Skin Hook Research Articles

TELESCOPING THE DORSAL HOOD IN HYPOSPADIAS SURGERY - AN INNOVATION TO PRESERVE MAXIMAL PENILE SKIN.

To describe a new technique or adjunct- telescoping the dorsal hood- with a view to banking excess skin on the penile shaft in hypospadias surgery. This would help if redo surgery, not a rare occurrence, is required in future. A review of a prospectively maintained database of hypospadias surgeries conducted between 1997 and 2023 by a single surgeon. After the hypospadias repair, instead of excising the dorsal hood and suturing the ventral penile skin in the usual way, a skin hook is applied on the ventral penile skin in the midline. As the skin hook is pulled down towards the scrotum, anywhere from 1 to 4 cms, it telescopes the dorsal hood down the penile shaft and also pulls in dorsal skin ventrally. (Technique described more fully in the manuscript) RESULTS: 1084 patients were operated for hypospadias over this 27 years' period. Telescoping of the dorsal hood was used in all patients, and in the 126 with proximal hypospadias, none had any skin of the dorsal hood excised! Sixty-two patients presented later with 73 fistulae which were operated on. Of note, no patient needed more than 2 surgical attempts for a cure. The dorsal hood is a useful source of not only skin but also underlying vascularised soft tissue. In hypospadias surgery where redo-operations are a predictable reality, preserving any excess skin on the phallus seems sensible. Our innovation of telescoping the dorsal hood achieves this goal nicely and takes only a few minutes to perform.

DS01 National dermatological surgery sustainability survey: an evaluation of healthcare professional beliefs and practices

Abstract Given the high prevalence of skin cancer in the UK, dermatological surgery contributes significantly to the environmental impact of healthcare services. To date, there are limited data evaluating current sustainability practices, attitudes and behaviours of UK health professionals involved in skin surgery. We evaluated this with a national sustainability questionnaire. An 11-item e-questionnaire was developed and pilot-tested prior to distribution. This included nested conditional branching, free-text, multiple-choice and Likert-type scale questions. The survey was distributed via professional dermatology groups to dermatological surgeons in the UK and Republic of Ireland (RoI) over 12 weeks in 2022. Qualitative data were evaluated via manual thematic analysis. Quantitative data were analysed using RStudio for descriptive statistics and SPSS for nonparametric tests (P < 0.05 was considered to be statistically significant). In total, 115 healthcare professionals from 15 UK and RoI regions responded, including 67 (58.3%) consultant dermatologists/Mohs fellows, 26 (22.6%) dermatology trainees, 12 (10.4%) specialty and associate specialist dermatologists and 10 (8.7%) nurse surgeons. Single-visit provision (e.g. ‘see and treat’) for non-Mohs skin surgery was reported by 32% of overall respondents, whereas regionally, London respondents displayed a significantly higher proportion (67% vs. 25% in other UK regions; P < 0.001). When working with single-use sets, 42% of respondents noted that there is at least one piece of equipment they use less than half of the time for skin surgeries, including nontoothed forceps, artery clips and skin hooks. Forty-eight per cent observed double wrapping of surgical equipment, with an additional 15% being unsure. On a seven-point Likert scale, when compared with single-use equipment, reusable equipment was perceived to outperform on safety (median 4 vs. 7; P = .006), quality (median 4 vs. 7; P < 0.001) and patient outcome (median 4 vs. 7; P = 0.007); no difference was found in usability (median 7 vs. 7; P = 0.689). Perceived sustainability was greater in reusable (median 7) than in single-use (median 1) equipment (P < 0.001). Almost all respondents believe global climate change is happening (97%), are concerned by the impact of dermatological surgery (74%), believe their patients have already been affected (75%), have adapted their personal/professional life accordingly (74%) and believe dermatological surgery should also take measures to reduce its impact (85%). However, only 44% feel comfortable discussing the health effects of climate change with patients. While 75% turn off surgical lighting in between lists, room lighting (31%), equipment (32%) and heating/air conditioning (22%) are often forgotten. Awareness of the impact of dermatological surgery on global climate change is high among UK dermatologists carrying out skin surgery. We encourage clinicians to translate this into local action, advocacy and service improvement to standards dictated by recently published British Society for Dermatological Surgery national sustainability guidance.

