ears is illustrated in Figure 8.2, Figure 8.3, Figure 8.4, and Figure 8.5.

Figure 8.1. MAJOR COSMETIC SUBUNITS OF THE FACE.

(Illustration by Caroline A. Nelson, MD.)
The scalp and face have distinct layers (Figure 8.6):
- Scalp: epidermis/dermis, subcutaneous fat, galea aponeurotica, loose subaponeurotic tissue, periosteum.
- Face: epidermis/dermis, subcutaneous fat, superficial musculoaponeurotic system (SMAS), periosteum.

Muscles

Muscles of the head and neck are illustrated in Figure 8.7.
- Muscles of mastication arise from the first branchial arch.
  
  Figure 8.2. TOPOGRAPHY OF THE EYELIDS.
  
  (Illustration by Caroline A. Nelson, MD.)
  
  Figure 8.3. TOPOGRAPHY OF THE NOSE.
  
  (Illustration by Caroline A. Nelson, MD.)
  
  Figure 8.4. TOPOGRAPHY OF THE LIPS.
  
  (Illustration by Caroline A. Nelson, MD.)
- Muscles of facial expression arise from the second branchial arch.
The SMAS, extending from the frontalis to the platysma, allows organized movement of muscles of facial expression. As a general rule, blood vessels and sensory nerves lie within or superficial to the SMAS, while motor nerves lie deep to the SMAS.
- The SMAS is pulled tight during a face-lift.

Figure 8.5. TOPOGRAPHY OF THE EARS.

(Illustration by Caroline A. Nelson, MD.)

Figure 8.6. LAYERS OF THE SCALP AND FACE. The SMAS extends from the galea aponeurotica of the scalp to the playtsma of the neck. Layers of the scalp and face are illustrated. Layers of the face vary based on location, with the addition of deep fascia, fat, muscle, and/or retaining ligaments below the SMAS. SMAS, superficial musculoaponeurotic system.

(Illustration by Caroline A. Nelson, MD.)

SCALP layers: Skin (epidermis/dermis), Connective tissue (subcutaneous fat), Aponeurosis (galea aponeurotica), Loose subaponeurotic tissue, and Periosteum.

Skin Lines

Langer lines run parallel to underlying muscles.
- If pierced, the skin will naturally gape open along Langer lines.
Skin tension lines (Kraissl and Borges lines) run perpendicular to underlying muscles (Figure 8.8).
- Incision or excision should be oriented parallel to skin tension lines.

Figure 8.7. MUSCLES OF THE HEAD AND NECK. * Modiolus anguli oris is a chiasma of facial muscles (buccinator, depressor anguli oris, levator anguli oris, levator labii superioris, orbicularis oris, platysma, risorius, zygomaticus major) held together by fibrous tissue that is important for mouth movement.

(Illustration by Caroline A. Nelson, MD.)

Figure 8.8. SKIN TENSION LINES.

(Illustration by Caroline A. Nelson, MD.)

Blood Vessels

Arteries of the head and neck, consisting of anastomosing branches of the internal carotid artery (ICA) and the external carotid artery (ECA), are illustrated in Figure 8.9.
Veins of the head and neck follow the arterial supply. The ophthalmic veins drain through the orbit into the cavernous sinus, which also drains blood from the anterior part of the base of the brain.
- Figure 8.10.
The lymphatic drainage of the head and neck varies, but generally flows in a downward diagonal direction. The parotid nodes (forehead and eyelids), submandibular nodes (lower and medial face), and submental nodes (central lower lip and chin) drain into the lateral cervical nodes.

Nerves

Sensory Innervation

Sensory nerves of the head and neck are illustrated in Figure 8.11.

Figure 8.9. ARTERIES OF THE HEAD AND NECK. ECA, external carotid artery; ICA, internal carotid artery.

(Illustration by Caroline A. Nelson, MD.)

