The author has a few "tricks" that will be discussed after we discuss the basics of stitching. No matter what surgeon sews you, your skin will scar. The key is forming a scar that is less noticeable. Much skill and experience go into deciding how to close a wound and how to match this "closure" with the type and characteristics of a particular patient's skin. The author believes that each patient should have the best cosmetic closure. Cosmetic closure implies perfect or near-perfect alignment of the edges between which something has been removed, be it excess face-lift skin, a cancer, a mole, etc. Tissues that are traumatized, misaligned or mismatched have a higher likelihood of infection and of bleeding, as well as of scarring. While a surgeon is concerned about giving the best cosmetic result, keeping complications low also provides him/her with the side benefits of less bleeding and a lower chance of infection.

The skin is composed of many different parts or layers which vary from body part to body part. The age and genetic make-up (heredity) of the patient influence how thick and how strong each layer is in a certain location. The finest cosmetic (best looking) results occur when the surgeon can perfectly align the layers as a wound is pulled together. Alignment is not be as easy as it sounds and depends on just how close the edges being matched in the skin layer being considered. Near-perfect or perfect alignment may lie within five hair widths on the surface of the skin. The author is extremely nearsighted, making it easy for him to sew even eyelid wounds to within one hair width in accuracy. Patients may find that many surgeons tolerate as much as one millimeter of inaccuracy (about 20 hair widths). A mismatch (misalignment) scatters light in a very obvious way and makes a scar more noticeable.

The use of very fine sutures (tiny stitches) makes alignment easier because the needle and material allow for very little error. Most surgeons use 5-0 suture to stitch the topmost surface of the face. The 5-0 suture is several times thicker than the 6-0, which itself is several times thicker than 7-0. The 7-0 stitch (thread) is very rare and finer than almost the finest of human hairs. Very few surgeons use 7-0 because it requires the use of loupes (binoculars attached to the surgeon's glasses) which, unfortunately, alter depth perception. The author benefits from extreme nearsightedness and is thus able to sew with 7-0 stereoscopically (with depth perception) on the surface of the skin.

The best stitching is performed by aligning layers. Good alignment means aligned down to the fatty layer, the layer to which most wounds are taken because the thicker dermal (leathery) tissues can glide freely and be stretched over the soft, lubricating, forgiving, fatty layer. It is important for the surgeon to build up deeper tissues with good stitch material to form a deep, tight scar. That deep scar, acting as fibrous glue, can take the tension off the surface, allowing the fine alignment to remain at the very top, which is what we all see as the final result. In the best of all worlds, thick strong absorbable stitch is used to align the deep tissues that will later scar/seal together, taking the tension off the surface. Taking tension off the finely stitched surface will keep a good surface scar from widening with time, and becoming more noticeable.

Not all stitch material is created equal. There are many different qualities and types. The two general types are those that the body can digest, "melt away" or absorb, called "absorbable stitches," and those that the body cannot digest, called "non-absorbables." Each has a place in sewing a wound, and there are high and low quality in each type. Absorbables are placed deeply, to hold and bind the tissues until the natural body glue (scar) can hold the tissues together. By design, the body digests absorbable stitches with inflammation and they rarely have to be removed. This is desirable, as they are placed deeply. To get the best results in sewing most types of skin, both types of stitch must be used.

Ask your surgeon what type of stitch he/she uses. The highest quality of non-absorbable stitch is Prolene®. The author uses only Prolene® on the surface because the body can neither recognize it nor react to it with redness. Prolene® is a monofilament, meaning it is not made of braids of smaller strands in which bacteria can hide or tissues can grow and get caught. When stitch removal day comes, the patients rarely can feel the doctor removing the Prolene® stitches from the surface.

The highest quality of buried absorbable stitch is Monocryl®. It is a digestible monofilament. But the neat thing about Monocryl® is that it digests without too much inflammation. Too much inflammation (gathering of white blood cells and their chemicals) can spill over and destroy some of the surrounding tissues, weakening the bonds that should be holding the healing tissues together. The author uses only Monocryl® in the deep tissues and only Prolene® in the superficial tissues. These are some of the most expensive of all stitches made, the cost of which is not reimbursed to the doctors by Medicare or managed care. The cost of each stitch is about $10, with a total cost of $20 to do just one repair. Because managed care pays so little, e.g., $120 to sew an arm, surgeons have little margin remaining from which to pay staff, rent and malpractice insurance premiums when paying for the best stitches. Patients with rosacea and other inflammatory skin diseases tend to react less and heal better with Monocryl® stitching.

Because of managed care, cost considerations and other reasons, surgeons will buy and use other products that may have a higher tendency to infect or leave marks. For example, nylon (sold under many names, e.g., Ethilon), although cheap, sticks to the skin, causes inflammation, even though it is classified as a non-absorbable stitch, and stings when the surgeon removes the stitch. Many surgeons will say one of the worst absorbable stitches ever made for skin surgery is Maxon®, which has a tendency to scratch the patients and "spit." Maxon®, although classified as an absorbable stitch, is difficult for the body to digest; so the body often just extrudes, or "spits" the Maxon® out through a nearby hair pore. If at all possible, ask your surgeon does not use Maxon® if it is still on the market or on his/her shelf.

The author uses several tricks that he uses to improve results.

1. The author prefers to use clear stitch to sew the surface when possible, so that patients do not always have to wear a bandage after surgery. The result is not as scary looking as black or blue stitches.
2. The author uses only the best materials, as described above. They go in easier, come out easier and produce a much better result. Another important consideration is that both materials (Prolene® and Monocryl®) activate the common disease rosacea less than any other materials. Rosacea is a hereditary tendency to facial redness caused by blood vessels, pimples and red bumps. Rosacea may be humankind's most common disease, and it tends to appear following stress and local surgery. Using materials that activate rosacea the least helps.
3. The author sews in many layers, starting with the deepest. Sewing all except the surface layers with thick, strong Monocryl® and tightening them takes the tension or tendency to spread off the surface stitching, reducing marking or spreading at the surface. Sometimes, the author prefers to "oversew" the deeper tissues to form a ridge that the body pulls flat over time, further reducing potential future spreading of the surface of the wound.
4. The author often sews the skin surface with a "running sub-cuticular" stitch. This means a stitch that only rarely exits or enters the surface of the skin, running like a snake just under the surface of the skin from side to side of the wound. This leaves less "train tracking" on the surface. Beware, however. This method of stitching may cause difficulty in the hands of some surgeons, resulting in misalignment if improperly placed.

Again, extreme nearsightedness is a great advantage to a doctor when applying the smallest stitch possible at the very surface of the defect to be solved (closed) or repaired. Use of the tiniest stitch at the very surface forces excellent alignment so that minimal light scattering occurs at the junction, allowing for the best possible result to the naked eye.

Paul J. Weber, M.D., P.A. 5353 North Federal Highway, Suite 400 Fort Lauderdale, FL 33308 Tel: 954-489-9800 | Fax: 954-489-0401