A computer based facial flaps simulator using projective dynamics

Background and ObjectivesInteractive surgical simulation using the finite element method to model human skin mechanics has been an elusive goal. Mass-spring networks, while fast, do not provide the required accuracy. MethodsThis paper presents an interactive, cognitive, facial flaps simulator based on a projective dynamics computational framework. Projective dynamics is able to generate rapid, stable results following changes to the facial soft tissues created by the surgeon, even in the face of sudden increases in skin resistance as its stretch limit is reached or collision between tissues occurs. Our prior work with the finite element method had been hampered by these considerations. Surgical tools are provided for; skin incision, undermining, deep tissue cutting, and excision. A spring-like “skin hook” is used for retraction. Spring-based sutures can be placed individually or automatically placed as a row between cardinal sutures. ResultsExamples of an Abbe/Estlander lip reconstruction, a paramedian forehead flap to the nose, a retroauricular flap reconstruction of the external ear, and a cervico-facial flap reconstruction of a cheek defect are presented. ConclusionsProjective dynamics has significant advantages over mass-spring and finite element methods as the physics backbone for interactive soft tissue surgical simulation.

Open Rhinoplasty: A Personal Evolution of Technique.

Rhinoplasty remains one of the most commonly performed aesthetic surgical procedures, and the open approach has gained more popularity.1,2 Closed rhinoplasty can address dorsal hump deformities, with minimal tip modification.1 Meanwhile, the open approach provides undistorted exposure of the nasal anatomy, allowing for greater accuracy in the diagnosis and approach to nasal obstruction or deformity.1–3 Many trainees and young plastic surgeons become accustomed to the way they were taught rhinoplasty. As an otolaryngology resident, I was taught to commence a rhinoplasty with marginal incisions. Once through the vestibular skin, the lower lateral cartilages are revealed and the nasal dorsum and sidewalls are undermined blindly with a Littler scissor. This was imprecise, often leading to out-of-plane dissections and subsequent bleeding. One reform I have made in fellowship under the direction of my program director (P.B.) is to first make the transcolumellar incision. Once the skin–soft tissue envelope is elevated, the medial crura are dissected and followed superolaterally to then dissect the lateral crura. Staying on cartilage with this technique helps the surgeon to stay in the right plane and maintain hemostasis. Next in the sequence of performing a proper rhinoplasty, the anterior septal angle needs to be identified to allow for proper mucoperichondrial dissection and cartilage release.4 It is especially important to start a septoplasty and dorsal work. The anterior septal angle represents the anteriormost projecting point of the septum, contributing to nasal tip support, projection, length, and airway function. In secondary rhinoplasty, its identification is paramount because it is usually one of the landmarks that is preserved, serving as a guide when anatomical planes have been scarred or are even missing.4 In residency, we retracted the domes laterally with single skin hooks to identify the anterior septal angle. This commonly traumatized the nasal cartilages, rendering them prone to damage or avulsion. In addition, the tactile feedback was not optimized. In fellowship, I have learned to handle cartilage delicately with Adson-Brown forceps (Fig. 1). This change has allowed me to preserve the integrity of the cartilages while maintaining proper control and feedback. Adson-Brown forceps are precise because they allow one grasp at a time from a single point.5 Another modification I have made is the process by which I identity the anterior septal angle. In residency, I would turn my Iris scissors parallel between the medial crura to find the caudal septum low as it takes off from the anterior nasal spine. In fellowship, I have transitioned to beginning my dissection superiorly under the direction of the senior author (P.B.) (Fig. 2). The septum has more stability at this position, thus making it less prone to fracture. In addition, we find this location easier to begin the mucoperichondrial dissection.Fig. 1.: Lower lateral cartilages being handled delicately with Adson-Brown forceps while maintaining tactile feedback.Fig. 2.: Dissection of the anterior nasal spine superiorly, allowing for easier identification and mucoperichondrial dissection.Although these nuances may seem subtle, they can impact the final result. Throughout one’s training and subsequent career, surgeons should be encouraged to reform their surgical technique and the use of surgical instruments accordingly. PATIENT CONSENT The patient provided written consent for use of the patient’s images. DISCLOSURE The authors report no financial disclosures or conflicts of interest. Jason E. Cohn, D.O.Sunrise Facial PlasticsLindenhurst, N.Y. Katherine Chemakin, B.S.Albert Einstein College of MedicineBronx, N.Y. Paige Bundrick, M.D.Department of Otolaryngology–Head and Neck SurgeryDivision of Facial Plastic Reconstructive SurgeryOchsner Louisiana State University of HealthShreveport, La.

