Atlas Các Kỹ Thuật Khâu Vết Thương Và Tạo Hình Thẩm Mỹ (Atlas of Suturing Techniques)

35
This approach should only rarely be
used in areas with a thick dermis and
under marked tension, such as the
chest and back. On the extremities, a
4-0 absorbable suture material may be
used, and on the ace and areas under
minimal tension a 5-0 absorbable suture
is adequate. A 3-0 caliber suture may be
used on areas such as the lower legs i
needed, though this should be utilized
with caution as the larger caliber suture
material has more o a tendency to spit
or result in oreign body reactions.
Technique
1. The wound edge is re ected back
using surgical orceps or hooks. Ade-
quate visualization o the underside
o the dermis is desirable.
2. While re ecting back the dermis,
the suture needle is inserted into the
undersur ace o the dermis parallel
to the incision line just lateral to the
incised wound edge.
3. The f rst bite is executed by placing
gentle pressure on the needle so that
it enters the papillary dermis and
then relaxing pressure to permit the
needle to exit on the undersur ace o
the dermis.
4. Keeping the loose end o suture
between the surgeon and the patient,
the dermis on the side o the f rst bite
is released. The tissue on the oppo-
site edge is then re ected back in a
similar ashion as on the f rst side.
The Buried Horizontal
Mattress Suture
C H A P T E R 4 . 4
Synonym
Fully buried horizontal mattress suture
Video 4-4. Buried horizontal
mattress suture
Access to video can be found via

Application
This is a niche technique, use ul when
closing narrow wounds or those where
there is limited space to insert the needle
driver, and when placing a buried suture
is desirable. It may be employed in a
variety o locations, including the scalp,
ears, and lower leg, though it has been
applied broadly and may be utilized in
any number o anatomic locations.
This technique results in adequate
wound eversion; depending on how ar
back the bites are taken and whether
the incised wound edge is cut with an
inward bevel, it may result in only modest
wound-edge approximation.
Suture Material Choice
As always, suture material choice depends
on pre erence and location; while the
suture material remains on the under-
sur ace o the dermis, it does traverse
the midpapillary dermis, and there ore
care should be taken to utilize the small-
est caliber o suture that provides ade-
quate tensile strength. Similarly, the knot
remains relatively superf cial at the level
o the reticular dermis, conf rming the
need to utilize the f nest suture available.

36
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
5. The second and f nal bite is executed
by inserting the needle into the under-
sur ace o the dermis on the contralat-
eral side, with a backhand technique
i desired, and completing a mirror-
image loop, so that the needle exits
directly across rom its original entry
point on the contralateral side.
6. The suture material is then tied uti-
lizing an instrument tie (Figures 4-4A
through 4-4F).
Figure 4-4A. The needle is inserted through the der-
mis running parallel to the incised wound edge.
A
Figure 4-4B. This procedure is then reversed on the
contralateral wound edge.
B
Figure 4-4C. Overview of the buried horizontal
mattress suture technique.
C
Figure 4-4D. The needle is inserted through the
dermis, slightly setback from the wound edge, running
parallel to the incised wound edge.
D
Figure 4-4E. This procedure is then reversed on the
contralateral wound edge.
E
Figure 4-4F. Wound appearance after placement of
a single buried horizontal mattress suture. Note the
marked wound-edge eversion.
F

37
The Buried Horizontal Mattress Suture
Tips and Pearls
This technique is use ul or narrow or
shallow wounds, such as those on the
scalp and shins. It may also be used when
adding an additional buried suture in an
otherwise largely closed wound, where
there is insu f cient space to insert a verti-
cally oriented buried suture in the narrow
space between two other already-placed
sutures.
As with the buried vertical mattress
approach, the f rst bite may be f nessed
by f rst re ecting the wound edge back
sharply during needle insertion and then
returning the edge medially a ter the apex
has been reached. This approach helps
lead the needle in the correct course with-
out an exaggerated change in direction
with the needle driver, though the needle
is oriented parallel to the incised wound
edge, as opposed to the perpendicular
approach utilized with the buried verti-
cal mattress.
The needle driver may also be held
like a pencil, and the needle may then be
rotated through the dermis while re ect-
ing back with the orceps to permit easy
visualization.
As with any buried technique, the apex
o the needle should be in or deep to the
papillary dermis; i the needle courses too
superf cially, dimpling may occur.
Drawbacks and Cautions
This technique should not be adopted in
all areas, and there are generally better
options or use in areas with a robust
dermis under moderate to marked ten-
sion, such as the back and shoulders. In
those locations, the buried horizontal
mattress approach should only be uti-
lized or inserting additional sutures in
between already placed buried sutures,
when there is insu f cient space to place a
set-back dermal suture or buried vertical
mattress suture.
While the eversion is less pronounced
than other techniques, such as the set-
back dermal suture, patients may still
be le t with a small ridge in the immedi-
ate postoperative period. While this is
desirable, it is also important to warn
patients o this outcome; explaining that
the technique is akin to placing a subcuta-
neous splint may help the patient develop
reasonable and realistic expectations and
reduce anxiety regarding the immediate
postoperative appearance o the wound.
Wound-edge necrosis has been raised
as a potential risk o horizontally oriented
suture placement, but in practice this is
only encountered very rarely and as a
complication o tightly placed traditional
horizontal mattress sutures, rather than
with the buried equivalent. This is likely
due to a constrictive e ect on the incised
wound edge, which is not typically seen
with buried sutures.
The original description o this
approach bears some resemblance to the
butter y suture; keeping in mind that
the buried horizontal mattress suture
should represent a buried version o the
traditional horizontal mattress approach,
however, the needle entry and exit points
should both be in the undersur ace o the
dermis just lateral to the incised wound
edge, as opposed to the butter y suture
where entry and exit occur at the junc-
ture o the incised wound edge and the
undersur ace o the dermis and where
the needle arcs on a diagonal.
Reference
Alam M, Goldberg LH. Utility of fully buried hori-
zontal mattress sutures. J Am Acad Dermatol.
2004;50(1):73-76.

38
2. The wound edge is re ected back using
surgical orceps or hooks. Adequate
ull visualization o the underside o
the dermis is very help ul.
3. While re ecting back the dermis,
the suture needle is inserted into the
undersur ace o the dermis near the
junction o the base o the incised
wound edge and the undersur ace
o the undermined dermis. The
needle driver is held like a pencil
at 90 degrees to the incised wound
edge and the needle may be held on
the needle driver at an oblique angle
to acilitate suture placement.
4. The f rst bite is executed by plac-
ing gentle pressure on the needle so
that it moves laterally and upward,
orming a horizontal loop that on
cross section resembles the wing o
a butter y. The needle then exits
the undersur ace o the dermis a ter
ollowing its curvature, in the same
plane as its entrance point.
5. Keeping the loose end o suture
between the surgeon and the patient,
the dermis on the side o the f rst bite
is released. The tissue on the oppo-
site edge is then re ected back in a
similar ashion as on the f rst side.
6. The second and f nal bite is executed
by inserting the needle into the
undersur ace o the dermis on the
contralateral side, with a backhand
technique i desired, and complet-
ing a mirror-image loop. The suture
The Butter y Suture
C H A P T E R 4 . 5
Video 4-5. Butterf y suture
Access to video can be ound via
SuturingTechniques.com.
Application
The butter y suture technique is a buried
technique designed or wounds under
moderate to marked tension. It is best uti-
lized on the trunk and shoulders, where
the combination o a thick dermis and
the need or marked tension relie make
it an occasionally use ul approach.
Suture Material Choice
As always, suture material choice depends
on pre erence and location. Though this
technique is designed or wounds under
signif cant tension on the trunk it is com-
monly utilized with a 3-0 suture. While
adopting a 2-0 suture material is some-
times use ul, especially to avoid bending
smaller needles, the knot or this suture is
buried in line with the incision and at the
base o the dermis and there ore suture
material spitting is a risk. Use o an absorb-
able monof lament (polydioxanone) has
been proposed as providing superior out-
comes over a braided absorbable suture.
Technique
1. This technique ideally requires that
the wound edges be incised with a
reverse bevel, allowing the epidermis
to overhang the dermis in the center
o the wound.

39
The Butter ly Suture
Figure 4-5A. First step o the butter y suture tech-
nique. Note that the needle driver is held like a pencil
and the needle is passed in a plane parallel to the
incised wound edge, at an approximately 45-degree
angle so that a more superfcial bite o dermis is taken
when the needle reaches its apex, leading to wound-
edge eversion.
A
Figure 4-5B. Second step o the butter y suture, pre-
senting a mirror image o the frst step.
B
Figure 4-5C. First step o the butter y suture
technique. Note that the needle driver is held like a
pencil and the needle is passed in a plane parallel to
the incised wound edge, at an approximately 45-degree
angle so that a more superfcial bite o dermis is taken
when the needle reaches its apex, leading to wound-
edge eversion.
C
Figure 4-5D. Second step o the butter y suture,
presenting a mirror image o the frst step.
D
Figure 4-5E. Immediate postoperative appearance.
Note the pronounced eversion.
E
material exits directly across rom its
initial entry point.
7. The suture material is then tied uti-
lizing an instrument tie (Figures 4-5 A
through 4-5E).

40
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Tips and Pearls
This technique is designed or areas under
tension, though it may be used in any
anatomic location. As such, utilizing a
su f ciently robust needle may be very
help ul in mitigating the risk o needle
bending that can be seen when attempt-
ing to place the needle in the thick dermis
o the back.
As with the buried vertical mattress
approach, the f rst bite may be f nessed
by f rst re ecting the wound edge back
sharply during needle insertion and then
returning the edge medially a ter the apex
has been reached. This approach helps
lead the needle in the correct course with-
out an exaggerated change in direction
with the needle driver, though the needle
is oriented parallel to the incised wound
edge, and on a diagonal relative to the
vertical axis, as opposed to the perpen-
dicular approach utilized with the buried
vertical mattress.
As with most approaches, the apex
o the needle's pass should be in the
papillary dermis or deeper; i the needle
courses too superf cially, dimpling may
occur. This technique is unique in that it
incorporates a large segment o dermis
along the axis o the wound, theoretically
increasing the robustness o each suture
placement, and that it has the needle
move on an upward and outward diago-
nal rom the wound edge, acilitating
wound eversion as well.
Proponents o this technique have
advocated the use o a long-lasting non-
absorbable monof lament suture mate-
rial, polydioxanone, since it retains its
strength or an extended period o time
and is there ore particularly amenable to
use in high-tension closures.
Like the buried horizontal mattress
suture, an advantage o this approach
is the relatively generous section o der-
mis included in each suture. In areas
o atrophy, the broader bite o dermis
included in each suture may help mitigate
the risk o tearing through the atrophic
dermis that may be encountered when
utilizing vertically oriented buried sutures
in these circumstances.
An additional benef t o this approach
is that since each completed suture is ori-
ented horizontally, less individual sutures
need to be placed to cover a given length
o the wound.
Drawbacks and Cautions
The need to bevel the w ound edges
means that this technique requires a
small degree o preplanning. The bevel
may, how ever, be use ul or other
techniques as well, as it may help with
w ound-edge apposition in general,
though there is also the theoretical risk
o contracture leading to a small separa-
tion between the wound edges. I the
butter y suture is utilized without bev-
eling the wound edges, a small amount
o dermis may overhang in the incised
wound edges, preventing wound-edge
apposition. In this event, surgical scissors
or a blade may be used to trim back the
overhanging dermis to permit the epi-
dermal wound edges to come together
unimpeded.
Some authors have raised concerns
regarding possible wound-edge necro-
sis associated w ith horizontally ori-
ented suture placement. Advocates o
this approach report that wound-edge
necrosis has not been seen as a compli-
cation, and necrosis is generally only an
issue with superf cially placed horizontal
mattress sutures, rather than with their
buried counterparts. This is likely due to
a constrictive e ect on the incised wound
edge, something not typically seen with
buried sutures.
This technique should probably be
avoided on the eyelids, as the dramatic

