84
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-15J. Wound appearance a ter placement
o a ull series o running percutaneous buried vertical
mattress sutures.
J
This approach may also be used when
it is di cult to visualize the undersur ace
o the dermis, since the needle throws
may be placed in an almost blind ash-
ion. 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
precludes ull exposure o the undersur-
ace o the undermined dermis.
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 utiliz-
ing this approach is an option as well,
and may provide additional knot security.
Alternatively, one could consider placing
an additional knot throw or leaving a lon-
ger suture tail when utilizing this approach.
Like the running percutaneous set-back
dermal suture, this technique may be con-
ceptualized as a largely buried alternative
to the simple running closure, since both
approaches do not require wide under-
mining or an easily ref ected wound edge
and both approaches may be utilized in
areas under modest tension.
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.
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. Reentering the skin
through the same hole may help minimize
the risk o dramatic dimpling, though it
carries the attendant risk o damaging the
suture material with the needle, potentially
leading to suture breakage.
Setting back the rst throw ar rom
the incised wound edge may result in
over-eversion; the chie drawback o over-
eversion is that the dermis may overhang
in the center o the incised wound edge,
barring the epidermal edges rom approxi-
mating appropriately, leading to a slightly
wider nal scar. This may be easily solved
by care ully beveling the dermis to allow
the epidermal edges to meet unimpeded.
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.
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
Justan I. New type of skin suture—fully buried run-
ning mattress suture. J Plast Reconstr Aesthet Surg.
2010;63(3):e338-339.
85
tension a 2-0 suture may be needed as
well. Braided suture tends to lock more
de nitively than mono lament, though
mono lament suture allows or easy pull
through when taking advantage o the
pulley e ect.
Technique
1. The wound edge is ref ected back
using surgical orceps or hooks.
2. While ref 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 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 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 super cial
papillary dermis. This bite should
be completed by ollowing the cur-
vature o the needle and avoiding
The Pulley Buried
Dermal Suture
C H A P T E R 4 . 1 6
Synonym
Double buried dermal suture
Video 4-16. Pulley buried
dermal suture
Access to video can be found via
Application
Wounds under marked tension may be
challenging to close even with well-placed
buried sutures. The pulley buried dermal
suture technique relies on the pulley e ect
o multiple loops o suture to permit the
closure o wounds under even signi cant
tension. In addition, the locking e ect o
placing a double loop o suture leads the
suture material to lock in place a ter the
rst throw o the surgical knot, obviating
the need or an assistant maintaining the
alignment o the wound edges.
Suture Material Choice
Suture choice is dependent in large part
on location. Because this technique leaves
signi cant residual suture material both
between the incised wound edges and in
the super cial dermis rom both loops,
care should be taken to minimize the
liberal use o larger-gauge suture mate-
rial. On the ace, while this approach is
only in requently utilized, a 5-0 absorb-
able suture is appropriate, and on the
distal extremities a 4-0 suture is generally
adequate. Using this technique, a 3-0
absorbable suture works well on the back,
though when the area is under marked
86
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
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 rst bite taken on
the contralateral side o the wound.
6. Steps (1) through (5) are then
repeated, a ter moving proximally
toward the surgeon, with the tail o
the suture material resting deep to
the loops o suture.
7. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-16A
through 4-16J).
Figure 4-16A. The needle is inserted through the
underside of the dermis, following the curvature of the
needle and exiting at the incised wound edge.
A
Figure 4-16B. The needle is then inserted at the
incised wound edge on the contralateral side, exiting in
the deep dermis.
B
Figure 4-16C. Moving proximally toward the surgeon,
with the suture material deep to the sutures and the
tail toward the surgeon, the needle is again inserted
through the dermis, exiting at the incised wound edge.
C
Figure 4-16D. The needle is then reinserted at the
incised wound edge on the contralateral side.
D
Figure 4-16E. The needle is inserted through the
underside of the dermis, following the curvature of the
needle and exiting at the incised wound edge.
E
87
The Pulley Buried Dermal Suture
Figure 4-16F. The needle is then inserted at the
incised wound edge on the contralateral side, exiting in
the deep dermis.
F
Figure 4-16G. Moving proximally toward the surgeon,
with the suture material deep to the sutures and the
tail toward the surgeon, the needle is again inserted
through the dermis, exiting at the incised wound edge.
G
Figure 4-16H. The needle is then reinserted at the
incised wound edge on the contralateral side.
H
Figure 4-16I. The double loop of suture material with
the tail deep to the loops is now visible.
I
Figure 4-16J. Appearance immediately after tying the
suture.
J
Tips and Pearls
This technique is use ul when there is
signi cant tension across the wound, and
there ore a single buried dermal suture
may not hold the edges together. As long
as undermining has been carried out e ec-
tively, utilizing a pulley technique with
a thicker gauge suture material should
allow or e ective closure o all but the
tightest wounds.
This technique is also very use ul when
the surgeon needs the rst throw o the
knot to securely hold the wound edges
together, as this technique is able to
e ectively lock the suture in position a ter
only a single throw. This obviates the
88
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
need or an assistant’s constant presence
in these instances, and permits precise
placement o the suture and knot to allow
or precise epidermal approximation.
It is critical to keep the suture material
deep to the loops o suture when using
this technique, as this is the mechanism
by which the suture locks in place a ter
the rst throw. As long as the surgeon
conceptualizes this approach as placing
a standard buried dermal suture ollowed
by a second standard buried dermal
suture closer to the surgeon, this tech-
nique can be very simple to learn and is
easily reproducible.
As always, the choice o suture mate-
rial is largely based on the individual
surgeon’s pre erence. Braided absorb-
able suture material has the advantage o
locking more reliably than mono lament,
though mono lament suture allows or
easier pull through and there ore may
acilitate the pulley e ect o the double
loop o suture material.
In areas under extreme tension, a three-
loop variation o this approach is pos-
sible as well, allowing or an even more
dramatic pulley e ect. This bene t must
be weighed against the added retained
suture material that would be associated
with the additional loop.
Drawbacks and Cautions
The pulley buried dermal suture, while
seemingly a simple approach, can some-
times be di cult to execute properly.
Care should be taken to remain at the
correct depth when utilizing this tech-
nique, as taking overly super cial bites
and not ollowing the course o the nee-
dle increases the risk o marked wound
inversion.
Since pulley sutures leave tw o loops
o suture material in the skin in lieu o
one, this may result in an increased risk
o oreign-body reaction, suture spit-
ting, or suture abscess ormation. Still,
since the bulk o retained suture mate-
rial is in the knots, rather than in the
thrown loops o suture, this theoretical
risk may not translate into a real-world
problem in most cases.
Unlike the pulley set-back dermal
suture, the pulley buried dermal suture
leaves suture material traversing the
incised wound edge, which may simi-
larly increase the theoretical risk o suture
spitting or suture abscess ormation,
especially since the pulley approach may
e ectively double the volume o nonknot
retained suture material when compared
to a standard dermal suture.
As with many buried techniques, epi-
dermal dimpling may 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. Similarly, areas
with sebaceous skin, such as the nose,
require meticulous avoidance o dim-
pling which has the potential to persist.
In truncal areas or those with thick der-
mis, however, a small degree o dimpling
will resolve with time as the absorbable
sutures are gradually resorbed.
The tendency toward wound inversion
with this approach means that super -
cial sutures are needed more requently
w ith this technique than w ith many
others, since the transepidermal sutures
are utilized in order to e ect eversion
o the wound edges. Since obviating the
need or super cial sutures may be desir-
able both in terms o patient com ort
and convenience and ultimate cosmetic
and unctional outcome, this should be
considered be ore broadly applying this
technique.
89
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. On the extremities, a
3-0 or 4-0 absorbable suture material may
be used, and on the ace, i this pulley
approach is needed at all, a 5-0 absorbable
suture is adequate. Braided suture tends to
lock more de nitively than mono lament,
though mono lament suture allows or
easy pull through when taking advantage
o the pulley e ect.
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 der-
mis 2-6 mm distant rom the incised
wound edge.
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
The Pulley Set-Back
Dermal Suture
C H A P T E R 4 . 1 7
Synonyms
Pulley Kantor suture, double set-back
suture, double set-back dermal suture
Video 4-17. Pulley set-back
dermal suture
Access to video can be found via
Application
This technique is best used in areas under
very signi cant tension. In addition to high-
tension wounds in general, areas under
marked tension that are prone to wound
inversion, such as the back and chest, may
be well-served utilizing this technique.
Wounds under marked tension may be
challenging to close even with well-placed
buried sutures. The pulley set-back dermal
suture technique relies on the pulley e ect
o multiple loops o suture to permit the
closure o wounds under even signi cant
tension. In addition, the locking e ect o
placing a double loop o suture leads the
suture material to lock in place a ter the
rst throw o the surgical knot, obviating
the need or an assistant maintaining the
alignment o the wound edges.
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 pulley buried dermal suture. Using
90
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
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 the
dermis 1-6 mm distant rom the incised
wound edge. Again, this bite should be
executed by ollowing the curvature
A
Figure 4-17A. The needle is inserted through the
underside of the dermis, exiting the underside of the
dermis closer to the incised wound edge but still
setback from the incised wound edge.
B
Figure 4-17B. The needle is then inserted through
the underside of the dermis on the contralateral wound
edge, exiting further away from the incised wound
edge on the undersurface of the dermis.
C
Figure 4-17C. With the loose end of the suture
material deep to the active sutures and resting between
the surgeon and the needle driver, the needle is then
reinserted through the undersurface of the dermis.
D
Figure 4-17D. The procedure is again repeated on the
contralateral wound edge.
o the needle and avoiding catching
the undersur ace o the epidermis 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 con-
tralateral side o the wound.
6. Steps (1) through (5) are then
repeated a ter moving proximally
toward the surgeon and taking care
to leave the tail o the suture material
deep to the loops o suture.
7. The suture material is then tied
utilizing an instrument tie.
91
The Pulley Set-Back Dermal Suture
E
Figure 4-17E. The needle is inserted through the
underside of the dermis, exiting the underside of the
dermis closer to the incised wound edge but still
setback from the incised wound edge.
F
Figure 4-17F. The needle is then inserted through the
underside of the dermis on the contralateral wound
edge, exiting further away from the incised wound
edge on the undersurface of the dermis.
G
Figure 4-17G. With the loose end of the suture
material deep to the active sutures and resting between
the surgeon and the needle driver, the needle is then
reinserted through the undersurface of the dermis.