Customised, disposable skin hook: a technical note.

The skin hook is a simple and practical instrument used in maxillofacial, plastic, and dermatological surgery to minimise undesirable trauma to the skin. With the reduction in injuries and gentler handling of skin, there will also be a decreased incidence of wound infection and inflammation.1

Commentary on Hooked on Hooks? A Study in the Utilization of Skin Hooks.

Commentary on Hooked on Hooks? A Study in the Utilization of Skin Hooks.

Commentary on Hooked on Hooks? A Study in the Utilization of Skin Hooks

Commentary on Hooked on Hooks? A Study in the Utilization of Skin Hooks

Hooked on Hooks? A Study in the Utilization of Skin Hooks.

The skin hook is a valuable instrument used in the practice of dermatologic surgery. However, because of numerous factors, the degree of its use varies extensively. The purpose of this study was to examine practice trends among dermatologic surgeons regarding the use of skin hooks, as well as analyze factors influencing their use. A survey comprising 14 questions was distributed to members of the American College of Mohs Surgery and the American Society for Dermatologic Surgery. Results were recorded, and statistical analysis was conducted using the 2-sample z-test to compare 2 population proportions. Five hundred seventy-one responses were received, with comments. 85.1% of respondents reported using skin hooks. Their use was further characterized as minimal (20.7%), moderate (29.0%), and extensive (35.4%). The utilization of skin hooks was additionally categorized based on age, gender, fellowship training, number of years in practice, practice setting, and history of experience/observance of a sharps exposure. Only the presence or absence of fellowship training demonstrated a statistically significant difference in the use of skin hooks. Skin hooks are highly used tools among dermatologic surgeons. Their use requires appropriate training and experience, and care must be taken to minimize risk of exposure.

Anesthetization of the tragus and antitragus to use skin hooks for full visualization of the auricular concha

Anesthetization of the tragus and antitragus to use skin hooks for full visualization of the auricular concha

Comparison of three strip harvesting technqiues (Haber's, Pathomvanich's and Ahmad's techniques).

To compare the three techniques, that is, using tissue spreader, using skin hooks technique, and using sharp scissor techniques. A double-blind, randomized study was conducted in 10 patients undergoing hair transplant surgery by strip harvest after informed consent. The marked strip was divided into 3 equal parts to be assigned randomly to one of the harvesting techniques, that is, (a) using tissue spreader technique (A), (b) using skin hooks technique (B), and (c) using sharp scissor technique (C). The total number of hair of the strip margins were counted. The number of transected hair were also counted. The time taken for harvesting for each technique was noted. All the data were analyzed using ANOVA test. The average length of the strip was 27.8cm. The mean harvesting time was 46.2seconds (technique A), 174.5seconds (technique B), and 49.9seconds (technique C) (P<0.05). The total hair density was 640.9 vs 664.5 vs 690.0, respectively. The total transection rate was 2.822 vs 2.689 vs 2.465 in technique A, B, and C, respectively. Sharp scissor technique is a safe technique which results in lower transection rate and no significant increase in operation time.

Freehand Technique of an Electromagnetic Navigation System Emitter to Avoid Interference Caused by Metal Neurosurgical Instruments

Electromagnetic (EM) navigation has been reported to be a noninvasive and easy-to-use technique. However, the use of metal neurosurgical instruments (e.g., skin hooks, head frames, brain retractors systems) can interfere with the magnetic fields of such systems. We present the freehand technique, a new technique involving the manual manipulation of the emitter of an EM navigation system, which helps to prevent interference caused by metal instruments during surgery. The AxiEM Electromagnetic StealthStation Navigation System (Medtronic) was used in this study. The emitter was placed in the sterilized surgical field, which allowed it to be moved freely during surgery. When navigation was necessary during the procedure, the assistant held the emitter at an appropriate angle to the sterile surgical field to avoid interference caused by the metal neurosurgical instruments. During surgery involving metal surgical instruments, all of the functions of the EM navigation system were available throughout the procedure. The accuracy of the navigation system was sufficient to allow craniotomy and intradural manipulation to be conducted. During the use of EM navigation systems, the freehand technique with the emitter can prevent interference caused by metal instruments.

