Using the best closure techniques

A "cosmetic" closure is another name for a multilayered closure. If you want to have the best scar appearance afterwards, a multilayered closure is fundamental to that process. 

The skin is made of 3 main layers: epidermis, dermis and subdermis (aka subcutaneous layer)

• Epidermis: outer most layer that provides the final layer of waterproofing of our skin. This is the part that our eyes see as "skin." Distortions of this layer show as scars. During wound closure this layer is meticulously aligned to prevent uneven step offs. Eversion of the layer is also a good idea to compensate for potential postoperative skin contraction. 
• Dermis: this layer is the main supportive layer to our skin. One of the key steps to a cosmetics closure is to make sure you have excellent approximation of this layer to remove tension from the wound. Without adequate closure of this layer the scar will often widen and deepen. 
• Subcutaneous: this is mostly fatty tissue. Sutures only in this layer do have much strength and often rip out. Generally speaking, this layer is not address with regards to wound closure. 

Closing the skin in a multilayered fashion after a surgery usually means at least 2 layers of repair. The dermis is closed so that the epidermis is aligned in a tension free manor. The best dermal repair will align the epidermis in such a way that it appears you may not need anything else at all to close the wound. Next, the skin edges are aligned and everted, even if just slightly. These are then secured in that position to allow for healing to occur. 

The dermis is best closed with sutures. Dissolvable sutures are most often used for this purpose since permanent sutures would be noticeable under the skin. The epidermis can be closed with a variety of techniques but most often uses sutures or glue. Sutures can vary from dissolvable, dissolvable hidden sutures under the skin surface, removable sutures either through the surface of the skin or hidden below it, or just glue on the surface. The main factor to consider is removing any sutures going through the skin before 5-7 days to prevent small dot shaped scars called "train tracks."

Note: using skin staples are NEVER part of a cosmetics repair except where hidden by hair such as the scalp.