134
is re ected back using surgical or-
ceps or hooks. Adequate visualiza-
tion o the underside o the dermis is
required.
2. While re ecting back the dermis, the
suture needle is inserted at 90 degrees
into the underside o the dermis
7-9 mm distant rom the incised
wound edge.
3. The f 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
5 mm distant rom the incised edge.
The size o this f rst bite is based on
the size o the needle and the thick-
ness o the dermis.
4. Keeping the loose end o suture
between the surgeon and the patient,
the dermis on the side o the f rst bite
is released. The tissue on the oppo-
site edge is then re ected back in a
similar ashion as on the f rst side,
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 5 mm distant rom the
incised wound edge. Again, this bite
should be per ormed by ollowing
the curvature o the needle and avoid-
ing catching the undersur ace o the
The Guitar String Suture
C H A P T E R 4 . 2 9
Video 4-29. Guitar string suture
Access to video can be found via
Application
This is a niche technique use ul or reduc-
ing the size o a de ect prior to ap or gra t
repair in wounds under marked tension.
It is most commonly employed on the
scalp, trunk, and extremities, though its
use has been described elsewhere as well.
It should probably be avoided on the ace,
where possible anatomical distortion, as
well as the long-term f brotic bands rom
the placement o these sutures, are unde-
sirable. O note, this technique does not
entirely close a de ect; instead, it serves
to pull the wound edges closer together,
reducing the size o the de ect prior to
def nitive closure.
Suture Material Choice
Suture choice is dependent in large part on
location. Since this technique is designed to
hold a air amount o tension, generally a
3-0 or 2-0 absorbable suture is appropriate.
As a large amount o suture material will
remain relatively superf cially in the bed
o the wound, longer-lasting absorbable
suture material (such as polydioxanone)
should probably be avoided.
Technique
1. The desired axis o partial wound
closure is visualized, and the wound
edge on one side o the desired axis
135
The Guitar String Suture
epidermis that could result in epider-
mal dimpling. It then exits urther dis-
tal to the wound edge, approximately
6-9 mm distant rom the wound edge.
This should mirror the f rst bite taken
on the contralateral side o the wound.
6. The suture material is then pulled cen-
trally, reducing the size o the open
wound, and the suture material is tied
utilizing an instrument tie. Hand tying
may be utilized as well. The use o an
Figure 4-29A. Overview of the guitar string suture
technique demonstrating its use with a series of buried
vertical mattress sutures.
A
Figure 4-29B. The needle is inserted from the under-
side of the dermis, exiting set back from the incised
wound edge.
B
Figure 4-29C. On the contralateral wound edge,
the needle is inserted close to the incised-wound
edge, exiting further set back along the undermined
undersurface of the dermis.
C
Figure 4-29D. The suture is tied as tightly as possible.
D
assistant to hold the wound edges in
place as ar medially as possible may be
help ul (Figures 4-29A through 4-29E.
E
Figure 4-29E. Immediate postoperative appearance
after placing a series of guitar string sutures.
136
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Tips and Pearls
Like the purse string suture—when it is
used solely or reducing de ect size—this
technique does not alone result in com-
plete de ect closure. It is there ore best
suited to areas that are under marked
tension, areas where a skin gra t will be
used, or where even a large ap may have
di f culty closing a de ect. A ter place-
ment o the guitar string sutures, a ull- or
partial-thickness skin gra t may be used
to cover the residual de ect.
A double, or pulley, variation o this
approach is possible as well, which may
aid in adding additional medial tension
on the suture material by taking advan-
tage o the pulley e ect. The benef ts o
the pulley e ect, however, should be
weighed against both the increase in
retained suture material as well as the
possible increased risk o tissue necrosis
rom the high-tension closure that may
be undertaken utilizing this approach.
This technique’s name, o course, is
derived rom the appearance o the resid-
ual suture material between the wound
edges, as the taut suture material has the
appearance o guitar strings as it traverses
over the underlying subcutaneous at or
ascia.
Drawbacks and Cautions
This technique results in a large volume
o suture material being le t in the wound
or many months. Even a ter the suture
material is hydrolyzed, it leaves behind
palpable-f brotic bands that may take
months to absorb entirely, and there is a
theoretical risk that these bands will not
disappear entirely.
The large volume o oreign-body
material that is le t in the wound may
increase the theoretical risk o in ection.
Moreover, depending on the depth o
these sutures, other complications, such
as sinus tract ormation, are possible as
well. Though these complications have
not been described by proponents o
this technique, they remain theoreti-
cally possible depending on individual
patient circumstances and local technique
variations.
The tension inherent in this approach
also increases the theoretical risk o tissue
necrosis and long-term residual dimpling
at the lateral borders o the wound. While
epidermal dimpling will occasionally
occur where the arc o the suture reaches
its apex at the dermal-epidermal junc-
tion, generally, a small degree o dimpling
will resolve with time as the absorbable
sutures are gradually resorbed.
Reference
Redondo P. Guitar-string sutures to reduce a large
surgical de ect prior to skin gra ting or f ap
movement. Dermatol Surg. 2014;40(1):69-72.
137
at this apex is re ected back using sur-
gical orceps or hooks, and adequate
visualization o the underside o the
dermis is required.
2. While re ecting back the dermis, the
suture needle is inserted at 90 degrees
into the underside o the dermis
4-6 mm distant rom the apex.
3. The f rst bite is executed by traversing
the dermis ollowing the curvature o
the needle and allowing the needle to
exit arther rom the incised wound
edge. Care should be taken to remain
in the dermis to minimize the risk o
epidermal dimpling. The needle exits
approximately 8-mm distant rom the
incised edge, though this depends on
the size o the standing cone that is
being smoothed. Keeping the loose
end o suture between the surgeon
and the patient, the dermis is released.
4. The standing cone may be gently
pulled by the suture material so that
the location o the f rst bite directly
overlies the planned f xation point.
This permits the surgeon to double-
check the f nal position o the suture.
The needle is then blindly inserted
through the at and deeper structures
until bone is reached. A 3-mm bite
o the periosteum or ascia 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 utiliz-
ing an instrument tie (Figures 4-30A
through 4-30D).
The Dog-Ear Tacking Suture
C H A P T E R 4 . 3 0
Video 4-30. Dog-ear tacking
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a niche technique used or
reducing the appearance o dog ears, or
standing cones, at the ends o elliptical
excisions or local aps. While dog-ear
minimization is generally accomplished
by excising lesions with usi orm inci-
sions, this o ten extends the length o the
wound signif cantly, which is undesir-
able. This technique was designed as an
approach to mitigate the raised dog-ear
appearance o the standing cone while
concomitantly avoiding unnecessarily
extending the length o the wound.
Suture Material Choice
Suture choice is dependent in large part on
location. Since this technique is designed
to bite the deep dermis and the underly-
ing ascia or periosteum, the surgeon may
choose to utilize a larger gauge suture than
would be used or an equivalently placed
buried suture. On the back and extremities,
a 2-0, 3-0 or 4-0 absorbable suture material
may be used, and on the ace and other
areas under minimal tension a 4-0 or 5-0
absorbable suture is adequate.
Technique
1. The apex o the wound where the
incipient dog ear is anticipated is
widely undermined. The wound edge
138
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-30A. Overview o the dog-ear tacking suture.
A
Figure 4-30B. The needle is inserted through the
undersur ace o the undermined dermis, exiting set back
rom the wound edge at the apex o the wound.
B
Figure 4-30C. The needle is then passed blindly
through the periosteum, anchoring the suture in place.
C
Figure 4-30D. Immediate postoperative appearance
demonstrating dimpling at each apex where dog-ear
tacking sutures were placed. This dimpling resolves with
time, though residual fbrosis helps mitigate the orma-
tion o dog ears as the suture material is absorbed.
D
Tips and Pearls
This technique works best when the
standing cone is f xed to a truly immobile
tissue, such as the periosteum. There ore,
this approach is o particular utility on
the orehead and other areas over bony
prominences. On the trunk and extrem-
ities, where no truly f xed underlying
anchoring point is present, the standing
cone can be f xed to the muscle ascia.
Though this does not lead to as dramatic
a degree o downward pull as when the
dog ear is f xed to the periosteum, it does
have a positive impact on the height o
the standing cone.
In some locations, such as convexities
over the orehead, even de ects repaired
with a 4:1 ellipse may still display residual
standing cones at the apices; there ore,
this approach may be used as an adjunct
in such cases as well.
This technique can be conceptualized as
a suspension suture or the standing cone,
where the dog ear is anchored downward
to prevent the residual ocal elevation
that will otherwise be seen in such cases.
Since no additional tissue is excised, this
technique will occasionally lead to a rip-
pling e ect in the areas where it is utilized,
139
The Dog-Ear Tacking Suture
though this is generally pre erable to the
dramatic bump that would otherwise be
present when dog ears are le t behind.
Some experience is help ul in deciding
what degree o residual standing cone
appearance is acceptable; wounds on
the lower legs, or example, o ten heal
well and residual standing cones may
smooth out spontaneously, likely due
to the tension over bony prominences;
conversely, standing cones over cheeks
and other areas with abundant so t tissue
o ten resolve only minimally over time,
and there ore leaving signif cant dog ears
in these locations should be assiduously
avoided i possible.
In some cases, instead o taking a single
bite rom the undersur ace o the dermis
it may be more e ective to take two bites,
as i a set-back dermal suture were being
taken rom the imaginary line splitting the
standing cone. These two bites are then
anchored to a central anchoring point
deep to the theoretical midpoint o the
standing cone.
This approach, when used in concert
with a technique such as the ascial pli-
cation suture that leads a round or oval
de ect to appear more usi orm, may per-
mit closure o wounds with signif cantly
less standing cone removal, leading to
shorter—and there ore more cosmetically
appealing—scars.
Drawbacks and Cautions
As with any suspension suture, since
the underside o the dermis is tacked to
periosteum, this technique may result in
an area o depression at the site o suture
placement.
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 appropriate locations or dog-ear
tacking suture placement.
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.
When tacking to the underlying as-
cia, since the anchoring point is not
entirely immobile, it is possible that the
degree o standing cone reduction will
be only modest. There ore, such cases
may require a greater degree o standing
cone excision than those overlying bony
prominences.
The residual ocal rippling o the epi-
dermis caused by tissue redundancy will
generally resolve with time, though in
areas with signif cant actinic damage and
solar elastosis the lack o underlying elas-
ticity may lead to residual textural changes
that do not resolve. In these unusual cases,
surgical revision may be use ul to excise
the residual area, as would be done or a
dog-ear removal, thus leading to a more
acceptable cosmetic outcome.
Reference
Kantor J. The dog ear tacking suture technique. J Am
Acad Dermatol. 2015;73:e25-6.
140
Technique
1. The wound edge at the ar end o the
round- or oval-shaped wound, par-
allel to the incision line, is re ected
back.
2. With the tail o the suture material
resting between the surgeon and the
ar end o the wound, the needle is
inserted into the underside o the
dermis on the ar edge o the wound
with a trajectory running parallel to
the incision. Generally, this entry
point in the dermis should be approx-
imately 3-6 mm set-back rom the
epidermal edge, depending on the
thickness o the dermis and the antic-
ipated degree o tension across the
closure. The needle, and there ore the
suture, should pass through the deep
dermis at a uni orm depth. Bite size is
dependent on needle size, though in
order to minimize the risk o necrosis
it may be prudent to restrict the size
o each bite. The needle should exit
the dermis at a point equidistant rom
the cut edge rom where it entered.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the needle
driver in an appropriate position to
repeat the preceding step to the le t
o the previously placed suture.