41
The Butter ly Suture
eversion may not resolve with time with
the thin dermis and minimal tension
across the wound edges. Similarly, in
areas where inversion is desirable, such
as the nasolabial olds, this technique
should similarly be avoided.
Given the marked eversion associated
with this technique, patients may be le t
with a small ridge in the immediate post-
operative period. While this is desirable, it
is also important to warn patients o this
outcome; explaining that the technique is
akin to placing a subcutaneous splint may
help the patient develop reasonable and
realistic expectations and reduce anxiety
regarding the immediate postoperative
appearance o the wound.
Re erence
Breuninger H, Keilbach J, Haaf U. Intracuta-
neous butterfly suture with absorbable
synthetic suture material. Technique, tissue
reactions, and results. J Dermatol Surg Oncol.
1993;19(7):607-610.

42
riction when removing the suture. Since
a relatively large amount o suture mate-
rial will be le t in the super cial dermis, i
absorbable material is used then utilizing
a nonbraided mono lament suture may
be best to minimize the risk o in ection
and oreign body reaction.
Technique
1. The needle is inserted at the ar
right corner o the wound, paral-
lel to the incision line, beginning
approximately 2-5 mm rom the apex.
The needle is passed rom this point,
which is lateral to the incision apex,
directly through the epidermis, exit-
ing into the interior o the wound just
medial to the apex. Note that this rst
pass may be nessed depending on
the technique used or nishing the
closure, as addressed in detail below.
2. With the tail o the suture material
resting lateral to the incision apex and
outside the wound, the wound edge
is gently ref ected back and the needle
is inserted into the dermis on the ar
edge o the wound with a trajectory
running parallel to the incision line.
The needle, and there ore the suture,
should pass through the dermis at a
uni orm depth. Bite size is dependent
on needle size, though in order to
minimize the risk o necrosis it may
be prudent to restrict the size o each
bite. The needle should exit the der-
mis at a point equidistant rom the cut
edge rom where it entered.
The Running
Subcuticular Suture
C H A P T E R 4 . 6
Video 4-6. Running
subcuticular suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is an epidermal approximation tech-
nique suitable or wounds under mini-
mal to no tension. This technique should
almost never be employed in the absence
o a deep dermal suture, since its strength
is in ne-tuning epidermal approximation
and it is less e ective in the presence o
signi cant tension. Its use is also predi-
cated on the presence o a relatively robust
dermis, since it is a primarily intradermal
technique and there ore does not recruit
any strength rom the epidermis. There-
ore, it should be avoided in the context
o atrophic skin or in areas with a very
thin dermis, such as the eyelids.
Suture Material Choice
As with any technique, it is best to utilize
the thinnest suture possible or any given
anatomic location. The subcuticular suture
technique is not designed to hold tension
irrespective o anatomic location. Since its
utility is limited to ne-tuning epidermal
approximation, 5-0 or 6-0 suture is o ten
use ul when adopting this technique.
Depending on the chosen technique
variation, this technique may be used
with either absorbable to nonabsorbable
suture. I nonabsorbable suture is used, it
is best to utilize a mono lament suture
material to minimize the coe cient o

43
The Running Subcuticular Suture
Figure 4-6A. A ter passing the needle rom outside
o the wound apex to the interior o the wound, the
needle is rotated superfcially through the dermis.
A
Figure 4-6B. This procedure is repeated on the con-
tralateral wound edge.
B
Figure 4-6C. Overview o the running subcuticular
technique.
C
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the nee-
dle driver. As the needle is reed rom
the tissue with the pickups, the needle
is grasped again by the needle driver
in an appropriate position to repeat
the above step on the contralateral
edge o the incised wound edge.
4. A small amount o suture material is
pulled through, the skin o the con-
tralateral wound edge is ref ected
back, and the needle is inserted into
the dermis on the contralateral side
o the incised wound edge and the
same movement is repeated. The
needle should enter slightly proximal
(relative to the wound apex where the
suture line began) to the exit point,
thus introducing a small degree o
backtracking to the snake-like f ow
o the suture material. This will help
reduce the risk o tissue bunching.
5. The same technique is repeated on
the contralateral side until the end o
the wound is reached. At this point,
the needle is inserted rom the inte-
rior o the wound in line with the
incision line and exits just lateral to
the apex o the wound (Figures 4-6A
through 4-6J).

44
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-6D. The needle is passed rom outside o the
wound apex to the interior o the wound.
D
Figure 4-6E. The needle is then rotated superfcially
through the dermis on one side o the incised wound edge.
E
Figure 4-6F. This procedure is repeated on the contra-
lateral wound edge.
F
Figure 4-6G. The technique is repeated on alternating
sides along the course o the wound.
G
Figure 4-6H. Immediate postoperative appearance,
with the leading and trailing suture material still
visible.
H
Figure 4-6I. Postoperative appearance when the
suture is tied over top o the wound.
I

45
The Running Subcuticular Suture
Figure 4-6J. Postoperative appearance when the
suture material is trimmed at the epidermis.
J
Tips and Pearls
Body positioning can be very help ul in
maintaining an e cient and com ortable
subcuticular technique. Most surgeons
are trained to work with the surgical site
f at and perpendicular to their body. Since
the motions associated with subcuticular
suture placement are 90 degrees o rom
this, it may be use ul to stand with the
surgeon's body (shoulder to shoulder) par-
allel to the incision line. This allows or a
f owing motion rom right to le t without
the need to twist the shoulders or wrists.
One o the classic conundra relating
to this technique is how to start and n-
ish the closure; there are myriad options
available to the surgeon. Some o the
available options or nishing this suture
include the ollowing:
1. Clipping the ends o the suture at the
level o the epidermis: This technique
is o maximal convenience to surgeon
and patient and minimizes the risk o
leaving any track marks whatsoever.
Since the ends o the suture are not
tacked down in any way, however,
it does not have the potential to hold
the epidermis in place in the ace o
stress. This is particularly true i an
absorbable mono lament suture is
used, as it can easily slip through the
dermis, and will naturally slip away
rom the areas under most tension.
2. Clipping the ends o the suture a ter
leaving a long (3-6 cm) tail: The tails
may be tacked down with adhesive
strips, tissue glue, or surgical tape to
minimize slippage over time. This
approach is most suited i nonab-
sorbable mono lament will be used,
as it may be le t in place or 6 weeks
or more. I the suture tails are not
xed in place, this may lead to some
sur ace irritation where the suture
material exits lateral to the apices o
the wound.
3. Tying a single buried dermal suture
or set-back dermal suture at each
end o the running subcuticular loop:
The rst dermal suture is tied at the
ar end and the end o the suture is
trimmed either at the knot or slightly
above the knot. The running subcu-
ticular technique is then executed
as noted earlier and a similar knot is
tied at the other end. In this case, the
rst and last throws o suture do not
begin and end outside o the wound
(as outlined previously), but rather as
dermal sutures at the apices o the
repair.
4. The ends o the suture may be tied to
each other in a bow over the top o
the wound: This requires leaving su -
cient laxity at the beginning as well
as pulling through su cient suture
material so that the bow may be tied
at approximately the center point
o the wound. Risks associated with
this approach include torque-induced
tissue damage at the apices where the
suture material exits the wound as
well as the risk that the loose bow
may be pulled by the dressing or an
inattentive patient.
Attempting to execute this technique
with ewer dermal bites occasionally
results in crimping o the epidermis as
the wound edges pleat together. This may

46
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
be avoided by setting back each bite o
the dermis slightly relative to the apex so
that the pattern the suture makes in the
dermis consists o wider U-shaped bites
moving in a serpiginous pattern. Assidu-
ous attention to detail in taking a su -
cient number o bites should e ectively
mitigate the risk o epidermal crimping.
A smooth, f owing technique is o para-
mount importance in executing this tech-
nique e ectively and e ciently. Some
authors have advocated adjusting the
angle used to hold the needle in the needle
driver rom the traditional 90 degrees
to 135 degrees to increase the surgeon’s
com ort and minimize the need or physi-
cal contortion, though slightly adjusting
the surgeon’s body position helps sig-
ni cantly in this regard and obviates the
need to adjust the needle loading angle.
Drawbacks and Cautions
While a central strength o the running
subcuticular suture is its entirely intra-
dermal placement, this may also repre-
sent one o its greatest drawbacks. This
technique results in leaving a signi cant
quantity o oreign-body material in the
dermis in a continuous ashion. While
this may not represent a major problem
in areas with a thick dermis such as the
back, in other anatomical locations the
large quantity o suture that is le t in situ
may result in concerns regarding in ec-
tion, oreign-body reaction, and even
the potential that the suture material
itsel could present a physical barrier
that would impinge on the ability o the
wound to heal appropriately—essentially
an iatrogenic eschar phenomenon.
A similar concern relates to leaving a
suture tunnel i nonabsorbable suture
material is used and is then removed a ter
a period o time. As one o the bene ts
o this approach is to permit the suture
to remain in place or many weeks or
months, it also means that removal o
long-standing suture entails a theoretical
risk that a potential space—albeit a thin
and long one—is created on the removal
o the suture material. Again, this theo-
retical risk may be mitigated by utilizing
the thinnest possible suture material.
I nonabsorbable suture material is
used, care should be taken to account or
the eventual necessity o suture removal.
Since the nonabsorbable mono lament
will be removed by applying a continu-
ous gentle pull on the ree edge o the
suture, it is imperative that the length
o the continuous suture be kept to a
reasonable maximum, to avoid the risk
o suture snapping mid pull. In cases
where a longer wound is closed using
nonabsorbable suture material, a single
simple interrupted suture may be placed
as part o the course o the suture mate-
rial every 4 cm or so, providing a site
where the suture material may be snipped
and pulled through at the time o suture
removal.
In the event that slow -absorbing
absorbable suture is used, consideration
should be given to utilizing undyed suture
material, since depending on the depth
o suture placement and the degree o
epidermal atrophy the suture material
may sometimes remain visible.
Depending on the placement o the
deep sutures, it is possible or this tech-
nique to lead to some mild inversion o
the epidermal edges as they are pulled
inward by the suture material. This is
particularly the case when the suture is
nished with a xed knot holding the
ends o the suture material in a xed
position.
References
Ahmed AM, Orengo I. Surgical pearl: alternate
method o loading needle to acilitate subcu-
ticular suturing. J Am Acad Dermatol. 2007;56
(5 suppl):S105-106.