H
Figure 4-17H. The procedure is again repeated on the
contralateral wound edge.
I
Figure 4-17I. Note the appearance of the suture
material prior to pulling it taut.
J
Figure 4-17J. Immediate postoperative appearance.
Note the marked wound eversion and the presence of
dimpling lateral to the incision line.
92
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Tips and Pearls
One o the chie advantages o this tech-
nique is its ease o execution; 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 pulley 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 the rst
throw o the needle begins 2-6 mm dis-
tant rom the incised wound edge.
This technique is use ul when there
is signi cant tension across the wound,
and a single set-back dermal suture may
not hold the edges together. As long as
undermining has been carried out e ec-
tively, utilizing a pulley technique with
a thicker gauge suture material should
allow or e ective closure o all but the
tightest wounds.
This technique is also very use ul when
the surgeon needs the rst throw o the
knot to securely hold the wound edges
together, as this technique is able to e ec-
tively lock the suture in position a ter only
a single throw. This obviates the need or
an assistant's constant presence in these
instances, and permits precise placement
o the suture and knot to allow or precise
epidermal approximation.
It is critical to keep the suture material
deep to the loops o suture when using
this technique, as this is the mechanism
by which the suture locks in place a ter
the rst throw. As long as the surgeon
conceptualizes this approach as placing a
standard set-back dermal suture ollowed
by a second standard set-back dermal
suture closer to the surgeon, this tech-
nique can be very simple to learn and is
easily reproducible.
As always, the choice o suture mate-
rial is largely based on the individual
surgeon's pre erence. Braided absorb-
able suture material has the advantage
o locking more reliably than mono-
lament, though mono lament suture
allows or easier pull through and there-
ore may better acilitate the pulley
e ect o the double loop o suture
material.
In areas under extreme tension, a three-
loop variation o this approach is pos-
sible as well, allowing or an even more
dramatic pulley e ect. This bene t must
be weighed against the added retained
suture material that would be associated
with the additional loop.
Drawbacks and Cautions
The pulley 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 pulley buried vertical mattress
technique.
Patients should be cautioned that
they might develop a signi cant ridge
in the immediate postoperative period.
Depending 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 subcutaneous splint may
help the patient develop reasonable and
realistic expectations and reduce anxiety
regarding the immediate postoperative
appearance o the wound.
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
93
The Pulley Set-Back Dermal Suture
this should be assiduously avoided.
Similarly, areas with sebaceous skin, such
as the nose, require meticulous avoidance
o dimpling which has the potential to
persist. 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 pulley sutures leave two loops
o suture material in the skin in lieu
o one, this may result in an increased
risk o oreign-body reaction, suture
spitting, or suture-abscess ormation.
Still, since the bulk o retained suture
material is in the knots, rather than in the
thrown loops o suture, this theoretical
risk may not translate into a real-world
problem in most cases.
Reference
Kantor J. The pulley set-back dermal suture: an easy
to implement everting suture technique for
wounds under tension. J Am Acad Dermatol.
2015;72(1):e29-30.
94
thicker 2-0 suture material. This needs
to be weighed against the bene t o uti-
lizing a larger CP-2 needle, which will
almost never bend even in the thickest
dermis, and the bene t o adopting the
2-0 suture material, which is less likely to
snap under tension or ail during tension
bearing activities, leading to attendant
dehiscence. 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.
Braided suture tends to lock more
de nitively than mono lament, though
mono lament suture allows or easy pull
through when taking advantage o the
pulley e ect.
Technique
1. The wound edge is ref ected back
using surgical orceps or hooks. Ade-
quate visualization o the underside
o the dermis is desirable.
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
The Pulley Buried Vertical
Mattress Suture
C H A P T E R 4 . 1 8
Synonyms
Double buried vertical mattress, dermal
buried pulley suture, SICM, modi ed
buried dermal suture
Video 4-18. Pulley buried
vertical mattress suture
Access to video can be ound via
SuturingTechniques.com.
Application
This technique is best used in areas under
very signi cant tension. Wounds under
marked tension may be challenging
to close even with well-placed buried
sutures. The pulley buried vertical mat-
tress suture technique relies on the pulley
e ect o multiple loops o suture to permit
the closure o wounds under even sig-
ni cant tension. In addition, the locking
e ect o placing a double loop o suture
leads the suture material to lock in place
a ter the rst throw o the surgical knot,
obviating the need or an assistant main-
taining the alignment o the wound edges.
Suture Material Choice
Suture choice is dependent in large part
on location. Though suture material tra-
verses the papillary dermis and the incised
wound edge, as always the smallest gauge
suture material appropriate or the ana-
tomic location should be utilized. On
the back and shoulders, 2-0 or 3-0 suture
material is e ective, though theoreti-
cally the risk o suture spitting or suture
abscess ormation is greater with the
95
The Pulley Buried Vertical Mattress Suture
while the needle exits in the incised
wound edge at the level o the reticu-
lar dermis.
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
Figure 4-18A. The needle is inserted through the der-
mis, angling upward and outward be ore exiting at the
incised wound edge.
A
Figure 4-18B. The needle is then inserted through the
incised wound edge on the contralateral side, again
moving superolaterally be ore exiting deep.
B
Figure 4-18C. Keeping the tail o the suture deep to
the suture throws and toward the surgeon, the frst
step is then repeated, with the needle entering deep
and exiting at the incised wound edge.
C
Figure 4-18D. Again with the tail deep, the needle is
inserted through the incised wound edge on the contra-
lateral side.
D
dermis. This should mirror the rst
bite taken on the contralateral side o
the wound.
6. Keeping the tail o the suture material
between the surgeon and the rst set
o loops, steps (1) through (5) are then
repeated, a ter moving proximally
toward the surgeon. The second set
o loops may be placed 2-6 mm apart
depending on the size o the de ect,
the thickness o the dermis, and the
degree o tension on the wound.
7. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-18A
through 4-18I).
96
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
E
Figure 4-18E. The needle is inserted through the der-
mis, angling upward and outward be ore exiting at the
incised wound edge.
F
Figure 4-18F. The needle is then inserted through the
incised wound edge on the contralateral side, again
moving superolaterally be ore exiting deep.
G
Figure 4-18G. Keeping the tail o the suture deep to
the suture throws and toward the surgeon, the frst
step is then repeated, with the needle entering deep
and exiting at the incised wound edge.
H
Figure 4-18H. Again with the tail o the suture deep,
the needle is inserted through the incised wound edge
on the contralateral side.
I
Figure 4-18I. Immediate postoperative appearance.
Note the wound-edge eversion.
Tips and Pearls
This technique requires some practice to
master, though once mastered it is straight-
orward to execute. The rst bite may be
nessed by rst ref 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
without an exaggerated change in direc-
tion with the needle driver.
A similar approach may be utilized by
surgeons who avor skin hooks over surgi-
cal orceps; here again, the hook may be
used to hyper-ref ect the skin edge back
during the rst portion o the rst bite and
97
The Pulley Buried Vertical Mattress Suture
then similarly pull the incised wound edge
toward the center o the wound during the
second portion o the rst bite. This will
encourage the needle to ollow the desired
heart-shaped path without necessitating
a dramatic twist o the needle driver as
the needle changes course.
The apex o the needle should be
in the papillary dermis; i the needle
courses too super cially, dimpling may
occur. While such dimpling is sometimes
almost unavoidable, it remains best to
avoid it i possible since: (1) patients
may sometimes have some concern
regarding the immediate postoperative
appearance, and (2) dimpling signi es
that the suture material traverses very
super cially, raising concern that it could
be associated with an increased risk o
suture spitting.
This technique is use ul when there is
signi cant tension across the wound, and
a single buried vertical mattress suture
may not hold the edges together. As long
as undermining has been carried out e ec-
tively, utilizing a pulley technique with
a thicker gauge suture material should
allow or e ective closure o all but the
tightest wounds.
This technique is also very use ul when
the surgeon needs the rst throw o the
knot to securely hold the wound edges
together, as this technique is able to e ec-
tively lock the suture in position a ter
only a single throw. This obviates the
need or an assistant’s constant presence
in these instances, and permits precise
placement o the suture and knot to allow
or precise epidermal approximation.
It is critical to keep the suture material
deep to the loops o suture when using
this technique, as this is the mechanism
by which the suture locks in place a ter
the rst throw. As long as the surgeon
conceptualizes this approach as placing
a standard buried vertical mattress suture
ollowed by a second buried vertical mat-
tress suture closer to the surgeon, this
technique can be very simple to learn
and is easily reproducible.
As always, the choice o suture mate-
rial is largely based on the individual
surgeon’s pre erence. Braided absorb-
able suture material has the advantage o
locking more reliably than mono lament,
though mono lament suture allows or
easier pull through and there ore may
acilitate the pulley e ect o the double
loop o suture material.
In areas under extreme tension, a three-
loop variation o this approach is pos-
sible as well, allowing or an even more
dramatic pulley e ect. This bene t must
be weighed against the added retained
suture material that would be associated
with the additional loop.
Drawbacks and Cautions
While the eversion is less pronounced
than that seen in other techniques, such
as the pulley set-back dermal suture,
patients may still be le t with a small ridge
in the immediate postoperative period.
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. Simi-
larly, areas with sebaceous skin, such as
the nose, require meticulous avoidance
o dimpling which has the potential to
persist. 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 pulley sutures leave two loops
o suture material in the skin in lieu
o one, this may result in an increased
risk o oreign-body reaction, suture spit-
ting, or suture abscess ormation. Still,
since the bulk o retained suture material
98
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
is in the knots, rather than in the thrown
loops o suture, this theoretical risk may
not translate into a real-world problem
in most cases.
References
Giandoni MB, Grabski WJ. Surgical pearl: the der-
mal buried pulley suture. J Am Acad Dermatol.
1994;30(6):1012-1013.
Jeon IK, Kim JH, Roh MR, Chung KY. The subcu-
taneous inverted cross mattress stitch (SICM
stitch) in our experience. Dermatol Surg.
2013;39(5):794-795.
Whalen JD, Du resne RG, Collins SC. Surgical pearl:
the modif ed buried dermal suture. J Am Acad
Dermatol. 1999;40(1):103-104.
Yag-Howard C. Novel surgical approach to subcu-
taneous closure: the subcutaneous inverted
cross mattress stitch (SICM Stitch). Dermatol
Surg. 2011;37(10):1503-1505.