Needle band release is performed with a skin hook to tension the scar bands and a 16-gauge needle to sharply release the bands

Needle band release is performed with a skin hook to tension the scar bands and a 16-gauge needle to sharply release the bands

What We Do: The Hynes Pharyngoplasty-Deep Prevertebrae Stitch.

The Hynes pharyngoplasty is the second most often performed procedure for velopharyngeal insufficiency in the United Kingdom and Ireland. A crucial step of the procedure is reliable fixation of the flaps onto the posterior pharynx wall. We prefer to fix the flaps to the prevertebral fascia. By using a manually straightened needle and a skin hook, in our hands, placement of this stitch can be made easier and faster.

The Hook and Release Technique During Enucleation Surgery.

To describe the results and potential benefit of direct muscle release from the globe during enucleation surgery without identifying sutures in the rectus muscle insertion sites, a technique referred to as the hook and release technique. Single center, retrospective chart review of patients who underwent enucleation with direct removal of the rectus muscles without identifying sutures in their insertion sites between January 2011 and September 2015 was carried out. The inclusion criteria were primary enucleation without previous strabismus surgery, retinal detachment surgery, or orbital surgery that entered the fibrous connective tissue framework. Forty charts of enucleated patients that had direct release of their extraocular muscles without identifying sutures before releasing them from the globe were identified and reviewed. The primary outcome measure was intraoperative or immediate postoperative complications. This retrospective chart review was performed with research ethics board approval and in compliance with the Declaration of Helsinki. Data show that following the hook and release technique, the rectus muscles were easily located and reconnected to the orbital implant wrap. The oblique muscles were not reattached. In each of the 40 patients, the 4 rectus muscles were easily located by gently applying traction anteriorly at the conjunctiva/Tenons' edge using double-pronged skin hooks. There was no instance of a lost or slipped muscle following the hook and release technique. The hook and release technique is a simple and efficient method to remove the 4 rectus muscles from the globe and still easily locate them. They are not "lost" and do not "slip out of position" but held in place by the orbital connective tissue framework and the extraocular muscle pulley system. This technique has been very helpful teaching resident staff how to do enucleation surgery as it avoids the more time consuming placement of double-armed locking sutures through the rectus muscle insertions and the potential risk of globe penetration while the muscles remain attached to the eye. If the surgeon desires to attach the muscles to the orbital implant, then sutures are passed after the eye is removed, thus eliminating the worry of globe penetration and avoiding accidentally cutting preplaced extraocular muscle sutures during the remaining enucleation procedure.

Localizing the Lost Rectus Muscle Using the Connective Tissue Framework: Revisiting the Tunnel Technique.

To describe a technique for localizing a lost rectus muscle during strabismus or retinal surgery or following trauma. In this single center, retrospective chart review, 5 patients were identified between January 2012 and June 2016 with a lost rectus muscle; 3 during strabismus surgery and 2 post trauma. The inclusion criteria included a lost rectus muscle during strabismus surgery, or a disinserted/lacerated rectus muscle following ocular/orbital trauma. The primary outcome measure was successful reattachment of the rectus muscle. The lost rectus muscle was identified in each patient and reattached to the globe by gently applying traction anteriorly at the conjunctiva/Tenon edge using double-pronged skin hooks and following the path of the rectus muscle through its Tenon capsule tunnel where it remained attached by suspensory ligaments. There was no instance where orbital fat was obscuring or blocking the view of the lost rectus muscles. There were no other complications associated with the procedure. The authors describe a simple and effective method in 5 patients to localize a lost rectus muscle based on knowledge of the orbital connective tissue framework.