47
The Running Subcuticular Suture
Bickel KD, Gibbs NF, Cunningham BB. The sub-
cuticular “spider” stitch: a simple solution to
suture breakage and patient discom ort in long
incisions. Pediatr Dermatol. 1998;15(6):480-481.
Clay FS, Walsh CA, Walsh SR. Staples vs subcuticular
sutures or skin closure at cesarean delivery: a
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Am J Obstet Gynecol. 2011;204(5):378-383.
Figueroa D, Jauk VC, Szychowski JM, et al. Surgi-
cal staples compared with subcuticular suture
or skin closure a ter cesarean delivery: a
randomized controlled trial. Obstet Gynecol.
2013;121(1):33-38.
Genders RE, Hamminga EA, Kukutsch NA. Securing
the subcuticular running suture. Dermatol Surg.
2012;38(10):1722-1724.
Lazar HL, McCann J, Fitzgerald CA, Cabral HJ.
Adhesive strips versus subcuticular suture or
mediansternotomy wound closure. J Card Surg.
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Mashhadi SA, Loh CY. A knotless method o secur-
ing the subcuticular suture. Aesthet Surg J.
2011;31(5):594-595.
McKinley LH, Dorton DW. Modif ed intermediate
running subcuticular technique with nonabsorb-
able suture. Dermatol Surg. 2012;38(6):924-925.
Onwuanyi ON, Evbuomwan I. Skin closure during
appendicectomy: a controlled clinical trial
o subcuticular and interrupted transder-
mal suture techniques. J R Coll Surg Edinb.
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Retzla K, Agarwal S, Song DH, Dora shar AH. The
our-step subcuticular suture technique. Plast
Reconstr Surg. 2010;126(1):50e-51e.
Sanders RJ. Subcuticular skin closure–description
o technique. J Dermatol Surg. 1975;1(4):61-64.
Tuuli MG, Rampersad RM, Carbone JF, et al. Staples
compared with subcuticular suture or skin
closure a ter cesarean delivery: a systematic
review and meta-analysis. Obstet Gynecol.
2011;117(3):682-690.
Watts GT. Modif ed subcuticular skin suture. Br J
Plast Surg. 1956;9(1):83-84.
Williams IM, Wright DD, Hickman J. Subcuticular
wound closure: alternative method o securing
the suture. Br J Surg. 1994;81(9):1312.

48
incision line, beginning approximately
2-5 mm rom the apex. The needle is
passed rom this point, which is lateral
to the incision apex, directly through
the epidermis, exiting into the interior
o the wound just medial to the apex.
2. With the tail o the suture material
resting lateral to the incision apex and
outside the wound, the wound edge
is gently re ected back and the needle
is inserted into the dermis on the ar
edge o the wound with a trajectory
running parallel to the incision line.
The needle, and there ore the suture,
should pass through the dermis at a
uni orm depth. Bite size is dependent
on needle size, though in order to
minimize the risk o necrosis it may
be prudent to restrict the size o each
bite. The needle should exit the der-
mis at a point equidistant rom the
cut edge rom where it entered.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the nee-
dle driver. As the needle is reed rom
the tissue with the pickups, the needle
is grasped again by the needle driver in
an appropriate position to repeat the
earlier mentioned step on the contra-
lateral edge o the incised wound edge.
4. A small amount o suture material
is pulled through and the needle is
inserted into the dermis on the contra-
lateral side o the incised wound edge
and the same movement is repeated.
The needle should enter slightly
The Backing Out Running
Subcuticular Suture
C H A P T E R 4 . 7
Synonym
Backing out subcuticular suture
Video 4-7. Backing out
running subcuticular suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is an epidermal approximation tech-
nique suitable or wounds under minimal
to no tension in areas with an excellent
vascular supply. This technique should
almost never be employed in the absence
o a deep dermal suture, since its strength
is in f ne-tuning epidermal approximation
and it is ine ective in the presence o
signif cant tension.
Suture Material Choice
As with any technique, it is best to uti-
lize the thinnest suture possible or any
given anatomic location. Since the back-
ing out subcuticular suture technique
is not designed to hold tension, and its
utility is limited to f ne-tuning epider-
mal approximation, 5-0 or 6-0 suture is
generally adequate when adopting this
technique. This is especially important
since a large volume o suture material is
le t in situ when utilizing this approach.
It is best to utilize a monof lament suture
material to minimize the coe f cient o
riction at the time o suture removal.
Technique
1. The needle is inserted at the ar right
corner o the wound, parallel to the

49
The Backing Out Running Subcuticular Suture
proximal (relative to the wound apex
where the suture line began) to the
exit point, thus introducing a small
degree o backtracking to the snake-
like ow o the suture material.
5. The same technique is repeated on the
contralateral side o the incision line,
and alternating bites are then taken
rom each side o the incision line,
with continuing on until the end o
the wound is reached. At this point,
the needle is inserted rom the interior
o the wound in line with the incision
line and exits just lateral to the apex o
the wound.
6. A small roll o petrolatum gauze (or a
dental roll) is then inserted in the space
between the apex o the wound and
the exit point o the suture material.
The needle is then reinserted between
the petrolatum gauze and the wound
apex, securing the gauze in place and
exiting at the interior o the wound.
7. Moving in the opposite direction,
steps (1) through (5) are then repeated,
A
Figure 4-7A. Overview o the backing out running sub-
cuticular suture technique.
B
Figure 4-7B. The needle is inserted rom outside o
the apex o the wound into the wound interior.
C
Figure 4-7C. The needle is then inserted through
the superfcial dermis, running parallel to the incised
wound edge.
D
Figure 4-7D. This is sequentially repeated on opposite
wound edges.
with the suture material snaking an
alternating course through the super-
f cial dermis, using a backhand tech-
nique i desired.
8. A ter exiting lateral to the apex where
the closure began, a roll o petrolatum
gauze is again placed between the
two ends o the suture and the suture
material is tied o (Figures 4-7A
through 4-7J).

50
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
F
Figure 4-7F. When the opposite wound apex is
reached, the needle is inserted rom the deep dermis
lateral to the apex directly outward through the skin.
G
Figure 4-7G. A piece o rolled gauze may be placed as
a bolster as the needle is loaded in a backhand ashion.
H
Figure 4-7H. The needle then ollows along the super-
fcial dermis in the opposite direction, heading toward
the initial wound apex.
I
Figure 4-7I. Once the starting apex is reached, the
needle again enters rom the undermined deep dermis
medial to the apex, exiting the skin medial to its initial
insertion point.
J
Figure 4-7J. Another piece o rolled gauze is placed
as a bolster and the suture is tied. Note the slight
gaping at the center o the wound where it is under the
greatest tension.
E
Figure 4-7E. The technique continues along the length
o the wound.
Tips and Pearls
This is a niche technique, as the addition
o a second row o subcuticular suture
material in the wound probably does not
add signif cantly to wound security while
it doubles the amount o suture material
that will ultimately need to be removed.
As with the standard running subcuticu-
lar suture, body positioning may be very
help ul in maintaining an e f cient and
com ortable backing out subcuticular tech-
nique. Most surgeons are trained to work
with the surgical site at and perpendicular
to their body. Since the motions associated
with subcuticular suture placement are
90 degrees o rom this, it may be use ul
to stand with the surgeon’s body (shoulder
to shoulder) parallel to the incision line.

51
The Backing Out Running Subcuticular Suture
This allows or a owing motion rom
right to le t without the need to twist the
shoulders or wrists.
Since this approach requires the surgeon
to per orm the second hal o the closure
moving in the opposite direction, it may
be use ul to use a backhand technique or
many o the suture throws when moving
back toward the original wound apex. This
may add signif cantly to the time needed
to complete this closure while acility with
a backhand technique is improved.
As with the standard running sub-
cuticular approach, a smooth, owing
technique is o paramount importance in
executing this technique e ectively and
e f ciently. Some authors have advocated
adjusting the angle used to hold the needle
in the needle driver rom the traditional
90 degrees to 135 degrees to increase the
surgeon’s com ort and minimize the need
or physical contortion, though adjusting
the surgeon’s body position may obviate
the need or this adjustment.
Drawbacks and Cautions
Though it may be conceptualized as a
bidirectional subcuticular closure, the
extra row o sutures in this technique
adds little to wound security, as the entire
suture line is secured with a single knot.
There ore, it is not recommended as a
solitary closure approach, but rather it
is best utilized layered over the top o a
deeper suturing technique.
This technique results in leaving a
very signif cant quantity o oreign-body
material in the dermis in a continuous
ashion—essentially twice as much as
the running subcuticular technique. While
this may not represent a major problem
in areas with a thick dermis such as the
back, in other anatomical locations the
large quantity o suture that is le t in situ
may result in concerns regarding in ec-
tion, oreign-body reaction, and even
the potential that the suture material
itsel could present a physical barrier
that would impinge on the ability o the
wound to heal appropriately—an iatro-
genic eschar phenomenon.
The extra row o subcuticular sutures
used in this technique raises urther concern
regarding the possibility o tissue strangu-
lation along the wound margin that could
theoretically be associated with tightly
placed subcuticular sutures. It, there ore,
should be reserved or areas with an out-
standing vascular supply, such as the ace.
Removal o long-standing suture entails
a theoretical risk that a potential space—
albeit a thin and long one—is created
on the removal o the suture material.
This theoretical risk may be mitigated
by utilizing the thinnest possible suture
material, and this risk is higher in this
approach than in the standard subcuticu-
lar suturing technique.
There is sometimes a tendency or the
apices o the wound to develop exagger-
ated dog ears due to the tension vector
created when looping and tying the suture
material over the gauze bolsters lateral to
the apices. Minimizing tension across this
suture helps minimize this potential issue.
Reference
Huang L. The backing out subcuticular suture. Br J
Oral Maxillofac Surg. 2011;49(5):e22-23.