Selected Arteries of the Head and Neck

• ICA → ophthalmic → central retinal, lacrimal, posterior ciliary, muscular branches, supraorbital, posterior ethmoidal, anterior ethmoidal → external nasal, medial palpebral, supratrochlear, dorsal nasal (infratrochlear)

• ECA → lingual; facial → angular, inferior labial, superior labial, lateral nasal; occipital; posterior auricular; maxillary → inferior alveolar → mental, buccal, infraorbital; superficial temporal → transverse facial, middle temporal, anterior auricular, frontal branch, parietal branch

Figure 8.10. DANGER TRIANGLE OF THE FACE. Retrograde spread of infection from the nasal area to the brain may lead to cavernous sinus thrombosis, meningitis, or brain abscesses. The area from the oral commissures to the nasal bridge is called the “danger triangle” of the face.

(Illustration by Caroline A. Nelson, MD.)

Figure 8.11. SENSORY NERVES OF THE HEAD AND NECK. CN, cranial nerve.

(Illustration by Caroline A. Nelson, MD.)

The trigeminal nerve (cranial nerve [CN] V) arises from gasserian ganglion to provide sensory innervation to the face and anterior 2/3 of the tongue (somatic).
- Trigeminal trophic syndrome may develop after surgical trigeminal ablation by rhizotomy or alcohol injection into the gasserian ganglion.
The facial nerve (CN VII) arises from the geniculate ganglion to provide sensory innervation to the conchal bowl (with glossopharyngeal and vagus nerves), external auditory meatus, and anterior 2/3 of the tongue (taste, chorda tympani nerve).
- Ramsay Hunt syndrome occurs when VZV reactivates from the geniculate ganglion.
The glossopharyngeal nerve (CN IX) innervates the conchal bowl (with facial and vagus nerves) and posterior 1/3 of the tongue (somatic and taste).
The vagus nerve (CN X) innervates the conchal bowl (with facial and glossopharyngeal nerves).
- A ring block around the ear will NOT anesthetize the conchal bowl or external auditory meatus.

Sensory nerves of the hands and feet are illustrated in Figure 8.12.

Figure 8.12. SENSORY NERVES OF THE HANDS AND FEET.

(Illustration by Caroline A. Nelson, MD.)

Remember that the ulnar nerve and the sural nerve innervate the 5th digits because both have u in the name.

Motor Innervation

Motor nerves of the head and neck are illustrated in Figure 8.13.
- The trigeminal nerve (CN V) provides motor innervation to the muscles of mastication.
- The facial nerve (CN VII) provides motor innervation to the muscles of facial expression. It exits the stylomastoid foramen, enters the parotid gland, and divides into branches (Table 8.1).

Surgical Danger Zones of the Head and Neck

Surgical danger zones of the head and neck are summarized in Table 8.2.

Figure 8.13. MOTOR NERVES OF THE HEAD AND NECK. CN, cranial nerve.

(Illustration by Caroline A. Nelson, MD.)

Remember the Temporal, Zygomatic, Buccal, Marginal mandibular, and Cervical branches of the facial nerve (CNVII) with the mnemonic “To Zanzibar By Motor Car.”

