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nylon monofilament suture, which some studies have shown results in superior cosmetic results. It has several other benefits, he says, including its ability to hold its shape and its strength. "The workhorse for me is nylon," he says. "I like it because its strength is beyond what one would expect for its size, so I can use a relatively small caliber knowing that it is less bother- some to the skin." The right suture depends on a number of factors, including the case, where the incision is located, the tension of the skin and surgeon prefer- ence. Some choices, though, are better than others to minimize scarring. Multifilament sutures may be easier to tie, but they result in a less-than- pretty outcome, says Dr. Vagley, since they more easily absorb surrounding fluid that could put pressure on tissue. Research also suggests that these braided sutures come with a higher infection risk, a key factor in scarring. Another suture consideration is absorbable vs. nonabsorbable. While many previously thought that absorbable sutures offered inferior post-op cosmetic outcomes, several recent studies have suggested that the 2 pro- duce similar results. Suture technique also plays a role in how scars form. Dr. Vagley prefers using a "buried retention" suture, which uses an inner circle — placed just below the skin's surface — and an outer circle to bring the incision togeth- er and create a less noticeable scar. He'll also use a subcuticular suture that snakes back and forth just below the skin's surface. One to try to avoid? The mattress stitch, says Dr. Vagley. Despite being a strong suture, he says the mattress stitch tends to dig into skin and cause prominent stitch-mark scars. 2. Explore your adhesive options Eliminating sutures and staples is one of the best ways to reduce scarring. "It goes without saying that the best suture is no suture at all," says Dr. Vagley. While deeper skin layers often require suturing, Dr. Vagley uses adhe- 7 4 O U T P A T I E N T S U R G E R Y M A G A Z I N E O N L I N E | M A Y 2 0 1 5