52
suture abscess ormation is greater with
the thicker 2-0 suture material, particu-
larly where the material has exited the
epidermis entirely. On the extremities,
a 3-0 or 4-0 absorbable suture material
may be used, and on the ace and areas
under minimal tension a 5-0 absorbable
suture is adequate.
Technique
1. The wound edge is re ected back
using surgical orceps or hooks.
In areas under marked tension, or
where ull visualization is not pos-
sible, the needle may be blindly
inserted rom the undermined space
without re ecting back the skin.
2. The suture needle is inserted at a
90-degree angle into the underside
o the dermis 4 mm distant rom the
incised wound edge.
3. The f rst bite travels rom the under-
side o the dermis in the undermined
space, passes entirely through the der-
mis, and exits through the epidermis
directly above the entry point.
4. The needle is then reloaded onto
the needle driver with a backhanded
technique, and inserted through the
epidermis either directly through the
same hole as the suture ollowed dur-
ing exit, or just medial to it. A shal-
low bite is taken and the needle exits
on the lateral margin o the incised
wound edge.
5. The needle is then reloaded, again in
a backhanded ashion, and is inserted
The Percutaneous Vertical
Mattress Suture
C H A P T E R 4 . 8
Synonym
Haneke-Marini suture, modif ed buried
vertical mattress suture
Video 4-8. Percutaneous
vertical mattress suture
Access to video can be ound via
SuturingTechniques.com.
Application
This technique is designed to allow or
excellent tension relie while concomi-
tantly permitting easy suture placement
in relatively tight spaces. It is best suited
to areas with thicker dermis, though it
may also be utilized in any body area
when tension-relieving sutures must be
placed and where insertion o the ull
needle is challenging.
Some authors have advocated this
technique as a replacement or stan-
dard buried suture approaches, and as
an easy to implement alternative to the
buried vertical mattress, while others
pre er to think o this as a niche approach
exclusively or areas where ully buried
approaches are more challenging.
Suture Material Choice
Suture choice is dependent in large part
on location. Because suture material trav-
els percutaneously, exiting the epidermis
and then reentering, the smallest gauge
suture material appropriate or the ana-
tomic location should be utilized. On the
back and shoulders, 2-0 or 3-0 absorb-
able suture material is e ective, though
theoretically the risk o suture spitting or

53
The Percutaneous Vertical Mattress Suture
into the contralateral incised wound
edge at the same depth as it exited
on the f rst side. The needle again
ollows a mirror-image superf cial
course through the dermis, exiting
through the epidermis again approxi-
mately 4 mm rom the wound edge.
Alternatively, this step may be com-
bined with the prior step and the
needle can be inserted into the con-
tralateral edge while it is still loaded
rom the initial pass exiting the
incised wound edge.
6. The needle is then loaded in a stan-
dard ashion and inserted either
through the same hole or just lateral
to it, ollowing a deeper course and
exiting the undersur ace o the der-
mis into the undermined space.
7. The suture material is then tied uti-
lizing an instrument tie (Figures 4-8A
through 4-8K).
A
Figure 4-8A. The percutaneous vertical mattress
suture is started by entering through the underside o
the undermined dermis and exiting directly upward
through the skin.
B
Figure 4-8B. The needle is then reinserted just medial
to its exit point relative to the wound edge, or directly
through the same hole, ollowing a superfcial course
through the dermis and exiting at the incised wound
edge.
D
Figure 4-8D. The needle then reenters through the
same hole or just lateral to it, ollowing a deeper
course and exiting through the underside o the dermis.
C
Figure 4-8C. The needle is then reinserted on the con-
tralateral wound edge ollowing a superfcial course.

54
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
E
I
Figure 4-8I. The needle then reenters through the
same hole or just lateral to it, ollowing a deeper
course and exiting through the underside o the dermis.
G
Figure 4-8G. The needle is then reinserted just medial
to its exit point relative to the wound edge, ollowing a
superfcial course through the dermis and exiting at the
incised wound edge.
H
Figure 4-8H. The needle is then reinserted on the
contralateral wound edge through the underside o the
undermined dermis.
J
Figure 4-8J. Immediate appearance a ter placement
o a single percutaneous vertical mattress suture. Note
the dimpling, which will resolve as the suture material
is absorbed.
Figure 4-8E. Cross-sectional view o the percutane-
ous vertical mattress technique.
F
Figure 4-8F. The needle enters through the underside
o the undermined dermis and exiting directly upward
through the skin.

55
The Percutaneous Vertical Mattress Suture
Tips and Pearls
This technique is ideal or use in areas
where placement o a traditional bur-
ied suture is challenging due to limited
space, such as the scalp and lower leg.
Even using small semicircular needles and
with extensive undermining, it may be
di f cult to insert the body o needle into
the undersur ace o the dermis in these
anatomic locations.
This technique may also be use ul when
placing an additional suture between two
reasonably tightly set sutures, and where
ull retraction o the wound edge is, there-
ore, impossible.
This approach may also be used when
it is di f cult to visualize the undersur ace
o the dermis, since the needle throws
may be placed in an almost blind ashion.
The skin is grasped gently to make it taut
and the needle is inserted through the
undermined space, exiting on the outside
o the skin. This may be executed by
eel, an approach well suited to the scalp,
where minimal dermal elasticity may
preclude ull exposure o the undersur ace
o the undermined dermis.
Finally, this technique may be utilized
when a buried suture needs to be placed
K
Figure 4-8K. Immediate postoperative appearance
a ter a series o percutaneous vertical mattress sutures
has been placed.
in an area that has not been undermined;
the initial suture placement, entering
rom the underside o the dermis, can
be per ormed blindly by sliding the needle
through the superf cial at and entering
rom the underside o the dermis.
Drawbacks and Cautions
Since suture material exits the skin and
then reenters, dimpling will likely occur.
Patients should be warned that this is
expected and will resolve with time.
Reentering the skin through the same
hole may help minimize the risk o dra-
matic dimpling, though this also increases
the chance that the suture material could
be cut by the needle.
Setting back the f rst throw ar rom
the incised wound edge may result in
overeversion; the chie draw back o
overeversion is that the dermis may
overhang the center o the incised wound
edge, barring the epidermal edges rom
approximating appropriately, leading to
a slightly wider f nal scar. This may be
easily solved by care ully beveling the
dermis to allow the epidermal edges to
meet unimpeded.
References
Marini L. The Haneke-Marini suture: not a “new”
technique. Dermatol Surg. 1995;21(9):819-820.
Sadick NS, D’Amelio DL, Weinstein C. The modi-
f ed buried vertical mattress suture. A new
technique o buried absorbable wound clo-
sure associated with excellent cosmesis or
wounds under tension. J Dermatol Surg Oncol.
1994;20(11):735-739.
See A, Smith HR. Partially buried horizontal mat-
tress suture: modi ication o the Haneke-
Marini suture. Dermatol Surg. 2004;30(12 pt 1):
1491-1492.
Vinciullo C, Bekhor P, Sinclair P, Richards S, Rosner L.
Credit where credit is due. The Haneke-Marini
suture: not a “new” technique. Dermatol Surg.
1995;21(9):819.

56
Technique
1. I possible, the wound edge is
re ected back using surgical orceps
or hooks. Adequate visualization o
the underside o the dermis is not
required.
2. While gently grasping the skin
edge, the suture needle is inserted
at 90 degrees into the underside o
the dermis 2-4 mm distant rom the
incised wound edge.
3. The f rst bite is executed by travers-
ing the dermis and piercing directly
up through the epidermis, with the
needle exiting the epidermis 2-4 mm
rom the incised wound edge.
4. The needle is then reloaded on the
needle driver in a backhand ashion
and inserted at 90 degrees just medial
to the exit point. The needle exits the
undermined sur ace o the dermis
into the undermined space between
the undersur ace o the dermis and
the deeper subcutaneous tissue,
medial to its entry point.
5. The needle is then reloaded, again
in a backhand ashion, and inserted
into the undersur ace o the dermis
on the contralateral wound edge,
2-4 mm distant rom the incised
wound edge. Depending on needle
size and the breadth o the wound,
this step may be combined with
the prior step, saving the need to
reload the needle. The needle should
The Percutaneous Set-Back
Dermal Suture
C H A P T E R 4 . 9
Synonym
Percutaneous Kantor suture
Video 4-9. Percutaneous
set-back dermal suture
Access to video can be found via

Application
This technique is designed primarily or
the closure o narrow wounds. In ana-
tomic locations such as the scalp and
lower leg, there is o ten insu f cient lax-
ity to permit the e ective visualization
o the undersur ace o the undermined
wound edge that would be ideal or the
placement o set-back dermal sutures.
This technique could theoretically be
utilized in other areas, though in prac-
tice the standard buried set-back dermal
suture should probably be utilized i at
all possible to e ect better wound-edge
approximation.
Suture Material Choice
On the scalp, a 3-0 or 4-0 absorbable
suture is probably best, as it allows or
robust closure in this area where tension
is occasionally moderate to severe. On the
lower legs, 3-0 or 4-0 absorbable suture
material may be used as well, as this area
is sometimes under marked tension. As
always, utilizing the smallest gauge suture
material that will permit adequate closure
under tension is best.

57
The Percutaneous Set-Back Dermal Suture
traverse the dermis and exit through
the epidermis 2-4 mm distant rom
the incised wound edge.
6. The needle is then reloaded in a stan-
dard ashion and inserted in the epi-
dermis just lateral to the exit point
at 90 degrees, exiting the undersur-
ace o the dermis in the undermined
space.
7. The suture material is then tied uti-
lizing an instrument tie (Figures 4-9A
through 4-9K).
Figure 4-9A. The needle is inserted from the underside
of the dermis in the undermined space directly upward
through the skin.
A
Figure 4-9B. The needle is then reinserted in a
backhand fashion just medial to its exit point, exiting
through the undersurface of the dermis in the under-
mined space.
B
Figure 4-9C. The needle is then inserted on the con-
tralateral side, again from the underside of the dermis,
exiting through the skin.
C
Figure 4-9D. The needle is then reinserted just lateral
to its exit point, exiting in the undermined space.
D

58
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-9E. Cross-sectional view of the percutaneous
set-back dermal suture.
E
Figure 4-9F. The needle is inserted from the underside
of the dermis in the undermined space directly upward
through the skin.
F
Figure 4-9G. The needle is then reinserted in a
backhand fashion just medial to its exit point.
G
Figure 4-9H. The needle exits through the undersur-
face of the dermis in the undermined space, now vis-
ible as it arcs toward the center of the wound.
H
Figure 4-9I. The needle is then inserted on the
contralateral side, again from the underside of the dermis,
exiting through the skin.
I
Figure 4-9J. The needle is then reinserted just lateral
to its exit point, exiting in the undermined space.
J