Table 8.1. FACIAL NERVE (CN VII) BRANCHES

Branch	Innervated Muscle(s)	Function	Notes
Temporal	Frontalis	Elevates eyebrows and wrinkles forehead.	Responsible for horizontal forehead rhytides.
Temporal	Corrugator supercilii	Pulls eyebrows medially and downward.	Responsible for vertical glabellar rhytides.
Temporal and zygomatic	Orbicularis oculi	Blinking and tight closure of eyelids. Lesser role as brow depressor.	Responsible for lateral canthal rhytides.
Zygomatic and buccal	Procerus	Pulls medial eyebrows and glabellar skin downward.	Responsible for horizontal glabellar rhytides.
Zygomatic and buccal	Nasalis	Alar flaring and compression.	Responsible for nasalis rhytides.
Buccal	Levator labii superioris	Elevates upper lip.
	Levator labii superioris alaeque nasi	Elevates upper lip and dilates nostrils.
	Levator anguli oris	Elevates corners of mouth.
	Zygomaticus major	Elevates and draws corner of mouth laterally.	Main contributor to smiling (nasolabial folds).
	Zygomaticus minor	Elevates upper lip.
	Buccinator	Presses cheek against teeth.	Allows blowing of cheeks. The buccinator is innervated on its surface, increasing risk of paralysis. The parotid duct is at risk of injury posterior to the buccinator.
Marginal mandibular	Risorius	Draws back corners of mouth.
	Orbicularis oris	Closes and purses lips.	Responsible for perioral rhytides.
	Depressor anguli oris	Depresses corners of mouth.	Responsible for melomental folds.
	Depressor labii inferioris	Depresses lower lip.
	Mentalis	Protrudes lower lip.	Responsible for mental crease and peau d’orange skin.
Cervical	Platysma	Depresses corners of mouth and tenses neck.	Responsible for platysma bands.
Posterior auricular	Occipitalis	Pulls scalp posteriorly.

Table 8.2. SURGICAL DANGER ZONES OF THE HEAD AND NECK

Structure	Location	Function	Complication(s)
Artery^a
Superficial temporal artery, frontal branch	Temple	Supplies blood to forehead.	Hemorrhage.
Facial artery	Mandibular rim	Supplies blood to face.	Hemorrhage.
Angular artery	Base of nasal ala	Supplies blood to nose and eyelids.	Hemorrhage.
Posterior auricular artery	Sulcus between ear and mastoid	Supplies blood to external ear and posterior auricular scalp.	Hemorrhage.
Motor Nerve
Facial nerve (CN VII), temporal branch	Between two lines: earlobe to lateral edge of eyebrow and tragus to lateral edge of highest horizontal forehead line.	Innervates frontalis.	Inability to raise ipsilateral eyebrow (loss of forehead furrows) and drooping (ptosis).
Facial nerve (CN VII), zygomatic branch	Inferomedial to the upper masseteric retaining ligament. Nerve is most superficial over bony prominence (zygomatic arch).	Innervates orbicularis oculi.	Inability to completely appose ipsilateral upper and lower eyelids and corneal desiccation.
Facial nerve (CN VII), marginal mandibular branch	Anterior to angle of mandible. Nerve is most superficial over bony prominence.	Innervates lip depressors.	Asymmetric smile or grimace and ipsilateral drooling. Highest risk of permanent motor deficit.
Spinal accessory nerve (CN XI)	Posterior triangle of neck within 2 cm of Erb point, located at the mid-posterior margin of the SCM where the cervical plexus emerges.	Innervates trapezius.	Ipsilateral winged scapula and difficulty with arm abduction.
CN, cranial nerve; SCM, sternocleidomastoid.
^aFor danger zones related to vascular occlusion after soft-tissue dermal filler injection, see Chapter 9: Soft Tissue Dermal Fillers.

Preoperative Considerations

Basic Concepts

Preoperative considerations include evaluating surgical options based on indication and cure rate, patient preference, medical comorbidities, and cost-effectiveness.
It is important to assess and minimize risk factors for poor wound healing such as medications (eg, systemic corticosteroids, isotretinoin, VEGF inhibitors, sorafenib) and cigarette smoking.
There is considerable practice variation in the management of anticoagulation and antibiotic prophylaxis.

Anticoagulation Management

Risk factors for bleeding include medications and supplements with anticoagulant effects, significant alcohol use, and hypertension.
- Medications include ASA, NSAIDs, clopidogrel/ticlopidine, enoxaparin, warfarin, direct oral anticoagulants (DOACs), new oral anticoagulants (NOACs), and ibrutinib.
- Supplements include bilberry, chondroitin, danshen, devil’s claw, dong quai, fish oil, feverfew, garlic, ginger, gingko, ginseng, licorice, and vitamin E.
ASA may be held for 10 days prior to and 5 to 7 days after surgery as long as doing so does not increase risk of MI or stroke. NSAIDs may be held 2 to 3 days prior to surgery. Other anticoagulant medications should not be discontinued in most patients; however, ensure INR < 3 for patients on warfarin.

