Skin Hooks in Surgery: Gillies, Joseph and Double-Prong Patterns

A 3 cm vermilion border laceration, a child under sedation, and a resident who has just grabbed a pair of toothed forceps to hold the flap. Watch the tissue afterwards: two crush marks either side of the repair, right where the scar will sit. That is the argument for skin hooks in one sentence.

The hook lifts. It does not squeeze. On a wound edge you intend to close cosmetically, that difference decides whether the scar reads as a line or a ladder.

What a Skin Hook Actually Does

A skin hook is a single-shafted retractor ending in one, two, or several fine curved prongs. The surgeon or assistant engages the prong in the dermis — from the underside of the wound edge, never through the epidermal surface — and applies traction. Because the load sits on a point rather than between two opposing jaws, there is no compressive force on the tissue at all.

That is the whole design brief. Everything else on the instrument — handle knurl, shaft taper, prong gap — exists to make that single lifting action controllable at 0.5 mm precision.

Typical shaft lengths run 15 cm to 20 cm, with the working prong measuring 2 mm to 12 mm across depending on pattern. Most are ground from AISI 420 martensitic stainless, hardened to roughly 48–52 HRC at the tip so the prong holds its point through repeated autoclave cycles without bending.

Gillies Skin Hook: The Single Sharp Prong

Sir Harold Gillies, working on facial reconstruction of First World War casualties, needed something that could tension a rotation flap without bruising it. The hook that carries his name is a single fine sharp prong on a slim flat handle, usually 18 cm overall.

Where it earns its place:

• Fine facial closure — eyelid, alar rim, vermilion, where a 1 mm mismatch is visible across a room
• Flap elevation — engaging the leading edge to define the dissection plane under direct vision
• Everting a wound edge for subcuticular suture placement, letting the needle pass through dermis at a consistent depth

The Gillies pattern usually pairs a hook at one end with a flat handle you can hold like a pencil. Some houses offer a double-ended version with a hook at one end and a small blunt dissector at the other, which is useful in a minor ops tray where instrument count matters more than perfect ergonomics.

Joseph Skin Hook: The Double Prong Workhorse

Jacques Joseph’s rhinoplasty work drove a different requirement: hold a soft tissue envelope open and keep it stable while both hands work. A single prong rotates under load. Two prongs, spaced apart, do not.

The Joseph skin hook comes in double prong widths of roughly 2 mm, 5 mm, 7 mm, and 10 mm, at lengths of 15 cm to 16 cm. Prongs are supplied sharp or blunt.

Sharp versus blunt is not a preference question. Sharp prongs are for dermis and cartilage perichondrium. Blunt prongs are for anything you would rather not perforate — nerve, vessel adventitia, thin mucosa — and for handing to an assistant whose attention is on the monitor rather than the field.

Double Prong Retractor Patterns Beyond Joseph

Several other patterns appear on the same tray and get confused with each other in ordering:

• Guthrie — double sharp prong, very fine, 12–13 cm, oculoplastic and lid work
• Cottle — double blunt prong with a broader spread, standard in septorhinoplasty
• Freer — a double hook variant used for nasal alar retraction, distinct from the Freer elevator that shares the name
• Frazier — usually a single hook, fine, neurosurgical and ENT contexts
• Multi-prong rake — four or six prong, sharp or blunt, essentially a miniature Volkmann for skin edges

When ordering, specify the pattern name, prong count, prong sharpness, prong spread in millimetres, and overall length. Pattern name alone is not enough — “Joseph hook” spans a 5x range in prong width across suppliers.

Technique Points That Damage Instruments

Skin hooks fail in two ways, and both are avoidable.

Prong deflection. A fine sharp prong is a cantilever. Pull along the shaft axis and it holds indefinitely. Pull at 90° to the shaft with an assistant leaning back, and the prong opens out by a fraction of a millimetre each time until it no longer engages. Traction should follow the shaft.

Point blunting. Dropping a hook point-down onto a metal Mayo stand rolls the tip over. So does tossing it into a wash tray with heavier clamps on top. Fine hooks should be processed in a protected rack or an instrument stringer, not loose in a perforated basket with rongeurs and retractors.

Inspect the point against a white background under magnification at reprocessing. A rolled or hooked-over tip drags through dermis instead of entering it, which is exactly the crush injury you bought the hook to avoid.

Sterilisation and Care

Nothing exotic here — surgical skin hooks follow standard reusable instrument protocol:

1. Point-protect immediately after use; do not let hooks sit in blood to dry
2. Enzymatic soak, then ultrasonic cleaning with hooks in a dedicated fine-instrument tray
3. Rinse with deionised water — chloride residue pits the fine tip first, because that is where the passive chromium oxide layer is thinnest over the ground edge
4. Lubricate any hinged double-ended variants; solid hooks need none
5. Steam sterilise at 134 °C for 3 minutes in a pouch or wrapped tray, with tip guards fitted

The tip guard matters more than most people assume. A fine 2 mm sharp prong that punctures a peel pouch has just failed the sterile barrier for the whole pack, and it will not be noticed until the pack is opened on the field.

Sourcing Notes

Prong geometry is the whole instrument, and it is also the first thing that goes wrong in low-cost manufacturing. Ask for the tip hardness specification, not just the steel grade — a 420 hook drawn back too soft will bend within a dozen cases regardless of what the invoice says.

Fizza Surgical manufactures skin hook patterns in Sialkot under ISO 13485, with CE marking against EU MDR, and supplies both sharp and blunt prong configurations across the standard width range. Our full range of general surgical instruments covers the retraction and soft-tissue handling instruments that sit alongside hooks on the same tray. For related fine-tissue instruments, see our guides to toothed versus non-toothed tissue forceps and biopsy punches and skin punch instruments. Certification documentation is available on our certifications page.