The Buried Purse-String
Suture
C H A P T E R 4 . 3 1
Video 4-31. Buried purse-
string suture
Access to video can be found via
Application
This technique is designed to either
shrink the size o a de ect or obviate it
entirely, depending on the degree o ten-
sion and the size o the de ect. It is a niche
technique, since the purse-string e ect
tends to lead to a slight puckering in the
surrounding skin, a eature that may be
acceptable (and will likely resolve with
time) on areas such as the orearms and
back but is less desirable in cosmetically
sensitive locations such as the ace. The
running nature o the technique means
that compromise at any point in the course
o suture placement may result in wound
dehiscence, though or this reason a larger
gauge suture material is generally utilized.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the smallest
gauge suture material appropriate or the
anatomic location should be utilized. On
the back and shoulders, 2-0 or 3-0 suture
material is e ective, and on the extremities
and scalp, a 3-0 or 4-0 absorbable suture
material may be used. When used on the
ace, a 5-0 absorbable suture is adequate.
Since the technique requires easy pull
through o suture material, monof lament
absorbable suture is generally pre erable.
141
The Buried Purse-String Suture
4. A small amount o suture material
is pulled through and the needle is
inserted into the dermis to the le t o
the previously placed suture, and the
same movement is repeated.
5. The same technique is repeated
moving stepwise around the entire
wound until the needle exits close to
the original entry point at the ar end
o the wound.
6. Once the desired number o throws
have been placed, the suture material
is then pulled taut, leading to com-
plete or partial closure o the wound,
and tied utilizing an instrument tie
(Figures 4-31A through 4-31F).
Figure 4-31A. Overview of the buried purse-string
suture technique.
A
Figure 4-31B. The needle is inserted through the
underside of the undermined dermis, set-back from
the wound edge and with a trajectory paralleling the
wound edge.
B
Figure 4-31C. The prior step is repeated sequentially
around the periphery of the wound.
C
Figure 4-31D. A backhand technique may be used
when following the curvature of the wound back to the
suture’s inception point.
D
Figure 4-31E. This continues until the inception point
is reached. The suture material is then pulled taut and
tied.
E
Tips and Pearls
This technique is designed as an e f -
cient method o wound area reduction. In
many cases, placing a purse-string suture
can e ect complete wound closure and
142
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
F
Figure 4-31F. Immediate postoperative appearance
after placement of the buried purse-string technique.
Note the slight residual pucker, though the wound
edges are well approximated overall.
it there ore represents an alternative to
a layered repair o a usi orm incision.
It has been suggested that some de ects
on the back and extremities, particularly
in elderly patients with loose skin, are
better closed with a purse-string approach
than with a traditional linear closure,
since linear closures o ten heal with a
residual scar and require a signif cantly
longer excision line, while the puckering
that may be present immediately post-
operatively with purse-string closures is
likely to resolve with time. That said,
in the right hands linear closures on the
trunk and extremities o ten heal with
subtle scarring, even when wounds are
closed under tension.
On a pragmatic level, this approach is
generally utilized when either a patient is
unwilling to undergo a traditional linear
closure or when their comorbidities make
the additional length o the incision or a
linear closure an unrealistic option.
As with linear running dermal tech-
niques, this technique may be used as a
modif ed winch or pulley suture, since the
multiple loops help minimize the tension
across any one loop and permit closure o
wounds under marked tension. Because
each throw is not tied o , however, it is
important to adequately secure the knot.
Tying a purse-string closure under
signif cant tension may be challenging, as
suture material tends to slip a ter the f rst
knot throw. Utilizing hemostats to secure
the suture ends in position during suture
lockdown may help mitigate this problem.
Absorbable purse-string sutures may
also be used to reduce the size o a de ect
prior to gra t placement, in a ashion simi-
lar to the guitar string suture.
Drawbacks and Cautions
As with other running dermal techniques,
this approach leaves a air amount o
absorbable suture material in the dermis.
There ore, oreign-body reactions, suture
abscess ormation, and in ection are pos-
sibilities. The entire suture line is secured
with a single knot, and since most o the
bulk o any suture line is in the knots,
rather than the lengths o suture mate-
rial between knots, this technique may
be less susceptible to suture abscess or
suture spitting than others.
The pucker e ect o this closure resolves
rapidly in atrophic skin, though it can per-
sist in other areas; patients should realize
that some degree o residual puckering
toward the center o the wound is to be
expected. Additionally, this technique may
be used to help recreate the nipple-areola
complex i ull reconstruction is not desired
and the nipple is lost to a local tumor.
Since the entire closure is held by a
single knot, this approach may be associ-
ated with a higher rate o wound dehis-
cence, as knot ailure or ailure in the
suture material at any point leads to an
immediate loss o tension on the closure.
Given the concern regarding knot break-
age, it may be help ul to attempt to better
secure the knot. This may be done by
paying particularly close attention to knot
tying, tying an extra ull knot, adding
extra throws, or leaving a longer tail than
would traditionally be executed.
143
The Buried Purse-String Suture
A recent study has suggested, however,
that the postoperative cosmesis o a purse-
string closure is no better than a wound
allowed to heal with secondary intention
healing though wounds closed with purse-
string sutures may heal approximately
two weeks aster than those allowed to
heal by secondary intention.
This approach provides less wound
eversion than vertically oriented
approaches such as the set-back dermal
or buried vertical mattress sutures.
There ore, consideration should be
given to adding additional superf cially
placed everting sutures, such as the verti-
cal mattress suture, in order to mitigate
this problem. Still, since this approach is
generally adopted when the surgeon has
accepted that the cosmetic outcome may
be less than ideal, it may be reasonable
to use this approach as a solitary closure.
References
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
Closure o round cutaneous postoperative
wounds with the purse string suture. South
Med J. 2006;99(12):1401-1402.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
The cuticular purse string suture: a modif ed
purse string suture or the partial closure o
round postoperative wounds. Int J Dermatol.
2007;46(7):746-753.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR. The
purse-string suture revisited: a use ul technique
or the closure o cutaneous surgical wounds.
Int J Dermatol. 2007;46(4):341-347.
Field LM. Inadvertant and undesirable sequelae o
the stellate purse-string closure. Dermatol Surg.
2000;26(10):982.
Greenbaum SS, Radonich M. Closing skin de ects
with purse-string suture. Plast Reconstr Surg.
1998;101(6):1749-1751.
Harrington AC, Montemarano A, Welch M,
Farley M. Variations o the pursestring suture
in skin cancer reconstruction. Dermatol Surg.
1999;25(4):277-281.
Ho man A, Lander J, Lee PK. Modif cation o the
purse-string closure or large de ects o the
extremities. Dermatol Surg. 2008;34(2):243-245.
Joo J, Custis T, Armstrong AW, et al. Purse-string
suture vs second intention healing: results o a
randomized, blind clinical trial. JAMA Dermatol.
2015; 151:265-70.
Ku BS, Kwon OE, Kim DC, et al. A case o erosive
adenomatosis o nipple treated with total
excision using purse-string suture. Dermatol
Surg. 2006;32(8):1093-1096.
Lackey J, Mendese G, Grande D. Using an absorbable
purse-string suture to reduce surgical de ects o
the nose be ore placement o ull-thickness skin
gra ts. Dermatol Surg. 2015;41:657-60.
Marquart JD, Lawrence N.. The purse-string lock-
down. Dermatol Surg. 2009;35:853-5.
Nicholas L, Bingham J, Marquart J. Percutaneous
buried modif cation o the purse-string closure.
Dermatol Surg. 2014;40(9):1052-1054.
Patel KK, Tel er MR, Southee R. A “round block”
purse-string suture in acial reconstruction a ter
operations or skin cancer surgery. Br J Oral
Maxillofac Surg. 2003;41(3):151-156.
Peled IJ, Zagher U, Wexler MR. Purse-string suture
or reduction and closure o skin de ects. Ann
Plast Surg. 1985;14(5):465-469.
Randle HW. Modif ed purse string suture closure.
Dermatol Surg. 2004;30(2 pt 1):237.
Romiti R, Randle HW. Complete closure by purse-
string suture a ter Mohs micrographic surgery
on thin, sun-damaged skin. Dermatol Surg.
2002;28(11):1070-1072.
Spencer JM, Malerich SA, Moon SD. A regional
survey o purse-string sutures or partial and
complete closure o Mohs surgical de ects.
Dermatol Surg. 2014;40(6):679-685.
Teitelbaum S. The purse-string suture. Plast Reconstr
Surg. 1998;101(6):1748-1749.
Zhu JW, Wu XJ, Lu ZF, Cai SQ, Zheng M. Purse-
string suture or round and oval de ects: a use ul
technique in dermatologic surgery. J Cutan Med
Surg. 2012;16(1):11-17.
144
On the back and shoulders, 2-0 or 3-0
suture material is e ective. Since the
technique requires easy pull through o
suture material, monof lament absorbable
suture is generally pre erable.
Technique
1. At the wound edge at the ar end o
the round- or oval-shaped wound,
the needle is inserted at 90 degrees
through the epidermis parallel to the
incision line 5-20 mm set-back rom
the wound edge. Alternatively, i
absorbable suture material is used,
the needle may enter rom the under-
side o the dermis so that the f nal
knot will be buried.
2. The curvature o the needle is
ollowed keeping the same distance
rom the wound edge so that the
needle exits through the epidermis
10-15 mm to the le t o the entry
point at the same distance set-back
rom the wound edge by ollowing
a trajectory running parallel to the
incision. Bite size is dependent on
needle size. The needle should exit
the dermis at a point equidistant rom
the cut edge rom where it entered.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the nee-
dle driver in an appropriate position
to repeat steps (1) through (3). With
The Percutaneous
Purse-String Suture
C H A P T E R 4 . 3 2
Video 4-32. Percutaneous
purse-string suture
Access to video can be ound via
SuturingTechniques.com.
Application
As with the buried purse-string closure,
this technique is designed to use circum er-
ential tissue advancement to either shrink
the size o a de ect or obviate it entirely,
depending on the degree o tension and the
size o the de ect. It is a niche technique,
since the purse-string e ect tends to lead to
a slight puckering in the surrounding skin,
a eature that may be acceptable (and will
likely resolve with time) on areas such as
the orearms and back but is less desirable
in cosmetically sensitive locations such as
the ace. The running nature o the tech-
nique means that compromise at any point
in the course o suture placement may
result in wound dehiscence, though or
this reason a larger gauge suture material
is generally utilized. This percutaneous
approach is most use ul either or relatively
narrow wounds or those with marked
atrophy o the surrounding skin, such as
on the shins and scalp.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate or
the anatomic location should be utilized.
On the extremities and scalp, where this
technique is generally used, a 3-0 or 4-0
absorbable suture material may be used.
145
The Percutaneous Purse-String Suture
Figure 4-32A. Overview o the percutaneous purse-
string technique.
A
Figure 4-32B. The needle is inserted rom the inside
o the wound up and directly through the dermis, exit-
ing the epidermis.
B
Figure 4-32C. The needle is reinserted directly adja-
cent to its exit point, or even through the same hole,
oriented parallel to the wound edge and set-back rom
the wound edge.
C
Figure 4-32D. The needle then moves directly through
the dermis, exiting the undersur ace o the dermis, and
then curves back up through the undersur ace o the
dermis, exiting the skin urther along the curvature o
the wound.
D
Figure 4-32E. This pattern continues around the
perimeter o the wound, where a backhand technique
may be used when heading away rom the surgeon.
E
each throw, however, the needle
pierces the epidermis through the
exit hole o the prior throw.
4. A small amount o suture material is
pulled through with each throw.
5. The same technique is repeated
moving stepwise around the entire
wound until the needle exits through
the original entry point at the ar end
o the wound.
6. The suture material is then pulled
taut, leading to complete or partial
closure o the wound, and tied utiliz-
ing an instrument tie (Figures 4-32A
through 4-32G).
146
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
F
Figure 4-32F. Once all sutures have been placed, the
fnal throw ends with the needle exiting the undersur-
ace o the dermis adjacent to the initial entry point. The
suture material is subsequently pulled taut and tied.
G
Figure 4-32G. Immediate postoperative appearance.
With this technique, wounds are sometimes only
partially closed, as seen here. The residual wound may
heal via granulation or a transepidermal suture may be
placed.
