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

285
The Lembert Suture
Tips and Pearls
This approach was originally developed
or intestinal suturing purposes, where
inversion is desirable, and indeed
necessary.
No suture material traverses the incised
wound edges, thus reducing the risk that
oreign material could impair e ective
wound healing.
This approach is very use ul when
attempting to recreate a natural crease,
especially since traditional everting
sutures have a tendency to blunt natu-
ral creases. Since the eye is naturally
drawn to skin olds and creases, this small
change may have a dramatic e ect on the
ultimate outcome o the repair.
Drawbacks and Cautions
This technique may lead to dramatic
wound inversion, and there ore should
only be used when the goal is recreating
a natural crease. Moreover, since wound
inversion may be associated with in erior
cosmesis over the long term, the bene t o
accentuated inversion should be weighed
against the possibility that the long-term
cosmetic outcome o the suture scar may
be less than ideal. The over-inversion o
the wound edges caused by the suturing
technique relaxes somewhat a ter suture
removal, allowing the wound edges to
meet and heal.
This technique does not contribute
at all to epidermal-edge apposition, and
there ore it should ideally be used a ter
dermal sutures have been placed that
have e ectively aligned the wound edges
to permit improved healing.
As with any transepidermal technique,
this approach may result in residual track
marks; removing sutures in a timely ash-
ion helps mitigate this risk, and utilizing
ast-absorbing gut suture may also be a
reasonable option.
Reference
Antoine Lembert 1802-1851. Study on intestinal
suture with a description of a new procedure
for performing this surgical operation. 1826.
Dis Colon Rectum. 1988;31(6):489-494.

286
moderate tension w here the goal o
suture placement is relieving tension
as well as epidermal approximation. In
select high-tension areas, 3-0 mono la-
ment suture may be utilized as well.
Though rarely used in these locations,
on the ace and eyelids a 6-0 or 7-0
mono lament suture is appropriate,
though ast-absorbing gut may be used
on the eyelids and ears to obviate the
need or suture removal.
Technique
1. The needle is inserted perpendicu-
lar 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 ollowing 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
The Combined Horizontal
Mattress and Simple
Interrupted Suture
C H A P T E R 5 . 3 0
Synonym
Rousso stitch
Video 5-30. Combined horizontal
mattress and simple interrupted
suture
Access to video can be found via

Application
This is an everting technique used or
closure and epidermal approximation,
and is a variation on the horizontal
mattress technique. As with many inter-
rupted techniques, it may be used alone
or wounds under minimal tension, such
as those ormed by either a small punch
biopsy or a traumatic laceration, or as
a secondary layer. Like other mattress
sutures, this technique may also be used
in the context o atrophic skin, as the
broader anchoring bites may help limit
tissue tear through that may be seen
with a simple interrupted suture.
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.
A 5-0 mono lament suture material is
appropriate i there is minimal tension
across the w ound, w hile 4-0 mono-
lament suture is used in areas under

287
The Combined Horizontal Mattress and Simple Interrupted Suture
surgical orceps as the body o the
needle is released rom the needle
driver.
4. The needle is then reloaded in a
backhand ashion and inserted at 90
degrees perpendicular to the epider-
mis proximal (relative to the surgeon)
to its exit point on the same side o
the incision line as the exit point.
5. The needle is rotated through its
arc, exiting on the right side o the
wound (relative to the surgeon) in a
mirror image o steps (2) and (3).
6. The needle is then reloaded in standard
ashion and inserted on the ipsilateral
wound edge distal to the original entry
point.
7. 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.
8. 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 5-30A through 5-30G).
Figure 5-30A. Overview of the combined horizontal
mattress and simple interrupted suture.
A
Figure 5-30B. The needle is inserted through the
epidermis at a 90-degree angle, exiting on the contra-
lateral wound edge.
B
Figure 5-30C. The needle is then reloaded in a back-
hand fashion and inserted through the epidermis proximal
to its exit point along the length of the wound on the
ipsilateral side, in a mirror image of the prior step.
C
Figure 5-30D. The needle is then reinserted through
the ipsilateral side, now distal to its original entry point
along the length of the wound.
D

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Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-30E. The needle follows its arc through the
dermis, exiting on the contralateral side.
E
Figure 5-30F. Appearance after placing all of the
above sutures.
F
Figure 5-30G. Immediate postoperative appearance.
Note the wound-edge eversion.
G
Tips and Pearls
This approach may be conceptualized
as a combined horizontal mattress and
simple interrupted suture. Like the lock-
ing mattress sutures, this approach makes
suture removal more straight orward by
including a portion o suture material
traversing over the incised wound edge.
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 curva-
ture o the needle when utilizing this
technique. This will allow or maximal
wound eversion and accurate wound-
edge approximation.
As with the simple interrupted suture,
care should be taken to avoid skimming
the needle super cially beneath the epi-
dermis. This results rom ailing to enter
the skin at a perpendicular angle and
ailing to ollow the curvature o the
needle. This may result in wound inver-
sion as the tension vector o the shallow
bite pulls the w ound edges outw ard
and down.
Since a w ide bite o dermis and
epidermis is included in the suture arc,
it is particularly important to avoid tying
the suture material too tightly, as this
could lead to wound-edge necrosis.
Drawbacks and Cautions
With any suturing technique, knowledge
o the relevant anatomy is critical. When
placing this suture it is important to recall
that the structures deep to the epidermis
may be compromised by the passage o
the needle and suture material.
Similarly, 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. These concerns are more acute
with the combined horizontal mattress
and simple interrupted suture and other
variants o the horizontal mattress
suture than with the simple interrupted
suture, since the wide arc o the suture
material and its horizontal component
incorporate more skin and underlying

289
The Combined Horizontal Mattress and Simple Interrupted Suture
structures, thus increasing the risk o
strangulation.
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.
Reference
Kinmon KJ, Rosen RG, Perler AD, London E,
Nyska N. The Rousso stitch: a new evert-
ing skin closure technique. J Foot Ankle Surg.
2003;42(4):244-246.

290
2. With a uid motion o the wrist, the
needle is rotated through the dermis,
running parallel to the incision line.
3. The suture material is then tied o
loosely, leaving a gap between the
suture material and the skin.
4. Steps (1) through (3) are then repeated
on the contralateral wound edge,
orming the contralateral anchoring
ramework.
5. A simple interrupted suture is then
placed, incorporating the suture
material rom the anchoring rame-
work. The needle is inserted around
the anchoring suture on the ar end
perpendicular to the epidermis.
6. With a 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
The Lattice Stitch
C H A P T E R 5 . 3 1
Video 5-31. Lattice stitch
Access to video can be found via

Application
This is a niche technique designed or
wounds with an atrophic dermis or under
signif cant tension, w here traditional
suturing techniques do not allow or
adequate tissue recruitment and wound-
edge apposition or tension relie . The
undamental principle is to place several
interrupted sutures parallel to the wound
edge and then tie the interrupted sutures
over the wound edge by incorporating
the lattice, increasing the stability o the
repair and broadly distributing its orce.
Suture Material 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. A 5-0 monof la-
ment suture material may be used i there
is minimal tension, and 4-0 monof lament
suture in areas under moderate tension.
In select high-tension areas, 3-0 mono-
f lament suture may be utilized as well.
Technique
1. Simple interrupted sutures are placed
parallel to the incision line, orming
the anchoring ramework: the needle
is inserted perpendicular to the epi-
dermis, approximately 8 mm distant
rom the wound edge.
Figure 5-31A. Overview of the lattice suture
technique.
A

291
The Lattice Stitch
Figure 5-31B. The needle is inserted through the epi-
dermis, parallel to the wound edge.
B
Figure 5-31C. The suture material is tied and trimmed,
forming a simple interrupted suture parallel to the
incised wound edge.
C
Figure 5-31D. This is repeated on the contralateral
wound edge, forming a lattice framework.
D
Figure 5-31E. The needle is inserted beneath the
interrupted suture on the far side.
E
Figure 5-31F. The procedure is repeated on the con-
tralateral side.
F
Figure 5-31G. The suture material traversing the
wound is now supported by the lattice framework.
G
Figure 5-31H. Immediate postoperative appearance.
H
needle tip exits the skin on the con-
tralateral side, on the outside o the
anchoring ramework.
7. 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 5-31A through 5-31H).