99
theoretically the risk o suture spitting
or suture abscess ormation is greater
with the thicker 2-0 suture material. This
needs to be weighed against the bene t o
utilizing a larger CP-2 needle, which will
almost never bend even in the thickest
dermis, and the bene t o adopting the
2-0 suture material, which is less likely to
snap under tension or ail during tension
bearing activities, leading to attendant
dehiscence. On the extremities, 3-0 or
4-0 absorbable suture material may be
used, and on the ace and areas under
minimal tension, though this technique
would only rarely be used, a 5-0 absorb-
able suture is adequate.
Braided suture tends to lock more
de nitively than mono lament, though
mono lament suture allows or easy pull
through when taking advantage o the
pulley e ect.
Technique
1. The wound edge is ref ected back
using surgical orceps or hooks. Ade-
quate visualization o the underside
o the dermis is desirable.
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 changing direction by twisting
the needle driver so that the needle
exits in the incised wound edge.
The Half Pulley Buried
Vertical Mattress Suture
C H A P T E R 4 . 1 9
Synonym
Dermal buried pulley suture; modi ed
buried dermal suture
Video 4-19. Half pulley buried
vertical mattress suture
Access to video can be found via
Application
This technique is best used in areas under
very signi cant tension, and can be con-
ceptualized as existing on the spectrum
between single and double buried vertical
mattress sutures. Wounds under marked
tension may be challenging to close even
with well-placed buried sutures. The hal
pulley buried dermal suture technique
relies on the pulley e ect o an additional
single loop o suture to permit the closure
o wounds under even signi cant tension.
In addition, the e ect o placing an extra
bite o suture leads the suture material to
lock in place a ter the rst throw o the
surgical knot, obviating the need or an
assistant maintaining the alignment o
the wound edges.
Suture Material Choice
Suture choice is dependent in large part
on location. Since some suture mate-
rial traverses the papillary dermis and
the incised wound edge, as always the
smallest gauge suture material appropri-
ate or the anatomic location should be
utilized. On the back and shoulders, 2-0
or 3-0 suture material is e ective, though
100
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
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 reticular dermis.
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
Figure 4-19A. Overview of the half pulley buried
vertical mattress suture.
A
Figure 4-19B. The needle is inserted through the deep
dermis and exits at the incised wound edge, as with a
buried vertical mattress suture.
B
Figure 4-19C. The needle is then inserted at the
incised wound edge on the contralateral side.
C
Figure 4-19D. After moving slightly upward and out-
ward, the needle exits the dermis.
D
bite taken on the contralateral side o
the wound.
6. Keeping the tail o the suture mate-
rial between the surgeon and the
rst set o loops, the needle is then
inserted into the undersur ace o the
dermis slightly urther set-back rom
the wound edge than the rst throw.
7. The needle then exits in the deep
reticular dermis, just deep to the exit
point o the rst loop o suture.
8. With both ends o the suture material
now exiting rom the same side o the
wound (generally the surgeon’s le t),
the suture material is then tied utiliz-
ing an instrument tie (Figures 4-19A
through 4-19F).
101
The Half Pulley Buried Vertical Mattress Suture
Figure 4-19E. The needle is then reinserted on the
contralateral side through the dermis and exiting near
the incised wound edge, forming a pulley system of a
one and one half buried vertical mattress suture.
E
Figure 4-19F. Immediate postoperative appearance
after placing a single half pulley buried vertical
mattress suture.
F
Tips and Pearls
This technique may be conceptualized
as a buried vertical mattress suture with
an additional bite, or as a 1½ loop bur-
ied vertical mattress pulley suture. It is
there ore slightly aster to execute than
the pulley buried vertical mattress, since
this technique saves one needle throw.
That said, since there is one less loop o
suture, the pulley e ect may similarly be
less pronounced, though this needs to be
weighed against the theoretical bene t o
less retained suture material in this tech-
nique than in a double buried vertical mat-
tress suture.
This technique requires some prac-
tice to master, though once mastered it
is straight orward to execute. The rst
bite may be nessed by rst ref ecting
the wound edge back sharply during nee-
dle insertion and then returning the edge
medially a ter the apex has been reached.
This approach helps lead the needle in the
correct course without an exaggerated
change in direction with the needle driver.
The apex o the needle should be in
the papillary dermis; i the needle courses
too super cially, dimpling may occur.
This technique is use ul when there is
signi cant tension across the wound, and
a single buried vertical mattress suture
may not hold the edges together.
This technique is also very use ul when
the surgeon needs the rst throw o the
knot to securely hold the wound edges
together, as this technique is able to e ec-
tively lock the suture in position a ter
only a single throw. This obviates the
need or an assistant’s constant presence
in these instances, and permits precise
placement o the suture and knot to allow
or precise epidermal approximation.
It is critical to keep the suture material
deep to the loops o suture when using
this technique, as this is the mechanism by
which the suture locks in place a ter the rst
throw. As long as the surgeon conceptual-
izes this approach as placing a standard
buried vertical mattress suture ollowed
by a second hal vertical mattress suture
slightly deeper, this technique can be very
simple to learn and is easily reproducible.
The extra throw may also be completed
with an oblique or near-horizontal ori-
entation, since it is very important that
this extra throw bite su cient dermis to
support the tension o the wound. The
extra throw may also be executed as a
single set-back dermal suture, though
doing so may lead to some discrepancy
in the depth o the wound edges, neces-
sitating the placement o depth-correcting
epidermal sutures.
102
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Drawbacks and Cautions
While the eversion is less pronounced than
that seen with other techniques, such as
the pulley set-back dermal suture, patients
may still be le t with a small ridge in the
immediate 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.
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. Simi-
larly, areas with sebaceous skin, such as
the nose, require meticulous avoidance
o dimpling which has the potential to
persist. 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 this pulley approach leaves an
extra single loop o suture material in the
skin, this may result in an increased risk
o oreign-body reaction, suture spitting,
or suture abscess ormation. Still, since
the bulk o retained suture material is
in the knots, rather than in the thrown
loops o suture, this theoretical risk may
not translate into a real-world problem
in most cases.
There is also a theoretical concern
that the extra loop o suture could lead
to some wound-edge necrosis, partic-
ularly i it is oriented in a horizontal
ashion, though this is not usually seen
in practice. Finally, since the suture
material is tied together on one side o
the wound, there may be less precise
epidermal approximation than is seen
with other techniques, such as the pulley
set-back dermal suture and the pulley
buried vertical mattress.
References
Giandoni MB, Grabski WJ. Surgical pearl: the der-
mal buried pulley suture. J Am Acad Dermatol.
1994;30(6):1012-1013.
Whalen JD, Du resne RG, Collins SC. Surgical pearl:
the modif ed buried dermal suture. J Am Acad
Dermatol. 1999;40(1):103-104.
103
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.
2. The wound edge is re ected back
using surgical orceps or hooks. Ade-
quate ull visualization o the under-
side 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 approxi-
mately 3 mm set-back rom the
medial edge o the dermis at the base
o the bevel. 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 ol-
lowing its curvature, similarly set-
back rom the incised wound edge.
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.
The Double Butter y
Suture
C H A P T E R 4 . 2 0
Video 4-20. Double butterf y
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This technique is best used in areas
under very signif cant tension. Wounds
under marked tension may be challeng-
ing to close even with well-placed bur-
ied sutures. The double butter y suture
technique relies on the pulley e ect o
multiple horizontally oriented diagonal
loops o suture to permit the closure o
wounds under even signif cant tension.
Since the loops are horizontally oriented,
a broader bite o dermis is included with
each throw, adding to the theoretical
robustness o this closure technique.
Suture Material Choice
As alw ays, suture material choice
depends on pre erence and location.
Though this technique is designed or
w ounds under signi icant tension on
the trunk, it is commonly utilized with
a 3-0 suture. While adopting a 2-0 gauge
suture material is sometimes use ul,
especially to avoid bending smaller
needles, the knot or this suture is
buried in line w ith the incision and
at the base o the dermis and there-
ore suture material spitting is a risk.
Use o an absorbable mono ilament
(polydioxanone) has been proposed
as providing superior outcomes over
a braided absorbable suture.
104
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
6. The second bite is executed by insert-
ing the needle into the undersur ace
o the dermis on the contralateral side
distal to the exit point, with a back-
hand technique i desired and the nee-
dle still pointing in the same direction
as the f rst throw, and completing a
A
Figure 4-20A. First bite o the double butter y suture.
Note that the needle courses parallel to the incised
wound edge, taking a more superfcial portion o der-
mis in the center o its trajectory.
B
Figure 4-20B. The needle then enters the contralat-
eral wound edge approximately level with its exit point,
still on the same trajectory as the frst bite.
C
Figure 4-20C. The needle is then reloaded so that it
points in the opposite direction o the frst two bites,
and enters on the contralateral side o the wound at
approximately the level o its exit point.
D
Figure 4-20D. Preparing or the fnal bite o the
double butter y suture, again with the needle entering
at the same level as its exit point so that the fnal exit
point o the needle will be directly across rom the ini-
tial entry point placed at the start o this technique.
loop that orms an S when viewed
along with the f rst loop.
7. The needle is then reinserted into
the contralateral wound edge in
line with its exit point, now head-
ing toward the surgeon, in a mirror
image o step (6).
105
The Double Butter ly Suture
E
Figure 4-20E. Overview o the double butter y suture
technique.
F
Figure 4-20F. First bite o the double butter y suture.
Note that the needle courses parallel to the incised
wound edge, taking a more superfcial portion o
dermis in the center o its trajectory.
G
Figure 4-20G. The needle then enters the contralat-
eral wound edge approximately level with its exit point,
still on the same trajectory as the frst bite.
H
Figure 4-20H. The needle is then reloaded so that it
points in the opposite direction o the frst two bites,
and enters on the contralateral side o the wound at
approximately the level o its exit point.
8. Finally, the needle is then rein-
serted into the contralateral side in
a mirror image o the f rst throw
(step 4). Thus, the entry point o the
f rst suture loop and the exit point o
the last suture loop are directly across
rom each other on the undersur ace
o the dermis.
9. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-20A
through 4-20J).
I
Figure 4-20I. Final bite o the double butter y suture,
again with the needle entering at the same level as its
exit point so that the fnal exit point o the needle is
now directly across rom the initial entry point placed
at the start o this technique.
106
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
J
Figure 4-20J. Immediate postoperative appearance
a ter placement o a central double butter y suture and
multiple set-back dermal sutures at the apices. Note
the wound eversion.