Antibiotic Prophylaxis

There exists considerable practice variation in the use of prophylactic antibiotics.
Dermatologic surgery wounds are typically classified as clean and have low infection rates (1%-2%).
Recommendations for antibiotic prophylaxis in dermatologic surgery are shown in Figure 8.14.
Sterile technique and minimizing wound tension are other measures to reduce infection risk.

Figure 8.14. RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS IN DERMATOLOGIC SURGERY. * Dicloxacillin 2 g PO is an alternative to cephalexin (nonoral surgical site). If PCN allergic, clindamycin 600 mg PO or azithromycin/clarithromycin 500 mg PO. If unable to take PO, cefazolin/ceftriaxone 1 g IV/IM or ampicillin 2 g IV/IM (oral surgical site). If unable to take PO and PCN allergic, clindamycin 600 mg IV/IM. AAOS, American Academy of Orthopaedic Surgeons; ADA, American Dental Association; AHA, American Heart Association; CHD, congenital heart disease; DS, double strength; HIV, human immunodeficiency virus; HTJI, hematogenous total joint infection; IE, infective endocarditis; PCN, penicillin; PO, per os; TMP-SMX, trimethoprim-sulfamethoxazole.

(Adapted from Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol. 2008;59(3):464-473. Copyright © 2008 American Academy of Dermatology, Inc. With permission. An alternative prophylaxis algorithm for dermatologic surgery has been proposed Bae-Harboe YS, Liang CA. Perioperative antibiotic use of dermatologic surgeons in 2012. Dermatol Surg. 2013;39(11):1592-1601.)

Antibiotic Regimens

• Prevention of surgical site infection:Wedge excisions of the lip and ear, skin flaps on the nose, and skin grafts: cephalexin 2 g PO*Lesions in the groin and lower extremity: cephalexin 2 g POˆ

• Prevention of IE, HTJI: Nonoral surgical site: cephalexin 2 g PO*Oral surgical site: amoxicillin 2 g PO*

ˆ If PCN allergic, TMP-SMX DS PO or levofloxacin 500 mg PO (lesions in the groin and lower extremity).

AHA recommends 30-60 minutes/ADA-AAOS recommends 60 minutes preoperative dosing.

High-risk Indications:

• Surgical site infection: lower extremity (especially leg), groin, wedge excision of lip or ear, skin flaps on nose, skin grafting, extensive inflammatory skin disease.

• IE: prosthetic cardiac valve, previous IE, CHDˆˆ, cardiac transplantation recipients who develop cardiac valvulopathy.

• HTJI: first 2 years following joint replacement, previous prosthetic joint infections, immunocompromised/immunosuppressed patients, insulin-dependent (type 1) diabetes mellitus, HIV infection, malignancy, malnourishment, hemophilia.

ˆˆ Unrepaired cyanotic CHD, including palliative shunts and conduits; completely repaired congenital heart defects with prosthetic material or device whether placed by surgery or catheter intervention, during the first 6 months after the procedure; repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization).

Anesthetics and Antiseptics

Basic Concepts

Anesthetics may be delivered via topical application, local injection, nerve block, or tumescent anesthesia (see Chapter 9: Body Contouring). Systemic anesthetics are beyond the scope of this chapter. In addition to anesthesia, anxiolytics may be considered (eg, benzodiazepines, reverse with flumazenil).
Antiseptics prevent the growth of disease-causing microorganisms.