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Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Tips and Pearls
This technique was developed or closing
wounds with an atrophic dermis or where
tissue tear through is a major problem,
such as on the lower legs and orearms in
patients with extensive actinic damage.
The anchoring sutures are designed
to broadly spread the tension across
the wound edge, mitigating the risk o
tissue tear through and helping to dis-
tribute tension evenly across the wound.
The physics o this closure have been
explored separately.
This technique has also been described
incorporating multiple other approaches,
such as a crossed lattice stitch, where the
suture running across the wound stretches
obliquely rom one anchoring suture to
the next; the double lattice suture, where
two sutures are placed across each set o
anchoring sutures; and the stacked (near-
ar) lattice stitch, where adjacent anchor
sutures are placed at variable distances
rom the wound edge with some overlap.
Drawbacks and Cautions
The greatest drawbacks o this approach
are time, suture material use, and the
risk o oversewing and subsequent tis-
sue necrosis, particularly with multiple
closely spaced anchoring sutures. Since
each suture crossing the incision requires
two anchoring sutures, this technique may
take signif cantly longer to execute than
other approaches. Moreover, the excess
suture material that needs to be used to
incorporate this approach means that on
longer closures additional packages o
suture material may be needed.
Finally, placing multiple anchoring
sutures parallel to the incision line may
lead to impaired vascularization and an
increased risk o wound-edge necrosis,
since a signif cant proportion o the skin
surrounding the wound is encompassed
by suture material that has the potential
to constrict the underlying vessels.
With any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing these sutures it is impor-
tant to recall that the structures deep
to the epidermis may be compromised
by the passage o the needle and suture
material.
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.
Reference
Knoell KA. The lattice stitch technique. Arch Dermatol.
2011;147(1):17-20.

293
one-hal the radius o the needle dis-
tant to the wound edge. This will
allow the needle to exit the wound on
the contralateral side at an equal dis-
tance rom the wound edge by simply
ollowing the curvature o the needle.
The Adhesive Strip
Bolster Technique
C H A P T E R 5 . 3 2
Video 5-32. Adhesive strip
bolster technique
Access to video can be ound via
SuturingTechniques.com.
Application
This is a niche technique designed or
wounds with an atrophic dermis, where
standard suturing techniques result in sig-
ni cant tissue tear through due to atrophic
skin. By placing adhesive strips on the
skin surrounding the wound, the skin’s
resistance to tear through is increased sub-
stantially, permitting closures on even very
atrophic lower leg and orearm skin.
Suture Material Choice
With this technique, sterile adhesive
strips are included on the surgical tray.
Other orms o sterile tape or adhesive
dressings may be used as well.
On the orearms, 4-0 mono lament
nonabsorbable suture may be used, while
on the lower legs a 3-0 mono lament
suture may be more e ective.
Technique
1. The adhesive strips are placed on the
skin surrounding the wound. They
should be placed immediately adja-
cent to the wound margin on dry
skin to acilitate adhesiveness.
2. Horizontal mattress sutures are then
placed, passing through both the skin
and adhesive strips. The needle is
inserted perpendicular to the adhesive
strip and epidermis, approximately
Figure 5-32A. Overview o the adhesive strip bolster
technique.
A

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Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-32B. Adhesive strips fxed to the area sur-
rounding the operative wound.
B
Figure 5-32D. The needle exits on the contralateral
side.
D
Figure 5-32E. The needle is reinserted on the ipsi-
lateral side, continuing the horizontal mattress suture
placement.
E
3. 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, piercing the skin and
adhesive strip.
4. The needle is then reloaded in a
backhand ashion and inserted at
90-degrees perpendicular to the epi-
dermis and adhesive strip proximal
(relative to the surgeon) to its exit
point on the same side o the incision
line as the exit point.
5. The needle is rotated through its
arc, exiting on the right side o the
wound (relative to the surgeon) in a
mirror image o steps (2) and (3).
Figure 5-32C. The needle is passed at 90 degrees
through the center o the adhesive strip. Note that the
area o overlap between two strips provides the great-
est bolster e ect.
C
6. 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 5-32A through 5-31G).
Figure 5-32F. The needle then exits on the contralat-
eral side.
F

295
The Adhesive Strip Bolster Technique
Figure 5-32G. Immediate postoperative appearance
a ter placement o a central horizontal mattress suture
and two simple interrupted sutures at the poles.
G
Tips and Pearls
This technique was developed or closing
wounds with an atrophic dermis or where
tissue tear through is a major problem,
such as on the lower legs and orearms in
patients with extensive actinic damage.
It is much aster than other approaches,
such as the lattice stitch, and concomi-
tantly does not share some o the lat-
tice stitch’s drawbacks that are rooted
in oversewing the wound.
One variation o this technique has
been described using a hydrocolloid
dressing as a bolster, w hile another
variation has ocused on utilizing cya-
noacrylate glue to bolster the atrophic
dermis. The glue is allowed to harden
on the skin, adding strength to the atro-
phic epidermis in a similar ashion to the
adhesive strips. While providing a bene t
in terms o elegance and ease o wound
care, the additional cost o the individu-
ally packaged glue or this technique may
make it less readily adopted. Regardless
o the particular bolster material used,
the principle o this approach remains
the same—an externally applied material
is used to adhere to and strengthen an
otherwise atrophic surgical site, permit-
ting placement o sutures when the suture
material would otherwise have ound
little purchase in the thin skin.
In order to recruit maximal dermis,
the horizontal mattress technique, as
described previously, is o ten used with
this approach, though other techniques,
such as simple interrupted sutures or ver-
tical mattress sutures may be utilized as
appropriate.
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 ailing to ollow the curvature o the
needle. This may result in wound inver-
sion as the tension vector o the shallow
bite pulls the wound edges outward and
down.
It is possible to utilize absorbable
sutures w ith this approach as w ell by
incorporating percutaneous approaches,
such as the percutaneous set-back der-
mal suture, so that the percutaneous
bites o suture material also capture
part o the adhesive strip in order to
increase their security. In this case,
how ever, the adhesive strips should
be care ully removed approximately
2 w eeks postoperatively.
Drawbacks and Cautions
Patients should be cautioned to expect
that the adhesive strips will appear some-
what crusted; generally, these strips serve
as a dressing and when they are removed
approximately 10-14 days postopera-
tively the underlying wound is ound to
be clean, dry, and intact.
With any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing these sutures it is important
to recall that the structures deep to the
epidermis may be compromised by the
passage o the needle and suture material.
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

296
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
traversing the scar line, such as buried
or subcuticular approaches. There ore,
sutures should be removed as early as
possible to minimize these complications.
That said, this approach is speci cally
utilized when the dermis is atrophic, and
as such buried techniques o ten are not
particularly e ective in these situations.
References
Mazzurco JD, Krach KJ. Use of a hydrocolloid dress-
ing to aid in the closure of surgical wounds in
patients with fragile skin. J Am Acad Dermatol.
2012;66(2):335-336.
Tayebi B, Kaniszewska M, Mahoney AM, Tung R.
A novel closure method for surgical defects
in atrophic skin using cyanoacrylate adhesive
and suture. Dermatol Surg. 2015;41(1):177-180.