Tips and Pearls
Unlike the ully buried purse-string
approach, this technique allow s or
additional recruitment o the surround-
ing tissue by permitting placement o
the sutures markedly set-back rom the
wound edge. This may there ore be a
technique o choice i maximal tension
is expected on the wound.
This variation may also be use ul when
the wound is relatively narrow, such as on
the shin, or when the skin is very atrophic
and the ull thickness o the dermis needs
to be recruited to provide stability and
minimize suture tear through.
This technique is designed as an e f cient
method o wound-area reduction. In
many cases, placing a purse-string suture
can e ect complete wound closure and
it there ore represents an alternative to
a layered repair o a usi orm incision.
On a pragmatic level, this approach is
generally utilized when either a patient is
unwilling to undergo a traditional linear
closure or when their comorbidities make
the additional length o the incision or a
linear closure an unrealistic option.
The knot may be buried by beginning
and ending this technique on the interior
o the wound (as opposed to starting
outside the skin), although the tension
across the knot generally pulls it inward
i the standard technique is used and
the suture line is started on the exterior
o the skin.
Tying a purse-string closure under sig-
nif cant tension may be challenging, as
suture material tends to slip a ter the f rst
knot throw. Utilizing hemostats to secure
the suture ends in position during suture
lockdown may help mitigate this problem.
Drawbacks and Cautions
As with other running dermal techniques,
this approach leaves a air amount o
absorbable suture material in the dermis.
There ore, oreign-body reactions, suture
abscess ormation, and in ection are pos-
sibilities. The entire suture line is secured
with a single knot, and since most o the
bulk o any suture line is in the knots,
rather than the lengths o suture mate-
rial between knots, this technique may
be less susceptible to suture abscess or
suture spitting than others.
Utilizing the same holes or exit and
entry o the needle is designed to mini-
mize residual skin dimpling, but increases
the risk that the suture material will be
cut by the needle as it renters the same
hole. Since the entire closure rests on the
resiliency o a single strand o suture, this
147
The Percutaneous Purse-String Suture
risk should not be overlooked. A simple
variation o this technique, where the
needle is reinserted through a hole just
lateral to the exit point, may help mitigate
this potential risk.
Skin dimpling is o ten seen w ith
this approach, particularly since these
wounds are o ten closed under signif cant
tension. This does generally resolve with
time, but patients should be warned to
expect these changes in the immediate
postoperative period.
As with the buried purse-string closure,
the pucker e ect o this closure resolves
rapidly in atrophic skin, though it can per-
sist in other areas; patients should realize
that some degree o residual puckering
toward the center o the wound is to be
expected.
Since the entire closure is held by a
single knot, this approach may be associ-
ated with a higher rate o wound dehis-
cence, as knot ailure or ailure in the
suture material at any point leads to an
immediate loss o tension on the closure.
Given the concern regarding knot break-
age, it may be help ul to attempt to better
secure the knot. This may be done by
paying particularly close attention to knot
tying, tying an extra ull knot, adding
extra throws, or leaving a longer tail that
would traditionally be executed.
While arguable better than the
ully buried purse-string closure, this
approach provides less w ound ever-
sion than vertically oriented approaches
such as the set-back dermal or buried
vertical mattress sutures. There ore, con-
sideration should be given to adding
additional superf cially placed everting
sutures, such as the vertical mattress
suture, in order to mitigate this problem.
Still, since this approach is generally
adopted when the surgeon has accepted
that the cosmetic outcome may be less
than ideal, it may be reasonable to use
this approach as a solitary closure.
References
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
Closure o round cutaneous postoperative
wounds with the purse string suture. South
Med J. 2006;99(12):1401-1402.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
The cuticular purse string suture: a modif ed
purse string suture or the partial closure o
round postoperative wounds. Int J Dermatol.
2007;46(7):746-753.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR. The
purse-string suture revisited: a use ul technique
or the closure o cutaneous surgical wounds.
Int J Dermatol. 2007;46(4):341-347.
Field LM. Inadvertant and undesirable sequelae o
the stellate purse-string closure. Dermatol Surg.
2000;26(10):982.
Greenbaum SS, Radonich M. Closing skin de ects
with purse-string suture. Plast Reconstr Surg.
1998;101(6):1749-1751.
Harrington AC, Montemarano A, Welch M,
Farley M. Variations o the pursestring suture
in skin cancer reconstruction. Dermatol Surg.
1999;25(4):277-281.
Ho man A, Lander J, Lee PK. Modif cation o the
purse-string closure or large de ects o the
extremities. Dermatol Surg. 2008;34(2):243-245.
Ku BS, Kwon OE, Kim DC, et al. A case o erosive
adenomatosis o nipple treated with total exci-
sion using purse-string suture. Dermatol Surg.
2006;32(8):1093-1096.
Marquart JD, Lawrence N. The purse-string
lockdown. Dermatol Surg. 2009;35:853-5.
Nicholas L, Bingham J, Marquart J. Percutaneous
buried modif cation o the purse-string closure.
Dermatol Surg. 2014;40(9):1052-1054.
Patel KK, Tel er MR, Southee R. A “round block”
purse-string suture in acial reconstruction a ter
operations or skin cancer surgery. Br J Oral
Maxillofac Surg. 2003;41(3):151-156.
Randle HW. Modif ed purse string suture closure.
Dermatol Surg. 2004;30(2 pt 1):237.
Romiti R, Randle HW. Complete closure by purse-
string suture a ter Mohs micrographic sur-
gery on thin, sun-damaged skin. Dermatol Surg.
2002;28(11):1070-1072.
Spencer JM, Malerich SA, Moon SD. A regional
survey o purse-string sutures or partial and
complete closure o Mohs surgical de ects.
Dermatol Surg. 2014;40(6):679-685.
Teitelbaum S. The purse-string suture. Plast Reconstr
Surg. 1998;101(6):1748-1749.
Zhu JW, Wu XJ, Lu ZF, Cai SQ, Zheng M.
Purse-string suture or round and oval de ects:
a use ul technique in dermatologic surgery.
J Cutan Med Surg. 2012;16(1):11-17.
148
Technique
1. A ter extensive undermining is per-
ormed, a single buried vertically ori-
ented suture is placed at the center o
the wound; a set-back dermal suture
may be utilized.
2. Once the wound has been bisected,
the wound edge at the ar end o one
o the nascent round- or oval-shaped
wounds, parallel to the incision line,
is re ected back.
3. With the tail o the suture mate-
rial resting between the surgeon
and the ar end o the wound, the
needle is inserted into the underside
o the dermis on the ar edge o the
wound with a trajectory running par-
allel to the incision. Generally, this
entry point in the dermis should be
approximately 3-6 mm set-back rom
the epidermal edge, depending on the
thickness o the dermis and the antici-
pated degree o tension across the
closure. The needle, and there ore the
suture, should pass through the deep
dermis at a uni orm depth. Bite size is
dependent on needle size, though in
order to minimize the risk o necrosis
it may be prudent to restrict the size
o each bite. The needle should exit
the dermis at a point equidistant rom
the cut edge rom where it entered.
4. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
The Figure 8 Double
Purse-String Suture
C H A P T E R 4 . 3 3
Video 4-33. Figure 8 double
purse-string suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a variation o the purse-string
approach or larger de ects. Like the
standard purse-string technique, it is
designed to either shrink the size o a
de ect or obviate it entirely, depending on
the degree o tension and the size o the
de ect. It is a niche technique, as it leads
to a slight puckering in the surrounding
skin, a eature that may be acceptable
(and will likely resolve with time) on
areas such as the orearms and back but
is less desirable in cosmetically sensitive
locations such as the ace.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate
or the anatomic location should be uti-
lized. On the back and shoulders, 2-0 or
3-0 suture material is e ective, and on
the extremities and scalp, a 3-0 or 4-0
absorbable suture material may be used.
In the unlikely event this technique is
used on the ace, a 4-0 or 5-0 absorbable
suture is adequate. Since the technique
requires easy pull through o suture mate-
rial, monof lament absorbable suture is
generally pre erable. I suture removal is
planned, a monof lament nonabsorbable
suture is also an option.
149
The Figure 8 Double Purse-String Suture
rom the tissue with the pickups, the
needle is grasped again by the needle
driver in an appropriate position to
repeat the preceding step to the le t
o the previously placed suture.
5. A small amount o suture material
is pulled through and the needle is
inserted into the dermis to the le t o
the previously placed suture, and the
same movement is repeated.
6. The same technique is repeated
moving stepwise around the entire
wound until the needle exits close to
the original entry point at the ar end
o the wound.
7. Once the desired number o throws
have been placed, the suture material
is then pulled taut, leading to complete
Figure 4-33A. Overview o the fgure 8 double purse-
string suture.
A
Figure 4-33B. The central suture is placed; this may
be a nonabsorbable simple interrupted suture or (as
shown here) a buried suture. The needle is inserted
rom the underside o the dermis, exiting set-back rom
the incised wound edge.
B
Figure 4-33C. On the contralateral wound edge, the
needle is inserted set-back rom the wound edge, exit-
ing in the undermined undersur ace o the dermis.
C
Figure 4-33D. A ter placing the central suture, the
purse-string suture is started by inserting the suture in
the dermis, parallel to the wound edge.
D
or partial closure o the wound, and
tied utilizing an instrument tie.
8. The same procedure (steps 2 through
7) is then repeated on the adjacent
open wound (Figures 4-33A through
4-33H).
E
Figure 4-33E. This is continued along the edge o the
wound.
150
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
F
Figure 4-33F. Once the end is reached, this may be
continued with a backhand technique.
G
Figure 4-33G. Appearance a ter placing the purse-
string sutures along one side.
H
Figure 4-33H. This procedure is then repeated on
the contralateral side o the central suture. Immediate
postoperative appearance.
Tips and Pearls
Bisecting the original de ect permits even
large areas to be closed with a purse-string
technique.
It has been suggested that some de ects
on the back and extremities, particularly
in elderly patients with loose skin, are
better closed with a purse-string approach
than with a traditional linear closure,
since linear closures o ten heal with a
residual scar and require a signif cantly
longer excision line, while the puckering
that may be present immediately post-
operatively with purse-string closures is
likely to resolve with time. That said,
in the right hands linear closures on the
trunk and extremities o ten heal with
subtle scarring, even when wounds are
closed under tension. Moreover, a recent
randomized controlled trial demonstrated
that the cosmetic outcome o a purse-
string closure is comparable to secondary
intention healing.
On a pragmatic level, like the standard
purse-string closure, this approach is gen-
erally utilized when either a patient is
unwilling to undergo a traditional linear
closure or when their comorbidities make
the additional length o the incision or a
linear closure an unrealistic option.
As with linear running dermal tech-
niques, this technique may be used as a
modif ed winch or pulley suture, since the
multiple loops help minimize the tension
across any one loop and permit closure o
wounds under marked tension. Because
each throw is not tied o , however, it is
important to adequately secure the knots.
Drawbacks and Cautions
As with other running dermal techniques,
this approach leaves a air amount o
absorbable suture material in the dermis.
There ore, oreign-body reactions, suture
abscess ormation, and in ection are pos-
sibilities. That said, since the entire suture
line is secured with a single knot, and
since most o the bulk o any suture line
is in the knots, rather than the lengths o
suture material between knots, this tech-
nique may be less susceptible to suture
abscess or suture spitting than others.
151
The Figure 8 Double Purse-String Suture
Nonabsorbable monof lament suture
may also be used, in which case suture
removal may be per ormed approxi-
mately 2 weeks postoperatively.
The pucker e ect o this closure
resolves rapidly in atrophic skin, though it
can persist in other areas; patients should
realize that some degree o residual puck-
ering toward the center o the wound is
to be expected.
This approach provides less wound
eversion than vertically oriented
approaches such as the set-back der-
mal or buried vertical mattress sutures.
