Before approaching a surgical repair, it is very helpful to have a working knowledge and appreciation of the appropriate surgical instruments and options for suture material and needle choice. As with any endeavor, organized and meticulous preparation will help foster a smooth, rapid, and elegant surgical closure.

Some prerequisites to performing skin and soft tissue surgery include an appreciation of surgical anatomy, basic operative technique, and an understanding of tissue movement and mechanics.

Attention to effective patient positioning is also helpful in creating a comfortable and ergonomically sensible environment. When possible, the surgical site should be level and at a comfortable working height for the surgeon. Surgical loops may be helpful in maintaining an ergonomically correct operating position. Time ostensibly saved by the assistant in failing to adequately prepare the surgical site is invariably lost intraoperatively as improper patient positioning or preparation leads to increased operative time and an ensuing increased risk of surgical site complications.

Surgeons are widely known for their particularity regarding surgical instruments. This is not without reason, as an experienced surgeon expects their surgical instruments to function flawlessly, functioning as an extension of the surgeon’s hands for precisely and accurately handling tissues and all aspects of the surgical field.

Surgical trays used for skin and soft tissue reconstruction may range from a simple set of four or five instruments to highly specialized instrument arrays consisting of dozens of finely calibrated surgical instruments. While larger surgical cases may require a larger quiver of instruments, most straightforward cases can be completed safely and efficiently with a few discrete components: the scalpel; the needle driver, used for holding the needle securely (and for knot tying); the surgical pick-ups or forceps, used for securely holding the tissue; the skin hook, used for atraumatically improving visualization of the deeper tissues and, in some hands, for wound edge control during suturing; tissue scissors, for delicately and accurately trimming the skin and soft tissues; and suture scissors, used for cutting and trimming suture material. Most surgical trays also include an electrosurgical device to aid in hemostasis as well as gauze. Nonwoven gauze is preferred as it has excellent wicking properties and does not tend to unravel, which could potentially introduce foreign-body material into the wound (Figure 2-1).

Surgical instruments may include tungsten carbide inserts to increase their longevity (and cost), as this material is both stiffer and denser than the stainless steel out of which most modern instruments are constructed.

Most modern scalpel blades are made from stainless or carbon steel. Stainless steel blades are very sharp and resist dulling from repetitive friction across tissue. Carbon steel blades, while marginally sharper than their stainless equivalents, are more susceptible to dulling. Disposable scalpel handles, with the blade permanently affixed, are sometimes used in settings where small volumes of procedures are performed, or where access to an autoclave is limited, but are generally not used in busy surgical practices.

While a variety of scalpel handles are available, most skin and soft tissue surgery is performed using a no. 3 Bard-Parker flat handle. This permits the use of various scalpel blades, including the 15 blade, by far the most frequently used surgical blade in cutaneous surgery. Other scalpel handles include the no. 7 scalpel handle, which accepts the same blades as the no. 3, and the Beaver handles, for which special blades must be used. In addition to the 15 blade, the smaller 15c is sometimes used for delicate excisions around the eyelids and ears (and, by some, on all facial cases), while the larger 10 blade is used for areas with a more robust dermis, such as the back. Despite the plethora of available options, it is possible to use a simple no. 3 handle and 15 blade for essentially all skin and soft tissue surgery without any compromise in outcome.