Anesthetics

Local anesthetics temporarily interfere with sodium influx across the cell membrane, thereby inhibiting depolarization and nerve conduction.
Loss of sensation occurs in the following temporal order: temperature → pain (C-type fibers) → touch → pressure → vibration → proprioception → motor function.
Local anesthetics possess a basic chemical structure: aromatic end (lipophilic), intermediate chain (amide or ester), amine end (hydrophilic).
- Amides (eg, bupivacaine, etidocaine, lidocaine, mepivacaine, prilocaine, ropivacaine): metabolized by CYP3A4 (contraindicated in ESRD), excreted by kidneys. Less cross-reactivity and sensitization than esters; however, methylparaben preservative (metabolized to PABA) may cause allergy (switch to preservative-free lidocaine).
  - Amides have 2 “I”s in the name.
- Esters (eg, chloroprocaine, procaine, tetracaine): metabolized by plasma pseudocholinesterases (contraindicated in pseudocholinesterase deficiency), excreted by kidneys. Contraindicated in PABA sensitivity—may cross-react (see Chapter 2: Eczematous Dermatoses and Related Disorders).
  - Esters have 1 “I” in the name.
  - The most well-known local anesthetic in each class provides a clue to its metabolism: lidocaine is metabolized by the liver; procaine is metabolized by plasma pseudocholinesterases.
Properties of local anesthetics:
- Onset of action (amine end): lower pKa correlates with more rapid onset. Lidocaine has the fastest onset of action (<1 minute).
- Duration of action (aromatic end): increased protein binding correlates with increased duration of action (lesser role for lipid solubility). Prilocaine has the shortest duration of action, while bupivacaine has the longest duration of action (up to 8 hours with epinephrine).
- Potency (aromatic end): lipid solubility correlates with increased potency (ease of diffusion across cell membranes).
Adverse effects of local anesthetics include:
- Local reactions (most commonly related to improper injection technique): bleeding, pain, infection, nerve injury, and tissue necrosis (rare).
- Systemic reactions: allergy (amides do not cross-react with esters) and cardiovascular toxicity (bupivacaine has the highest risk.
  - Bupivacaine may cause fetal bradycardia.
Safe adult dosing of lidocaine: 4.5 to 5 mg/kg (without epinephrine), 7 mg/kg (with epinephrine). 1% lidocaine is 10 mg/mL.
- Safe pediatric dosing of lidocaine: 1.2 to 2 mg/kg (without epinephrine), 3 to 4.5 mg/kg (with epinephrine).
β-Blockers increase lidocaine levels.
Lidocaine is the anesthetic of choice in pregnancy (historical pregnancy risk category B).
Local anesthetics are vasodilatory except for cocaine. Adding epinephrine improves hemostasis, prolongs duration, and decreases systemic toxicity risk due to decreased absorption. 1:200,000 compared to 1:100,000 has equivalent efficacy with decreased toxicity. Maximal vasoconstriction is achieved 15 minutes after injection. Epinephrine should be used with caution in patients with preexisting conditions (eg, ischemic heart disease, narrow-angle glaucoma, pheochromocytoma [absolute contraindication], uncontrolled hypertension or hyperthyroidism), pregnancy (decreases uterine blood flow, historical pregnancy risk category C), and select medications (eg, β-blockers, MAOIs, and TCAs).
Adding hyaluronidase increases anesthetic diffusion and decreases tissue distortion but decreases duration of action and toxicity and may contain the contact allergen thimerosal.
Adding sodium bicarbonate (8.5%, 1 mL to 9 mL of 1% lidocaine) increases onset of action and decreases injection pain but decreases shelf life. Other methods to decrease injection pain include pretreating with ice packs or topical anesthetics, warming the anesthetic to body temperature, using small diameter needles (eg, 30 gauge), injecting with a slow fanning motion, reintroducing the needle at previously anesthetized sites, music and mental distraction, and pinching or rubbing surrounding skin (based on “gate theory” of pain).
- Preservatives prevent pain.

Topical Anesthetics

Topical anesthetics are more effective on mucosal surfaces because the stratum corneum of nonmucosal surfaces limits efficacy.
Preparations include:
- Eutectic mixture of local anesthesia (EMLA): 2.5% lidocaine and 2.5% prilocaine. Requires occlusion, cannot be used near the eye due to risk of corneal injury.
  - Do NOT use prilocaine in infants or patients with G6PD deficiency due to risk of methemoglobinemia.
  - EMLA causes artifactual swelling and vacuolization of the upper epidermis and a basal layer split.
- LMX4: 4% lidocaine. Does not require occlusion.
- Other: benzocaine (mucosal), cocaine (illicit drug), proparacaine/tetracaine (ocular).