There ore, consideration should be given
to adding additional superf cially placed
everting sutures, such as the vertical mat-
tress suture, in order to mitigate this prob-
lem. Still, since this approach is generally
adopted when the surgeon has accepted
that the cosmetic outcome may be less
than ideal, it may be reasonable to use
this approach as a solitary closure.
References
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
Closure o round cutaneous postoperative
wounds with the purse string suture. South
Med J. 2006;99(12):1401-1402.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
The cuticular purse string suture: a modif ed
purse string suture or the partial closure o
round postoperative wounds. Int J Dermatol.
2007;46(7):746-753.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR. The
purse-string suture revisited: a use ul technique
or the closure o cutaneous surgical wounds.
Int J Dermatol. 2007;46(4):341-347.
Field LM. Inadvertant and undesirable sequelae o
the stellate purse-string closure. Dermatol Surg.
2000;26(10):982.
Greenbaum SS, Radonich M. Closing skin de ects
with purse-string suture. Plast Reconstr Surg.
1998;101(6):1749-1751.
Harrington AC, Montemarano A, Welch M,
Farley M. Variations o the pursestring suture
in skin cancer reconstruction. Dermatol Surg.
1999;25(4):277-281.
Ho man A, Lander J, Lee PK. Modif cation o the
purse-string closure or large de ects o the
extremities. Dermatol Surg. 2008;34(2):243-245.
Joo J, Custis T, Armstrong AW, et al. Purse-string
suture vs second intention healing: results o a
randomized, blind clinical trial. JAMA Dermatol.
2015; 151:265-70.
Ku BS, Kwon OE, Kim DC, et al. A case o erosive
adenomatosis o nipple treated with total exci-
sion using purse-string suture. Dermatol Surg.
2006;32(8):1093-1096.
Lin H, Li W. Complete closure using a double purse-
string closure or skin de ects. Dermatol Surg.
2009;35(9):1406-1409.
Nicholas L, Bingham J, Marquart J. Percutaneous
buried modif cation o the purse-string closure.
Dermatol Surg. 2014;40(9):1052-1054.
Patel KK, Tel er MR, Southee R. A “round block”
purse-string suture in acial reconstruction a ter
operations or skin cancer surgery. Br J Oral
Maxillofac Surg. 2003;41(3):151-156.
Peled IJ, Zagher U, Wexler MR. Purse-string suture
or reduction and closure o skin de ects. Ann
Plast Surg. 1985;14(5):465-469.
Randle HW. Modif ed purse string suture closure.
Dermatol Surg. 2004;30(2 pt 1):237.
Romiti R, Randle HW. Complete closure by purse-
string suture a ter Mohs micrographic sur-
gery on thin, sun-damaged skin. Dermatol Surg.
2002;28(11):1070-1072.
Spencer JM, Malerich SA, Moon SD. A regional
survey o purse-string sutures or partial and
complete closure o Mohs surgical de ects.
Dermatol Surg. 2014;40(6):679-685.
Teitelbaum S. The purse-string suture. Plast Reconstr
Surg. 1998;101(6):1748-1749.
Zhu JW, Wu XJ, Lu ZF, Cai SQ, Zheng M. Purse-
string suture or round and oval de ects: a use ul
technique in dermatologic surgery. J Cutan Med
Surg. 2012;16(1):11-17.
152
Technique
1. Wide and deep undermining is per-
ormed around the de ect.
2. The wound edge at the ar end o the
round- or oval-shaped wound, parallel
to the incision line, is re ected back.
3. With the tail o the suture material
resting between the surgeon and the
ar end o the wound, the needle is
inserted into the deep dermis or
superf cial ascia on the ar edge o
the wound with a trajectory running
parallel to the incision. The needle,
and there ore the suture, should pass
through the deep dermis or ascia at
a uni orm depth. Bite size is depen-
dent on needle size, though in order
to minimize the risk o necrosis it
may be prudent to restrict the size o
each bite. The needle should exit at a
point equidistant rom the cut edge
rom where it entered.
4. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the needle
driver in an appropriate position to
repeat the preceding step to the le t
o the previously placed suture.
5. A small amount o suture material
is pulled through and the needle is
inserted into the deep dermis or super-
f cial ascia to the le t o the previously
placed suture, and the same move-
ment is repeated.
The Stacked Double
Purse-String Suture
C H A P T E R 4 . 3 4
Video 4-34. Stacked double
purse-string suture
Access to video can be ound via
SuturingTechniques.com.
Application
Like all purse-string approaches, this tech-
nique is designed to either shrink the size
o a de ect or obviate it entirely, depend-
ing on the degree o tension and the size
o the de ect. It is a niche technique, since
the purse-string e ect tends to lead to a
slight puckering in the surrounding skin,
a eature that may be acceptable (and will
likely resolve with time) on areas such as
the orearms and back but is less desirable
in cosmetically sensitive locations such as
the ace. This technique relies on f rst per-
orming a purse-string closure o the ascia
or deeper structures ollowed by a second
purse-string layer through the dermis.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate
or the anatomic location should be uti-
lized. On the back and shoulders, 2-0 or
3-0 suture material is e ective, and on
the extremities and scalp, a 3-0 or 4-0
absorbable suture material may be used.
In the unlikely event this technique is
used on the ace, a 4-0 or 5-0 absorbable
suture is adequate. Since the technique
requires easy pull through o suture mate-
rial, monof lament absorbable suture is
generally pre erable.
Deep set
Superfical set
153
The Stacked Double Purse-String Suture
6. The same technique is repeated
moving stepwise around the entire
wound until the needle exits close to
the original entry point at the ar end
o the wound.
7. Once the desired number o throws
have been placed, the suture mate-
rial is then pulled taut, leading to a
partial closure o the wound, and tied
utilizing an instrument tie.
8. Steps (2) through (7) are then
repeated, but now in the mid-
dermis, closer to the incised wound
edge, so that two sets o nested cir-
cum erentially oriented sutures are
ultimately placed (Figures 4-34A
through 4-34I).
Deep set
Superfical set
A
Figure 4-34A. Overview o the stacked purse-string
technique.
B
Figure 4-34B. The needle is inserted parallel to the
de ect in the deep dermis.
C
Figure 4-34C. This is repeated moving around the
wound edge.
D
Figure 4-34D. When the contralateral side o the
wound is reached, a backhand technique may be used
or loading the needle.
E
Figure 4-34E. Appearance a ter placement o the
deep set o purse-string sutures.
Tips and Pearls
This technique may be thought o as a
hybrid between corset plication and a
traditional purse-string closure, and is
designed as an e f cient method o wound
154
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-34F. Appearance a ter tying the deep set o
purse-string sutures.
F
Figure 4-34G. The needle is then inserted parallel to
the wound edge through the superfcial dermis.
G
Figure 4-34H. This is repeated moving around the
wound.
H
Figure 4-34I. Immediate postoperative appearance
a ter placement o both sets o purse-string sutures.
Note the stellate appearance.
I
area reduction. In many cases, placing a
stacked double purse-string suture can
e ect complete wound closure and it
there ore represents an alternative to a
layered repair.
On a pragmatic level, this approach is
generally utilized when either a patient is
unwilling to undergo a traditional linear
closure or when their comorbidities make
the additional length o the incision or a
linear closure an unrealistic option.
As with linear running dermal tech-
niques, this technique may be used as a
modif ed winch or pulley suture, since the
multiple loops help minimize the tension
across any one loop and permit closure o
wounds under marked tension. Because
each throw is not tied o , however, it is
important to adequately secure the knot.
Drawbacks and Cautions
As with other running dermal techniques,
this approach leaves a air amount o
absorbable suture material in the dermis,
and since this technique places two sets o
purse-string sutures, it leaves even more
suture material in place than the standard
purse-string approach. There ore, oreign-
body reactions, suture abscess ormation,
and in ection are possibilities. That said,
since each suture line is secured with a sin-
gle knot, and since most o the bulk o any
suture line is in the knots, rather than the
lengths o suture material between knots,
this technique may be less susceptible to
suture abscess or suture spitting than others.
The pucker e ect o this closure resolves
rapidly in atrophic skin, though it can per-
sist in other areas; patients should realize
that some degree o residual puckering
155
The Stacked Double Purse-String Suture
toward the center o the wound is to be
expected.
Since the entire closure is held by two
knots, this approach may be associated
with a higher rate o wound dehiscence,
as knot ailure or ailure in the suture
material at any point leads to an immedi-
ate loss o tension on the closure. Given
the concern regarding knot breakage,
it may be help ul to attempt to better
secure the knot. This may be done by
paying particularly close attention to knot
tying, tying an extra ull knot, adding
extra throws, or leaving a longer tail than
would traditionally be executed.
This approach provides less wound
eversion than vertically oriented
approaches such as the set-back der-
mal or buried vertical mattress sutures.
There ore, consideration should be given
to adding additional superf cially placed
everting sutures, such as the vertical mat-
tress suture, in order to mitigate this prob-
lem. Still, since this approach is generally
adopted when the surgeon has accepted
that the cosmetic outcome may be less
than ideal, it may be reasonable to use
this approach as a solitary closure.
References
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
Closure o round cutaneous postoperative
wounds with the purse string suture. South
Med J. 2006;99(12):1401-1402.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR.
The cuticular purse string suture: a modif ed
purse string suture or the partial closure o
round postoperative wounds. Int J Dermatol.
2007;46(7):746-753.
Cohen PR, Martinelli PT, Schulze KE, Nelson BR. The
purse-string suture revisited: a use ul technique
or the closure o cutaneous surgical wounds.
Int J Dermatol. 2007;46(4):341-347.
Davis JC, Baillis B, Love WE. Novel stacked
double purse-string closure. Dermatol Surg.
2014;40(12):1409-1412.
Field LM. Inadvertant and undesirable sequelae o
the stellate purse-string closure. Dermatol Surg.
2000;26(10):982.
Greenbaum SS, Radonich M. Closing skin de ects
with purse-string suture. Plast Reconstr Surg.
1998;101(6):1749-1751.
Harrington AC, Montemarano A, Welch M,
Farley M. Variations o the pursestring suture
in skin cancer reconstruction. Dermatol Surg.
1999;25(4):277-281.
Ho man A, Lander J, Lee PK. Modif cation o the
purse-string closure or large de ects o the
extremities. Dermatol Surg. 2008;34(2):243-245.
Joo J, Custis T, Armstrong AW, et al. Purse-string
suture vs second intention healing: results o a
randomized, blind clinical trial. JAMA Dermatol.
2015; 151:265-70.
Ku BS, Kwon OE, Kim DC, et al. A case o erosive
adenomatosis o nipple treated with total exci-
sion using purse-string suture. Dermatol Surg.
2006;32(8):1093-1096.
Nicholas L, Bingham J, Marquart J. Percutaneous
buried modif cation o the purse-string closure.
Dermatol Surg. 2014;40(9):1052-1054.
Patel KK, Tel er MR, Southee R. A “round block”
purse-string suture in acial reconstruction a ter
operations or skin cancer surgery. Br J Oral
Maxillofac Surg. 2003;41(3):151-156.
Peled IJ, Zagher U, Wexler MR. Purse-string suture
or reduction and closure o skin de ects. Ann
Plast Surg. 1985;14(5):465-469.
Randle HW. Modif ed purse string suture closure.
Dermatol Surg. 2004;30(2 pt 1):237.
Romiti R, Randle HW. Complete closure by purse-
string suture a ter Mohs micrographic surgery
on thin, sun-damaged skin. Dermatol Surg.
2002;28(11):1070-1072.
Spencer JM, Malerich SA, Moon SD. A regional
survey o purse-string sutures or partial and
complete closure o Mohs surgical de ects.
Dermatol Surg. 2014;40(6):679-685.
Teitelbaum S. The purse-string suture. Plast Reconstr
Surg. 1998;101(6):1748-1749.
Zhu JW, Wu XJ, Lu ZF, Cai SQ, Zheng M.
Purse-string suture or round and oval de ects:
a use ul technique in dermatologic surgery.
J Cutan Med Surg. 2012;16(1):11-17.