Tips and Pearls
This technique is designed or areas under
marked 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.
It is help ul to conceptualize this
technique as orming an S which is then
turned into a f gure 8. Importantly, the
double butter y technique is not exe-
cuted by per orming two sets o butter y
sutures sequentially.
As with the pulley 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
without 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 vertical mattress.
The apex o the needle should be in
the papillary dermis; i the needle courses
too superf cially, dimpling may occur.
In particularly high-tension areas, the
suture loops may be placed close together
in order to mitigate the risk o an accor-
dion e ect. The horizontal orientation o
the suture loops means that a relatively
signif cant amount o dermis is included
within each suture loop. Particularly
in areas under marked tension where
there is concern regarding the ability o
the dermis to withstand tensile orces,
this represents an advantage over other
double or pulley approaches.
Drawbacks and Cautions
The need to bevel the wound edges
means that this technique requires a small
degree o preplanning. The bevel may,
however, be use ul or other techniques
as well, as it may help with wound-edge
apposition in general, though there is also
the theoretical risk o contracture leading
to a small separation between the wound
edges. I the butter y suture is utilized
without beveling 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 epidermal wound edges to
come together unimpeded.
Some authors have raised concerns
regarding possible wound-edge necrosis
associated with horizontally oriented
suture placement. Advocates o this
approach report that wound-edge necro-
sis has not been seen as a complication,
and indeed the only time that necrosis
seems to be an issue is 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, which is not typi-
cally seen with buried sutures.
While the suture loops may be rela-
tively close together, especially under
areas o marked tension, the loops
107
The Double Butter ly Suture
themselves should not overlap, as this
has the potential to compress the wound
edges together leading to central bunching
o the wound edges.
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 erences
Breuninger H. Double butterf y suture or high
tension: a broadly anchored, horizontal,
buried interrupted suture. Dermatol Surg.
2000;26(3):215-218.
Breuninger H, Keilbach J, Haa U. Intracutaneous but-
terf y suture with absorbable synthetic suture
material. Technique, tissue reactions, and results.
J Dermatol Surg Oncol. 1993;19(7):607-610.
108
wound edge, as always the smallest gauge
suture material appropriate or the ana-
tomic location should be utilized. On
the back and shoulders, 2-0 or 3-0 suture
material is e ective, though theoreti-
cally the risk o suture spitting or suture
abscess ormation is greater with the
thicker 2-0 suture material. This needs
to be weighed against the bene t o uti-
lizing a larger CP-2 needle, which will
almost never bend even in the thickest
dermis, and the bene t o adopting the
2-0 suture material, which is less likely to
snap under tension or ail during tension-
bearing activities, leading to attendant
dehiscence. On the extremities, a 3-0 or
4-0 absorbable suture material may be
used. Braided suture tends to lock more
de nitively than mono lament, though
mono lament suture allows or easy pull
through when taking advantage o the
pulley e ect.
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
4-8 mm distant rom the incised
wound edge.
3. The rst bite, which represents the
extra pulley loop, is executed by
traversing the dermis ollowing the
The Half Pulley Buried
Dermal Suture
C H A P T E R 4 . 2 1
Synonyms
Lateral pulley buried dermal suture,
set back pulley dermal suture
Video 4-21. Half pulley buried
dermal suture
Access to video can be found via
Application
This technique is best used in areas under
very signi cant tension, and can be con-
ceptualized as existing on the spectrum
between single and double buried vertical
mattress sutures. It is similar to the hal
pulley buried vertical mattress suture, but
with the extra loop placed at the begin-
ning, rather than the end o the technique.
Wounds under marked tension may
be challenging to close even with well-
placed buried sutures. The hal pulley
buried dermal suture technique relies
on the pulley e ect o multiple loops o
suture to permit the closure o wounds
under even signi cant tension. In addi-
tion, the locking e ect o placing a
double loop o suture leads the suture
material to lock in place a ter the rst
throw o the surgical knot, obviating the
need or an assistant maintaining the
alignment o the wound edges.
Suture Material Choice
Suture choice is dependent in large part
on location. Though suture material tra-
verses the papillary dermis and the incised
109
The Half Pulley Buried Dermal Suture
curvature o the needle and allow-
ing 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 dim-
pling. The needle does not, however,
exit through the incised wound edge,
but rather 3-4 mm distant rom the
incised edge, as would be done with
a set-back dermal suture. The size o
this rst loop is based on the size o
the needle and the thickness o the
dermis, and should be designed as a
modestly sized extra loop which will
allow or a pulley e ect.
4. Keeping the loose end o suture
between the surgeon and the patient,
the needle is then reinserted again on
the same side o the dermis as the
Figure 4-21A. Overview of the half pulley buried
dermal suture.
A
Figure 4-21B. The suture is started by placing the
needle through the dermis, markedly set-back from the
wound edge.
B
Figure 4-21C. The needle is then inserted through the
dermis, exiting at the incised wound edge.
C
Figure 4-21D. The needle is then reinserted on the
contralateral side through the incised wound edge,
exiting in the dermis.
D
rst loop, just distal to the entry and
exit points o the rst loop o suture,
but again through the undermined
undersur ace o the dermis. It should
enter approximately 3-8 mm set-
back rom the incised wound edge.
The needle then exits at the wound
margin as in a simple buried dermal
suture.
5. The tissue on the opposite side o
the wound is then ref ected back in
a similar ashion as on the rst side,
and the third bite is executed by
inserting the needle into dermis at
the wound edge. This bite should be
executed by ollowing the curvature
o the needle and avoiding catching
the undersur ace o the epidermis.
It then exits the undersur ace o
110
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-21E. Immediate postoperative appearance
after placing a single half pulley buried dermal suture.
E
the dermis approximately 3-8 mm
lateral to the incised wound margin.
This should mirror the second bite
taken on the contralateral side o the
wound.
6. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-21A
through 4-21E).
Tips and Pearls
Like the hal pulley buried vertical mattress
suture, this technique may be conceptu-
alized as a simple buried dermal suture
with an additional loop, or as a 1½ loop
simple buried dermal pulley suture, though
with the extra loop taken at the beginning,
rather than at the end o the technique. It
is slightly aster to execute than other pul-
ley sutures, since this technique saves one
needle throw. That said, since there is one
less loop o suture, the pulley e ect may
similarly be less pronounced, though this
needs to be weighed against the theoreti-
cal bene t o less retained suture material
in this technique than in a pulley buried
dermal suture.
This technique is use ul when there
is signi cant tension across the wound,
and a single buried suture may not hold
the edges together.
As always, the choice o suture mate-
rial is largely based on the individual
surgeon’s pre erence. Braided absorb-
able suture material has the advantage o
locking more reliably than mono lament,
though mono lament suture allows or
easier pull through and there ore may
acilitate the pulley e ect o the extra
loop o suture material.
Drawbacks and Cautions
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. Simi-
larly, areas with sebaceous skin, such as
the nose, require meticulous avoidance
o dimpling which has the potential to
persist. 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 this pulley approach leaves an
extra single loop o suture material in the
skin, this may result in an increased risk o
oreign-body reaction, suture spitting, or
suture-abscess ormation. Still, since the
bulk o retained suture material is in the
knots, rather than in the thrown loops o
suture, this theoretical risk may not trans-
late into a real-world problem in most cases.
There is also a theoretical concern that
the extra loop o suture could lead to some
wound-edge necrosis, particularly i it is
oriented in an oblique ashion, though
this is not usually seen in practice. Finally,
since the additional loop o suture material
is located on the side o the rst bite, the
pulley e ect may not be as pronounced as
in other pulley techniques, since there is
no back-and- orth pulley e ect between
the two sides o the wound.
References
Huang L. The lateral pulley buried dermal suture.
Australas J Dermatol. 2011;52(3):207-208.
Huang L. The setback pulley dermal suture for skin
defects. Am Surg. 2011;77(5):647-648.
111
mitigate some o the concerns related to
leaving a nonabsorbable oreign body in
place or an extended period o time. A 4-0
absorbable suture may o ten be utilized or
this approach on the ace. While utilizing
smaller gauge absorbable suture material
is reasonable, it may not provide su cient
tensile strength to adequately and reliably
x the tissue to the periosteum.
Technique
1. The wound edge is ref ected back
using surgical orceps or hooks, and
adequate visualization o the under-
side o the dermis is desirable.
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.
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. This will minimize the
risk o vascular compromise. Care
should be taken to remain in the der-
mis to minimize the risk o epider-
mal dimpling. The needle does not,
however, exit through the incised
wound edge, but rather 1-4 mm
distant rom the incised edge, or, in
select cases, potentially urther back
rom the wound edge.
4. The f ap o skin may be gently pulled
by the suture material so that the
location o the rst bite directly
The Suspension Suture
C H A P T E R 4 . 2 2
Synonyms
Pexing suture, ImPli, tacking suture
Video 4-22. Suspension suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a niche technique designed to x
one or both edges o a de ect to a deeper
structure. This approach has also been
re erred to as a pexing suture or tacking
suture, and is utilized typically in several
situations. First, when repairing a de ect
that crosses a natural sulcus, it is impor-
tant to tack down the skin overlying the
sulcus so that the natural depression is not
blunted, or bridged, by the repair. Second,
it is used when working near cosmetic
subunit boundaries and ree margins, to
avoid unctional challenges such as ectro-
pion and eclabium, as well as cosmetic
distortion o sensitive areas such as the lip
and eyebrows. It is also use ul in order to
x a f ap in place and minimize tension on
the distal portion o the f ap. Finally, this
approach may also be used to prevent nasal
valve collapse in the appropriate setting.
Suture Material Choice
Suture choice is dependent in large part on
location, though this technique is usually
utilized on the ace. While some authors
have advocated or nonabsorbable clear
mono lament suture to provide a last-
ing suspension e ect, in general absorb-
able suture material is adequate and may
112
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
overlies the planned xation point.
This permits the surgeon to double-
check the nal position o the sus-
pension suture. The needle is then
blindly inserted through the at and
deeper structures until the bone is
reached. A 3-mm bite o the perios-
teum is then taken, and the needle
is brought back up through the so t
tissues into the open center o the
wound.
5. The suture material is then tied uti-
lizing an instrument tie. Hand tying
may be utilized as w ell, w hich
may be use ul i the depth o the
de ect is signi icant (Figures 4-22A
through 4-22F).
Figure 4-22A. Overview o the suspension suture
technique.
