Preface

The fundamental building blocks of surgical repairs of the skin and soft tissues are basic suture placement techniques that become second nature to experienced surgeons and yet remain mysteries to novices. Often, it is attention to the subtleties of suture choice and placement that explain why particular clinicians have different and more ideal outcomes than their peers.

Despite a burgeoning literature supporting the importance of suture technique choice and its potential impact on long-term cosmesis, a thorough, comprehensive discussion of the available array of suturing techniques has not been included in the canon of general and reconstructive surgery. Most texts focus instead either on general operative principles or the specific use of flaps in particular reconstructive areas. Unfortunately, even the best-designed flap can be undone by less-than-optimal suturing techniques.

This book was designed to fill this void, providing an organized, clear, and comprehensive representation of many of the suturing techniques available to those engaged in skin and soft tissue reconstruction. The text is divided into four main parts: First, the introductory section addresses fundamental principles of wound closure, instrument choice, suture material choice, and approaches to the instrument tie used in skin and soft tissue repairs; second, techniques usually performed with absorbable sutures are discussed in detail, with a separate chapter dedicated to each approach; third, techniques generally performed with nonabsorbable sutures are addressed in detail; and finally, a section is included with tips on closures based on anatomic location, providing a regional approach to repair choices.

This text is unique in that it includes approximately 200 professional drawings as well as almost 450 clinical photographs, breaking down each technique to its fundamentals. Rather than simply showing photographs of wounds after they have been closed with the various techniques, this atlas includes photographs taken from the surgeon’s perspective at every critical stage during the course of each technique. Videos of each technique, as well as some fundamental approaches to instrument handling, are also embedded in the text; QR codes are included for each chapter, permitting the reader to immediately reference almost 100 narrated videos, most performed on a proprietary skin substitute designed to effectively demonstrate technique from the perspective of the clinician.

Each technique chapter is divided into four sections: Application, where the background of the technique, and its ideal area of applicability, is discussed; Technique, which breaks down the technique in a step-by-step fashion; Tips and Pearls, where variations, subtleties, and fine-tuning approaches are discussed; and Drawbacks and Cautions, where the potential pitfalls of each technique are addressed in detail. This unique combination of step-by-step drawings, photographs, and videos—as well as the comprehensive discussion in each chapter—permits the reader to grasp the fundamentals of each approach and decide what approaches may be useful additions to their own personal surgical armamentarium.

Common synonyms are included at the start of many of the chapters; there is broad regional variability in technique nomenclature, and this text has aimed to present each technique as a variation on a few basic themes. Conceptualizing each approach in this way permits the budding surgeon to focus on core technical skills and then build slowly on these. For the advanced reader, this approach helps better organize the literature and highlight some techniques that may have been overlooked. Therefore, some liberty has been taken in naming techniques so that the names in this atlas ideally convey some information regarding the mechanics of each approach. No slight is intended on the brilliant artists who have contributed to developing many of these approaches.

This text is meant to be used as an atlas; as such, while it may be read cover to cover, the reader may then notice some redundancy in the text of select chapters, as some of the advantages and disadvantages of closely related approaches may be very similar. For many, this atlas may be best utilized by first reviewing the introductory sections, if desired, and then referring to technique choices as needed; the budding surgical maestro, however, may prefer a front-to-back reading of the text, or even a review of the figures and legends, to quickly build a comfort level with a wide array of approaches.

This text is aimed at those who perform the bulk of skin and soft tissue reconstructive procedures, from dermatologists and plastic surgeons to emergency medicine physicians, general surgeons, and family practice physicians. While this text may be very helpful to medical students and postgraduate trainees, others, including physician assistants, nurse practitioners, and the many other medical providers engaged in skin and soft tissue repairs, should hopefully benefit from its approach as well.

Shifting tension deeper, away from the epidermis and to the deep dermis and fascia, is the fundamental principle of all skin and soft tissue surgery when closing defects under tension. Techniques that accomplish this goal are repeatedly highlighted in the text, as such approaches have the potential to dramatically impact clinical outcomes for the better, as has been amply shown by a spate of recent randomized controlled trials. Hopefully, this atlas will inspire others to not only reexamine their approach to suture placement but contribute to the literature—and innovate—as well.