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  • Linear closures involve direct side-to-side closure of the surgical wound.

  • Layered linear closure remains the gold standard for wound closure given its predictable outcomes, reasonable cost to the patient and healthcare system, and low risk of complications.

  • Even very large defects, including those on the face, can often be closed in a linear fashion, as long as aggressive undermining and dog-ear correction are performed.

  • A significant advantage of linear closures is their predictability; since outstanding blood flow is maintained to the wound edge, these closures often result in fine-line nearly imperceptible scars when carefully designed and executed.

image Beginner Tips

  • Breaking down the excision and linear repair into its component parts helps conceptualize each requisite step.

  • Never attempt to rush a step; most shortcuts result in the need for a far more time-consuming correction.

image Expert Tips

  • Large defects on the face do not necessarily require flap repair.

  • Linear closures have almost no risk of flap loss, and so are particularly useful approaches for closures in tobacco users.

  • Using a rhombus or tangent-to-circle closure approach may result in smaller apical angles and less dog-ear formation.

image Don’t Forget!

  • When deciding between a large linear closure and a flap, keep in mind that linear closures have less of a tendency to “burn bridges” for future repairs, an important consideration in the patient with florid skin cancers.

  • If a wound closed with buried sutures alone results in significant gaping or overhanging dermis, do not attempt to solve this with superficial suture placement. Instead, remove the excess dermis and/or replace the deep sutures.

image Pitfalls and Cautions

  • Always carefully identify the source of any oozing and address it directly; judicious use of electrosurgical approaches will help reduce the amount of necrotic tissue left in a wound.

  • Gentle tissue handling will result in improved outcomes, decreasing the risk of necrosis and infection.

image Patient Education Points

  • Explaining that any additional scar length will likely heal with a minimally visible line may go a long way toward patient reassurance.

  • Always review the planned degree of eversion with the patient so that there is no confusion or worry in the immediate postoperative period regarding the ridged appearance of the wound.

image Billing Pearls

  • As a general rule, extensive undermining, dog-ear correction, or other complex steps are needed to bill for a complex closure.

  • No amount of undermining shifts a linear excision and repair to a bilateral advancement flap for billing purposes.


Direct linear closure of surgical wounds is the primary technique used for defect closure in dermatologic surgery. Learning to perform an outstanding linear excision and repair will go a long way to making a budding clinician’s career, as patients and providers alike place great value on well-executed excisions. Linear closure is favored ...

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