156
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. Since the technique
requires easy pull through o suture mate-
rial, mono lament absorbable suture is
probably pre erable.
Technique
1. At the midpoint o the wound, 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 ol-
lowing 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 der-
mis, 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 opposite edge is then gently
grasped with the orceps.
5. The second bite is executed by insert-
ing the needle into the incised wound
The Bootlace Suture
C H A P T E R 4 . 3 5
Video 4-35. Bootlace suture
Access to video can be found via
Application
Like traditional running buried sutures,
this is a hybrid technique, combining
the tension relie and lack o transepider-
mal suture placement o a classic buried
suture with the rapidity o placement
and lack o resilience o a super cial run-
ning technique. This is there ore a niche
approach, since the running nature o the
technique means that compromise at any
point in the course o suture placement
may result in wound dehiscence. It does
a ord the advantage o the knot resting
in the center o the wound, which may
reduce the tendency or the central por-
tions o the wound to gape open. Still,
unless truly needed, this approach should
not be utilized as a solitary technique or
the closure o most wounds.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the smallest
gauge suture material appropriate or the
anatomic location should be utilized. On
the back and shoulders, 2-0 or 3-0 suture
material is e ective, though i there is
marked tension across the wound this
approach would not be appropriate as the
primary closure, and would be used best
or its pulley bene ts. On the extremities,
157
The Bootlace Suture
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
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. Instead o tying the suture, a tail is
le t protruding rom this rst set o
sutures and may be secured with a
hemostat.
7. Moving superiorly toward the dis-
tal pole o the wound, the proce-
dure is then repeated sequentially,
repeating steps (2) through (5)
while moving distally toward the
apex or as many throws as are
desired, without placing any addi-
tional knots.
8. Once the superior-most set o
throws is placed, the needle is
passed beneath all o the previ-
ously placed sets o sutures until
it exits proximal to the start-
ing point at the midpoint o the
wound. Only then are the ends o
the suture material pulled to e ect
partial closure o the distal portion
o the wound.
9. Starting at the in erior or proximal
apex, steps (2) through (5) are then
repeated, with the pairs o sutures
moving upward toward the center
o the wound.
10. Once the desired number o throws
have been placed, and the midpoint
o the wound has been reached,
the suture material is then pulled
taut, leading to complete closure
o the wound, and tied utilizing
an instrument tie (Figures 4-35A
through 4-35J).
A
Figure 4-35A. Overview of the bootlace suture technique.
B
Figure 4-35B. The needle is inserted at the center
of the wound through the dermis and exiting at the
incised wound edge.
C
Figure 4-35C. The needle is then inserted on the contra-
lateral side of the wound, still at the center of the wound,
entering the incised wound edge and exiting in the dermis.
158
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-35D. Moving distally, similar bites are taken
from alternating wound edges.
D
Figure 4-35E. When the distal apex of the wound is
reached, the needle is reloaded on the needle driver.
E
Figure 4-35F. The needle is then passed carefully
under the already placed loops of suture and reloaded
on the needle driver.
F
Figure 4-35G. Starting at the proximal wound apex,
the needle is then again inserted through the incised
wound edge, exiting in the dermis.
G
Figure 4-35H. Alternating bites are then taken,
moving toward the center of the wound.
H
Figure 4-35I. The ends of the suture are then pulled
gently, tightening the length of suture and bringing the
wound edges together.
I
Tips and Pearls
This technique was designed as an alter-
native to other running dermal techniques
that would solve one o their chie draw-
backs, the tendency toward di erential
scar-spread in the center o the wound
as a unction o the increased tension in
this central area.
While originally described as a modi -
cation o the buried dermal suture, it may
159
The Bootlace Suture
Figure 4-35J. Immediate postoperative appearance,
after tying the suture in the center of the wound.
J
be easily modi ed as a buried vertical
mattress or set-back suture technique as
well, with the same principle that suture
material is tied in the central portion o
the wound.
Like other running dermal techniques,
this technique may be used as a modi-
ed winch or pulley suture, since the
multiple loops help minimize the tension
across any one loop and permit closure o
wounds under marked tension. Because
each throw is not tied o , however, it is
important to adequately secure the knot.
Given the theoretical susceptibility to
suture material breakage or compromise,
this is a technique that is probably best
used in a layered ashion, either super-
cial to previously placed interrupted
buried sutures, or deep to a set o more
super cially placed buried sutures.
It may be bene cial to place the run-
ning sutures closer together toward the
center o the wound than at the poles o
the incision, as this may oster a more
pronounced pulley e ect at the center
o the wound where the tensile orces
are greatest.
Given the concern regarding knot
breakage, it may be help ul to attempt to
better secure the central (and only) knot.
This may be done by paying particularly
close attention to knot tying, tying an
extra ull knot, adding extra throws, or
leaving a longer tail than would tradition-
ally be executed. An additional approach
is to secure the nal knot with the aid
o a tacking knot, which may similarly
provide extra security.
Drawbacks and Cautions
Unlike other running dermal techniques,
this approach leaves an additional bolus
o suture material in the wound rom
the suture material traversing rom the
superior apex to the in erior apex at the
hal way point o the closure. This added
oreign-body material increases the the-
oretical risk o oreign-body reaction,
suture abscess ormation, and in ection.
That said, these theoretical disadvantages
should be weighed against the real bene t
o tying the knot centrally and better
securing the central, highest tension por-
tion o the wound.
As noted previously, this approach
should usually not be used as a solitary
closure technique, since there is no redun-
dancy in the closure. It may be use ul as
an adjunct when there is either minimal
tension across a wound (and there ore
interrupted buried sutures may be unnec-
essary) or as a pulley approach to bring
recalcitrant wound edges together.
Like the standard buried dermal suture,
this approach as originally described pro-
vides less wound eversion than other
approaches such as the set-back dermal
or buried vertical mattress; there ore, a
bootlace variation o the latter two tech-
niques, as discussed earlier, may o ten be
pre erred to a bootlace running dermal
approach, since wound eversion may be
associated with improved cosmesis over
the long term.
Reference
Esdaile BA, Turner R. The bootlace suture: a novel
buried running dermal continuous suture for
primary closure of wounds. Clin Exp Dermatol.
2013;38(7):795-796.
160
Technique
1. The ap is brought into place using
buried sutures, allowing the tip to
rest with only minimal tension in its
desired position. The wound edge
o the distal portion o non ap skin
is gently re ected back, permitting
visualization o the dermis.
2. The needle is inserted into the
underside o the dermis on the
ar right edge o the distal non ap
section o skin with a trajectory run-
ning parallel to an imaginary circle
around the point where all three seg-
ments o skin will meet. Generally,
this entry point in the dermis should
be approximately 1-3 mm set-back
rom the epidermal edge, depending
on the thickness o the dermis and
the anticipated degree o tension
across the tip. The needle, and there-
ore the suture, should pass through
the deep dermis at a uni orm depth.
Bite size is dependent on needle size,
though in order to minimize the risk
o necrosis it may be prudent to
restrict the size o each bite.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the needle
driver in an appropriate position to
repeat the preceding step on the ap
tip to the le t o the previously placed
suture.
The Buried Tip Stitch
C H A P T E R 4 . 3 6
Synonym
Deep tip stitch
Video 4-36. Buried tip stitch
Access to video can be found via
Application
This technique is designed to bring three
ends o tissue together, and is o ten used
in the context o a ap, where it per-
mits the tip o tissue to be inset. The
buried variation o the tip stitch can be
conceptualized as a low-tension purse-
string closure, since it utilizes a mild orm
o circum erential tissue advancement.
Since it is used only when attempting to
approximate three segments o skin, it is
a niche technique.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate or
the anatomic location should be utilized.
On the ace, where this technique may
be used or ap repairs, a 5-0 absorbable
suture is appropriate. On the extremities
and scalp, a 3-0 or 4-0 absorbable suture
material may be used, and on the back
and shoulders, 2-0 or 3-0 suture material
is e ective, though care should be taken
with leaving the relatively thick 2-0 suture
in the superf cial dermis, as it may hydro-
lyze relatively slowly. Monof lament and
braided suture materials may both be
appropriate when utilizing this technique.
161
The Buried Tip Stitch
4. A small amount o suture material
is pulled through and the needle is
inserted into the dermis in the ap tip,
and the same movement is repeated.
5. The same technique is then repeated
on the proximal non ap edge o skin,
keeping the needle parallel to the
imaginary circle and moving in the
same counterclockwise direction.
The needle then exits close to the
original entry point on the right side
o the wound.
6. The suture material is then gen-
tly pulled taut and tied utilizing an
instrument tie, burying the knot
(Figures 4-36A through 4-36E).
Figure 4-36A. Overview of the buried tip stitch.
A
Figure 4-36B. The needle is inserted in the mid-
dermis, parallel to the surface of the skin, on an axis
following the curvature of an imaginary circle drawn
between the two edges and the tip.
B
Figure 4-36C. The needle is then inserted through the
dermis at the same depth on the tip.
C
Figure 4-36D. The needle’s course continues on the
contralateral wound edge, remaining at the same depth
and on the same axis.
D
Figure 4-36E. Immediate appearance after suture
placement. Note that the tip is brought into close
approximation with the other wound edges.
E
Tips and Pearls
The buried tip stitch is very use ul when
bringing the tip o a ap into place. Impor-
tantly, this technique is designed to gently
approximate the tissues so that the ap
162
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
is properly inset in the surrounding skin.
While it bears a technical resemblance
to the buried purse-string approach, it is
important to appreciate that the buried
tip stitch is not designed to work under
signif cant tension, as tension across the
suture may lead to necrosis o the delicate
and lightly vascularized tip o the ap.
Placing set-back dermal sutures, imbrica-
tion sutures, or suspension sutures prior to
placement o the tip stitch will ensure that
the tip itsel is not under tension when it is
approximated with the surrounding skin.
Depending on patient positioning,
the three wound edges may be approxi-
mated in any order, so that a backhand
approach could be used i desired, or
the bite through the ap tip could be
executed as the f rst step in a closure. I
this is done, however, the knot will be
placed directly adjacent to the tip o the
ap, which may not be ideal.
A downside o traditional tip stitch
placement is the tendency or the tip to sit
deeper than the surrounding tissues. This
may be related to the relative upward
pull on the nontip sections o skin by the
transepidermal sutures in the standard
tip stitch. There ore, the problem o a
depressed tip is not generally seen with
the buried tip stitch approach, another
signif cant advantage o this technique.
Drawbacks and Cautions
Since some absorbable suture material is
le t in the dermis, oreign-body reactions,
suture abscess ormation, and in ections
are possibilities. That said, this tech-
nique joins only three edges o tissue,
and there ore leaves only slightly more
suture material in situ than a standard
buried suture.
Flap tip necrosis is the greatest risk
with this technique, since suture mate-
rial traverses the dermis containing the
tip’s vascular supply. This risk may be
mitigated by tying the suture together
relatively loosely so that the tip is not
overly constricted when the knot is tied.
Additionally, i the bites o dermis are
su f ciently setback rom the wound edge,
a small bite comprising less than hal o
the dermis in the tip could be taken. This
would allow blood supply to the tip even
in the context o a relatively tight loop
running through the distal ap.
Finally, while ap tip necrosis is a risk,
studies have suggested that the tip stitch
provides less vascular constriction than
other options, such as placing two verti-
cally oriented sutures at the edges o the
tip or a suture directly through the tip
itsel . Vascular compromise and ensuing
necrosis o the ap tip is always a risk,
even i no sutures are placed through
the tip itsel , and there ore the buried tip
stitch approach likely provides a reason-
able balance between tissue approxima-
tion and adequate vascular supply.
Reference
Chan JL, Miller EK, Jou RM, Posten W. Novel surgi-
cal technique: placement of a deep tip stitch.
Dermatol Surg. 2009;35(12):2001-2003.