297
Tips and Pearls
Knowledge o eyelid anatomy is critical
be ore embarking on this oculoplastic
technique. The suture should penetrate
the tarsus or directly in erior to it, but
care should be taken to avoid the in erior
lateral punctum or canaliculus.
The Frost Suture
C H A P T E R 5 . 3 3
Synonym
Temporary eyelid suspension suture
Application
This is a niche approach, used to secure
the lower eyelid margin in place to help
prevent postoperative ectropion. It is use-
ul when there is concern that postopera-
tive edema could result in a downward
pull on the lower eyelid during the post-
operative period. It is not, however, to be
used to correct ectropion that is apparent
intraoperatively.
Suture Material Choice
Usually, a 4-0 nonabsorbable mono la-
ment suture is adequate or Frost suture
placement.
Technique
1. A ter the closure has been com-
pleted, the needle is inserted through
the tarsus or just in erior to it.
2. With a f uid motion o the wrist, the
needle is rotated, taking a 3-mm bite.
3. The needle is then reloaded and
passed through the skin above the
medial eyebrow, keeping the angle
and placement o the lower lid in its
anatomic position.
4. The suture material is then tied o
gently, orming a sling. Alternatively,
the positioning above the medial eye-
brow may be secured using adhesive
strips (Figures 5-33A through 5-31D).
Figure 5-33A. Overview o the Frost suture.
A
Figure 5-33B. The needle is inserted through the tar-
sal plate, lateral to the punctum.
B

298
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
C
Figure 5-33C. The needle is then inserted through the
skin o the medial eyebrow, per orming a simple inter-
rupted suture.
D
Figure 5-33D. Appearance immediately a ter suture
placement. The eyelid is now suspended in anatomic
position, minimizing the risk o developing edema-
induced ectropion in the frst ew postoperative days.
This technique is designed to prevent
the eyelid rom developing an ectropion
in the postoperative period. It is not,
how ever, able to correct an ectropion
that is already apparent intraopera-
tively. Sutures may be removed approx-
imately 3 days postoperatively, but may
be le t in place longer i a large amount
o postoperative edema or bleeding is
present.
The superior anchor point may be
secured with adhesive strips and liquid
adhesive i desired, which also permits
adjustment o the tension across the
suture in the postoperative period based
on the degree o edema.
Drawbacks and Cautions
As noted previously, suture placement
in the medial lower eyelid should only
be undertaken by those with a thorough
amiliarity and com ort w ith eyelid
anatomy.
Since the sling o suture projects in ront
o the eye, patients should be educated
regarding postoperative care and may
consider using an eye patch in order to
protect the area rom inadvertent tugging
on the suture.
Reference
Desciak EB, Eliezri YD. Surgical pearl: temporary
suspension suture (Frost suture) to help prevent
ectropion after infraorbital reconstruction. J Am
Acad Dermatol. 2003;49(6):1107-1108.

299
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 ollowing the curvature o
the needle.
2. With a 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
contralateral side.
3. 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 f rst
anchoring knot or the running line
o pleated sutures. The loose tail is
trimmed, and the needle is reloaded.
4. Starting proximal to the prior knot
relative to the surgeon, the needle
is inserted perpendicular to the epi-
dermis on the side without tissue
excess, approximately one-hal the
radius o the needle distant to the
wound edge.
5. With a uid motion o the wrist,
the needle is rotated through the
dermis, and the needle tip exits into
the undermined space.
6. The needle is then reloaded and
inserted through the superf cial
dermis on the contralateral wound
edge, taking a more superf cial bite
on this side o the wound.
The Running Pleated Suture
C H A P T E R 5 . 3 4
Video 5-34. Running pleated
suture
Access to video can be ound via
SuturingTechniques.com.
Application
This technique is designed to correct an
imbalance in tissue length on two sides
o a wound, as is commonly encoun-
tered in ap repairs. When per orming
advancement and rotation aps, Burrow’s
triangles are o ten taken at the poles o
the ap in order to account or the dis-
crepancy in tissue quantity between the
two edges o the wound. This technique
is designed to take advantage o orm-
ing multiple small pleats in the tissue
that may be thought o as tiny Burrow’s
triangles all along the wound length,
leading ultimately to a shorter scar.
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. Generally this technique
is used on the ace, where 6-0 or 7-0
monof lament nonabsorbable suture is
appropriate. On aps on other body sites,
5-0 suture may be appropriate as well.
Technique
1. The needle is inserted perpendicu-
lar to the epidermis, approximately
one-hal the radius o the needle
Excess
tissue

300
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
7. Steps (4) through (6) are then
sequentially repeated until the end
o the wound is reached, so that
there is more space between bites
on the wound side with excess.
8. For the f 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.
9. The suture material is only partly
pulled through, leaving a loop o
suture material on the side o the
incision opposite to the needle.
10. The suture material is then tied to
the loop using an instrument tie
(Figures 5-34A through 5-34H).
Figure 5-34A. Overview o the running pleated suture.
Excess
tissue
A
Excess
tissue
Figure 5-34B. The anchoring suture is tied. Note the
presence o excess tissue on the side o the wound
where the anchoring suture’s knot has been placed.
B
Figure 5-34C. The needle is inserted superfcially
through the dermis on the side o excess, a moderate
distance rom the anchoring suture.
C

301
The Running Pleated Suture
D
Figure 5-34D. The needle is then inserted deep on the
contralateral side, closer to the anchoring suture.
E
Figure 5-34E. Another superfcial bite is taken on the
side o excess, again moderately distant rom the prior
suture.
F
Figure 5-34F. A deep bite is taken, exiting close to the
prior suture, on the side without excess.
G
Figure 5-34G. This pattern continues along the course
o the wound.
H
Figure 5-34H. Immediate postoperative appearance.
Note that the wound edges now demonstrate less
pronounced excess.
Tips and Pearls
While originally described or ap repairs,
this technique may be used in any situ-
ation where there is a di erential in tis-
sue quantity between the two sides o
a wound. Taking widely spaced super-
f cial bites on the side with excess and
narrowly spaced deep bites on the side
without excess has the e ect o pleating
down the wound edge with excess tis-
sue and tacking it into place against the
contralateral wound edge.
A deeper layer o sutures should be
placed to relieve tension across the
wound edges be ore placing the running
pleated suture.

302
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Drawbacks and Cautions
Some visible pleating, particularly on
the side with excess, is expected in the
immediate postoperative period. In most
areas, this will resolve with time as the
wound heals.
As with all running techniques, the
integrity o the entire suture line rests on
two knots, and suture material compro-
mise at any point may lead to a complete
loss o the integrity o the line o sutures.
Since this technique is designed or low-
tension environments, however, even in
the ace o suture material breakage the
remaining throws o suture may permit
some residual epidermal approximation
and wound edge length equalization.
Since all loops o suture are placed in
succession, this technique does not per-
mit the same degree o f ne-tuning o
the epidermal approximation as a simple
interrupted suture.
As with any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing running pleated sutures 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.
Similarly, i the knot is tied relatively
tightly, structures deep to the de ect may
be constricted. This can lead to necro-
sis due to vascular compromise or even,
theoretically, superf cial nerve damage;
again, this risk may be mitigated by main-
taining some laxity in the suture throws.
This technique may elicit an increased
risk o track marks, necrosis, in amma-
tion, and other complications when com-
pared with techniques 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.
Reference
Kouba DJ, Miller SJ. “Running pleated” suture
technique opposes wound edges of unequal
lengths. Dermatol Surg. 2006;32(3):411-414.