59
The Percutaneous Set-Back Dermal Suture
Tips and Pearls
A central advantage o this approach is its
ease o execution; since the suture pierces
the epidermis and dermis at a 90-degree
angle, there is no need to change planes,
e ect a heart-shaped suture placement,
or guarantee that the suture exit point is
precisely at the inside edge o the lower
dermis, as may be needed with other
techniques.
This technique is also appropriate in
areas where extensive undermining is
not possible; since the undersur ace o
the dermis does not need to be visual-
ized to e ectively place the sutures, the
throws can be essentially placed blindly.
An important theoretical advantage o
this approach over other percutaneous
approaches is that no suture material
is le t between the wound edges. Since
even absorbable suture material may rep-
resent a physical impediment to wound
healing, this is an important benef t that
this approach shares with the standard
set-back dermal suture technique.
This technique may also be use ul
when adding additional sutures to an
already largely closed wound. In these
cases there may not be su f cient room
to insert a traditional vertically oriented
buried suture, both as the space avail-
able to insert the needle driver is limited
and the degree o possible wound-edge
K
Figure 4-9K. Immediate postoperative appearance.
Note the marked wound eversion.
re ection is limited by the presence o
surrounding buried sutures. In these
cases, a percutaneous set-back dermal
suture can be easily executed.
Drawbacks and Cautions
The percutaneous set-back dermal
approach creates signif cant wound ever-
sion, and the degree o eversion elicited
by this approach may be more marked
than that seen with the standard set-back
dermal suture approach. This pronounced
eversion may lead the epidermal portion
o the wound edges to separate as the der-
mis is brought together, as the epidermal
edges ail to drape together as they would
normally do with the standard set-back
dermal technique.
There are tw o possible approaches
to this situation: (1) Superf cial running
or interrupted sutures may be placed to
better approximate the epidermal edges,
and (2) The de ect could be removed
with an inward bevel (as is done with the
butter y suture technique), or the dermis
may be incised at an inward bevel a ter
the original de ect is created, permitting
the epidermal edges to come together
gently even in the ace o the marked
eversion seen with this approach. Many
clinicians avor a bilayered approach in
general, and there ore placing the epi-
dermal sutures is an easy solution and
does not require the degree o preplan-
ning associated with the bevel approach,
though a combination o the two solu-
tions may be utilized as well.
Patients should be cautioned that they
might develop a signif cant ridge in the
immediate postoperative period. Depend-
ing on the suture material used and the
density o the sutures, this ridge may last
rom weeks to months. Explaining that
the technique is akin to placing a subcuta-
neous splint may help the patient develop
reasonable and realistic expectations and

60
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
reduce anxiety regarding the immediate
postoperative appearance o the wound.
Epidermal dimpling will o ten occur
with this approach, since the suture
material traverses the epidermis. A small
degree o dimpling will resolve with time
as the absorbable sutures are gradually
resorbed, and patients should be warned
that this is a likely occurrence and that it
is o no long-term clinical consequence.
Since suture material traverses the epi-
dermis, there is a theoretically greater
risk o in ection with this technique than
with approaches that remain entirely
buried on the undersur ace o the dermis.
Meticulous attention to sterile technique
may help mitigate this theoretical risk,
and anecdotally in ection is seen no more
requently with this approach than with
any other closure technique.
Reference
Kantor J. The percutaneous set-back dermal suture.
J Am Acad Dermatol. 2015;72(2):e61-2.

61
Technique
1. The wound edge is re ected back
using surgical orceps or hooks. In
areas under marked tension, or where
ull visualization is not possible, the
needle may be blindly inserted rom
the undermined space.
2. The suture needle is inserted per-
pendicular to the incision line at a
90-degree angle into the underside
o the dermis 4 mm distant rom the
incised wound edge.
3. The f rst bite is started by ollowing
the needle and traversing rom the
underside o the dermis in the under-
mined space and passing entirely
through the dermis and exiting the
skin.
4. The needle is then reloaded onto the
needle driver and inserted through
the epidermis either directly through
the same hole as the suture ollowed
during exit, or just distal to it, with
the needle-oriented parallel to the
incision line. A shallow bite is taken,
staying in the superf cial dermis, exit-
ing on the same side o the incision
line distal to the entry point.
5. The needle is then reloaded and
inserted into the same hole or just
medial to it, while being held per-
pendicular to the incision line. The
needle should travel through the
ull thickness o the skin, exiting on
the undersur ace o the undermined
dermis.
The Percutaneous Horizontal
Mattress Suture
C H A P T E R 4 . 1 0
Synonym
Buried horizontal mattress suture
Video 4-10. Percutaneous
horizontal mattress suture
Access to video can be ound via
SuturingTechniques.com.
Application
As with other percutaneous approaches,
this technique is designed to allow or
excellent tension relie while concomi-
tantly permitting easy suture placement
in relatively tight spaces. It is best suited
to areas with thicker dermis, though it
may also be utilized in any body area
when tension-relieving sutures must be
placed and where insertion o the ull
needle is challenging.
Suture Material Choice
Suture choice is dependent in large part on
location. Though suture material travels
percutaneously, exiting the epidermis and
then reentering, the smallest gauge suture
material appropriate or the anatomic
location should be utilized. On the back
and shoulders, 2-0 or 3-0 suture material
is e ective, though theoretically the risk
o suture spitting or suture abscess orma-
tion is greater with the thicker 2-0 suture
material, particularly where the material
has exited the epidermis entirely. On the
extremities, a 3-0 or 4-0 absorbable suture
material may be used, and on the ace
and areas under minimal tension a 5-0
absorbable suture is adequate.

62
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
6. The needle is then reloaded and
enters the undersur ace o the under-
mined dermis on the contralateral
wound edge, exiting through the sur-
ace o the epidermis. This step may
be combined with the prior step and
the needle can be inserted into the
contralateral wound edge while it is
still loaded rom the initial pass.
7. The needle is then loaded and inserted
either through the same hole or just
proximal to it, oriented parallel to
the incision line but in the opposite
Figure 4-10A. Overview o the percutaneous horizontal
mattress suture technique.
A
Figure 4-10B. First step o the percutaneous horizontal
mattress suture technique. Note that the needle is
inserted through the undersur ace o the undermined
dermis directly upward, exiting the skin set back rom
the wound edge.
B
Figure 4-10C. The needle is reinserted directly adja-
cent to its exit point (or even through the same hole
as it exited), now parallel to the incised wound edge.
C
direction as in step 4, ollowing a
superf cial course and exiting on the
same side o the incision line proxi-
mal to the incision entry point.
8. The needle is then reloaded in a
standard ashion and inserted either
through the same hole or just medial
to it perpendicular to the incision
line, exiting on the undersur ace o
the undermined dermis.
9. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-10A
through 4-10J).
Figure 4-10D. The needle passes superfcially through
the dermis, exiting at a point equidistant rom the
incised wound edge.
D

63
The Percutaneous Horizontal Mattress Suture
Figure 4-10F. The needle is inserted on the contra-
lateral wound edge through the undersur ace o the
undermined dermis, directly upward, again exiting the
skin set back rom the wound edge.
F
Figure 4-10G. The needle is reinserted directly adja-
cent to its exit point (or even through the same hole as
it exited), now parallel to the incised wound edge, in
the direction o the initial entry point.
G
Figure 4-10H. The needle is then reinserted directly
adjacent to its exit point (or through the same hole),
now oriented perpendicular to the wound edge, exiting
in the open wound space.
H
Figure 4-10I. Wound appearance a ter placement o a
single percutaneous horizontal mattress suture.
I
Figure 4-10J. Final wound appearance. Note the
marked wound-edge eversion.
J
Figure 4-10E. The needle is then reinserted directly
adjacent to its exit point (or even through the same
hole), now oriented perpendicular to the wound edge to
permit it to traverse the wound.
E

64
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Tips and Pearls
This technique is best or use in areas
where placement o a traditional buried
suture is challenging due to limited space,
such as the scalp and lower leg. Even
a ter using small semicircular needles and
with extensive undermining, it may be
di f cult to insert the body o needle into
the undersur ace o the dermis in these
anatomic locations.
This approach may also be used when
it is di f cult to visualize the undersur ace
o the dermis, since the needle throws
may be placed in an almost blind ashion.
The skin is grasped gently to make it
taught and the needle is inserted through
the undermined space, exiting on the
outside o the skin. This may be executed
by eel, an approach well suited to the
scalp where minimal dermal elasticity
precludes ull exposure o the undersur-
ace o the undermined dermis. The ear
is another area where this approach may
be very use ul, since the limited elastic-
ity o the thin dermis on the helix may
make placement o traditional vertically
oriented buried sutures challenging.
Drawbacks and Cautions
Since suture material exits the skin and
then reenters, dimpling may occur.
Patients should be warned that this is
expected and will resolve with time,
though residual dyspigmentation is
certainly possible. Reentering the skin
through the same hole may help mini-
mize the risk o dramatic dimpling.
Setting back the f rst throw ar rom
the incised wound edge may result in
over-eversion; the chie drawback o over-
eversion is that the dermis may over-
hand in the center o the incised wound
edge, barring the epidermal edges rom
approximating appropriately, leading to
a slightly wider f nal scar. This may be
easily solved by care ully beveling the
dermis to allow the epidermal edges to
meet unimpeded.
Theoretically, horizontally oriented
sutures may con er a slightly increased risk
o epidermal-edge necrosis, since suture
material has the potential to constrict the
small vessels supplying the wound margin.
That said, this complication is rarely seen
in practice as long as the bite size is not
overly large and suture material is not tied
with excessive tension.
References
Epstein E. The buried horizontal mattress suture.
Cutis. 1979;24(1):104-106.
See A, Smith HR. Partially buried horizontal mattress
suture: modif cation o the Haneke-Marini suture.
Dermatol Surg. 2004;30(12 pt 1):1491-1492.

65
Technique
1. The wound edge is re ected back
using surgical orceps or hooks.
2. While re ecting back the dermis,
the suture needle is inserted at
90 degrees into the underside o the
dermis 2 mm distant rom the incised
wound edge.
3. The f rst bite is executed by ollow-
ing the curvature o the needle and
allowing the needle to exit in the
incised wound edge. The size o
this bite is based on the size o the
needle, the thickness o the dermis,
and the need or and tolerance o
eversion. The needle’s zenith with
respect to the wound sur ace should
be between the entry and exit points.
4. Keeping the loose end o suture
between the surgeon and the patient,
the dermis on the side o the f rst bite
is released. The tissue on the oppo-
site edge is then gently grasped with
the orceps.
5. The second bite is executed by insert-
ing the needle into the incised wound
edge at the level o the superf cial
papillary dermis. This bite should
be completed by ollowing the cur-
vature o the needle and avoiding
catching the undersur ace o the epi-
dermis that could result in epidermal
dimpling. It then exits approximately
2 mm distal to the wound edge on
the undersur ace o the dermis. This
should mirror the f rst bite taken on
the contralateral side o the wound.
The Running Buried
Dermal Suture
C H A P T E R 4 . 1 1
Video 4-11. Running buried
dermal suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a hybrid technique, combining
the tension relie and lack o transepi-
dermal suture placement o a classic
buried suture with the rapidity o place-
ment and lack o resilience o a super-
f cial running technique. This is a niche
approach, since the running nature o
the technique means that compromise at
any point in the course o suture place-
ment may result in wound dehiscence.
There ore, unless absolutely necessary,
this approach should not be utilized as
a solitary technique or the closure o
most wounds.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate
or the anatomic location should be
utilized. On the back and shoulders,
3-0 suture material is e ective, though
i there is marked tension across the
w ound this approach w ould not be
appropriate as the primary closure,
and would be used best or its pulley
benef ts. On the extremities, a 3-0 or
4-0 absorbable suture material may be
used, and on the ace and areas under
minimal tension a 5-0 absorbable suture
is adequate.