163
locations, on the ace and areas under
minimal tension a 5-0 absorbable suture
is adequate. Braided absorbable suture
has been advocated as ideal or this
approach, as it helps lock each o the
throws in place while still permitting
su cient slippage to take advantage o
the pulley e ect o the multiple throws.
Technique
1. A ter incising the wound with an
inward bevel, the wound edge is
ref ected back using surgical orceps
or hooks.
2. The suture is anchored to the under-
sur ace o the dermis distal to the
apex o the wound. This may be
accomplished by taking a bite o
dermis distal to the wound apex
and tying o the suture material. A
minimum o our throws is recom-
mended to maximize knot security.
3. While ref ecting back the dermis on
the le t side o the wound, the suture
needle, loaded in a backhand ash-
ion, is inserted parallel to the skin
sur ace into the base o the beveled
undersur ace o the dermis 2-mm
distant rom the incised wound edge.
4. The needle is rotated through its arc,
moving parallel to the skin sur ace
toward the surgeon.
5. The rst bite is completed by ol-
lowing the curvature o the needle
and allowing the needle to exit in
the incised wound edge. The size
The Backtracking
Running Butter y Suture
C H A P T E R 4 . 3 7
Synonym
G suture, continuous buried backstitch
Video 4-37. Backtracking
running butterf y suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a niche hybrid technique, combin-
ing the tension relie , eversion, and lack
o transepidermal suture placement o a
butterf y suture with the locking ability
o a running locking suture and the rapid-
ity o placement and lack o resilience
o a super cial running technique. This
approach is in requently used, since the
running nature o the technique means
that compromise at any point in the
course o suture placement may result
in wound dehiscence.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate
or the anatomic location should be
utilized. On the back and shoulders,
2-0 or 3-0 suture material is e ective,
though i there is marked tension across
the w ound this approach w ould not
be appropriate as the primary closure,
and would be used best or its pulley
bene ts. On the extremities, a 3-0 or
4-0 absorbable suture material may be
used, and, while rarely utilized in these
164
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
o this bite is based on the size o
the needle, the thickness o the der-
mis, 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.
6. Keeping the loose end o suture
material distal to the preceding bite,
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.
7. The second bite is executed by
inserting the needle into the incised
wound edge, parallel to the skin
sur ace and again at the level o the
super cial papillary dermis. This
bite should be completed by ol-
low ing the curvature o the needle
and avoiding catching the under-
sur ace o the epidermis, w hich
could result in epidermal dimpling.
It then exits approximately 2 mm
distal to the wound edge on the
Figure 4-37A. Overview o the backtracking running
butter y suture.
A
Figure 4-37B. Beginning o the anchoring suture. The
needle is inserted through the underside o the dermis,
exiting through the incised wound edge.
B
Figure 4-37C. Second portion o the anchoring
suture; the needle is inserted on the contralateral side
through the incised wound edge, exiting at the under-
sur ace o the wound.
C
undersur ace o the dermis, distal
to its entry point.
8. The procedure is then repeated
sequentially,
repeating
steps
(2)
through (7) while moving proximally
toward the surgeon or as many
throws as are desired, without plac-
ing any additional knots until the
desired number o loops have been
placed. Each backstitch should over-
lap the preceding suture throw by
approximately hal o its radius.
9. The suture material is then tied utiliz-
ing an instrument tie (Figures 4-37A
through 4-37H).
165
The Backtracking Running Butter ly Suture
Figure 4-37D. The anchoring suture is tied.
D
Figure 4-37E. With the needle driver held in a pencil-
like ashion, the needle is rotated through the dermis,
entering the deep dermis and taking a bite parallel to
the incised wound edge, with the needle reaching its
zenith at the center o the bite.
E
Figure 4-37F. A similar bite is taken on the contralat-
eral wound edge, with the needle exiting the contra-
lateral wound edge proximal to its exit point rom the
previous side, leading to a backstitch confguration.
F
Figure 4-37G. The bites are repeated on alternating
sides, each time with the needle exiting at the mid-
point o its prior throw, so that a continuous backstitch
is executed.
G
Figure 4-37H. Immediate postoperative appearance.
H
Tips and Pearls
This technique may be used as a modi-
ed winch or pulley suture, since the
multiple loops help minimize the tension
across any one loop and permit closure o
wounds under marked tension. Because
each throw is not tied o , however, it is
important to adequately secure the rst
and nal throws with a well-locked knot.
Like the butterf y suture, this tech-
nique is best used with a beveled inci-
sion. Indeed, the horizontal orientation
o this suture may be conceptualized
as a continuous butterf y suture with a
backstitch component.
Given the theoretical susceptibility to
suture material breakage or compromise,
this is a technique that is probably best
166
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
used in a layered ashion, either super-
cial to previously placed interrupted
buried sutures, or deep to a set o more
super cially placed buried sutures.
I braided absorbable suture is used,
the added riction betw een loops may
help lock the suture material in place
with each throw, but caution should be
taken to pull su cient suture material
through w ith each throw, as this ric-
tion may impede the surgeon’s abil-
ity to pull suture material through the
course o multiple loops. Similarly, i
mono lament suture is used it may
be easier to pull the additional suture
material through but it may make it
more di cult to lock the suture in place
be ore tying, and the running suture
loops may gape open as the surgeon
moves proximally through the di erent
sets o throws.
It may be bene cial to place the run-
ning sutures closer together toward the
center o the wound than at the poles o
the incision, as this may oster a more
pronounced pulley e ect at the center
o the wound where the tensile orces
are greatest.
Given the concern regarding knot
breakage, it may be help ul to attempt
to better secure the rst and nal knots
at the ends o the running series o loops.
This may be done by paying particularly
close attention to knot tying, tying an
extra ull knot, adding extra throws, or
leaving a longer tail than would tradition-
ally be executed. An additional approach
is to secure the nal knot with the aid
o a tacking knot, which may similarly
provide extra security.
This technique calls or horizontally
oriented suture loops to be placed with a
slight upward tilt at their apex (i.e., when
the suture material moves laterally away
rom the incised edge). This approach, in
the context o a beveled incision, leads to
a nicely everted wound edge, as is seen
with the butterf y suture.
Drawbacks and Cautions
As noted previously, this approach should
usually not be used as a solitary closure
technique, since there is no redundancy in
the closure. It may be use ul as an adjunct
when there is either minimal tension
across a wound (and there ore interrupted
buried sutures may be unnecessary) or as
a pulley approach to bring recalcitrant
wound edges together.
The central drawback o this approach
is the act that it is a running technique;
there ore, suture material or knot com-
promise at any point will lead to potential
wound dehiscence. While the locking
e ect o the backstitch w hen using
braided suture material is somew hat
help ul, it does not guarantee that the
edges will remain locked in the absence
o an anchoring suture.
Theoretically, the horizontal orienta-
tion o the suture loops may increase
the risk o wound edge necrosis, though
this has not been reported as a signi cant
problem. The backstitch component does
result in a slightly larger quantity o suture
material being le t in the wound when
compared with a standard running buried
technique, theoretically increasing the
risk o a oreign-body reaction or other
complications.
Re erence
Almuhammadi RA. The G-suture: continuous bur-
ied backstitch (CBB). An innovative aesthetic
dermal suture technique. J Dtsch Dermatol Ges.
2011;9(12):1058-1061.
167
Technique
1. The needle is inserted at the ar right
corner o the wound, parallel to the
incision line, beginning approxi-
mately 2-5 mm rom the apex. The
needle is passed rom this point,
which is lateral to the incision apex,
directly through the epidermis, exit-
ing into the interior o the wound
just medial to the apex.
2. With the tail o the suture material
resting lateral to the incision apex and
outside the wound, the wound edge
is gently re ected back and the needle
is inserted into the deep dermis or as-
cia on the ar edge o the wound with
a trajectory running parallel to the
incision line. The needle, and there-
ore the suture, should pass through
the deep dermis or ascia at a uni orm
depth. Bite size is dependent on nee-
dle size, though in order to minimize
the risk o necrosis it may be prudent
to restrict the size o each bite. The
needle should exit the deep dermis or
ascia at a point equidistant rom the
cut edge rom where it entered.
3. The needle is then grasped with the
surgical pickups and simultaneously
released by the hand holding the
needle driver. As the needle is reed
rom the tissue with the pickups, the
needle is grasped again by the nee-
dle driver in an appropriate position
to repeat the previously mentioned
The Stacked Backing Out
Subcuticular Suture Technique
C H A P T E R 4 . 3 8
Synonym
Super loop suture
Video 4-38. Stacked backing
out subcuticular suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a niche technique that may be
conceptualized as a backing out subcu-
ticular approach with the f rst row o
subcuticular sutures placed in the deep
dermis, or as a variation o the stacked
double purse-string technique. It is use ul
or wounds under mild to moderate ten-
sion, and may be used overlying deeper
tension-relieving sutures.
Suture Material Choice
As with any technique, it is best to uti-
lize the thinnest suture possible or any
given anatomic location. As this tech-
nique is not designed to hold marked
tension irrespective o anatomic loca-
tion, generally a 4-0 or 5-0 suture may
be used. This is especially important
since a large volume o suture mate-
rial is le t in situ w hen utilizing this
approach. It is best to utilize a mono-
f lament suture material to minimize
the coe f cient o riction at the time
o suture removal, though this tech-
nique may also be f nessed or use with
absorbable suture material.
168
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
step on the contralateral edge o the
incised wound edge.
4. A small amount o suture material
is pulled through and the needle is
inserted into the deep dermis or as-
cia on the contralateral side o the
incised wound edge a ter re ecting
back the skin, and the same move-
ment is repeated. The needle should
enter slightly proximal (relative to
the wound apex where the suture
line began) to the exit point, thus
introducing a small degree o back-
tracking to the snake-like ow o the
suture material. This will help reduce
the risk o tissue bunching.
5. The same technique is repeated on
the contralateral side o the incision
Figure 4-38A. Overview o the stacked backing out
subcuticular suture.
A
Figure 4-38B. The needle is inserted rom outside the
skin, lateral to the wound apex, exiting in the interior
o the wound.
B
Figure 4-38C. The needle is passed through the deep
dermis, parallel to the incised wound edge.
C
line, and alternating bites are then
taken rom each side o the incision
line, continuing on until the end o the
wound is reached. At this point, the
needle’s direction is changed to head
in the opposite direction, toward the
apex where the suture began.
6. Moving in the opposite direc-
tion, steps (1) through (5) are then
repeated, but now in the superf -
cial dermis, with the suture mate-
rial snaking an alternating course
through the superf cial dermis, using
a backhand technique i desired.
7. The suture material may either be
tied to the ree end o suture at the
original apex or alternatively it may
be tied on the exterior o the wound
(Figures 4-38A through 4-38J).
169
The Stacked Backing Out Subcuticular Suture Technique
Figure 4-38D. This is repeated along the contralateral
wound edge.
D
Figure 4-38E. Suture placement continues in the deep
dermis parallel to the wound edge, alternating sides.
E
Figure 4-38F. Once the end o the wound is reached,
the needle is passed through the deep dermis lateral to
the wound apex, exiting the skin lateral to the apex.
F
Figure 4-38G. The needle is reinserted lateral to the
apex, entering the interior o the wound, now heading
in the opposite direction.
G
Figure 4-38H. The needle is passed through the
superfcial dermis parallel to the wound edge in the
direction o the initial entry point.
H
Figure 4-38I. A ter reaching the end o the wound by
successively taking bites o the superfcial dermis on
alternating edges o the wound, the needle again exits
lateral to the apex.
I
Tips and Pearls
This is a niche technique, as the addi-
tion o a second row o subcuticular
suture material in the wound may add
only modest wound security, since it is
a running technique, while it doubles the
amount o suture material that will ulti-
mately need to be removed or absorbed.
As w ith the standard subcuticular
technique, body positioning can be very
170
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-38J. Immediate postoperative appearance
a ter the suture material has been pulled taut and tied.
Note the bunching at the wound’s poles, which may be
mitigated by utilizing a bolster so that the downward
pull o the suture loops does not lead to exaggerated
dimpling.