A
Figure 4-22B. A set-back suture bite is taken rom the
dermis overlying the anticipated anchoring point on the
lower orehead.
B
Figure 4-22C. The suture material is gently pulled to
determine the location o the desired anchoring point.
C
Figure 4-22D. A bite o periosteum is taken over
the desired suspension point. Note that the needle is
inserted blindly through the subcutaneous at until the
periosteum is reached.
D
Figure 4-22E. The suture has now been tied, tacking
the dermis to a fxed point, leading to subtle dimpling.
E
113
The Suspension Suture
Tips and Pearls
This technique is very use ul w hen
working around the eyelids and lips,
though its use demands amiliarity with
the underling anatomy so that no sen-
sitive deeper structures are injured or
entrapped during the blind placement
o the deep anchoring suture. The deep
suture should also be placed parallel to
the underlying vascular plexus to similarly
mitigate this risk.
Placement is based on several consid-
erations, including the degree o tension
across the advanced tissue, the presence
o a bony prominence, which can be used
easily or suspension purposes, and the
absence o underlying nerves, which
could inadvertently become strangulated
by the anchoring suture.
The rst hal o this suture technique,
where the suture material is xed to the
underside o the dermis, may be concep-
tualized as a single throw o a set-back
dermal suture. Depending on the location
o the repair and the degree o suspension
necessary, a single throw o this technique
may be adequate. When reconstructing
longer sulci, such as the mental sulcus, a
series o spaced suspension sutures can
be placed to assure that the natural crease
is not bridged by the repair.
Pulling on the suture once it is anchored
to the periosteum may help assure the
surgeon that the suture is indeed tacked
down to an immobile sur ace.
A central advantage o this technique
is that it may permit the use o linear
closures in areas where otherwise a f ap
would have been advisable to minimize
ree-margin distortion. Thus, or example,
closures on the lower orehead or upper
malar area may be closed in a linear ash-
ion i the advancing skin (the superior and
in erior portions o the repairs, respec-
tively) is e ectively tacked down.
A three-point variation o this approach
is possible as well, which allows wound-
edge approximation and a tacking e ect
to occur all with one suture placement.
This is accomplished by rst placing
either a buried vertical mattress or set-
back dermal suture at the two wound
edges and then taking a bite o the under-
lying periosteum prior to tying the knot.
The suture material thus xes the wound
edges together as well as to the underlying
anchoring point. This approach, however,
may result in suboptimal wound-edge
eversion and places additional stress
on the suture material, increasing the
risk o scar spread. Moreover, it is only
appropriate i the anchor target lies in the
approximate midpoint o the de ect, since
it recreates a natural sulcus but does not
permit di erential pull rom one side o
the de ect; there ore, this approach is o
little utility when attempting to avoid
cosmetic distortion o sensitive areas.
This technique may also be used as
an alternative to cartilage gra ting when
reconstructing the nose. Loss o alar car-
tilage may lead to nasal valve collapse,
which traditionally was addressed by
placing an auricular cartilage gra t along
the reconstructed alar rim in order to
maintain valve patency. A simple and
elegant alternative is placing a suture in
the ala and xing it to a point superolater-
ally in the maxillary periosteum, permit-
ting the nasal valve to remain open and
Figure 4-22F. Immediate postoperative appearance.
F
114
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
obviating the need or a cartilage gra t
in many cases.
In select cases, a suspension suture may
be used to x a f ap to ascia or other
so t tissue structures, rather than perios-
teum, in order to secure its position and
decrease the tension across super cial
sutures at the time o nal closure.
Drawbacks and Cautions
Since the underside o the dermis is tacked
to the periosteum, this technique may
result in an area o depression at the site
o suspension suture placement. It is there-
ore important to utilize this approach
exclusively in areas with adequate lax-
ity, as poorly placed suspension sutures
could theoretically result in an aggravated
degree o distortion in cosmetically sen-
sitive areas. Moreover, the presence o
only minimal laxity increases the risk
o subsequent dehiscence and ischemia.
The anchoring portion o this suture
technique carries the risk o damage to
an underlying vascular or neural plexus.
Familiarity with the underlying bony
anatomy is there ore o paramount
importance, as it also permits the surgeon
to select the best location or suspension
suture placement. Such areas include the
mental crease, the zygomatic arch, malar
eminence, and supraorbital and in raor-
bital ridges. As suture material is tacked
to the periosteum—and traverses muscle
and ascia—patients should be warned
that they may experience more pain with
this approach than would be experienced
with a typical bilayered closure.
References
Robinson JK. Suspension sutures aid acial recon-
struction. Dermatol Surg. 1999;25(3): discussion
184-193.
Robinson JK. Suspension sutures in acial reconstruc-
tion. Dermatol Surg. 2003;29(4):386-393.
Salasche SJ, Jarchow R, Feldman BD, Devine-Rust
MJ, Adnot J. The suspension suture. J Dermatol
Surg Oncol. 1987;13(9):973-978.
Wang JH, Finn D, Cummins DL. Suspension suture
technique to prevent nasal valve collapse a ter
Mohs micrographic surgery. Dermatol Surg.
2014;40(3):345-347.
Webster RC, Davidson TM, Reardon EJ, Smith RC.
Suspending sutures in blepharoplasty. Arch
Otolaryngol. 1979;105(10):601-604.
Yag-Howard C. Novel approach to decreasing ten-
sion when approximating wound edges in
advancement f aps: the ImPli stitch. Dermatol
Surg. 2012;38:661-3.
115
Suture Material Choice
Suture choice is dependent in large part
on location, though this technique is usu-
ally utilized on the ace. Since the suture
is placed percutaneously, absorbable
suture is pre erred. A 4-0 or 5-0 absorb-
able suture may be used on the ace.
While utilizing smaller gauge absorb-
able suture material is reasonable, it may
not provide su cient tensile strength to
adequately and reliably x the tissue to
the periosteum.
Technique
1. Unlike the traditional suspension
suture, visualization o the percuta-
neous tacking site on the mobile f ap
o skin is not necessary.
2. The suture needle is inserted at
90 degrees into the underside o the
dermis at the point in the undermined
f ap where xation to the underlying
anchoring point is desired. The needle
then pierces through the epidermis.
3. The rst bite is completed by either
reinserting the needle back through
the epidermis with the twist o a wrist
or by grasping the needle where it
exits the epidermis and reintroducing
it directly down through the epidermis
so that it exits 2-4 mm away rom the
entry point.
4. The f ap o skin may be gently pulled
by the suture material so that the
location o the rst bite directly
The Percutaneous
Suspension Suture
C H A P T E R 4 . 2 3
Video 4-23. Percutaneous
suspension suture
Access to video can be found via
Application
Like the traditional suspension suture,
this is a niche technique designed to x
the edge o a de ect to a deeper struc-
ture, and may also be utilized typically
in three situations: (1) When repairing a
de ect that crosses a natural sulcus, (2)
When working near cosmetic subunit
boundaries and ree margins, to avoid
unctional challenges such as ectropion
and eclabium, as well as cosmetic distor-
tion o sensitive areas such as the lip and
eyebrows, and (3) When xing a f ap in
place to minimize tension on the distal
portion o the f ap.
Since the dermal component o the
suture is percutaneous, how ever, it
consistently results in immediate post-
operative dimpling. The advocates o
this technique have suggested that the
dimpling resolves spontaneously over
time, though unless the technique is truly
necessary in order to be able to x the
tissue—which may be the case i it is chal-
lenging to insert the needle and needle
driver through an undermined tunnel o
skin—it would probably be pre erable
to per orm a standard suspension suture
in order to minimize the risk o long-
term dimpling at the site o percutaneous
suture placement.
116
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-23A. Overview of the percutaneous suspen-
sion suture.
A
Figure 4-23B. The needle is inserted from the under-
side of the dermis in the undermined space, up directly
through the skin.
B
Figure 4-23C. The needle is then inserted just medial
to its exit point through the skin, exiting on the under-
side of the dermis in the undermined space.
C
Figure 4-23D. Appearance after placing the percuta-
neous component of the suture.
D
Figure 4-23E. The needle is then inserted blindly
through the fat until the periosteum is reached, and a
small bite of periosteum is taken. The suture is then
tied, suspending the skin over the target point over the
periosteum.
E
overlies the planned xation point.
This permits the surgeon to double-
check the nal position o the sus-
pension suture. The needle is then
blindly inserted through the at and
deeper structures until the bone is
reached. A 3-mm bite o the perios-
teum is then taken, and the needle is
brought back through the so t tissues
into the open center o the wound.
5. The suture material is then tied uti-
lizing an instrument tie. Hand tying
may be utilized as well, which
may be use ul i the depth o the
de ect is signi cant (Figures 4-23A
through 4-23F).
Tips and Pearls
This technique probably should be used
only in cases w here insertion o the
needle through the undersur ace o the
117
The Percutaneous Suspension Suture
Figure 4-23F. Immediate postoperative appearance.
F
dermis is not easible. Thus, this approach
is probably more use ul in closing smaller
de ects in areas such as the orehead,
where it may be challenging to insert the
needle driver body through a small space,
rather than in f aps where presumably a
large amount o tissue has already been
undermined.
As with the traditional suspension
suture, this technique’s use demands
amiliarity with the underlying anatomy
so that no sensitive deeper structures
are injured or strangled during the blind
placement o the deep anchoring suture.
The deep suture should also be placed
parallel to the underlying vascular plexus
to similarly mitigate this risk.
Placement is based on several consid-
erations, including the degree o tension
across the advanced tissue, the presence
o a bony prominence, which can be used
easily or suspension purposes, and the
absence o underlying nerves, which
could inadvertently become entrapped
by the anchoring suture.
While a series o spaced percutaneous
suspension sutures can be placed to assure
that a natural crease is not bridged by a
surgical repair, it may be best to minimize
the number o sutures placed in order to
mitigate the risk o pronounced persistent
dimpling o the overlying skin.
Pulling on the suture once it is anchored
to the periosteum may help assure the
surgeon that the suture is indeed tacked
down to an immobile sur ace.
As with the traditional suspension
suture, an advantage o this technique
is that it may permit the use o linear
closures in areas where otherwise a f ap
would have been advisable to minimize
ree-margin distortion. Thus, or example,
closures on the lower orehead may be
closed in a linear ashion i the advancing
skin (the superior portion o the repair)
is e ectively tacked down, thus avoiding
raising the ipsilateral eyebrow.