303
4. The suture is then similarly inserted
at the 9 o’clock position relative to
the gra t, ollowing steps (1) and (2).
5. The suture is then similarly inserted
at the 12 o’clock position relative to
the gra t, ollowing steps (1) and (2).
6. The suture is then similarly inserted
at the 6 o’clock position relative to
the gra t, ollowing steps (1) and (2).
7. The needle is passed around the
suture material segment between the
9 o’clock and 12 o’clock position.
8. Nonadherent dressing and gauze are
then cut to size and slipped over top
o the gra t in the desired position by
passing them through the approxi-
mately 5 o’clock position.
9. The ends o the suture material
may be pulled toward the 3 and
9 o’clock positions to tighten. The
suture material is then tied o gen-
tly over top o the bolster, securing
the bolster in place (Figure 5-35A).
The Running Bolster Suture
C H A P T E R 5 . 3 5
Video 5-35. Running bolster
suture
Access to video can be found via

Application
This is a niche technique used or secur-
ing bolsters over top o skin gra ts. It
represents a running suture approach or
tying over a bolster dressing, which was
traditionally per ormed with multiple
interrupted sutures tying down a bolster
dressing.
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. Generally, a 5-0 or 6-0
nonabsorbable mono lament suture is
appropriate, as the suture is not designed
to bear signi cant tension.
Technique
1. A ter securing the gra t in place, the
needle is inserted at the 3 o’clock posi-
tion, 5-mm lateral to the gra t edge
perpendicular to the epidermis and
tangential to the angle o the gra t.
2. With a f uid motion o the wrist, the
needle is rotated through the dermis,
and the needle tip exits 2-3 mm dis-
tant rom the entry point.
3. The ree end o the suture may be
secured with a hemostat.
A
Figure 5-35A. Overview of the running bolster
technique.

304
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-35B. After placing the bolster in place, the
needle is inserted parallel to the bolster edge, exiting
distally at an equivalent distance from the edge of the
bolster.
B
Figure 5-35C. The needle is then inserted through
the skin directly across the bolster from its exit point,
and the needle travels so that it exits directly across
from the original entry point on the contralateral wound
edge.
C
Figure 5-35D. Appearance after placing the sutures,
before securing the bolster.
D
Figure 5-35E. Immediate appearance after suture
placement.
E
Tips and Pearls
This is a niche technique, and represents
an alternative to the standard tie-over
approach or securing ull-thickness skin
gra ts. Since it is a running technique, only
one knot is needed, increasing the speed
with which the bolster may be placed.
Full-thickness skin gra ts bene t rom
being secured in place to maintain direct
contact between the donor and recipient
sites and minimize lateral movement.
Moreover, a bolster dressing helps
decrease the risk o hematoma ormation
by maintaining constant even pressure
across the sur ace o the gra t.
An alternate technique has been
described, where each pass o the run-
ning bolster suture crosses over the center
o the bolster, obviating the need to lock
the last loop o suture.
A simpli ed version o this approach (as
shown in Figures 5-35B through 5-35E)
has also been described or small gra ts,
where the initial suture enters at 6 o’clock
and exits at 9 o’clock and then, a ter pass-
ing over the bolster, enters at 3 o’clock
and exits at 12 o’clock. When the suture
material is tied, the running bolster is
secured.

305
The Running Bolster Suture
Drawbacks and Cautions
The central drawback o this approach is
that the integrity o the entire suture rests
on one knot. Moreover, suture material
compromise at any point may lead to
a complete loss o the integrity o the
running bolster.
Suturing a bolster in place results in addi-
tional suture material traversing the skin;
this both takes additional time to execute
and potentially increases the risk o in ec-
tion or track marks. That said, the bene ts
o adequately securing a ull-thickness
skin gra t in place—minimizing the risk o
gra t necrosis, hematoma ormation, and
other complications—likely outweigh the
downside o adding the bolster.
References
Adams DC, Ramsey ML, Marks VJ. The running
bolster suture for full-thickness skin grafts.
Dermatol Surg. 2004;30(1):92-94.
Skouge JW. The running bolster suture for
full thickness skin grafts. Dermatol Surg.
2004;30(8):1180-1181.

306
2. With a 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 between the incised
wound edges.
3. The needle is then reloaded and
inserted through the deep dermis on
the contralateral wound edge.
4. The needle is then reloaded again
in a backhand ashion and inserted
through the deep dermis on the origi-
nal wound edge.
5. The needle is then reloaded, entering
rom beneath the dermis on contra-
lateral wound edge, exiting approxi-
mately 6 mm rom the wound edge.
The Combined Vertical
Mattress-Dermal Suture
C H A P T E R 5 . 3 6
Synonym
Subcutaneous loop suture
Video 5-36. Combined vertical
mattress-dermal suture
Access to video can be ound via
SuturingTechniques.com.
Application
This is a combination suture that may
be conceptualized as a hybrid between
a vertical mattress suture and a dermal
suture. It was designed to permit closure
o deep de ects and simultaneously per-
mit wound eversion with a single suture,
obviating the need or bilayered closures.
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.
Typically, 5-0 monof lament nonab-
sorbable suture material is appropriate i
there is minimal tension, and 4-0 mono-
f lament suture maybe used in areas under
moderate tension. In high-tension areas,
3-0 monof lament suture may be utilized
as well.
Technique
1. The needle is inserted perpendicular
to the epidermis, approximately 6 mm
distant to the wound edge.
Figure 5-36A. Overview o the combined vertical
mattress-dermal suture.
A

307
The Combined Vertical Mattress-Dermal Suture
Figure 5-36B. The needle is inserted perpendicular to
the skin ar rom the wound edge, exiting in the open
wound space.
B
Figure 5-36C. The needle is inserted in the deep der-
mis on the contralateral side.
C
Figure 5-36D. The needle is then inserted through the
deep dermis on the original side o entry.
D
Figure 5-36E. The needle is then inserted rom the
underside o the dermis up through the skin on the con-
tralateral side, ar rom the wound edge.
E
Figure 5-36F. The needle is then inserted near the
wound edge on the ipsilateral side, exiting in the
undermined wound space, ollowing a superfcial
course.
F
Figure 5-36G. The needle then enters the contralat-
eral side, running superfcially, and exiting near the
wound edge.
G

308
Atlas o Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-36H. Immediate postoperative appearance.
Note the wound-edge eversion.
H
6. The needle is then reloaded in a
backhand ashion and inserted at 90
degrees perpendicular to the epider-
mis approximately 3 mm rom the
wound edge on the same side o the
incision line as the exit point.
7. The needle is rotated superf cially
through its arc, exiting on the contra-
lateral side o the wound 3 mm rom
the incised wound edge.
8. 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 5-36A through 5-36H).
Tips and Pearls
This technique has been described as a
simple approach to closure that permits
closure o deeper structures (and dead-
space obviation) as well as epidermal
approximation and eversion. Perhaps its
most use ul niche is or the closure o very
small de ects or punch biopsies, where a
single nonabsorbable suture may be used
or the entire closure.
Like the standard vertical mattress tech-
nique, this technique is generally used or
its pronounced e ect on wound eversion.
There ore, while it is appropriate or most
skin closures, it should be avoided when
inversion is desired.
As w ith m ost transepiderm al
techniques, 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 ol-
lowing the curvature o the needle when
utilizing this technique. This will allow
or maximal wound eversion and accurate
wound-edge approximation.
An advantage o this approach, as with
the vertical mattress technique, is that
no suture material traverses the incised
wound edge and that the suture similarly
does not cross the sur ace o the wound.
While this may be less than desirable
when attempting to f ne-tune epidermal
apposition, it is help ul in minimizing the
risk o unsightly track marks.
Drawbacks and Cautions
Since the dermal portion o the suture is
executed with the same suture as the ver-
tical mattress portion, i suture removal
occurs too early there is a risk o dehis-
cence, since no residual absorbable suture
material is le t in the wound. Similarly,
i sutures are le t in place or too long,
there is a high chance o leaving residual
track marks.
As the dermal portion o the suture is
per ormed, it may be challenging to visu-
alize the deep portion o the wound ade-
quately, making placement o the deeper
portion o the suture more challenging.
When removing sutures, a greater
degree o orce may need to be applied
to remove the ull length o the suture
material, since the single length o suture
has per ormed multiple loops in both the
dermis and epidermis. Suture material
breakage is there ore a possibility, and
care should be taken to apply constant
gentle traction.
With any suturing technique, knowl-
edge o the relevant anatomy is critical.
When placing this suture it is important

