Chapter 13 - Incision Closure, Nasal Splint, Postoperative Considerations

CLOSURE OF THE MIDCOLUMELLAR INCISION

A single, subcutaneous 6-0 polydioxanone suture (PDS) can be positioned in the dermal tissues to enhance skin-edge eversion and take tension off of the closure (Fig. 1). This su ­ ture should provide skin-edge alignment and slight eversion. Excessive eversion will cre ­ ate a deformity that may require many months to resolve. The level of the skin edges must be precisely aligned with this suture; otherwise, an unsightly scar may result. If there is no tension on the closure, a subcutaneous suture may not be necessary.

To close the skin, five 7-0 nylon vertical mattress sutures are used. The first suture lines up the apex of the inverted V. The next two sutures are angled from medial on the lower flap to lateral on the upper flap to align the closure properly. A 6-0 chromic suture is used to line up the vestibular skin at the corner of the columellar flap. This corner suture is im ­portant because aberrant healing of this corner can result in a visible notch defect.

Figure 1. A—D: Closure of external columellar incision. Note how the two sutures placed just off the midline are angled from medial on the lower flap to lateral on the upper flap. This will recruit redundant skin medially and prevent lateral notching of the columellar incision. Intraoperative photographs highlight proper suture placement. When the columellar flap is elevated properly, and then closed meticulously, it should be inconspicuous, as illus­trated (E,F) in this preoperative and postoperative base view.

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