Drawbacks and Cautions
The percutaneous nature o this approach
e ectively guarantees an area o depres-
sion at the site o suspension suture place-
ment. It is there ore important to utilize this
approach exclusively in areas with adequate
laxity, as poorly placed suspension sutures
could theoretically result in an aggravated
degree o distortion in cosmetically sensi-
tive areas. Moreover, the presence o only
minimal laxity increases the risk o subse-
quent dehiscence and ischemia. There ore,
this technique is best used in the event that
placement o traditional suspension sutures
is not easible.
The anchoring portion o this suture
technique carries the risk o damage to an
underlying vascular or neural plexus. Famil-
iarity with the underlying bony anatomy
is there ore o paramount importance, as
it also permits the surgeon to select the
best location or suspension suture place-
ment. As suture material is tacked to the
periosteum—and traverses muscle and
ascia—patients should be warned that
they may experience more pain with this
approach than would be experienced with
a typical bilayered closure.
Reference
Cruz A, Wang AR, Campbell R, Chang KH, Dufresne
R. The percutaneous suspension suture.
Dermatol Surg. 2012;38(6):929-931.
118
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 at
90 degrees into the underside o the
dermis 4-mm distant rom the incised
wound edge.
3. The f 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 twist-
ing 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 nee-
dle exits in the incised wound edge at
the level o the reticular 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.
5. The second bite is executed by insert-
ing the needle into the incised wound
edge at the level o the reticular der-
mis. It then angles upward and later-
ally so that the apex o the needle is at
the level o the papillary dermis. This
should mirror the f rst bite taken on
the contralateral side o the wound.
6. The suture material is then tied uti-
lizing an instrument tie.
The Tie-Over Suture
C H A P T E R 4 . 2 4
Video 4-24. Tie-over suture
Access to video can be found via
Application
This technique is use ul when attempt-
ing to recreate a natural sulcus w hen
the de ect lies parallel to the sulcus. It
involves encircling a buried vertical mat-
tress suture w ith an anchoring suture
that attaches to deeper structures such
as the periosteum. It is a tissue-to-suture
technique, since the anchoring suture
is tied not to the overlying dermis but
rather to a previously placed buried
vertical mattress suture. Since its appli-
cation is limited to areas w here the
buried vertical mattress suture directly
overlies the natural sulcus, this repre-
sents a niche technique.
Suture Material Choice
This technique is generally utilized on
the ace, and there ore the smallest gauge
suture material with appropriate tensile
strength should be utilized. Generally,
a 4-0 or 5-0 absorbable suture material
provides adequate security when anchor-
ing to the periosteum. Nonabsorbable
material could theoretically be utilized,
and may provide a longer-lasting depres-
sive e ect on the tissue, but this benef t
is likely outweighed by the increased
risk o oreign-body reaction and suture
material extrusion.
119
The Tie-Over Suture
7. Once the buried vertical mattress
suture has been completed, starting
rom one side o the tied buried ver-
tical mattress suture the needle is
blindly inserted through the at and
deeper structures until the bone is
reached. A 3-mm bite o the perios-
teum is then taken, and the needle
is brought back up through the so t
tissues into the open center o the
wound on the contralateral side o
the buried vertical mattress suture
Figure 4-24A. Surgeon’s eye view of the tie-over
suture. A buried vertical mattress suture has been
placed and a suspension suture is now being secured
perpendicular to the buried vertical mattress suture.
A
Figure 4-24B. Cross-sectional view of the tie-over
suture. Note that the suspension suture connects
the deeper tissues to the previously placed buried
vertical mattress suture.
B
Figure 4-24C. The buried vertical mattress suture is
started by inserting the needle into the deep dermis,
angling upward, and exiting at the incised wound edge.
C
Figure 4-24D. A mirror image technique is utilized on
the contralateral wound edge.
D
and li ted above the buried vertical
mattress suture.
8. The suture material is then tied over
the buried vertical mattress suture
using an instrument tie, anchoring
down the buried vertical mattress
suture(Figures 4-24A through 4-24G).
E
Figure 4-24E. After placing the buried vertical mattress
suture, the needle is blindly inserted parallel to the wound
axis and perpendicular to the buried vertical mattress suture.
120
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
F
Figure 4-24F. The needle exits on the contralateral
side of the buried vertical mattress suture. It is then
tied over the buried vertical mattress suture, pulling the
suture down and creating a sulcus.
G
Figure 4-24G. Immediate postoperative appearance.
Tips and Pearls
While originally described or use with the
buried vertical mattress suture, this tech-
nique may also be used to anchor perios-
teum to a set-back dermal suture. Since the
technique entails the placement o a large
amount o suture material (a minimum o
six knots) in a single location, a set-back
dermal starting suture may be pre erable
in order to lessen the risk o oreign-body
reaction and suture material extrusion.
Since a previously placed buried suture
is anchored to underlying periosteum,
unlike the traditional suspension suture
this technique can only be used when the
buried suture directly overlies a natural
sulcus. There ore, it is most widely used
with de ects along the naso acial sulcus,
though theoretically it could be utilized
over other sulci and creases as well.
Drawbacks and Cautions
The relatively large amount o suture
material that is le t in situ with this tech-
nique means that the chances o oreign-
body reaction, suture abscess, or suture
spitting are probably higher than with
other suspension suture approaches.
This should be taken into account be ore
broadly adopting this approach.
Since the anchoring suture is tied directly
to the previously placed buried vertical
mattress suture, the additional torque
placed on the buried suture may translate
into a greater risk o suture material rup-
ture, or at least o added tension on the
dermis where the buried vertical mattress
suture is anchored. There ore, attention
to detail in placing and tying the buried
vertical mattress suture is o particular
importance when utilizing this technique.
As with any suspension suture, there
is a risk o damaging underlying struc-
tures when placing the anchoring bite
o suture material. Com ort with and
knowledge o the underlying anatomy,
and particularly the location o neural
and vascular bundles, is o paramount
importance when adopting this approach.
Finally, there is a risk o creating a long-
standing depression at the site o suture
placement. While the immediate postop-
erative dimpling generally resolves, this
depends largely on the patient’s f brotic
response, and an exaggerated f brotic
response may translate into a permanent
depression at the site o suture placement.
Reference
Otley CC. The tie-over suture for re-creating the naso-
facial sulcus. Dermatol Surg. 2000;26(3):270-272.
121
a longer-lasting depressive e ect on the tis-
sue, but this bene t is likely outweighed by
the increased risk o oreign-body reaction
and suture material extrusion.
Technique
1. The wound edge is ref ected back
using surgical orceps or hooks. Ade-
quate visualization o the underside
o the dermis is desirable.
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 twist-
ing 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 nee-
dle exits in the incised wound edge at
the level o the reticular dermis.
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 insert-
ing the needle into the incised wound
edge at the level o the reticular der-
mis. It then angles upward and later-
ally so that the apex o the needle is
at the level o the papillary dermis.
The Buried Vertical Mattress
Suspension Suture
C H A P T E R 4 . 2 5
Synonyms
Criss-cross tie-over tacking suture, three
point suspension suture
Video 4-25. Buried vertical
mattress suspension suture
Access to video can be ound via
SuturingTechniques.com.
Application
Like the tie-over suture, this technique
is use ul when attempting to recreate a
natural sulcus when the de ect lies par-
allel to the sulcus. It may be conceived
as a hybrid betw een the traditional
suspension suture and the tie-over
suture, as it entails combining a bur-
ied vertical mattress suture w ith an
anchoring suture that attaches to deeper
structures, but rather than separately
executing a buried vertical mattress
suture and a tie-over suture these two
steps are combined into one. Since its
application is limited to areas where the
buried vertical mattress suture directly
overlies the natural sulcus, this repre-
sents a niche technique.
Suture Material Choice
This technique is generally utilized on
the ace, and there ore the smallest gauge
suture material with appropriate tensile
strength should be utilized. Generally, a 4-0
or 5-0 absorbable suture material provides
adequate security when anchoring to the
periosteum. Nonabsorbable material could
theoretically be utilized, and may provide
122
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
This should mirror the rst bite taken
on the contralateral side o the wound.
6. The suture material is then tied uti-
lizing an instrument tie, but impor-
tantly the suture material is not cut,
thus leaving a long tail.
7. Once the buried vertical mattress
suture has been completed, starting
rom the side o the tied buried ver-
tical mattress suture where the long
tail is present, the needle is blindly
inserted through the at and deeper
structures until the bone is reached. A
3-mm bite o the periosteum is then
taken, and the needle is brought back
up through the so t tissues into the
open center o the wound on the con-
tralateral side o the buried vertical
Figure 4-25A. Overview o the the buried vertical
mattress suspension suture, simplifed version.
A
Figure 4-25B. The needle is inserted blindly through
the at, grasping ascia or periosteum, as appropriate,
to e ect the tacking component o the suture.
B
Figure 4-25C. The needle is then inserted through
the dermis, moving upward and outward, and exiting
through the incised wound edge, orming hal o a bur-
ied vertical mattress suture.
C
Figure 4-25D. The needle is then inserted on the
contralateral wound edge through the wound margin,
exiting in the dermis, in a mirror image.
D
Figure 4-25E. Immediate postoperative appearance.
Note the wound inversion.
E
mattress suture and li ted above the
buried vertical mattress suture.
8. The suture material is then tied to
the loose tail over the buried vertical
mattress suture using an instrument
tie, anchoring down the buried ver-
tical mattress suture (Figures 4-25A
through 4-25E).
123
The Buried Vertical Mattress Suspension Suture
Tips and Pearls
Since the buried suture is anchored
to the underlying periosteum, unlike
the traditional suspension suture this
technique can only be used when the
buried suture directly overlies a natural
sulcus. There ore, it is most widely used
with de ects along the naso acial sulcus,
though theoretically it could be utilized
over other sulci and creases as well.
A variation o this technique, the modi-
ed crisscross tie-over suture, was designed
to assure that the second knot (securing
the anchoring suture to the buried vertical
mattress) remains buried lateral or deep
to the buried vertical mattress, since the
original iteration o this technique may
result in the second knot riding above the
buried vertical mattress suture, increasing
the risk o suture abscess ormation. In the
modi ed version o this technique, the
deep anchoring throw is placed ipsilateral
to the loose tail, and does not encircle
the buried vertical mattress suture. This
encourages the second knot to remain
rmly buried while resulting in the same
degree o tissue suspension.