J
help ul in maintaining an e f cient and
com ortable technique. Most surgeons
are trained to work with the surgical site
at and perpendicular to their body. Since
the motions associated with subcuticular
suture placement are 90-degrees o rom
this, it may be use ul to stand with the
surgeon’s body (shoulder to shoulder) par-
allel to the incision line. This allows or a
owing motion rom right to le t without
the need to twist the shoulders or wrists.
Since this approach requires the sur-
geon to per orm the second hal o the
closure moving in the opposite direc-
tion, it may be use ul to use a backhand
technique or many o the suture throws
when moving back tow ard the origi-
nal wound apex. This may add signif -
cantly to the time needed to complete
this closure.
A smooth, owing technique is o
paramount importance in executing
this technique e ectively and e f ciently.
Some authors have advocated adjust-
ing the angle used to hold the needle in
the needle driver rom the traditional
90-135 degrees to increase the surgeon’s
com ort and minimize the need or physi-
cal contortion, though slightly adjusting
the surgeon’s body position helps signif -
cantly in this regard.
Drawbacks and Cautions
Though it may be conceptualized as a
bidirectional, two-depth subcuticular
closure, the extra row o sutures in this
technique pulls the deep tissues together
but also adds only modestly to wound
security, as the entire suture line is secured
with a single knot. There ore, it is prob-
ably best not used as a solitary closure
approach, but rather layered over the top
o a deeper suturing technique.
While a central strength o this technique
is its entirely intradermal placement, this
may also represent one o its greatest draw-
backs. This technique results in leaving a
very signif cant quantity o oreign-body
material in the dermis and deeper tissues
in a continuous ashion. While this may
not represent a major problem in areas
with a thick dermis such as the back, in
other anatomical locations the large quan-
tity o suture that is le t in situ may result
in concerns regarding in ection, oreign-
body reaction, and even the potential that
the suture material itsel could present a
physical barrier that would impinge on the
ability o the wound to heal appropriately.
The extra row o deep sutures used
in this technique raises urther concern
regarding the possibility o tissue strangu-
lation along the wound margin that could
theoretically be associated with tightly
placed subcuticular sutures. It, there ore,
should be reserved or areas with an out-
standing vascular supply, such as the ace.
I nonabsorbable suture material is used,
removal o long-standing suture entails a
theoretical risk that a potential space—
albeit a thin and long one—is created on
the removal o the suture material. This
theoretical risk may be mitigated by utiliz-
ing the thinnest possible suture material.
Reference
Bolander L. The super loop suture: a way of sutur-
ing skin and subcutaneous tissue. Plast Reconstr
Surg. 1992;89(4):766.
171
Technique
1. The wound edge is re ected back
using surgical orceps or hooks.
2. While re ecting back the dermis,
the suture needle is inserted at
90 degrees into the underside o
the dermis 2 mm distant rom the
incised wound edge.
3. The f rst bite is executed by ollow-
ing the curvature o the needle and
allowing the needle to exit in the
incised wound edge. The needle’s
zenith with respect to the wound
sur ace should be between the
entry and exit points.
4. Keeping the loose end o suture
between the surgeon and the
patient, the dermis on the side o
the f rst bite is released. The tissue
on the opposite edge is then gently
grasped with the orceps.
5. The second bite is executed by insert-
ing the needle into the incised wound
edge at the level o the superf cial
papillary dermis. This bite should
be completed by ollowing the cur-
vature o the needle and avoiding
catching the undersur ace o the epi-
dermis. It then exits approximately
2 mm distal to the wound edge on
the undersur ace o the dermis. This
should mirror the f rst bite taken on
the contralateral side o the wound.
The Running Locked
Intradermal Suture
C H A P T E R 4 . 3 9
Video 4-39. Running locked
intradermal suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a niche hybrid technique, com-
bining the tension relie and lack o
transepidermal suture placement o a
classic buried suture w ith the rapid-
ity o placement and lack o resilience
o a superf cial running technique and
the locking benef t o a running locked
suture. The locking loops o suture add
signif cantly to the volume o retained
suture material and also make suture
placement more challenging to learn
than other techniques.
Suture Material Choice
Suture choice is dependent in large part
on location, though as always the small-
est gauge suture material appropriate or
the anatomic location should be utilized.
On the back and shoulders, a 3-0 suture
material is e ective, though i there is
marked tension across the wound this
approach would not be appropriate as
the primary closure. 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.
172
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
6. This f rst anchoring set o sutures is
then tied with an instrument tie.
7. Moving proximally toward the
surgeon, steps (1) through (5) are
then repeated, leaving a loop o
suture material created between the
anchor suture and the start o this
second dermal suture protruding
rom the wound center.
8. The needle is inserted beneath the
loop o suture and then looped
again around the loop, creating a
secondary loop o suture material.
9. The needle is then pulled through
this secondary loop and gently
pulled upward, securing the loop in
place.
10. The needle is then inserted through
the center o the wound underneath
the newly ormed loop.
11. The procedure is then repeated
sequentially, repeating steps (7)
through (10) while moving proxi-
mally toward the surgeon or as
many throws as are desired, with-
out placing any additional knots
until the desired number o loops
have been placed.
Figure 4-39A. Overview o the running locked intra-
dermal suture.
Pull
A
Figure 4-39B. Placement o the anchoring suture; the
frst bite enters rom the dermis, exiting in the incised
wound edge.
B
Figure 4-39C. The needle then enters the incised
wound edge on the contralateral side, exiting in the
dermis. The suture is then tied and the loose end o
suture material is trimmed.
C
Figure 4-39D. Moving proximally toward the surgeon,
a loop o suture is le t as the needle is passed through
the dermis, exiting the incised wound edge.
D
12. The suture material is then tied utiliz-
ing an instrument tie. Alternatively,
a hand tie may be used i desired
(Figures 4-39A through 4-39K).
173
The Running Locked Intradermal Suture
Figure 4-39E. This is repeated on the contralateral
side, with the needle exiting between the wound apex
and the newly placed portion o suture material.
E
Figure 4-39F. The needle is then passed through the
loop le t on the contralateral side.
F
Figure 4-39G. The needle may be gently grasped with
surgical orceps.
G
Figure 4-39H. The needle is then passed again
through this loop o suture.
H
Figure 4-39I. The needle is then passed through the
newly created secondary loop o suture material.
I
Figure 4-39J. The suture material is then pulled taut,
locking the suture in place. This procedure is then
repeated sequentially along the length o the wound.
J
Tips and Pearls
This is a complex technique, and takes
some time to master. Its chie advantage
is that although each individual dermal
suture is not ully tied, it is locked so
securely that compromise along the line
o sutures will likely not lead to a com-
plete loss o security in the suture line.
As with other techniques, i braided
absorbable suture is used, the added ric-
tion between loops may help lock the
suture material in place with each throw,
174
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 4-39K. Immediate postoperative appearance.
K
but caution should be taken to pull su -
f cient suture material through with each
throw, as this riction may impede the
surgeon’s ability to pull suture material
through the course o multiple loops.
Similarly, i monof lament suture is used
it may be easier to pull the additional
suture material through but it may make
it more di f cult to lock the suture in place
be ore tying.
It may be help ul to attempt to bet-
ter secure the f rst and f nal knots at the
ends o the running series o loops. This
may be done by paying particularly close
attention to knot tying, tying an extra ull
knot, adding extra throws, or leaving a
longer tail than would traditionally be
executed.
Drawbacks and Cautions
The major drawback o this technique is
that it may be challenging to learn. Once
mastered, this technique presents a viable
option or securing deep sutures, though
as with all techniques it does have some
limitations.
This approach leaves a sizable quan-
tity o suture material in place along the
incised wound edge. Since this material
may serve as a barrier to healing, and may
also increase the risk o suture spitting,
this is a disadvantage. Moreover, since
some o the suture material is placed airly
superf cially, and extends laterally along
the incised wound edge, i suture spitting
or suture abscess ormation becomes a
problem this may be particularly trouble-
some as it may a ect a greater propor-
tion o the wound rather than the single
punctate area as is seen with interrupted
sutures.
The added time needed to e ectively
lock each throw also means that one o
the greatest advantages o the running
approach—that it is aster than inter-
rupted sutures—is minimized, since the
di erential between the time needed to
tie individual sutures and to e ectively
lock the line o sutures may not be that
great.
Like the standard buried dermal suture,
this approach provides less wound ever-
sion than other approaches such as the
set-back dermal or buried vertical mat-
tress; there ore, a running locking varia-
tion o the latter two techniques may
be pre erred to a running locking dermal
approach, since wound eversion may be
associated with improved cosmesis over
the long term.
Reference
Wong NL. The running locked intradermal suture.
A cosmetically elegant continuous suture for
wounds under light tension. J Dermatol Surg
Oncol. 1993;19(1):30-36.
Suture Techniques or Super cial
Structures: Transepidermal Approaches
C H A P T E R 5
176
placement is solely epidermal approxi-
mation, this suture material may be used
on the extremities as well. Otherwise,
5-0 mono lament suture material can
be used i there is minimal tension, and
4-0 mono lament suture may be used
in areas under moderate tension where
the goal o suture placement is relieving
tension as well as epidermal approxi-
mation. In select high-tension areas, 3-0
mono lament suture may be utilized as
well, particularly in the context o a mul-
timodality approach, or example when
mattress sutures are placed in the center o
the wound to maximize tension relie and
eversion, and simple interrupted sutures
are placed at the lateral edges o the
wound to minimize dog-ear ormation.
Technique
1. The needle is inserted perpendicular
to the epidermis, approximately one-
hal the radius o the needle distant
to the wound edge. This will allow
the needle to exit the wound on the
contralateral side at an equal distance
rom the wound edge by simply ol-
lowing the curvature o the needle.
2. With a f uid motion o the wrist, the
needle is rotated through the dermis,
taking the bite wider at the deep
margin than at the sur ace, and the
needle tip exits the skin on the con-
tralateral side.
3. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping the
The Simple Interrupted Suture
C H A P T E R 5 . 1
Video 5-1. Simple interrupted
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is the standard benchmark suture
used or closure and epidermal approxi-
mation. It may be used alone in the
context o small wounds under minimal
to no tension, such as those ormed by
either a small bunch biopsy or a traumatic
laceration. It is also requently used as a
secondary layer to aid in the approxima-
tion o the epidermis when the dermis
has been closed using a dermal or other
deep suturing technique.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement. Simple interrupted
sutures may be placed with the goal o :
(1) accomplishing epidermal approxima-
tion in a wound under moderate tension,
such as a laceration or punch biopsy, or (2)
ne-tuning the epidermal approximation
o a wound where the tension has already
been shi ted deep utilizing a deeper der-
mal or ascial suturing technique.
On the ace and eyelids a 6-0 or 7-0
mono lament suture may be utilized
or epidermal approximation. When
the goal o simple interrupted suture
177
The Simple Interrupted Suture
Figure 5-1A. Overview o the simple interrupted
suture technique.
A
Figure 5-1B. Beginning o the simple interrupted
suture. Note that the needle enters the skin at a
90-degree angle be ore curving slightly away rom the
wound edge to take a fask-like bite o tissue.
B
Figure 5-1C. Completion o the simple interrupted
suture. Note that the needle now exits the skin at a
90-degree angle.
C
Figure 5-1D. Appearance a ter placement o the simple
interrupted suture. Note the presence o the adjacent
horizontal mattress suture and the depth-correcting
simple interrupted suture, whose postoperative appear-
ance is identical to that o the simple interrupted suture.
D
needle tip, which can be easily dulled
by repetitive riction against the sur-
gical orceps. It is gently grasped
and pulled upward with the surgi-
cal orceps as the body o the needle
is released rom the needle driver.
Alternatively, the needle may be
released rom the needle driver and
the needle driver itsel may be used
to grasp the needle rom the contra-
lateral side o the wound to complete
its rotation through its arc, obviating
the need or surgical orceps.