Non-surgical wound closure—a simple inexpensive technique

Primary suture closure of wounds is often the optimal solution for soft tissue defect closure because of its simplicity and satisfactory outcome, yet it may be impeded by high -tension closure. The customary application of skin grafts, flaps, free tissue transfer, or tissue expansion is often associated with relatively more complex surgical reconstructive procedures, significant morbidity and extended hospitalization and prolonged recovery period. We retrospectively investigated all patients who underwent wound closure using a mechanical wound closure device between 2014 and 2016 in a tertiary hospital center. The device consisted of stainless steel hooks, sutured over the opposite wound edges, and rubber bands for generating tension which is gradually increased. Approximated wound margins were sutured or allowed to heal by secondary intention. The mechanical device was applied in 50 patients. There were 38 males and 12 females. Wound size ranged from 3 to 25 cm. In most of the patients there was a satisfactory wound margin approximation. However, in 6 patients skin hook cut through from wound margins occurred due to excessive rubber band tension. In 5 patients, it was decided to also apply negative-pressure wound therapy along with the device. After application of the wound closure device, a residual raw area remained in other 4 patients in whom a split thickness graft was applied. During follow-up, hypertrophic scar and wound dehiscence were found in 5 patients. The mechanical wound closure device herein presented is a simple and inexpensive technique that allows a significant reduction in surgical costs and surgery-related morbidity. Level of Evidence: Level IV, therapeutic study.

Staples for intra-operative skin retraction in hand surgery.

In certain situations staples are a quick and effective method of retracting the skin to give access to the operative site. Staples, once placed, are more reliable and predictable than an assistant with a skin hook. Furthermore, their use frees up the assistant to perform other tasks including further deeper tissue retraction. Staples pinch the skin rather than piercing it and this is especially of value in patients on steroid treatment or with thin skin that may bruise easily. They leave no discernible marks on removal.

A New and Practical Instrument for Antihelix Scoring: Gillies Skin Hook

Prominent ears are relatively common, with an incidence in whites of about five percent¹. It is inherited as an autosomal dominant trait and is commonly caused by a combination of two defects: (1) underdevelopment of antihelical folding and (2) overdevelopment of the conchal wall. Many techniques have been described to correct the antihelical fold. In 1958 after Gibson and Davis2 showed the ability of injured cartilage to bend away from the side of injury, Stenstrom described scoring of the anterior auricular cartilage to create an antihelical fold, Chongchet’s technique used sharp scoring of the lateral scaphal cartilage to form an antihelix with a scalpel.2-4 Stenstrom, in contrast, used a rasp to blindly score the antihelix.3 Many different instruments have been used for scoring, including scalpels, rasps, abraders, diamond burr drills, Adson-Brown forceps, hypodermic needles and bipolar cautery.5 We present in this paper, a new instrument which can be used for scoring,a fine skin hook.

Aneurysm Needle as an Effective Tool in Laparoscopic Port Closure.

The importance of port closure after laparoscopic surgeries is emphasized by the extensive number of techniques being described for the same. Even so, the search for a simple, time-saving, and effective technique still continues. One commonly overlooked factor is the obliquity of laparoscopic ports, which makes direct visualization of the rectus fascia through the skin incision difficult. Also, our patients, mostly of Indian ethnicity, tend to have relatively thick subcutaneous fat that again acts as a constraint during port closure. We have described a simple and effective method of laparoscopic port closure using Moynihan's aneurysm needle and a skin hook. This technique is particularly advantageous in the above-mentioned scenarios. We have been successfully using this technique in our institution for the past 6 years, and we have not encountered any case of port-site hernia. Our technique does not require expensive instruments or the need for visualization via a camera.

Secure and quick transumbilical initial trocar insertion with skin hooks: The skin hook method

Abstract Objective To evaluate clinical safety and ease of the entry technique using an optical access system and skin hooks. Materials and methods A total of 80 gynecological patients who have undergone laparoscopic surgery with either the skin hook method using skin hooks or the conventional method using Pean clamps. Results The skin hook method was compared with the conventional method using Pean clamps ( n = 40 patients each). The skin hook method required less time and there was less device slippage than in the conventional method. No other severe complications occurred after either method. Conclusion This method is a simple and secure approach and can be applied during laparoscopic surgery and in patients other than gynecological patients.