A simpli ed version o this technique
(as shown in the gures) permits place-
ment o the buried vertical mattress suture
and the suspension suture all with a single
set o knots; the suspension suture may
be placed rst, ollowed by placement o
the buried vertical mattress suture, and
then the suture can be tied, minimizing
the number o knots that will need to be
absorbed. This three-point suspension
suture, or buried vertical mattress suspen-
sion suture, may be pre erable to the other
variations as less suture material will be
le t in the dermis to be hydrolyzed.
Drawbacks and Cautions
The relatively large amount o suture
material that is le t in situ with this
technique means that the chances o
oreign-body reaction, suture abscess,
or suture spitting are probably higher
than other suspension suture approaches.
This should be taken into account be ore
broadly adopting this approach, and
while some proponents have suggested
that these complications are rarely, i ever,
seen, others have stated that this may be
a requent occurrence.
In the standard version o this
approach, since the anchoring suture is
tied directly to the loose tail o the buried
vertical mattress suture, the additional
torque placed on the buried suture may
translate into a greater risk o suture
material rupture, or at least o added
tension on the dermis where the bur-
ied vertical mattress suture is anchored.
There ore, attention to detail in placing
and tying the buried vertical mattress
suture is o particular importance when
utilizing this technique.
As w ith any suspension suture,
there is a risk o damaging underlying
structures w hen placing the anchor-
ing bite o suture material. Com ort
with and knowledge o the underlying
anatomy, and particularly the location
o neural and vascular bundles, is o
paramount importance when adopting
this approach.
Finally, there is a risk o creating a
longstanding depression at the site o
suture placement. While the immedi-
ate postoperative dimpling generally
resolves, this depends largely on the
patient’s brotic response, and an exag-
gerated brotic response may translate
into a permanent depression at the site
o suture placement.
References
Albertini JG. The criss-cross tie-over tacking suture.
Dermatol Surg. 2002;28(2):188-189.
Finley EM. The crisscross tie-over tacking suture
revisited. Dermatol Surg. 2003;29(3):281-283.
124
large cysts, the muscle ascia may be
directly visible. Otherwise, visualiz-
ing the subcutaneous at is appropri-
ate as well.
2. The suture needle is inserted at
90 degrees through the deep at
2-4 mm medial to the lateral under-
mined edge o the wound.
3. The rst bite is executed by entering
the ascia and ollowing the curvature
o the needle. The suture material may
be gently pulled to test that a success-
ul bite o ascia has been taken.
4. Keeping the loose end o suture
between the surgeon and the patient,
attention is then shi ted to the
The Fascial Plication Suture
C H A P T E R 4 . 2 6
Video 4-26. Fascial plication
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This technique is designed or wounds
under marked tension, especially those on
the back and shoulders. It is a deep tech-
nique, permitting the tension o wound
closure to shi t rom the dermis to the
ascia, concomitantly creating a lower-
tension closure which is associated with
less scar spread. In addition to tension
reduction, this approach also leads to an
increase in the apparent length to width
ratio o an excised ellipse and improved
dead-space minimization.
Suture Material Choice
Suture choice is dependent in large part
on location. As this technique is designed
to bite the ascia, generally a larger-gauge
suture can be utilized. There ore, or the
back and shoulders a 2-0 or 3-0 absorbable
suture may be used. Since suture material
traverses the ascia, the incidence o suture
abscess ormation is vanishingly rare. I this
technique is used on the scalp or orehead,
a 4-0 absorbable suture may be used.
Technique
1. The wound edges are ref ected back to
permit visualization o the deep bed
o the wound. In deep excisions, such
as those per ormed or melanoma or
Figure 4-26A. Overview o the ascial plication suture
technique.
A
125
The Fascial Plication Suture
Figure 4-26B. Beginning o the rst throw o the ascial
plication suture. Note that the needle is inserted blindly
through the subcutaneous at at a 90-degree angle.
B
Figure 4-26C. Completed rst throw o the ascial
plication suture.
C
Figure 4-26D. Beginning o the second throw o the
ascial plication suture. Note again that the needle
entry occurs at 90 degrees to the at and that the
undermined dermis is refected back, away rom the
center o the wound.
D
Figure 4-26E. Completed second throw o the ascial
plication suture.
E
Figure 4-26F. Wound appearance a ter placing a single
ascial plication suture. Note the more exaggerated usi-
orm appearance o the wound a ter suture placement.
F
Figure 4-26G. Postoperative wound appearance a ter
placement o a single ascial plication suture ollowed by a
series o set-back dermal sutures. Note the slight pucker-
ing lateral to the wound edges at the center o the wound.
This will resolve rapidly as the sutures are absorbed.
G
opposite side o the wound. The sec-
ond bite is executed by repeating the
procedure on the contralateral side.
5. The suture material is then tied uti-
lizing an instrument tie. Hand tying
may be utilized as well, particularly
i the wound is deep and the instru-
ments cannot be easily inserted
to complete the tie (Figures 4-26A
through 4-26G).
126
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Tips and Pearls
This technique is very use ul or wounds
under marked tension, especially or large
de ects on the back and shoulders. Even
a deep, gaping wound can be converted
into a manageable usi orm de ect with a
single well-placed ascial plication suture.
It can there ore be conceptualized as an
alternative to pulley sutures that a ords
both a decrease in tension across the
wound sur ace (by shi ting tension rom
the dermis to the ascia) and an increase
in the length-to-width ratio o the ellipse.
Indeed, this approach o ten leads
to a more usi orm de ect, even when
an oval-shaped excision has been per-
ormed. There ore, it may be use ul when
attempting to keep a de ect as short as
possible without dog-ear ormation. In
cases where this approach is anticipated,
it may be worthwhile to create a de ect
with a length-to-width ratio o less than
3 to 1, as is traditionally employed, as
that may be su cient to lead to a tapered
ellipse.
A single ascial plication suture may
be placed in the center o the wound.
This balances the bene t o dead-space
minimization and tension relie with the
desire to minimize suture material pierc-
ing the muscle ascia which may be asso-
ciated with increased postoperative pain
and a theoretical increase in in ection rate.
In large wounds under marked tension,
a series o spaced ascial plication sutures
may be placed as well. Except or the larg-
est wounds, typically no more than three
or our sutures are needed to e ectively
plicate the underlying ascia.
This technique is also use ul when
large space-occupying lesions, such as
cysts or lipomas, have been extirpated. In
these cases, placing dermal sutures alone
results in signi cant residual dead space
that may be associated with a higher
risk o hematoma or seroma ormation,
as well as subsequent in ection. Fascial
plication may serve to help minimize this
dead space by pulling deeper structures
centrally and thereby lling the potential
space.
Drawbacks and Cautions
The chie drawback o this approach is
the potential or increased postopera-
tive pain when compared with utilizing
dermal sutures alone. While this is not a
typical occurrence, depending on how
deep the suture material traverses through
ascia—and the underlying muscle—pain
may sometimes be experienced that is out
o proportion to the de ect size and depth.
As with any postoperative pain caused
by sutures traversing the muscle, it is
generally sel -limited. That said, it is
always important to minimize the risk
o any pain whatsoever and there ore
this technique should not be employed
unless there is signi cant tension that
cannot be relieved with standard buried
dermal techniques.
The lateral bites in the ascia should
be taken no closer than 1-2 mm rom the
undermined edge o the tissue. Taking
bites too ar laterally, where there is no
undermined plane between ascia and
dermis, may result in dimpling at the
lateral edges. This dimpling occurs when
the bites o ascia are directly contiguous
with the overlying dermis and epidermis,
and the suture's lateral tension on the
ascia also pulls on the dermis. While
the dimpling may resolve with time, it
is best avoided i possible.
References
Dzubow LM. The use of fascial plication to facili-
tate wound closure following microscopi-
cally controlled surgery. J Dermatol Surg Oncol.
1989;15(10):1063-1066.
Kantor J. The fascial plication suture: an adjunct
to layered wound closure. Arch Dermatol.
2009;145(12):1454-1456.
127
Since suture material traverses the ascia,
the incidence o suture abscess ormation
is vanishingly rare.
Technique
1. The wound edges are re ected back to
permit visualization o the deep bed o
the wound. In deep excisions, such as
those per ormed or melanoma or large
cysts, the muscle ascia may be directly
visible. Otherwise, visualizing the sub-
cutaneous at is appropriate as well.
2. Starting at one pole o the ellipse, the
suture needle is inserted at 90 degrees
through the deep at 2-4 mm medial
to the undermined edge o the wound.
3. The f rst bite is executed by entering
the ascia and ollowing the curvature
o the needle, allowing the needle
to exit closer to the incised wound
edge. The suture material may be
gently pulled to test that a success ul
bite o ascia has been taken.
4. Keeping the loose end o suture dis-
tal to the f rst bite, attention is then
shi ted to the opposite side o the
wound. The second bite is executed
by repeating the procedure on the
contralateral side.
5. Steps (2) through (4) are then repeated
sequentially in pairs moving toward
the contralateral pole o the wound.
6. Once the desired number o paired
bites have been taken, the suture is
then pulled tight and tied onto itsel
using either an instrument or hand
tie (Figures 4-27A through 4-27F).
The Corset Plication Suture
C H A P T E R 4 . 2 7
Synonym
Running ascial plication suture
Video 4-27. Corset plication
suture
Access to video can be found via
Application
This technique is designed or wounds
under marked tension, especially those
on the back and shoulders, and can be
conceptualized as a running variation o
the ascial plication suture. Like ascial
plication, it is a deep technique, permit-
ting the tension o wound closure to
shi t rom the dermis to the ascia, and
concomitantly creating a lower-tension
closure which is associated with less scar
spread. In addition to tension reduction,
this approach also leads to a modest
increase in the apparent length to width
ratio o an excised ellipse and improved
dead-space minimization.
Suture Material Choice
Suture choice is dependent in large
part on location. Since this technique is
designed to bite the ascia, generally a
larger-gauge suture can be utilized. There-
ore, or the back and shoulders a 2-0
or 3-0 monof lament absorbable suture
may be used. As the running technique
is predicated on pulling through mul-
tiple lengths o suture material, monof la-
ment suture material should be utilized
to minimize the coe f cient o riction.
128
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-27A. Overview of the corset plication suture.
A
Figure 4-27B. The needle is inserted (here blindly)
through the deep fascia on one side of the wound.
B
Figure 4-27C. This is then repeated on the contralateral
side of the wound.
C
Figure 4-27D. The pattern of alternating fascial bites
continues along the course of the wound.