66
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repairs
A
Figure 4-11A. Overview o the running buried dermal
suture.
B
Figure 4-11B. Beginning o the frst anchoring throw
o the buried running dermal suture. The needle
entered the deep dermis and ollowed its curvature,
exiting at the incised wound edge.
C
Figure 4-11C. The needle is then reinserted at the
incised edge on the contralateral wound edge, and
again ollows its curvature, exiting the deep dermis.
The suture is then tied o .
D
Figure 4-11D. First running step o the technique,
again ollowing the curvature o the needle.
E
Figure 4-11E. The running throw is completed. These
continue successively along the course o the wound.
6. This f rst anchoring suture is then
tied with an instrument tie.
7. The procedure is then repeated sequen-
tially, repeating steps (2) through (5) in
sets while moving proximally toward
the surgeon or as many throws as
are desired, without placing any addi-
tional knots until the desired number
o loops have been placed.
8. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-11A
through 4-11F). The f nal anchoring
knot is tied by leaving a loop on the
penultimate throw, and tying the ree
end o suture material rom the f nal
throw to this loop. The ends o the
suture are then trimmed.

67
The Running Buried Dermal Suture
F
Figure 4-11F. Immediate postoperative appearance.
Tips and Pearls
This technique may be used as a modi-
f ed winch or pulley suture, since the
multiple loops help minimize the tension
across any one loop and permit closure o
wounds under marked tension. Because
each throw is not tied o , however, it is
important to adequately secure the f rst
and f nal throws with a well-locked knot.
Given the theoretical susceptibility to
suture material breakage or compromise,
this is a technique that is probably best
used in a layered ashion, either superf -
cial to previously placed deep interrupted
buried sutures, or deep to a set o more
superf cially placed buried sutures.
I braided absorbable suture is used,
the added riction between loops may
help lock the suture material in place
with each throw, but caution should be
taken to pull su f cient suture material
with each throw, as this riction may
impede the surgeon’s ability to pull suture
material through the course o multiple
loops. Similarly, i monof lament suture
is used it may be easier to pull the addi-
tional suture material through but it may
make it more di f cult to lock the suture
in place be ore tying.
It may be benef cial to place the running
sutures closer together toward the center
o the wound than at the poles o the inci-
sion, as this may oster a more pronounced
pulley e ect at the center o the wound
where the tensile orces are greatest.
Given the concern regarding knot
breakage, it may be help ul to attempt
to better secure the f rst and f nal knots
at the ends o the running series o loops.
This may be done by paying particularly
close attention to knot tying, tying an
extra ull knot, adding extra throws, or
leaving a longer tail than would tradition-
ally be executed. An additional approach
is to secure the f nal knot with the aid
o a tacking knot, which may similarly
provide extra security.
Drawbacks and Cautions
As noted previously, this approach should
usually not be used as a solitary closure
technique, since there is no redundancy in
the closure. It may be use ul as an adjunct
when there is either minimal tension
across a wound (and there ore interrupted
buried sutures may be unnecessary) or as
a pulley approach to bring recalcitrant
wound edges together.
Like the standard buried dermal suture,
this approach provides less wound ever-
sion than other approaches such as the
set-back dermal or buried vertical mat-
tress; there ore, a running variation o
the latter two techniques may o ten be
pre erred to a buried running dermal
approach, since wound eversion may
be associated with improved cosmesis
over the long term.
References
Ftaiha Z, Snow SN. The buried running dermal
subcutaneous suture technique. J Dermatol Surg
Oncol. 1989;15(3):264-266.
Skaria AM. The buried running dermal subcutane-
ous suture with a tacking knot. Dermatol Surg.
2002;28(8):739-741.

68
On the extremities, a 3-0 or 4-0 absorb-
able suture material may be used, and on
the ace and areas under minimal tension
a 5-0 absorbable suture is adequate. While
this approach should probably not be
routinely utilized on the back, using a 2-0
absorbable suture on the back with this
technique results in only vanishingly rare
complications, since the thicker suture
remains largely on the underside o the
dermis, and suture spitting is an uncom-
mon occurrence.
Braided suture material will allow or
better locking o the suture in place,
though it w ill also impede the sur-
geon’s ability to pull suture material
through multiple loops, and there ore
adequate suture material should be
pulled through w ith each loop. Mono-
lament absorbable suture material will
pull through more easily, though the
lower coe cient o riction means that
it w ill easily slide back through the
w ound and it w ill there ore not lock
in place until tied.
Technique
1. The wound edge is ref ected back
using surgical orceps or hooks.
Adequate visualization o the under-
side o the dermis is required.
2. While ref ecting back the dermis, the
suture needle is inserted at 90 degrees
into the underside o the dermis
2-6 mm distant rom the incised
wound edge.
The Running Set-Back
Dermal Suture
C H A P T E R 4 . 1 2
Synonym
Running Kantor suture; running set-back
suture
Video 4-12. Running set-back
dermal suture
Access to video can be found via

Application
This approach is best used in areas under
mild to moderate tension, as it is a running
technique that allows rapid placement o
multiple buried suture throws. It may be
utilized in a variety o anatomic locations,
including the ace, neck, and extremities.
While it may be utilized on the trunk,
interrupted set-back sutures are generally
more appropriate in this location.
Since it is a running technique, it may
be associated with a higher risk o dehis-
cence, as interruption o the suture mate-
rial in any point in its course would lead
to loss o e ectiveness o the entire suture
line. There ore, it is o ten used in concert
with other sutures techniques rather than
as a sole closure approach.
Suture Material Choice
Suture choice is dependent in large part
on location. Though this technique is
designed to bite the deep dermis and
remain buried well below the wound
sur ace, the surgeon may choose to utilize
a larger gauge suture than would be used
or an equivalently placed running simple
or running buried vertical mattress suture.

69
The Running Set-Back Dermal Suture
3. The rst bite is executed by travers-
ing the dermis ollowing the curva-
ture o the needle and allowing the
needle to exit closer to the incised
wound edge. Care should be taken to
remain in the dermis to minimize the
risk o epidermal dimpling. The nee-
dle does not, however, exit through
the incised wound edge, but rather
1-4 mm distant rom the incised
edge. The size o this rst bite is
based on the size o the needle, the
thickness o the dermis, and the need
or and tolerance o eversion.
4. Keeping the loose end o suture
between the surgeon and the patient,
the dermis on the side o the rst bite
is released. The tissue on the oppo-
site edge is then ref ected back in a
similar ashion as on the rst side,
assuring complete visualization o
the underside o the dermis.
5. The second bite is executed by insert-
ing the needle into the underside o
Figure 4-12A. Overview of the running set-back
dermal suture.
A
Figure 4-12B. The anchoring suture: a set back
dermal suture is started at the wound apex, and the
needle is inserted into the underside of the dermis
set-back from the wound edge.
B
the dermis 1-6 mm distant rom the
incised wound edge. Again, this bite
should be executed by ollowing the
curvature o the needle and avoiding
catching the undersur ace o the epi-
dermis that could result in epidermal
dimpling. It then exits urther distal
to the wound edge, approximately
2-6 mm distant rom the wound
edge. This should mirror the rst bite
taken on the contralateral side o the
wound.
6. A knot is tied using an instrument tie
to secure the suture in place. The tail
end o the suture is cut with mini-
mal to no tail, and the needle, now
attached to suture material that is
securely anchored in the dermis, is
reloaded.
7. Steps (1) through (5) may then be
repeated in pairs, moving toward
the surgeon, but without tying addi-
tional knots with each throw.
8. Once the end o the wound is
reached, the suture material is tied
utilizing an instrument or hand tie
(Figures 4-12A through 4-12G). The
nal anchoring knot is tied by leaving
a loop on the penultimate throw, and
tying the ree end o suture material
rom the nal throw to this loop. The
ends o the suture are then trimmed.

70
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
D
Figure 4-12D. The suture material is tied off, complet-
ing the anchoring set-back dermal suture, and the short
end of the suture material is trimmed.
E
Figure 4-12E. The needle is then inserted into the
dermis, exiting set-back from the wound edge, moving
along the wound edge.
F
Figure 4-12F. The needle is then inserted on the
contralateral wound edge. This alternating pattern is
continued along the length of the wound.
G
Figure 4-12G. Immediate postoperative appearance.
Note the pronounced eversion and excellent wound-
edge approximation.
Figure 4-12C. The needle is then inserted at the
contralateral side in a similar fashion.
C
Tips and Pearls
As with any running buried technique,
this approach provides the bene t o per-
mitting rapid placement o a long string
o tension relieving sutures. The pulley
e ect o the multiple throws also permits
e ective closure o wounds under even
marked tension.
That said, it is critical to ocus on out-
standing knot security, since the entire
suture line is held in place by the knots
at the beginning and end o the set o
suture throws.
Adding an additional tacking knot,
when utilizing this approach is an option
as well. It may provide additional knot
security. Alternatively, one could con-
sider placing an additional knot or leaving
a longer suture tail when utilizing this
approach.
A theoretical bene t o the running
approach is that there is less suture mate-
rial le t in situ, since the bulk o retained
absorbable suture material is in the knots;

71
The Running Set-Back Dermal Suture
as there are knots only at the beginning
and end o the row o sutures, this tech-
nique theoretically decreases the risk o
suture spitting and suture abscess orma-
tion. Still, the set-back approach leaves
suture material deep to the undersur ace
o the dermis, and there ore the risk o
suture spitting and suture abscess orma-
tion is negligible.
This is an easy to execute running
buried suture approach; since the suture
ollows the arc o the needle on the
undersur ace o the dermis there is no
need to change planes, e ect a heart-
shaped suture placement, or guarantee
that the suture exit point is precisely at
the inside edge o the lower dermis, as
may be needed with the running buried
vertical mattress suture.
Accurate suture placement is predi-
cated on having a su ciently undermined
plane, since the entire suture loop lays on
the undersur ace o the dermis. There ore,
broad undermining is a prerequisite or
utilizing this technique, since each throw
o the needle begins 2-6 mm distant rom
the incised wound edge on the under-
mined undersur ace o the dermis.
Suture throws may be placed closer
together toward the higher-tension areas
at the center o the wound to permit
greater mechanical advantage and to
allow the pulley e ect to have a more
pro ound impact at the center o the
wound. The throws may then be spaced
arther apart toward the apices where
the pulley e ect is neither needed nor
desired, allowing minimization o the
quantity o retained buried absorbable
suture material le t in the wound.
Drawbacks and Cautions
The main drawback o this approach
is the same as with any running buried
suture. The integrity o the entire suture
line rests on the quality o the knots at
each end o the row o sutures. There ore,
attention to detail when tying these knots
is o paramount importance.
This approach should there ore not be
used as a solitary closure technique, but
rather may be used deep to interrupted
transepidermal sutures or super cial to
ascial plication sutures, to a ord greater
redundancy and add to the resilience o
the closure.
The running set-back dermal approach
creates signi cant wound eversion, and
the degree o eversion elicited by this
approach may, depending on how ar
set-back the dermal bite is taken, elicit
signi cantly more wound eversion than
even the running buried vertical mattress
technique.
Patients should be cautioned that they
might develop a signi cant ridge in the
immediate postoperative period. Depend-
ing on the suture material used and the
density o the sutures, this ridge may last
rom weeks to months.
Epidermal dimpling w ill occasion-
ally occur where the arc o the suture
reaches its apex at the dermal-epidermal
junction; on the ace and areas w ith
thin dermis this should be assiduously
avoided. In truncal areas or those with
thick dermis, how ever, a small degree
o dimpling w ill resolve w ith time as
the absorbable sutures are gradually
resorbed. Since tension is distributed
broadly across multiple suture loops,
the dimpling is not usually overly
pronounced, as the tension averages
across multiple throw s and there ore
it is less likely that any one area will
yield marked dimpling.
Reference
Kantor J. The running set-back dermal suture. J Am
Acad Dermatol. 2015;72:e163-4.