309
The Combined Vertical Mattress-Dermal Suture
to recall that the structures deep to the
epidermis may be compromised by the
passage o the needle and suture mate-
rial, or that constriction may take place.
That said, the vertical orientation o this
approach helps minimize this risk.
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 complica-
tions, 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.
Reference
Naimer SA, Biton A, Topaz M. The subcutaneous
loop: a single suture technique or skin closure
a ter superf cial and subcutaneous surgery.
J Drugs Dermatol. 2006;5(10):966-968.

310
utilized in areas under moderate tension
where the goal o suture placement is
relieving tension and hemostasis as well
as epidermal approximation.
Technique
1. The needle is inserted perpendicu-
lar 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 ollowing the curvature o
the needle.
2. With a 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
surgical orceps in the le t hand,
and pulled upward with the surgical
orceps as the body o the needle is
released rom the needle driver.
4. A tail o ree suture material is then
le t, and no knot is tied. A hemostat
may be used to clamp the tail o the
suture to avoid the risk o pulling it
through during the subsequent steps.
5. Starting proximal to the prior knot
relative to the surgeon, steps (1)
through (3) are then repeated sequen-
tially and the needle is advanced
along the course o the wound until
the contralateral apex is reached.
The Cross Stitch
C H A P T E R 5 . 3 7
Video 5-37. The cross stitch
Access to video can be found via

Application
This is a niche technique used or closure,
hemostasis, and epidermal approximation
o select wounds. It may be conceptual-
ized as a simple running suture that is
per ormed without an anchoring knot
and that, when the terminus is reached,
travels in the opposite direction toward
the original wound apex. While it dem-
onstrates an elegant and symmetrical
postoperative appearance, it also entails
the placement o a greater number o
transepidermal sutures while providing
little extra in terms o unctional benef t,
and there ore is used only in requently.
Suture Material Choice
As 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. Suture choice will
depend largely on anatomic location and
the goal o suture placement. The cross
stitch may be utilized either to aid in
wound-edge approximation or to help
with hemostasis. In the latter case, slightly
thicker suture material may be utilized.
On the ace, a 6-0 or 7-0 monof lament
suture may be used or epidermal approx-
imation. Indeed, 5-0 or 6-0 monof lament
may be used on the extremities as well,
though 4-0 monof lament suture may be

311
The Cross Stitch
Figure 5-37A. Overview of the cross-stitch technique.
A
Figure 5-37B. Initiation of the suture. Note that a tail
is left and there is no traditional anchoring suture to
be tied.
B
Figure 5-37C. Second bite, following the pattern of a
simple running suture.
C
Figure 5-37D. The running series continues until the
end of the wound is reached.
D
Figure 5-37E. After reaching the end of the wound,
the suture pattern then reverses direction and moves
distally toward the origination point.
E
6. Once the apex is reached, steps (1)
through (3) are then repeated head-
ing in the contralateral direction,
again advancing along the wound,
but now with entry and exit points
crossing the previously placed line o
sutures, orming an X appearance.
7. Once the apex is reached, the lead-
ing end o the suture is tied to the tail
end o the suture using an instrument
tie (Figures 5-37A through 5-37G).

312
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
Figure 5-37F. The suture material is then pulled taut,
creating a cross-stitch pattern.
F
Figure 5-37G. Immediate postoperative appearance.
G
Tips and Pearls
As with the simple running suture, 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 curva-
ture o the needle when utilizing this
technique. This will allow or maximal
wound eversion and accurate wound-
edge approximation.
As always, care should be taken to
avoid skimming the needle superf 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 inver-
sion as the tension vector o the shallow
bite pulls the wound edges outward and
down.
In order to maintain uni ormity in the
length o the visible running sutures and
to allow all o the suture loops to remain
parallel, it is important to take uni orm
bites with each throw. There ore, each
subsequent loop should begin at the same
point lateral to the incised wound edge
and at a uni orm distance closer to the
surgeon than the preceding entry point.
Sutures should not be tied too tightly,
and it is help ul to permit su f cient laxity
between the epidermis and the suture
material when using this technique. This
approach will help minimize the risk o
track marks that may be associated with
postoperative edema.
Drawbacks and Cautions
This technique has two main drawbacks.
First, the integrity o the entire suture
line rests on the integrity o a single
knot. When this technique is used only
to f ne-tune epidermal approximation,
knot ailure is unlikely to lead to dehis-
cence, but i there is signif cant tension
across the wound this may be more prob-
lematic. Second, the additional row o
simple interrupted sutures used in this
technique does little to aid in wound-edge
approximation or wound security, while
concomitantly increasing the risk o track
mark ormation. There ore, unless this
approach is being utilized or its hemo-
static e ects, it may not be the ideal
technique in most circumstances.
As with all running techniques, since
each loop o the running suture material
is designed to hold an equal amount o
tension, it ollows that areas o the wound
under greater tension, such as its central
portion, may tend to gape or potentially
exist under greater tension leading to an
increased risk o track marks.
As w ith any suturing technique,
knowledge o the relevant anatomy is
critical. When placing the cross stitch it

313
The Cross Stitch
is important to recall that the structures
deep to the epidermis may be compro-
mised by the passage o the needle and
suture material. Thus, the needle may
pierce a vessel leading to increased bleed-
ing, while a tightly placed suture may lead
to necrosis due to vascular compromise
or even, theoretically, superf cial nerve
damage.
This technique may elicit an increased
risk o track marks, necrosis, in amma-
tion, and other complications when com-
pared with techniques 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 tech-
niques in the event that sutures will not
be able to be removed in a timely ashion.
Reference
Johnson TM, Bichakjian CK, Wang TS. Surgical
pearl: the cross-stitch. J Am Acad Dermatol.
2001;44(4):673-674.

