DESTIN, Fla. — It might look easy, but getting a perfect result after dermatologic surgery takes skill and experience, Dr. Christopher J. Miller said.

For dermatologists who are relatively new to incision, excision, and undermining, there are multiple opportunities to assess your expertise during and after surgery. These “quality control checkpoints” include the assessment of incision depth and uniformity of the cut, as well as using your fingers to check for any gaps in your suture line, Dr. Miller said.

Results 1 week after surgery, in particular, provide important feedback on your surgical technique, he said. The goal at 1-week suture removal is wound edges that are sealed and blended together well with minimal inflammation.

“It takes a lot of work to figure out how to do that,” he said.

Recognize that technical errors in the early stages of excision affect subsequent results, said Dr. Miller, director of dermatologic surgery at the University of Pennsylvania, Philadelphia.

-- Incision. Avoid the tendency to bevel edges during incision, because this prevents proper apposition. The goal is for a vertical wound with no internal bevel, so ensure that your scalpel remains perpendicular to the skin.

“If those wound edges cannot come together … you will be forced to have tension on the wound,” which almost guarantees that track marks will develop along the wound, Dr. Miller said.

And make sure you incise all the way through the dermis when you make your ellipse. “This is really your quality control checkpoint.” Applying pressure toward the outward edge of the ellipse is a way to minimize the formation of a bevel, he added.

“No matter what you do, the dermis and epidermis will retract more than the fat. There will always be a little bit of fat popping into the wound,” Dr. Miller said. Take the extra step and remove any excess fat after you undermine; otherwise it will impede your wound edges.

-- Excision. When it is time for excision, remove your ellipse in a uniform plane, Dr. Miller said. The tendency with a scalpel is to go deeper. “What I like to use, which is more reproducible, is scissors at a 45° angle to make a sharp cut. You’ll get a release. Then go across like a plane on a landing strip and you will get a uniform depth of excision.”

Dr. Miller said he generally targets the plane between the upper layer of more organized fat lobules and the less organized lower layer above the fascia. “You are not going to go to the fascia all the time. You might choose to stay just under the dermis—it depends on the size of your incision,” he said. Check for uniform thickness once you excise—this is another quality control checkpoint.

-- Undermining. Which instrument you use to perform your retraction is important for undermining. Forceps, for example, can cause tissue trauma. “I prefer blunt-tip scissors and skin hooks,” Dr. Miller said. Be careful not to place the hooks too superficially or too close to the edge of the wound, he said. Instead, place the hook deeper and apply counterpressure with your finger.

“Understanding the anatomy is really going to drive where you choose to undermine,” Dr. Miller said. For example, remember that the superficial musculoaponeurotic system (SMAS) envelopes the muscles of facial expression. “Your motor nerves are always protected by this SMAS. You cannot cut the motor nerves if you remain above the SMAS. There will still be sensory nerves going to the skin.”

“If you are tentative, stay up higher in the fat on the lateral sides of the face,” Dr. Miller said.

Again, remove any extraneous fat that pops in under the wound edges after you undermine, Dr. Miller suggested. The questions to ask at this point are: Is the dermis clearly visible? Are the wound edges clean and vertical?

When it comes to suturing, Dr. Miller recommended the buried vertical mattress suture. It is a heart-shaped loop, similar to the superficial mattress suture. “The suture ideally is biting your reticular dermis, as far away as possible from the wound edge. This will give you wiggle room,” Dr. Miller said. “If it is too high, up near the epidermal edge, it is harder to adjust.”

Another quality control checkpoint comes after you finish throwing the needle toward the center of wound. Let go of your retracting instrument. “If it snaps back toward your needle, you are at the right depth,” Dr. Miller said.

Finally, “precise, deep sutures are key to the ideal scar,” Dr. Miller said. To confirm the adequacy of your sutures, perform the pull test. “Place your fingers on either side, and if you get a gap [the two wound edges come apart], then you need another deep suture.”

Dr. Miller had no relevant financial disclosures.

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