72
back, using a 2-0 or 3-0 absorbable suture
in this area would be appropriate.
Braided suture material w ill allow
or better locking o the suture in place,
though it will also impede the surgeon’s
ability to pull suture material through
multiple loops, and there ore adequate
suture material should be pulled through
with each loop. Mono lament absorbable
suture material will pull through more
easily, though the lower coe cient o
riction means that it will easily slide back
through the wound and it will there ore
not lock in place until tied.
Technique
1. The wound edge is ref ected back
using surgical orceps or hooks. Ade-
quate visualization o the underside
o the dermis is required.
2. While ref ecting back the dermis,
the suture needle is inserted at 90
degrees into the underside o the
dermis 4 mm distant rom the incised
wound edge.
3. The rst bite is executed by ollow-
ing the needle initially at 90 degrees
to the underside o the dermis and
then, critically, changing direction
by twisting the needle driver so that
the needle exits in the incised wound
edge. This allows the apex o the
bite to remain in the papillary dermis
while the needle exits in the incised
wound edge at the level o the reticu-
lar dermis.
The Running Buried
Vertical Mattress Suture
C H A P T E R 4 . 1 3
Synonym
Zipper stitch
Video 4-13. Running buried
vertical mattress suture
Access to video can be ound via
SuturingTechniques.com.
Application
This approach is best used in areas under
mild to moderate tension, as it is a run-
ning technique that allows rapid place-
ment o multiple buried suture throws. It
may be utilized in a variety o anatomic
locations, including the ace, neck, and
extremities. While it may be utilized on
the trunk, interrupted buried vertical mat-
tress sutures are generally more appropri-
ate in this location.
Since it is a running technique, it may
be associated with a higher risk o dehis-
cence, as interruption o the suture mate-
rial in any point in its course would lead
to loss o e ectiveness o the entire suture
line. There ore, it is o ten used in concert
with other sutures techniques rather than
as a sole closure approach.
Suture Material Choice
Suture choice is dependent in large part
on location. On the extremities, a 3-0 or
4-0 absorbable suture material may be
used, and on the ace and areas under
minimal tension a 5-0 absorbable suture
is adequate. While this approach should
probably not be routinely utilized on the

73
The Running Buried Vertical Mattress Suture
4. Keeping the loose end o suture
between the surgeon and the patient,
the dermis on the side o the rst bite
is released. The tissue on the oppo-
site edge is then ref ected back in a
similar ashion as on the rst side.
5. The second bite is executed by
inserting the needle into the incised
wound edge at the level o the reticu-
lar dermis. It then angles upward
and laterally so that the apex o the
needle is at the level o the papillary
dermis. This should mirror the rst
bite taken on the contralateral side o
the wound.
6. A knot is tied using an instrument tie
to secure the suture in place. The tail
end o the suture is cut with mini-
mal to no tail, and the needle, now
attached to suture material that is
securely anchored in the dermis, is
reloaded.
7. Steps (1) through (5) may then be
repeated, moving in pairs toward the
Figure 4-13A. Overview o the running buried vertical
mattress suture technique.
A
Figure 4-13B. Beginning o the frst anchoring throw
o the running buried vertical mattress suture. Note
that the needle has moved outward and upward be ore
exiting at the incised wound edge.
B
Figure 4-13C. Completion o the frst anchoring throw.
The needle entered at the incised wound edge. The
suture material is then tied o .
C
surgeon with each set o throws, but
without tying additional knots with
each throw.
Figure 4-13D. Initiation o the running component o
the technique per ormed in the same ashion as the
initial anchoring suture.
D

74
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
E
Figure 4-13E. Continuation o the running row o
sutures.
F
Figure 4-13F. Immediate postoperative appearance.
Note the wound eversion.
8. Once the end o the wound is
reached, the suture material is tied
utilizing an instrument or hand tie
(Figures 4-13A through 4-13F). This
nal anchoring knot is tied by leaving
a loop on the penultimate throw, and
tying the ree end o suture material
rom the nal throw to this loop. The
ends o the suture are then trimmed.
That said, it is critical to ocus on out-
standing knot security, since the entire
suture line is held in place by the knots
at the beginning and end o the set o
suture throws.
Adding an additional tacking knot
when utilizing this approach is an option
as well, as it may provide additional knot
security. Alternatively, one could con-
sider placing an additional knot or leaving
a longer suture tail when utilizing this
approach.
A theoretical bene t o the running
approach is that there is less suture mate-
rial le t in situ, since the bulk o retained
absorbable suture material is in the knots;
as there are knots only at the beginning and
end o the row o sutures, this technique
theoretically decreases the risk o suture
spitting and suture abscess ormation.
Suture throws may be placed closer
together toward the higher-tension areas
at the center o the wound to permit
greater mechanical advantage and to
allow the pulley e ect to have a more
pro ound impact at the center o the
wound. The throws may then be spaced
arther apart toward the apices where
the pulley e ect is neither needed nor
desired, allowing minimization o the
quantity o retained buried absorbable
suture material le t in the wound.
Drawbacks and Cautions
The main drawback o this approach
is the same as with any running buried
suture. The integrity o the entire suture
line rests on the quality o the knots at
each end o the row o sutures. There ore,
attention to detail when tying these knots
is o paramount importance.
This approach should there ore probably
not be used as a solitary closure technique,
but rather may be used deep to interrupted
transepidermal sutures or super cial to
ascial plication or deeper buried dermal
Tips and Pearls
As with any running buried technique,
this approach provides the bene t o per-
mitting rapid placement o a long string
o tension relieving sutures. The pulley
e ect o the multiple throws also permits
e ective closure o wounds under even
marked tension.

75
The Running Buried Vertical Mattress Suture
sutures, to a ord greater redundancy and
add to the resilience o the closure.
Patients should be cautioned that they
may develop a signi cant ridge in the
immediate postoperative period. Depend-
ing on the suture material used and the
density o the sutures, this ridge may last
rom weeks to months.
Epidermal dimpling will occasionally
occur where the arc o the suture reaches
its apex at the dermal-epidermal junction;
on the ace and areas with thin dermis this
should be assiduously avoided. In truncal
areas or those with thick dermis, however,
a small degree o dimpling will resolve with
time as the absorbable sutures are gradually
resorbed. Since tension is distributed
broadly across multiple suture loops, the
dimpling is not usually overly pronounced,
as the tension averages across multiple
throws and there ore it is less likely that
any one area will yield marked dimpling.
References
Ftaiha Z, Snow SN. The buried running dermal
subcutaneous suture technique. J Dermatol Surg
Oncol. 1989;15(3):264-266.
Skaria AM. The buried running dermal subcutaneous
suture technique with a tacking knot. Dermatol
Surg. 2002;28(8):739-741.
Yag-Howard C. Zipper stitch: a novel aesthetic
subcutaneous closure. Dermatol Surg.
2013;39(9):1400-1402.

76
Technique
1. I possible, the wound edge is re ected
back using surgical orceps or hooks.
Adequate visualization o the under-
side o the dermis is not required.
2. While gently grasping the skin edge,
the suture needle is inserted at 90
degrees into the underside o the der-
mis 2-4 mm distant rom the incised
wound edge.
3. The f rst bite is executed by travers-
ing the dermis and piercing directly
up through the epidermis, with the
needle exiting the epidermis 2-4 mm
rom the incised wound edge.
4. The needle is then reloaded on the
needle driver in a backhand ashion
and inserted at 90 degrees just medial
to the exit point. The needle exits the
undermined sur ace o the dermis
into the undermined space between
the undersur ace o the dermis and
the deeper subcutaneous tissue.
5. The needle is then reloaded, again
in a backhand ashion, and inserted
into the undersur ace o the dermis
on the contralateral wound edge,
2-4 mm distant rom the incised
wound edge. Depending on needle
size and the breadth o the wound,
this step may be combined with the
prior step, saving the need to reload
the needle. The needle should tra-
verse the dermis and exit through
the epidermis 2-4 mm distant rom
the incised wound edge.
The Running Percutaneous
Set-Back Dermal Suture
C H A P T E R 4 . 1 4
Synonym
Running percutaneous Kantor suture
Video 4-14. Running
percutaneous set-back
dermal suture
Access to video can be found via

Application
This is a niche technique appropriate
or the closure o narrow wounds under
modest tension. In anatomic locations
such as the scalp and lower leg, there is
o ten insu f cient laxity to permit e ective
visualization o the undersur ace o the
undermined wound edge that would be
ideal or the placement o running set-
back dermal sutures.
Since this is a running technique, it
may be associated with a higher risk o
dehiscence, as interruption o the suture
material in any point in its course or o
one o the knots would lead to loss o
e ectiveness o the entire suture line.
Suture Material Choice
On the scalp, a 3-0 or 4-0 absorbable
suture is probably best, as it allows or
robust closure in this area where tension
is occasionally moderate to severe. On the
lower legs, 3-0 or 4-0 absorbable suture
material may be used as well, as this area
is sometimes under marked tension. As
always, utilizing the smallest gauge suture
material that will permit adequate closure
under tension is best.

77
The Running Percutaneous Set-Back Dermal Suture
6. The needle is then reloaded in a stan-
dard ashion and inserted in the epi-
dermis just lateral to the exit point at
90 degrees, exiting the undersur ace o
the dermis in the undermined space.
7. The suture material is then tied uti-
lizing an instrument tie, and the trail-
ing end o the suture is trimmed.
Figure 4-14A. Overview of the running percutaneous
set-back dermal suture.
A
Figure 4-14B. The needle is inserted from the undermined
underside of the dermis directly up and through the skin.
B
Figure 4-14C. The needle is then reinserted just
medial to its exit point, again penetrating directly
through the skin and exiting in the undermined space.
C
Figure 4-14D. The needle is reinserted on the con-
tralateral side, through the undermined dermis and
directly up and through the skin.
D
8. Moving proximally toward the sur-
geon, steps (1) through (6) are then
repeated in pairs; once the desired
number o throws are placed, the
suture material is then tied o in a
secure ashion utilizing an instru-
ment tie (Figures 4-14A through 14J).
The f nal anchoring knot is tied by
leaving a loop on the penultimate
throw, and tying the ree end o
suture material rom the f nal throw
to this loop. The ends o the suture
are then trimmed.