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Suturing Tips and Approaches
by Anatomic Location
C H A P T E R 6

316
In general, every e ort should be made
to close wounds in a linear ashion. This
allows or the greatest chance o healing
with minimal scarring, obviates the risk
o ap or gra t necrosis, and is generally
the most cost-e ective approach.
For the most part, reconstruction o
the skin and so t tissues on the trunk
does not present any major challenges.
Unlike the head and neck, there are ew
danger zones to avoid, and the relative
thickness o the underlying tissue planes
makes or a rather orgiving canvas on
which to work.
A ew areas deserve special mention—
the nipple unit and umbilicus may both
be thought o as cosmetic subunits o
their own. As with acial reconstruction,
it is important to appreciate that the eye
is drawn to these subunits and that any
compromise o their unity leads to a cos-
metic impression o imbalance out o
proportion to the actual size and nature
o the scar. There ore, every e ort should
be made to maintain the integrity o these
subunit boundaries.
For the nipple and areola, de ects in
the periareolar zone should be conf ned
to this area. This may be accomplished
by the use o rotation aps in the imme-
diate periareolar area, which may take
advantage o the ability to hide incision
lines in the outer boundary o the areola.
Similarly, transposition aps, M-plasties,
and other approaches to shi t the Burow’s
triangles may also be used to avoid
extending the incision onto the areola.
The Chest, Back,
and Shoulders
C H A P T E R 6 . 1
The chest, back, and shoulders are at once
amongst the least challenging areas to
repair—given the o ten ample tissue lax-
ity, low-patient expectations or cosmesis,
and lack o anatomic danger zones and
cosmetic unit boundaries—and amongst
the most challenging, since the rate o
hypertrophic scar ormation and the ten-
sion rom repetitive actions o daily living
are rather high.
There ore, reconstruction o these
areas a ords the exibility o a pot-
pourri o treatment approaches while
demanding a reconstructive technique
aimed at assuring that the tension across
the w ound sur ace, both at the time
o closure and in the perceived uture,
remains kept to a minimum. Anticipating
patient activity levels is o the utmost
importance, as wounds in these areas
may appear to be under a mild degree
o tension at the time o reconstruction,
while the patient lays in a restricted posi-
tion and in a controlled environment;
that same patient, however, is likely to
be quite active even in the immediate
postoperative period and the tension
across the nascent wound may increase
exponentially. There ore, designing a
closure with an eye to the uture and
a ter gaining a modicum o appreciation
o the patient’s activity level is absolutely
critical, since the same wound may be
closed utilizing a variety o suturing tech-
niques depending on the anticipated
degree o tension that it will need to
withstand.
Horizontal
mattress
suture
Simple
interrupted
suture
Buried
vertical
mattress
suture
Set-back
dermal
suture
Running
subcuticular
suture
Pulley set-back
dermal suture

317
The Chest, Back, and Shoulders
For de ects within the areola, every
attempt should be made to conf ne the
repair within the boundaries o the areola
itsel . In the event o complete loss o
the nipple or areola, some basic suturing
techniques may be use ul in reconstruct-
ing these anatomic landmarks. For exam-
ple, the circular appearance o the areola
may be evoked by utilizing a purse-string
suturing approach, and reconstruction o
a lost nipple may be e ected by per orm-
ing an exaggerated purse-string approach
leading to bunching o the central skin,
creating a rudimentary nipple.
Similarly, the umbilicus should be
thought o a unique subunit; de ects or
wounds in this area should ideally be
repaired by localizing the scar line either
within the umbilicus, or reconstructing
a modif ed umbilicus in cases o larger
de ects.
O note, an inverting approach is use-
ul here in order to recreate the natural
inversion o the skin at the boundaries o
the umbilcus. This may be accomplished
with either simple buried dermal sutures
or inverting horizontal mattress sutures.
The Lembert stitch, or its running variant,
the Cushing suture, may also be used to
e ect dramatic wound inversion.
Meticulous attention to technique
remains the undamental building block
o all o these approaches, as even the
best-planned ap or most thought-out
approach can be w aylaid by leaving
suture track marks or other residual evi-
dence o past surgical repair.
Suture Material Choice
High-tension areas such as the back,
chest, and shoulders should always be
closed w ith the assumption that the
patient will have at least a moderate level
o activity in the postoperative period. It
is ar better to use a slightly thicker suture
than planned (as long as it is placed in the
correct plane) than to err on the side o
using too thin a suture or the tension in
a given area.
Typically, 2-0 or 3-0 absorbable suture
material may be used or ascial and
dermal repairs in these areas. While a
0 suture may be used on thicker back
dermis, in all but in the rarest o occa-
sions no suture material thicker than 2-0
should be required, especially i appropri-
ate undermining has been e ected.
Needle choice is similarly o critical
importance when planning closures in
high-tension areas. Smaller needles may
easily bend when traversing the thicker
dermis o the back; larger, semicircular
needles such as the Ethicon CP-2 needle
and its equivalents work very well and
reliably penetrate even the thickest der-
mis without losing their curvature.
Not all backs are created equal; some
older women, in particular, have relatively
thin dermis on the back and attendant
laxity; in these cases, a 3-0 suture material
is more than adequate.
Suture Technique Choice
Among the most popular technique
choices in these areas are the set-back
dermal suture and the buried vertical
mattress suture techniques. The butter y
suture may be used as well, though it is
slightly more challenging to execute than
the previously mentioned approaches and
does not result in as much eversion as
the set-back dermal technique. Because
o the high tension in these areas, ever-
sion is particularly critical and leaving a
residual ridge, mainly on the back and
shoulders, is desirable as it may result in
a more inconspicuous scar as the wound
heals and the suture is absorbed.
In cases o particularly high tension,
the various pulley suture approaches may
be used to allow or better wound-edge
approximation even in the ace o extreme

318
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
tension. Buried pulley approaches o er
the mechanical advantage o a pulley
e ect without risking the attendant track
marks and necrosis that could be associ-
ated with the placement o superf cial
pulley sutures.
Tw o easily e ected buried pulley
approaches or the back include the
pulley set-back dermal suture and the
pulley buried vertical mattress suture.
The ormer o ers signif cant advantages
in terms o eversion and also relegates the
suture material to the deeper dermis and
avoids placing suture material between
the incised wound edges, a signif cant
advantage especially when larger gauge
suture material is being used (Figure 6-1).
While the winch stitch or running
external pulley suture may be utilized,
it is usually unnecessary in these anatomic
locations where a robust dermis allows
a great deal o material to be placed in a
buried ashion, translating into an easily
placed and e ective buried pulley suture.
Superf cial suture approaches include
simple interrupted sutures or added secu-
rity, as well as or f nessing wound-edge
approximation. These may also be used
toward the edges o an elliptical incision
in order to tamp down incipient dog ears,
especially when overeverting the bulk
o the wound in high-tension areas, as
overeversion toward the apices o an
elliptical incision may increase the risk
o dog-ear ormation.
In wounds under extreme tension, a
ew well-placed interrupted horizontal
mattress sutures, using a relatively large-
gauge suture material (such as 3-0 nylon),
may be use ul both or added eversion
Figure 6-1. Frequently used suturing techniques on the chest and back.
Horizontal
mattress
suture
Simple
interrupted
suture
Buried
vertical
mattress
suture
Set-back
dermal
suture
Running
subcuticular
suture
Pulley set-back
dermal suture

319
The Chest, Back, and Shoulders
as well as or a measure o extra wound
security. Care should be taken, however,
to remove these sutures early (5-7 days
in most cases) in order to reduce the risk
o residual track marks. Other mattress
approaches, such as the vertical mattress
or hybrid mattress, may also be used in
high-tension areas.
Running subcuticular sutures may
also be used as an outer layer o closure;
importantly, this approach adds little i
any strength to the wound, though they
may be use ul in f nessing wound-edge
approximation. With experience, the need
or subcuticular suture material may be
largely obviated by meticulous attention
to technique in the placement o a su -
f cient number o buried sutures.
For the back and shoulders, elliptical
excisions may be closed with a buried
vertical mattress approach toward the
apices and a set-back dermal approach
toward the center. This allows or su -
f cient eversion all around with a more
dramatic central eversion corresponding
to the area that will be under the greatest
tension. This also helps reduce the risk
o overeverting the apices, as outlined
previously.
For the superf cial aspect o the closure,
i the wound has been e ectively closed
under minimal tension, a running subcu-
ticular technique may be used to f nesse
wound-edge approximation. I there is
signif cant tension at the time o the clo-
sure, or i the patient’s activity level is
anticipated to be high, placement o a set
o simple interrupted sutures may be ben-
ef cial. Horizontal mattress sutures may
be used toward the center o the wound
to allow or additional wound security,
though they should be avoided toward
the apices to minimize overly dramatic
eversion leading to dog-ear ormation.