Figure 8.15. NERVE BLOCKS OF THE HAND.

(Illustration by Caroline A. Nelson, MD.)

Nerve Blocks

Face: supraorbital, supratrochlear, infraorbital, and mental nerve blocks. Injection into these foramina leads to prolonged anesthesia. The nose and oral commissures are relatively resistant to nerve blocks.
Hand (Figure 8.15):
- Median nerve block: inject at proximal wrist crease between palmaris longus and flexor carpi radialis tendons.
- Radial nerve block: inject along proximal wrist crease just lateral to radial artery.
- Ulnar nerve block: inject at proximal wrist crease radial to flexor carpi ulnaris.
Foot:
- Posterior tibial block (sole numbness): inject in groove between medial malleolus and Achilles tendon, posterior to the posterior tibial artery.
- Sural nerve block (lateral foot numbness): inject in groove between lateral malleolus and Achilles tendon.
- Deep peroneal block (first interdigital webspace numbness): inject lateral to hallucis longus tendon or inject between the first and second toe in the interdigital cleft.
- Saphenous and superficial peroneal block (dorsal foot numbness): inject just anterior to the lateral malleolus.
For nail unit anesthetic considerations, see Chapter 8: Nail Unit Surgery.
Advantages: immediate pain relief, allow damaged nerve time to heal.
Disadvantages: lack of epinephrine hemostasis, risk of neurovascular injury or infiltration.

Antiseptics

Hand hygiene is fundamental to eliminating the superficial (transient, nonresident) pathogens responsible for most healthcare worker-transmitted infections. Hand sanitizer with alcohol (70% optimal) works by denaturing proteins. Cleaning with soap and water is preferable for soiled hands (eg, Norwalk virus, Clostridium difficile).
Clippers or chemical depilatories are preferable to shaving, which creates microscopic abrasions that may serve as a portal of entry for pathogens.
Antiseptics are summarized in Table 8.3.

Table 8.3. ANTISEPTICS

Name^a	Spectrum	Advantages	Disadvantages
Benzalkonium (Zephiran)	GP and GN bacteria	Not irritating, stable, strong antimicrobial	Slow onset of action, short duration of action, inactivated by anionic compounds (eg, soaps)
Chlorhexidine (Hibiclens)	Broad (viruses, bacteria, fungi)	Rapid onset of action, long duration of action, additive effect with repetitive use, low absorption	Corneal injury, ototoxicity (use with caution around eye or ear), does not cover Serratia or spores
Hexachlorophene (pHisoHex)	GPCs	Sustained activity	Teratogenic, neurotoxic (avoid in pregnant women and children)
Hydrogen peroxide	Bacteria, fungi (at high concentrations)	Rapid onset of action	Corrosive to normal skin, bleaching potential
Isopropyl alcohol	GP bacteria	Rapid onset of action, inexpensive	Flammable, skin irritant, inactive against spores
Povidone-iodine (Betadine)	Broad (bacterial, viral, fungal)	Fast acting	Short onset of action, efficacious when dry, inactivated by blood or sputum, may stain skin/fabrics, risk of contact dermatitis, cross-reacts with iodides in medication/radiopaque isotopes
Silver sulfadiazine (Silvadene)	See Chapter 6: Antimicrobials.
FDA, Food and Drug Administration; GN, gram-negative; GP, gram-positive; GPCs, gram-positive cocci.
^aTriclosan, a previously popular antiseptic, is now banned by the FDA.

Surgical Instruments and Materials

Basic Concepts

Surgical instruments include forceps, needles, needle drivers, scalpels, and scissors.
Surgical materials include topical hemostasis materials, wound closure materials, and wound dressings.

