Principles and Techniques for Optimal Primary Skin Closure

Conclusions

• Successful cutaneous surgery depends on understanding the reason behind each design and suturing choice, not just memorizing techniques.
• The best outcomes come from tailoring excision length, orientation, undermining, and closure method to the individual patient and anatomic site.
• The primary goals are to maintain the lowest possible morbidity while minimizing scar visibility.
• Simple instruments are usually sufficient; careful technique matters more than specialized tools.
• Standing cones do not always need aggressive removal because small ones may flatten on their own, especially in high-elasticity, low-tension areas.
• Skin tension lines are variable in real patients, so intraoperative assessment by touching and positioning the patient is often more useful than relying on diagrams alone.
• Undermining should be used selectively to release tension, because it is not always necessary and can increase bleeding risk.
• Proper tissue handling requires lifting the epidermis rather than crushing it so the layers can be visualized and sutures placed cleanly.
• Eversion is situational and most helpful in high-tension, high-mobility, or convex areas where scars are prone to invert.
• Dermal suture geometry determines whether the wound everts, inverts, or lies flat, so understanding bite height and angle is essential.
• High-tension closures can benefit from techniques such as buried vertical mattress, set-back sutures, and tension-sharing stitches like SICM.
• A secure knot is critical in tensioned wounds, and techniques that prevent air knots or looseness can improve closure stability.
• Overall, good cutaneous surgery is a case-by-case balance of anatomy, tension, patient factors, and simple but precise execution.