78
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-14F. After tying, the needle is inserted
further along the wound edge from the underside of the
dermis and up through the skin.
F
Figure 4-14G. The needle is then reinserted just medial
to its exit point, exiting the underside of the dermis.
G
Figure 4-14H. The needle is then inserted on the con-
tralateral wound edge from the underside of the dermis
and up through the skin.
H
Figure 4-14I. The needle is then reinserted just lateral
to its exit point, exiting the underside of the dermis.
This pattern continues along the length of the wound
until the apex is reached. At that point, the suture
material is tied and the knot is buried.
I
Figure 4-14J. Immediate postoperative appearance.
J
Figure 4-14E. The needle is then reinserted just
lateral to its exit point, again penetrating directly
through the skin and exiting in the undermined space.
The suture material is then tied and the short end is
trimmed.
E

79
The Running Percutaneous Set-Back Dermal Suture
Tips and Pearls
As noted previously, this is an in re-
quently utilized approach, and is best
or closing areas under mild to moderate
tension when other running approaches
are not easible. Since knots are tied only
at the beginning and the end o the entire
line o sutures, this technique is aster
than utilizing standard interrupted percu-
taneous set-back dermal sutures, though
this benef t must be weighed against the
increased risk o suture line compromise
with this approach.
It is critical to ocus on outstanding knot
security, since the entire suture line is held
in place by the knots at the beginning and
end o the set o suture throws. Adding an
additional tacking knot when utilizing this
approach is an option as well. It may pro-
vide additional knot security. Alternatively,
one could consider placing an additional
knot or leaving a longer suture tail.
Although it requires utilizing a back-
hand technique, this approach may be
easier than other running buried tech-
niques, since the suture pierces the epider-
mis and dermis at a 90 degree angle there
is no need to change planes or guarantee
that the suture exit point is precisely at
the inside edge o the lower dermis.
This approach may also be used in
wounds under modest tension where
extensive undermining is not possible;
since the undersur ace o the dermis does
not need to be visualized to e ectively
place the sutures, the throws can be
essentially placed blindly.
This technique may be conceptual-
ized as a largely buried alternative to
the simple running closure, since both
approaches do not require wide under-
mining or an easily re ected wound edge
and both approaches may be utilized in
areas under modest tension.
An important theoretical advantage
o this approach over other running
percutaneous approaches is that no suture
material is le t between the wound edges.
Since even absorbable suture material
may represent a physical impediment
to wound healing, this is an important
benef t that this approach shares with
the percutaneous and standard set-back
dermal suture techniques.
Another theoretical benef t o the run-
ning approach is that there is less suture
material le t in situ, since the bulk o
retained absorbable suture material is in
the knots; as there are knots only at the
beginning and end o the row o sutures,
this technique theoretically decreases
the risk o suture spitting and suture
abscess ormation. Still, the standard
running set-back approach leaves suture
material deep to the undersur ace o the
dermis, and there ore the risk o suture
spitting and suture abscess ormation
is negligible.
Drawbacks and Cautions
Like the interrupted percutaneous set-
back dermal suture, the running percu-
taneous set-back dermal approach may
result in very dramatic wound eversion,
and the degree o eversion elicited by this
approach may be more marked than that
seen with the standard set-back dermal
suture approach. This pronounced ever-
sion may lead the epidermal portion o
the wound edges to separate as the der-
mis is brought together, as the epidermal
edges ail to drape together as they would
normally do with the standard set-back
dermal technique.
There are tw o possible approaches
to this situation: (1) Superf cial running
or interrupted sutures may be placed to
better approximate the epidermal edges;
and (2) The de ect could be initially
excised with an inward bevel (as is done
with the butter y suture technique), or
the dermis may be incised at an inward

80
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
bevel a ter the original de ect is cre-
ated, permitting the epidermal edges
to come together gently even in the
ace o the marked eversion seen with
this approach. Many clinicians avor a
bilayered approach in general, and there-
ore placing the epidermal sutures is an
easy approach and does not require the
degree o preplanning associated with
the bevel approach, though a combina-
tion o the two solutions may be utilized
as well. Since the running percutaneous
set-back dermal approach relies on the
security o only two knots to stabilize
the entire length o the wound, placing
simple interrupted epidermal sutures
may be worthwhile.
Patients should be cautioned that
they might develop a signif cant ridge
in the immediate post-operative period.
Depending on the suture material used
and the density o the sutures, this ridge
may last rom weeks to months.
Epidermal dimpling will o ten occur
w ith this approach, since the suture
material traverses the epidermis. A small
degree o dimpling w ill resolve w ith
time as the absorbable sutures are gradu-
ally resorbed, and patients should be
warned that this is a likely occurrence
and that it is o no long-term clinical
consequence.
Since suture material traverses the
epidermis, there is a theoretically greater
risk o in ection with this technique than
with approaches that remain entirely
buried on the undersur ace o the dermis.
Meticulous attention to sterile technique
may help mitigate this theoretical risk,
and anecdotally in ection is seen no more
requently with this approach than with
any other closure technique.
Reference
Kantor J. The running percutaneous set-back dermal
suture. J Am Acad Dermatol. 2015;73:e57-8.

81
is e ective, though theoretically the risk
o suture spitting or suture abscess orma-
tion is greater with the thicker 2-0 suture
material, particularly where the material
has exited the epidermis entirely. On the
extremities, a 3-0 or 4-0 absorbable suture
material may be used, and on the ace
and areas under minimal tension a 5-0
absorbable suture is adequate.
In addition to utilizing absorbable
suture material, nonabsorbable suture
material may also be utilized with this
technique. In that event, the knots at the
beginning and end o the suture line are
tied externally, permitting easy suture
removal. In such cases, a mono lament
would be pre erable to permit easy pull
through at suture removal, reinsertion o
the needle through the same hole, and a
more pronounced pulley e ect.
Technique
1. I possible, the wound edge is
ref ected back using surgical orceps
or hooks. In areas under marked ten-
sion, or where ull visualization is not
possible, the needle may be blindly
inserted rom the undermined space.
2. The suture needle is inserted at a
90-degree angle into the underside
o the dermis 4-mm distant rom the
incised wound edge.
3. The rst bite is started by ollowing the
needle and traversing rom the under-
side o the dermis in the undermined
space and passing entirely through the
dermis and exiting the skin.
The Running Percutaneous
Buried Vertical Mattress
Suture
C H A P T E R 4 . 1 5
Video 4-15. Running
percutaneous buried vertical
mattress suture
Access to video can be ound via
SuturingTechniques.com.
Application
This running technique is designed to allow
or moderate tension relie while concomi-
tantly permitting easy suture placement in
relatively tight spaces. It is best suited to
areas with thicker dermis, though it may
also be utilized in any body area when
deep sutures are placed and where inser-
tion o the ull needle is challenging.
Some authors have advocated this
technique as a replacement or stan-
dard running buried suture approaches,
while others pre er to treat it as a niche
approach exclusively or areas where
other running ully buried approaches
are more challenging to execute.
Suture Material Choice
Suture choice is dependent in large part
on location. Though suture material trav-
els percutaneously, exiting the epidermis
and then reentering, the smallest gauge
suture material appropriate or the ana-
tomic location should be utilized. O ten
absorbable suture material is used to
allow or an entirely buried suture line.
I reentry is to be attempted through the
same hole as suture exit, mono lament
suture material may be pre erred over
the braided alternatives. On the back
and shoulders, 2-0 or 3-0 suture material

82
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
4. The needle is then reloaded onto the
needle driver with a backhanded
technique, and inserted through the
epidermis either directly through the
same hole as the suture ollowed dur-
ing exit, or just medial to it. A shallow
bite is taken and the needle exits on
the margin o the incised wound edge.
5. The needle is then reloaded, again
in a backhanded ashion, and it
is inserted into the contralateral
incised wound edge at the same
depth as it exited on the rst side.
The needle again ollows a mirror-
image super cial course through
the dermis, exiting through the epi-
dermis again approximately 4 mm
rom the wound edge. Alterna-
tively, this step may be combined
with the prior step and the needle
can be inserted into the contra-
lateral edge w hile it is still loaded
rom the initial pass exiting the
incised wound edge.
6. The needle is then loaded in a stan-
dard ashion and inserted either
through the same hole or just lateral
to it, ollowing a deeper course and
exiting the undersur ace o the dermis
into the undermined space.
7. The suture material is then tied,
securing the anchoring stitch, and
the trailing end is trimmed.
8. Steps (1) through (6) are then
repeated sequentially or the desired
number o throws, moving proxi-
mally toward the surgeon a ter each
set o two sutures.
9. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-15A
through 4-15J). The nal anchoring
knot is tied by leaving a loop on the
penultimate throw, and tying the ree
end o suture material rom the nal
throw to this loop. The ends o the
suture are then trimmed.
Figure 4-15A. Overview o the running percutaneous
buried vertical mattress technique.
A
Figure 4-15B. Beginning o the initial anchoring
percutaneous buried vertical mattress suture. Note
that the needle enters the undersur ace o the dermis,
exiting directly upward through the skin.
B
Figure 4-15C. The needle is then inserted in with a
backhand technique, running more superfcially through
the dermis, exiting in the incised wound edge.
C

83
The Running Percutaneous Buried Vertical Mattress Suture
Figure 4-15D. The needle is inserted on the contra-
lateral wound edge, again rom the underside o the
undermined dermis.
D
Figure 4-15E. The needle is then reinserted through the
same hole or just lateral to it, again running superfcially
through the dermis and exiting in the incised wound edge.
E
Figure 4-15F. Completed anchoring suture.
F
Figure 4-15G. The running technique continues in
a similar ashion to the placement o the anchoring
suture. Note that each time the suture enters a wound
edge, it enters rom the deep undermined space
through the dermis.
G
Figure 4-15H. As the percutaneous technique contin-
ues, each pass that moves inward toward the wound
center is placed superfcially, exiting through the
incised wound edge.
H
Figure 4-15I. Appearance o the incision as the
suture is pulled tight. When using a braided absorbable
suture, the suture material should be pulled through
with each pass to ensure appropriate locking. With
monoflament suture, as is used here, the suture mate-
rial may be pulled tight intermittently to ensure appro-
priate wound-edge apposition.
I
Tips and Pearls
This technique is best or areas where
placement o a traditional running buried
suture is challenging due to limited space,
such as the scalp and lower leg, though it
has been advocated as an approach with
broader application.