Surgical Instruments

Most surgical instruments are a blend of stainless steel admixed with carbon alloy, chromium, nickel, and/or tungsten carbide (gold handles). Steam autoclave can dull sharp instruments.
Scalpel handles and blades (Figure 8.16) are used for incising tissue.
- Scalpel handle: holds the blade. Bard-Parker (most common) is flat. Siegel is a thin, round, knurled handle that makes it well suited for MMS. Beaver is round/hexagonal and holds smaller and sharper blades used in delicate areas (eg, eyelid, conchal bowl).
- Scalpel blades (in order of decreasing popularity): #15, #10, and #11. The #10 blade is larger than the #15 blade and is preferred in sites with thick dermis (eg, back). The #11 blade is tapered to a sharp point and is used for cutting and stabbing incisions. The #67 blade (smaller version of #15 blade) and #65 blade (smaller version of #11 blade) are used in delicate areas (eg, eyelid, conchal bowl).
- The Shaw hemostatic scalpel is an electronically heated metal cutting blade.
Forceps (Figure 8.17) are used for grasping the tissue and the needle.
- Serrated forceps facilitate gripping the needle but increase risk of damage to tissue compared to toothed forceps.
- Adson forceps are relatively large. They are commonly used on the trunk and extremities.
- Bishop-Harmon forceps are fine tipped and small with three holes on the handle to decrease overall weight. They are commonly used on delicate tissue (eg, eyelids).
- Jewelers forceps are pointy tipped. They are commonly used for suture removal.

Needles and needle drivers (Figure 8.18):

Needle tip: distal portion. A round tip is less likely to cut or tear tissue. A cutting (triangular-shaped) tip is preferred for skin. Conventional cutting needles have a cutting surface along the inner arc. Reverse cutting needles have cutting surface on outer arc, which minimizes risk of sutures tearing through wound edge. Frequent grasping of the tip will quickly dull it.
Needle body: middle and strongest portion. 3/8 circle is most common shape.

Needle shank (swage): weakest portion that attaches to suture. Determines suture tract size.

Figure 8.16. SCALPEL HANDLES AND BLADES. A, Bard-Parker scalpel handle with #10, #11, and #15 blades. B, Beaver scalpel handle with straight and curved blades.

Figure 8.17. SELECTED FORCEPS. A, Adson forceps (serrated). B, Adson forceps (toothed). C, Bishop-Harmon forceps. Jewelers forceps (not shown) are pointy tipped.

Figure 8.18. NEEDLES AND NEEDLE DRIVERS. A, Needle. B, Webster needle driver. C, Castroviejo needle driver.

Table 8.4. SCISSOR TYPES

Type	Handle	Tip	Notes
Gradle	Short	Sharp	Curved and tapered tip, used for sharp dissection of delicate tissue (eg, periorbital skin) and snip biopsy
Iris	Short	Sharp	Curved or straight blade, used for sharp dissection and snip biopsy
Mayo	Long	Blunt	1:1 handle:blade length, used for blunt dissection
Metzenbaum	Long	Blunt	Long handles used for blunt dissection in areas requiring long reach
O’Brien	Short	Sharp	Fine-angled tip, used for suture removal
Spencer	Short	Blunt	Hook-shaped tip on one blade, used for suture cutting
Westcott	Short	Sharp	Spring loaded, used for dissection of delicate tissue (eg, eyelid)

Needle driver: holds the needle. Serrated jaws minimize twisting of needles during suturing but increase risk of damage to delicate needles (P3 and smaller) and suture (6-0 and smaller) as compared to smooth jaws. Use of large needles with small needle drivers (eg, Webster) will ruin them. The Castroviejo needle driver has spring handles and an optional self-locking device, which provides increased control for surgery near the eye.

Scissors (Table 8.4, Figure 8.19) are used for cutting tissue, suture material, and wound dressings.
- Tip: sharp scissors are used for sharp dissection; blunt scissors are used for blunt dissection. Supercuts (one blade with a razor edge, black handle) are available for multiple scissor types.
  
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