Authors: Kasper Baasch Nielsen, Med. Stud., Mie Pilegaard Bjarnesen, Med. Stud., Anne Mosebo, MD, Julie Tastesen, MD and Magnus Balslev Avnstrup, MD
Preoperative markings are used to assist during surgery and should be drawn while gently overlapping the excess skin. This is done to estimate how much skin can be removed without putting too much stress on the skin postoperatively.
There are different placements of the preoperative markings which affect the position of the postoperative scar.
Using the following method the postoperative scar will be placed in the biceptal groove. The epicondyle of the humerus functions as point A and the apex of the axillary fossa functions as point B. Draw a line between the two points of reference following the posterior-medial line not the biceptial groove nor the lower line posteriorly as seen in figure 1. This line is the predicted position of the scar (figure 2).
Figure 1 | Anatomical lines on the arm should be considered when drawing predicted position of the scar.
Figure 2 | The predicted position of the scar.
Draw a line between points A and B approximately 1 cm above the line indicating the position of the scar. This will mark the incision line (comitted incision line). Afterwards draw an incision line placed under the line predicted for the scar marking (predicted incision line) (figure 3). The distance to the lower incision line will differ based on the individual case and amount of excess skin that needs to be removed.
Figure 3 | The final placement of the preoperative markings.
The following method is used in the step-by-step guide below placing the postoperative scar on the back of the arm.
Figure 4 | Preoperative markings placing the postoperative scar on the back of the arm.
Step 1: Preoperative markings
The patient is placed in supine position. The entire arm is placed in a position which benefits the surgeon.
Step 2: Reexamine the preoperative markings
Reexamine the preoperatively drawn lines by pinching the higher and lower incision lines together, starting at point A next to the epicondyle and moving on the point B at the apex of the fossa. Check the circumference and laxity of the skin to ensure that the excision does not cause too much stress on the skin.
Step 3: Incisions
Use a no. 10 scalpel blade. The first incision should be made at the higher incision line from point A to point B. The same is done at the lower incision line.
Step 4: Incisions continued
The excess skin has now been separated from the adjacent skin.
Step 5: Excision
Use an Adson forceps and a monopolar electrosurgical dissector to gradually excise the skin flap, starting from point A to point B.
Step 6: Excess skin removed
Step 7: The excised skin
Step 8: Pinch sides together
Once hemostasis is done sufficiently, pinch the sides together and check for symmetry.
Step 9: Closure
A proper closing of the incision is imperative for reducing tension on the scar. The closure of the incision should be performed in two layers. First, the profund layer is closed by continuously suturing the superficial fascia of the arm1.
Step 10: Inferior layer closed
Step 11: Superficial layer closed
The superficial layer has been closed by suturing the superficial layer of the skin. Use long-absorbing sutures such as barb Monocryl suture for the best result.
Step 12: Cover sutured incisions
Use micropore tape on both arms to cover the sutured incisions.
Illustrators: Anne Mosebo, Med. Stud.