D
Figure 4-27E. Appearance of the wound with multiple
bites of the corset plication suture in place.
E
Figure 4-27F. Appearance after tying the corset plica-
tion suture. Note that the wound now appears more
fusiform.
F
129
The Corset Plication Suture
Tips and Pearls
This technique can be conceptualized
as a pulley version o a ascial plication
suture. The multiple loops o suture
material serve to exert a pulley e ect,
allowing even the tightest wound to be
e ectively brought together. Like the
ascial plication approach, this technique
is very use ul or wounds under marked
tension, especially or large de ects on
the back and shoulders.
As with the ascial plication suture, this
approach o ten leads to a more usi orm
de ect, even when an oval-shaped exci-
sion has been per ormed. There ore, it
may be use ul when attempting to keep
a de ect as short as possible without
dog-ear ormation. In cases where this
approach is anticipated, it may be worth-
while to create a de ect with a length
to width ratio o less than 3 to 1, as is
traditionally employed, as that may be
su f cient to lead to a su f ciently tapered
ellipse.
As with the ascial plication suture,
this technique is also use ul when large
space-occupying lesions, such as cysts or
lipomas, have been extirpated. In these
cases, placing dermal sutures alone results
in signif cant residual dead space that may
be associated with a higher risk o hema-
toma or seroma ormation, as well as sub-
sequent in ection. Corset plication may
serve to help minimize this dead space
by pulling deeper structures centrally and
thereby f lling the potential space.
Drawbacks and Cautions
Since this is a running variation o the
ascial plication technique, its e f cacy
is predicated on both suture material
integrity and adequate knot security.
The value o the entire row o corset
sutures w ould be nullif ed by either
breakage anyw here along the row o
suture material or knot ailure. There-
ore, its proponents have suggested
utilizing a 2-0 monof lament suture
in order to mitigate the risk o suture
breakage, since this material has signif -
cant tensile strength. That said, since
this technique is exclusively used when
w ounds are under marked tension,
suture material ailure remains a risk.
Additionally, adding an extra throw
when tying the knots may help mitigate
the risk o knot ailure.
Another important drawback o this
approach is the potential or increased
postoperative pain when compared with
utilizing dermal sutures alone, or even
when compared with placing a single
ascial plication suture. Depending on
how deep the suture material traverses
through ascia and the underlying muscle,
pain may sometimes be experienced that
is out o proportion to the de ect size and
depth, particularly since this technique
involves the placement o multiple throws
o suture material through the ascia.
The lateral bites in the ascia should
be taken no closer than 1-2 mm rom the
undermined edge o the tissue. Taking
bites too ar laterally, where there is no
undermined plane between ascia and
dermis, may result in dimpling at the
lateral edges. This dimpling occurs when
the bites o ascia are directly contiguous
with the overlying dermis and epidermis,
and the suture's lateral tension on the
ascia also pulls on the dermis. While
the dimpling may resolve with time, it
is best avoided i possible.
While there is a theoretical risk o dis-
tortion o the ellipse caused by these run-
ning ascial sutures, this is not typically
seen in practice. Because this approach
entails multiple passes o suture material
through the ascia, the risk o pain and
in ection are theoretically higher than
with placing one or tw o interrupted
130
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
ascial plication sutures. While this is
balanced by the theoretical benef t o
the pulley e ect o this technique, this
pulley e ect is only rarely needed even
in the largest wounds. Coupled with the
chance that the entire line o sutures can
be annulled by breakage anywhere in the
suture material or a single knot ailure,
this approach probably should be used
less requently than the standard ascial
plication technique.
References
Dzubow LM. The use of fascial plication to facili-
tate wound closure following microscopi-
cally controlled surgery. J Dermatol Surg Oncol.
1989;15(10):1063-1066.
Kantor J. The fascial plication suture: an adjunct
to layered wound closure. Arch Dermatol.
2009;145(12):1454-1456.
Tierney E, Kouba DJ. A subcutaneous corset
plication rapidly and effectively relieves ten-
sion on large linear closures. Dermatol Surg.
2009;35(11):1806-1808.
131
wound edges are re ected back using
surgical orceps or hooks.
2. While re ecting back the wound
edge, including the galea (or deep
at, as applicable), the suture needle
is inserted at 90 degrees into the
underside o the deep tissue 4-8 mm
distant rom the incised wound edge,
but medial to the edge o the under-
mined plane.
3. The f rst bite is executed by enter-
ing the deep tissue and ollowing the
curvature o the needle parallel to the
wound edge. The suture material may
be gently pulled to test that a success-
ul bite o deep tissue has been taken.
4. Keeping the loose end o suture
between the surgeon and the patient,
attention is then shi ted to the oppo-
site side o the wound. The second
bite is executed by repeating the pro-
cedure on the contralateral side.
5. The suture material is then tied utiliz-
ing an instrument tie. Hand tying may
be utilized as well, particularly i the
wound is deep and the instruments
cannot be easily inserted to complete
the tie (Figures 4-28A through 4-28D).
The Imbrication Suture
C H A P T E R 4 . 2 8
Video 4-28. Imbrication suture
Access to video can be found via
Application
This technique is designed or wounds
under marked tension, especially those
on the scalp and upper orehead. It is a
deep tissue support technique, permitting
the tension o wound closure to shi t rom
the dermis to the galea or ascia, thereby
creating a lower-tension closure that is
associated with less scar-spread. Like the
ascial plication technique, in addition
to tension reduction, this approach also
leads to an increase in the apparent length
to width ratio o an excised ellipse and
improved dead-space minimization.
Suture Material Choice
Suture choice is dependent in large part
on location. As this technique is designed
to bite the galea or the undersur ace o
the deep at, generally a 3-0 (on the scalp),
4-0, or even 5-0 absorbable suture may
be used. Since suture material is le t deep
to the subcutaneous at, the incidence
o suture abscess ormation is vanish-
ingly rare.
Technique
1. A ter adequate undermining in the
subgaleal (on the scalp and upper
orehead) or supra rontalis (on the
lower orehead) plane, and a ter any
lagging at has been extirpated, the
Figure 4-28A. Overview of the imbrication suture.
A
132
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-28B. The needle is inserted through the
fascia, far lateral to the incised wound edge. Depending
on the depth of the defect, this may be performed in
muscle or fascia, as long as the depth is kept constant
on each side.
B
Figure 4-28C. The procedure is repeated in a mirror
image on the contralateral wound edge.
C
Figure 4-28D. Immediate postoperative appearance.
Note that the wound has an exaggerated fusiform
appearance.
D
Tips and Pearls
This technique is use ul or w ounds
under marked tension, especially or
larger de ects on the scalp and orehead.
I needed, a galeotomy—relaxing inci-
sions through the galea—may be placed
parallel to the long axis o the wound to
acilitate even greater tissue movement.
Like the ascial plication approach, this
can there ore be conceptualized as an
alternative to pulley sutures that a ords
both a decrease in tension across the
wound sur ace (by shi ting tension rom
the dermis to the galea) and an increase
in the length to width ratio o the ellipse.
Like the ascial plication technique, this
approach o ten leads to a more usi orm
de ect, even when an oval-shaped exci-
sion has been per ormed. There ore, it
may be use ul when attempting to keep
a de ect as short as possible without
dog-ear ormation. In cases where this
approach is anticipated, it may be worth-
while to create a de ect with a length
to width ratio o less than 3 to 1, as is
traditionally employed, as that may be
su f cient to lead to a tapered ellipse.
I possible, a single galeal imbrication
suture may be placed at the center o
the wound. This balances the benef t o
dead-space minimization and tension
relie with the desire to minimize suture
material piercing the galea that may be
associated with a theoretical increase in
in ection rate.
In large wounds under marked tension,
a series o spaced imbrication sutures may
be placed as well. Except or the largest
wounds, typically no more than three
or our sutures are needed to e ectively
imbricate the underlying galea.
This technique is also use ul when large
space-occupying lesions, such as pilar
cysts, have been excised rom the scalp. In
these cases, placing dermal sutures alone
results in a signif cant residual dead space
133
The Imbrication Suture
that may be associated with a higher risk
o hematoma or seroma ormation, as
well as subsequent in ection. Imbrica-
tion may serve to help minimize this
dead space by pulling deeper structures
centrally and thereby f lling the potential
space.
A double, or pulley, version o this
approach is possible as well, that may
be use ul when the imbricated tissues
are under marked tension. As with any
pulley approach, this a ords a mechani-
cal advantage and allows the imbricated
tissues to be drawn together with greater
ease. As an added benef t, this also per-
mits immediate locking o the suture
material a ter the f rst knot throw, which
may obviate the need or an assistant in
some cases.
Drawbacks and Cautions
It is important that the surgeon have
excellent amiliarity with the relevant
tissue planes w hen executing deep-
tissue imbrication. Since deep tissues are
incised, undermined, extirpated, and then
imbricated, there is the theoretical poten-
tial or damage to an underlying neural or
vascular plexus in the course o wound
preparation and suturing. As long as
meticulous attention is paid to the depth
o undermining and the correct tissue
planes (subgaleal generally, or supra ron-
talis on the lower central orehead), this is
not generally a problem, though certainly
this technique should not be applied in
any o the “danger zones” o the ace
where damage to the acial nerve, or other
vital structures, is possible.
Another possible draw back o this
approach is the potential or increased
postoperative pain when compared with
utilizing dermal sutures alone. While this
is not a typical occurrence, depending
on how deep the suture material tra-
verses through rontalis muscle, pain may
sometimes be experienced that is out o
proportion to the de ect size and depth.
Since the integrity o the galea has
been compromised, there is similarly a
theoretically increased risk o in ection
with this technique. That said, many
closures on the scalp and upper orehead,
even when placing only dermal sutures,
benef t rom subgaleal undermining, and
there ore this risk is not unique to this
technique.
The lateral bites in the undersur ace
o the galea should be taken no closer
than 1-2 mm rom the lateral undermined
edge o the deep tissue. In addition, or
horizontally oriented excisions on the
orehead the surgeon may wish to di er-
entially undermine so that a broad area is
undermined at the superior portion o the
wound but only a relatively narrow area
is undermined at its in erior edge. This
will aid in avoiding adding a dramatic li t
to the lower orehead.
Reference
Radonich MA, Bisaccia E, Scarborough D.
Management of large surgical defects of the fore-
head and scalp by imbrication of deep tissues.
Dermatol Surg. 2002;28(6):524-526.