320
appearance, as the central portions o the
closure are tightened relative to the sur-
rounding skin leading to an exaggerated
standing cone appearance at the apices.
There ore, when possible, horizontally
oriented closures may be pre erable in
these anatomic locations.
A major challenge relating particularly
to orearm closures is the pro ound atro-
phy present in this sun-exposed area.
Even closures under minimal tension
must contend with the challenges o
suture placement in atrophic areas, as
the tendency toward suture material tear
through may be a problem even in the
absence o marked tension. Percutaneous
approaches, horizontally oriented tech-
niques, and the use o tape bolsters may
help in e ectively closing such atrophic
areas.
Suture Material Choice
For modest-tension closures on the upper
arms, 3-0 or 4-0 absorbable suture mate-
rial is generally adequate, while most
orearm closures may be accomplished
with 4-0 absorbable suture. Rarely, high-
tension closures, such as those e ected
a ter a large melanoma resection on the
muscular upper arm o a young patient,
may bene t rom 2-0 absorbable suture.
Transepidermal sutures, i used, are
usually 5-0 nonabsorbable suture, though
5-0 absorbable mono lament suture may
also be used or a subcuticular closure
on the upper arm. In atrophic skin, sub-
cuticular approaches are best avoided,
The Arms
C H A P T E R 6 . 2
As with the chest and shoulders, the arms
are o ten relatively straight orward to
close, as or all but the largest de ects
ample tissue is generally available or
recruitment. When conceptualizing
closure options on the arms, the anatomic
location—the upper arm, inner arm, f exor
versus extensor sur ace, and the degree
o atrophy shoulder all be considered.
Classic approaches to closures on the
extremities o ten advocate or attempt-
ing closure along the long axis o the
extremity. While this approach may be
reasonable or large de ects, many smaller
de ects bene t rom a closure either per-
pendicular to the long axis o the arm (ie,
horizontally oriented) or on a diagonal.
In either event, taking the time preopera-
tively to assess the degree o skin laxity
and its direction is critical in designing the
ideal closure. Sometimes, this orientation
alls along the relaxed skin tension lines
or Langer’s lines, but this is not always
the case, as closures must consider not
only minimizing the tension across the
wound but also minimizing the appear-
ance o standing cones or dog ears.
On convex sur aces, such as the outer
arms (as well as others, such as the ore-
head), it may be di cult to ensure a
completely f at contour in the immediate
postoperative period, though a signi cant
degree o standing cone blunting o ten
occurs in the postoperative period.
Closures along the long axis o the
upper arm and orearm similarly may
result in a more pro ound dog-ear
Buried
vertical
mattress
suture
Running subcuticular
suture
Adhesive strip bolster
Simple
interrupted
suture
Set-back
dermal
suture

321
The Arms
as there is little dermis available to grasp
and the small volume o surrounding
skin means that suture absorption may
be delayed.
Suture Technique Choice
The workhorse technique or most arm
closures is a vertically oriented buried
suture. The set-back dermal suture is
highly e ective, and the buried vertical
mattress suture may be utilized as well.
Wide undermining is very help ul in
leading to an e ective closure, and under-
mining at the apices o the ellipse may aid
in reducing the appearance o dog ears.
As always, a linear closure is pre erable
to a f ap, and in all but the most extreme
cases most de ects on the arms are easily
closed in a linear ashion. An s-plasty
may be utilized in order to mitigate the
appearance o standing cones in select
cases (Figure 6-2).
While buried vertical mattress or set-
back dermal sutures are requently used
Figure 6-2. Frequently used suturing techniques on the arms.
Buried
vertical
mattress
suture
Running subcuticular
suture
Adhesive strip bolster
Simple
interrupted
suture
Set-back
dermal
suture

322
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
or the bulk o these closures, other tech-
niques may also be employed. In wounds
under marked tension, pulley approaches,
such as the pulley set-back dermal suture
or pulley buried vertical mattress may be
use ul; as always, however, these tech-
niques should only be used i needed as
they result in an increased volume o
retained suture material when compared
with their single-throw equivalents.
In wounds under very mild tension,
running buried approaches may be uti-
lized, though in general interrupted bur-
ied sutures are avored whenever possible
in order to militate against the problems
associated with suture material breakage.
Super icial approaches, i utilized,
include the running subcuticular tech-
nique, though as noted earlier this should
be avoided on the atrophic orearms.
Other requently used approaches include
the simple running suture and the running
horizontal mattress technique.
On atrophic orearms, patients may
bene t rom closures using the percu-
taneous set-back dermal suture, the
percutaneous buried vertical mattress
suture, or the buried (or percutaneous)
horizontal mattress suture. When the
degree o atrophy is extreme, an adhe-
sive strip bolster technique may be most
appropriate.
As in other anatomic locations, com-
bining the set-back dermal suture or
the bulk o wound closure with buried
vertical mattress sutures at the wound
apices may help e ect marked wound
eversion while concomitantly avoiding
extreme eversion (and thus standing cone
ormation) at the apices.
In wounds under extreme tension, a
pulley set-back dermal suture or pulley
buried vertical mattress suture may be
placed at the center o the wound, with
standard set-back or buried vertical mat-
tress sutures placed over the remainder
o the wound.
Similarly, when super cial sutures are
used, placing a horizontal mattress suture
toward the center o the wound coupled
with a simple interrupted suture at the
wound apex may be a use ul approach.

323
and individual closure approaches should
be tailored to each patient so that a patient
who spends most o the day seated at a
computer or in a wheelchair may have
their wound closed on a slightly di erent
axis than a highly-active patient.
Suture Material Choice
Most wounds on the thighs are closed
with a 3-0 absorbable suture material,
though in small wounds under minimal
tension a 4-0 absorbable suture may be
used. Similarly, wounds on the shins are
o ten closed with a 3-0 absorbable suture,
though when an adhesive strip bolster
technique is used a 3-0 nonabsorbable
suture may be used as well.
Suture Technique Choice
The standard approach to closure would
include the set-back dermal suture or the
buried vertical mattress suture or most
leg closures. Generally these approaches
are used on the thighs, though o course
with larger de ects under marked ten-
sion a pulley variation o the previously
mentioned techniques is possible as
well. When closing wounds on the shins,
however, other speci c challenges may
emerge. These wounds are o ten very
narrow and the skin is o ten airly inelas-
tic, and there ore may not permit easy
placement o buried vertically oriented
sutures. In such cases, placing a percuta-
neous set-back dermal suture may be an
alternative. Other approaches would also
The Legs
C H A P T E R 6 . 3
When contemplating wound closures on
the lower extremities, clinicians should
keep in mind that closures above the
knee are undamentally di erent rom
their below-the-knee counterparts. Thigh
closures may be conceptualized as similar
to closures on the upper arm—the dermis
is moderate in thickness, and the area
is under o ten-substantial tension. On
the shins, however, closures are o ten
signi cantly more challenging. The pres-
ence o impaired circulation and high ten-
sion mean that closures below the knee
may be technically challenging to e ect
and are concomitantly raught with an
increased risk o in ection and dehiscence
when compared with closures elsewhere
on the body.
An important principle when closing
wounds below the knee is to anticipate
the high risk o closure ailure and there-
ore minimize the size o the de ect.
Thus, concerns regarding standing cone
ormation should be set aside when clos-
ing most shin de ects. The high ten-
sion in these areas also means that as
the repair heals over time the tension
across the central portion o the wound
may lead to blunting o the initial valley
created by the closure, and there ore the
appearance o the dog ears will eventu-
ally resolve.
As with other highly mobile areas, it
is important to plan appropriately when
developing an ideal axis o wound closure.
There ore, the leg should be examined
preoperatively both f exed and extended,
Pursestring suture
Percutaneous
set-back dermal
suture
Percutaneous buried
vertical mattress suture
Buried
vertica l
mattress
suture
Set-back
dermal
suture
Adhesive strip bolster