4. The suture material is then tied o
gently, with care being taken to mini-
mize tension across the epidermis and
avoid overly constricting the wound
edges (Figures 5-1A through 5-1D).
Tips and Pearls
It is important to enter the epidermis
at 90 degrees, allowing the needle to
travel slightly laterally away rom the
wound edge be ore ully ollowing the
curvature o the needle w hen utiliz-
ing this technique. This will allow or
maximal wound eversion and accurate
wound-edge approximation. The nal
cross-sectional appearance o the needle’s
course should be a f ask-like shape, wider
at the base than at the sur ace.
The simple interrupted suture may also
be used layered over the top o another
suture in order to ne-tune epidermal
approximation. For example, i a vertical
mattress suture was placed to acilitate
178
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
eversion, occasionally the wound edges
may not be ully approximated. A small
simple interrupted suture, placed at the
point where the wound edges are arthest
apart, may be used to solve this problem
and e ect accurate approximation o the
wound edges.
Care should be taken to avoid skim-
ming the needle super cially beneath
the epidermis. This results rom ailing
to enter the skin at a perpendicular angle
and to ollow the curvature o the needle.
This may result in wound inversion as the
tension vector o the shallow bite pulls
the wound edges outward and down.
Drawbacks and Cautions
With any suturing technique, knowledge
o the relevant anatomy is critical. When
placing a simple interrupted suture it is
important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material. For example, the needle
may pierce a vessel leading to increased
bleeding.
Similarly, particularly i the knot is tied
relatively tightly, structures deep to the
de ect may be constricted. This can lead
to necrosis due to vascular compromise
or even, theoretically, super cial nerve
damage.
The potential to constrict deeper struc-
tures may be used to the surgeon’s advan-
tage in the event that a small vessel deep
to the incision line is oozing; rather than
opening the wound, localizing the source
o the bleed, and tying o the individual
vessel, it may be possible to simply place
an interrupted suture incorporating the
culprit vessel within its arc, tie it tightly,
and thus indirectly ligate the vessel. This
should only be used in the event that
the o ending vessel is relatively small,
since otherwise there is a signi cant risk
that this indirect ligation will not be su -
ciently resilient. Moreover, tying the
suture too tightly may increase the risk
o developing track marks or super cial
necrosis.
This technique may elicit an increased
risk o track marks, necrosis, and other
complications when compared with tech-
niques that do not entail suture material
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complications,
and consideration should be given to
adopting other closure techniques in the
event that sutures will not be able to be
removed in a timely ashion. Some stud-
ies have also demonstrated an increased
rate o dehiscence when utilizing inter-
rupted sutures alone without underlying
dermal tension-relieving sutures, high-
lighting that this technique should be
used either or wounds under minimal
tension or in concert with deeper tension-
relieving sutures.
179
Technique
1. The needle is inserted perpendicular
to the epidermis, approximately one-
hal the radius o the needle distant
to the wound edge.
2. I the side o the wound where the
needle is rst inserted is higher than
the contralateral side, a shallow bite
is taken, with the needle skimming
the dermal-epidermal junction and
exiting in the center o the wound. I
the side where the needle rst enters
is lower than the contralateral side,
a deep bite is taken, with the needle
exiting through the deep dermis or
into the undersur ace o the dermis,
depending on the degree o desired
correction.
3. The needle body is grasped with
surgical orceps in the le t hand and
pulled medially with the surgical
orceps as the body o the needle is
released rom the needle driver.
4. The needle is reloaded on the needle
driver, and the contralateral wound
edge is gently ref ected back with the
orceps.
5. I the second side o the wound is
deeper than the rst, then depending
on the required degree o depth cor-
rection, the needle is inserted either
through the underside o the dermis
or laterally through the deep dermis
on the contralateral side o the wound.
The Depth-Correcting
Simple Interrupted Suture
C H A P T E R 5 . 2
Synonym
Step-o correction suture
Video 5-2. Depth-correcting
simple interrupted suture
Access to video can be ound via
SuturingTechniques.com.
Application
This technique is used to correct depth
disparities when the depth o the epi-
dermis on each side o an incised wound
edge is signi cantly di erent. This prob-
lem usually stems rom inaccurate place-
ment o deeper sutures, though it may
also occur as the result o di erential
dermal thicknesses in certain anatomic
locations, such as the boundary o the
lateral nose and medial cheek.
Suture Choice
With all techniques, it is best to use
the thinnest suture possible in order
to minimize the risk o track marks
and oreign-body reactions. Since this
technique is used to ne-tune epidermal
depth and is there ore not designed to
hold a signi cant amount o tension, a
6-0 mono lament suture is o ten appro-
priate. In areas under greater tension,
such as the trunk and extremities, a 5-0
mono lament suture material may be
used as w ell.
180
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-2A. Overview o the depth-correcting simple
interrupted suture technique.
A
Figure 5-2B. First throw o the depth-correcting simple
interrupted suture technique. The side where the needle
exits was super cial relative to the contralateral wound
edge. Thus, the needle passes super cially through the
dermis on this side, exiting in the center o the wound.
B
Figure 5-2C. Needle insertion on the contralateral,
deeper side. Note that the skin is refected upward to
permit insertion o the needle through the deep under-
sur ace o the dermis.
C
Figure 5-2D. The needle exits the skin at a 90-degree
angle.
D
Figure 5-2E. Final appearance a ter suture placement.
Note that the wound edges are now o equal depth.
E
I the second side is higher than the
rst, a super cial bite is taken, through
the dermal-epidermal junction i
needed, to permit correction.
6. The needle is rotated and exits
through the epidermis, equidistant
rom the incised wound edge relative
to the rst bite.
7. The suture material is then tied o gen-
tly, with care being taken to minimize
tension across the epidermis and avoid
overly constricting the wound edges
(Figures 5-2A through 5-2E).
181
The Depth-Correcting Simple Interrupted Suture
Tips and Pearls
This suture technique is very use ul or
correcting depth disparities between the
two sides o a wound. This may be help-
ul as it is o ten ar easier to ne-tune
depth disparities by adding this suturing
technique than it is to remove a less-than-
ideally placed deeper suture.
The depth-correcting simple inter-
rupted suture may be used layered over
the top o another suture in order to ne-
tune the depth o epidermal approxima-
tion. For example, i a vertical mattress
suture were placed to acilitate eversion,
occasionally the wound edges remain at
slightly di erent depths. A small depth-
correcting simple interrupted suture,
placed at the point where the wound
edges are most unequal, may be used to
solve this problem and e ect accurate
approximation o the wound edges.
This technique may also be used in
the context o a simple running suture
technique, as it can be placed over the top
o the simple running sutures to equalize
the depth or it can be incorporated into
the running sutures themselves so that
interspersed between traditional simple
running bites (entering and exiting lateral
to the wound at 90 degrees) some depth-
correcting bites are taken as well to equal-
ize the relative depths o the epidermis
on either side o the wound. This allows
the surgeon to minimize the number o
ties necessary, though it should only be
used when the wound is under minimal
tension, since the security o the depth
correcting bite may be compromised by
an increase in laxity across the wound
sur ace over time and the unpredictability
o suture material stretch.
Drawbacks and Cautions
This technique can be very use ul in
correcting slight imper ections in the
equality o the depth o wound edges.
Ideally, however, this technique should
be employed in requently, since as long as
the deeper sutures are placed accurately
and appropriately, it should only rarely
be necessary.
There ore, caution should be exer-
cised to avoid utilizing this technique as
a crutch; as long as the surgeon appreci-
ates that the use o this approach should
be the exception, rather than the rule, it is
acceptable, but it should not be utilized
in lieu o attention to detail and precise
placement o deeper sutures.
Some anatomic locations, however,
may intrinsically present the surgeon
with areas o di erential dermal thick-
ness, in which case unless the dermal
sutures were placed di erentially, depth-
correcting simple interrupted sutures may
be needed. This includes areas such as the
nasal sidewall, the cheek-eyelid junction,
and naso acial sulcus, as well as other
skin old areas.
Finally, caution should be exercised
to avoid over-sew ing areas w ith the
goal o correcting slight imbalances
in epidermal depth. While one or two
depth-correcting sutures may be neces-
sary, moderation is key as each suture
introduces additional oreign-body mate-
rial and has the potential to induce an
inf ammatory response.
Reference
Moy RL, Waldman B, Hein DW. A review of sutures
and suturing techniques. J Dermatol Surg Oncol.
1992;18(9):785-795.
182
may be used on the extremities as well.
Otherw ise, 5-0 mono lament suture
material may be used i there is minimal
tension, and 4-0 mono lament suture
may be utilized in areas under moderate
tension where the goal o suture place-
ment is relieving tension as well as epi-
dermal approximation.
Technique
1. The needle is inserted perpendicular
to the epidermis, approximately one-
hal the radius o the needle distant
to the wound edge. This will allow
the needle to exit the wound on the
contralateral side at an equal distance
rom the wound edge by simply ol-
lowing the curvature o the needle.
2. With a f uid motion o the wrist, the
needle is rotated through the dermis,
taking the bite wider at the deep
margin than at the sur ace, and the
needle tip exits the skin on the con-
tralateral side.
3. The needle body is grasped with sur-
gical orceps in the le t hand, with
care being taken to avoid grasping
the needle tip, which can be easily
dulled by repetitive riction against
the surgical orceps. It is gently
grasped and pulled upward with the
surgical orceps as the body o the
needle is released rom the needle
driver. Alternatively, the needle may
be released rom the needle driver
and the needle driver itsel may be
The Simple Running Suture
C H A P T E R 5 . 3
Video 5-3. Simple running
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is the standard running suture used
or epidermal approximation. It may be
used alone in the context o small wounds
under minimal to no tension, such as
those ormed by a traumatic laceration.
It is generally used as a secondary layer to
aid in the approximation o the epidermis
when the dermis has been closed using a
dermal or other deep suturing technique.
Suture Material Choice
With all techniques, it is best to use the
thinnest suture possible in order to mini-
mize the risk o track marks and oreign-
body reactions. Suture choice will depend
largely on anatomic location and the goal
o suture placement. Simple running
sutures may be placed with the goal o
(1) accomplishing epidermal approxima-
tion in a wound under mild to moderate
tension, such as a laceration, or, more
requently, (2) ne-tuning the epidermal
approximation o a wound where the
tension has already been shi ted deep
utilizing a deeper dermal or ascial sutur-
ing technique.
On the ace and eyelids a 6-0 or 7-0
mono lament suture is use ul or epider-
mal approximation. When the goal o the
simple running suture layer is solely epi-
dermal approximation, 6-0 mono lament
183
The Simple Running Suture
Figure 5-3A. Overview o the simple running suture
technique.
A
Figure 5-3B. Beginning o the frst anchoring throw
o the simple running suture technique. Note that the
needle enters the skin at 90 degrees prior to moving
laterally away rom the wound edge.
B
Figure 5-3C. Completion o the frst anchoring throw
o suture. Note that the needle has taken a wide bite
o dermis.
C
Figure 5-3D. The anchoring suture has now been tied
o .
D
used to grasp the needle rom the
contralateral side o the wound to
complete its rotation through its
arc, obviating the need or surgical
orceps.
4. The suture material is then tied o
gently, with care being taken to
minimize tension across the epider-
mis and avoid overly constricting the
wound edges. This orms the rst
anchoring knot or the running line
o sutures. The loose tail is trimmed,
and the needle is reloaded.
5. Starting proximal to the prior knot
relative to the surgeon, steps (1)
through (3) are then repeated.
6. Instead o tying a knot, steps (1)
through (3) are then sequentially
repeated until the end o the wound
is reached.
7. For the nal throw at the in erior
apex o the wound, the needle
is loaded with a backhand tech-
nique and inserted into the skin at
a 90-degree angle in a mirror image
o the other throws, entering just
proximal to the exit point relative
to the surgeon on the same side o
the incision line and exiting on the
contralateral side.
8. The suture material is only partly
pulled through, leaving a loop o