WASHINGTON – To make scalp surgery seamless, remember what makes the scalp unique: hair and tension, Dr. Mark Welch said.
The scalp is "a bloodless plain," said Dr. Welch of the Skin Cancer Surgery Center in Bethesda, Md.
Also, the scalp is painless, so it’s possible to go beyond the field of anesthesia, he noted at the Atlantic Dermatological Conference.
To keep hair out of the surgical field, Dr. Welch uses a razor to shave the immediate area, and then tapes down the surrounding hair. "The surrounding hair will find its way into your surgery site and wound," he said. Alternatively, moistening the hair with saline or water can keep it away from the surgical field. Tubular bandaging also can be used to hold the hair away from the surgery site.
The tension on the scalp presents a unique surgical challenge, said Dr. Welch. "The scalp skin is holding the weight of the body; there’s lots of tension up there."
Dr. Welch said he starts with a temporary pulley stitch to decrease the distance across the wound, which allows easier placement of subcutaneous stitches. "Then the pulley stitch can come out," he said.
"One technique I use a lot is preplaced subcutaneous sutures," Dr. Welch said. "You leave yourself a tail long enough to tie, then go posterior to the first subcutaneous stitch, and then go back and tie the first stitch, then the second, then go to the external stitches."
Dr. Welch said he uses a running stitch for external stitches. "On the last external running stitch, go out and come back in on the same side, and angle it back slightly." This technique allows for a more perpendicular closing to the wound edge, he explained.
Dr. Welch cited one case of a large defect in a patient with skin cancer on the scalp. He opted for a pulley stitch with gel foam in the center, and some silver nitrate. The wound was essentially healed in 8 weeks, even without the defect being completely closed.
For scalp dressings, Dr. Welch said he often prefers a Xeroform gauze bolster, which he sews in place, "so we don’t have to use any tape." When the stitches come out after a week, flexible collodion can be used. "It hardens, and over the next 3 or 4 weeks of shampooing, it flakes off."
When using wraps, Dr. Welch recommends combining vertical and horizontal wraps to create tension and promote healing.
He said he had no financial conflicts to disclose.