324
Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair
include the percutaneous buried vertical
mattress technique (though the shallow
portion o the bite may result in tissue
tear through in the thin skin o the shins)
and the percutaneous horizontal mattress
suture (where the horizontal orientation
allows or a broader and more robust bite
o dermis). The adhesive-strip bolster
approach utilized in concert with a hori-
zontal mattress suture is also a mainstay
o therapy or closing narrow atrophic
wounds on the shins (Figure 6-3).
Super cial closures may be per ormed
utilizing a running subcuticular technique;
when absorbable mono lament suture
is used with this approach it a ords
the bene t o long-lasting wound-edge
approximation. Other interrupted sutures
may be used as well, with simple inter-
rupted, horizontal mattress, and vertical
Figure 6-3. Frequently used suturing techniques on the legs.
Pursestring suture
Percutaneous
set-back dermal
suture
Percutaneous buried
vertical mattress suture
Buried
vertical
mattress
suture
Set-back
dermal
suture
Adhesive strip bolster

325
The Legs
mattress representing some o the most
requently used techniques or wounds
on the thighs.
On the shins, care should be taken
not to over-sew the area. There is some-
times a temptation to add additional
sutures when the wound edges are not
precisely approximated. While other
anatomic locations, such as the ace,
are very orgiving when extra sutures
are placed, the poor vascular supply to
the lower legs means that adding extra
suture material, except when necessary,
should be avoided.
An additional option when closing the
lower legs is to per orm a purse-string
closure. Since cosmesis on the shins is
o ten subpar, and keeping the wound as
small as possible is o paramount impor-
tance, the purse-string approach may be
a use ul adjunct. Since the skin on the
shins is o ten atrophic, the percutaneous
purse-string technique may generally be
the most appropriate in this location.
On the thighs, the usual approach o
utilizing set-back dermal sutures except
at the apices where buried vertical mat-
tress techniques are used may be the most
appropriate. On the knees, adding addi-
tional horizontal mattress sutures layered
over top o set-back dermal sutures may
aid in tension reduction in these high-
mobility areas.
The percutaneous purse-string tech-
nique may be used on the shins in concert
with simple interrupted or horizontal
mattress sutures to obtain wound-edge
approximation. Partial closure o large
de ects on the lower leg with purse-string
closures may be augmented by allowing
the remainder o the wound to close via
secondary intention healing.

326
lymphedema. That said, individual varia-
tions and individual propensities must
alw ays be taken into account w hen
designing a closure.
Suture Material Choice
On the hands and eet, 3-0 or 4-0 absorb-
able suture material is o ten used as the
mainstay o closure. Although the skin in
these areas is o ten under marked tension,
smaller needles such as the PS-3 or P-3
needle may be most use ul since the de ects
are generally modest in size and the dermis
on the hands, while tougher on younger
patients, may become markedly atrophic
with age and accumulated solar damage.
For super cial closures, 5-0 absorbable
suture may be used or a subcuticular
closure, while 5-0 nonabsorbable suture
may be used or transepidermal closures.
On the eet o younger patients, 4-0 or
even 3-0 nonabsorbable suture may also
be used when placing interrupted tran-
sepidermal sutures.
Suture Technique Choice
As in most locations, the set-back dermal
suture or buried vertical mattress suture is
generally the technique o choice on the
hands and eet. Since these wounds are
sometimes airly narrow, percutaneous
approaches such as the percutaneous set-
back dermal suture, percutaneous buried
vertical mattress, or buried horizontal
mattress approaches may be use ul as
well (Figure 6-4).
The Hands and Feet
C H A P T E R 6 . 4
The hands and eet present some novel
challenges to wound closure. First, these
areas are highly mobile—by their very
nature, these locations are under constant
stress, so that the dorsal hands are subject
to signi cant stretching when making a
st or grasping an object. Second, these
areas are subject to repetitive riction, on
the hands when they are put in a pocket
or purse and on the eet while wearing
shoes. Moreover, since the hands are re-
quently exposed to bacteria in the course
o everyday events and the eet o ten
spend the day occluded and are bathed in
a signi cant bacterial load during show-
ers, these areas also have a theoretically
higher risk o postoperative in ection.
Due to these considerations, wound
repair on the hands and eet is best accom-
plished by e ecting a robust closure with
the minimal degree o transepidermal
suture placement. As with all anatomic
locations, linear closure is generally pre-
erred i at all possible, and the overwhelm-
ing majority o de ects on the hands and
eet may be closed in a linear ashion.
Care ul broad undermining is very
help ul in these locations w here the
vasculature is o ten easily visualized in
the subdermal plane. As with all clo-
sures, examining the patient throughout
their range o motion may be help ul in
determining the best axis or closure.
Generally, longitudinal closures along the
long axis o the hand or oot are avored,
both in terms o minimizing tension
and mitigating the risk o postoperative
Pursestring
suture
Vertical
mattress suture
Horizontal
mattress
suture
Simple
interrupted
suture
Buried
vertical
mattress
suture
Set-back
dermal
suture

327
The Hands and Feet
In wounds under marked tension, the
pulley set-back dermal or pulley buried
vertical mattress may be use ul tech-
niques, particularly when placed toward
the center o a wound under tension. The
relatively robust dermis on the hands
and eet o younger patients means that
everting horizontally or obliquely ori-
ented techniques, including the butterf y
suture, are viable options as well.
The presence o signi cantly sized
vessels very close to the underside o
the dermis means that caution should
be exerted when placing transepidermal
sutures on the dorsal hands and eet.
With wide undermining in the appropri-
ate plane, these larger vessels are easily
visualized when placing buried sutures.
Transepidermal sutures could easily
per orate a super cial vessel, and there-
ore unless they are necessary it may be
best to avoid traditional approaches such
as the simple running suture. Instead,
utilizing either skin adhesive or a run-
ning subcuticular approach may be pre -
erable, especially on the highly vascular
dorsal hands. This has the added ben-
e t o minimizing the amount o suture
material extruding rom the skin that
could be caught when placing the hand
in a pocket or purse in the postopera-
tive period.
In select cases, purse-string approaches
may be use ul as well, although the post-
operative cosmesis is generally not as
appealing as when using linear closures.
Figure 6-4. Frequently used suturing techniques on the hands and feet.
Pursestring
suture
Vertical
mattress suture
Horizontal
mattress
suture
Simple
interrupted
suture
Buried
vertical
mattress
suture
Set-back
dermal
suture

328
The convex nature o the scalp also
lends itsel to unique challenges, as repairs
over a convex sur ace have a tendency
to lead to pronounced dog-ear orma-
tion even when utilizing narrow ellipses
with a high length to width ratio. Speci c
techniques, including the dog-ear tacking
suture, may be help ul in such cases.
Suture Material Choice
Repairs on the scalp under moderate
tension may bene t rom utilizing a 3-0
absorbable suture, while those under
minimal tension, such as de ects created
by excising a pilar cyst, can be closed with
4-0 absorbable suture. Moderately sized
needles, such as the FS-2, are a reasonable
choice or most scalp closures. Super cial
sutures may include suture material rom
a 3-0 nonabsorbable suture that may be
used or additional tension relie in large
closures, to a 5-0 nonabsorbable suture
that may be used or improving wound-
edge approximation.
Suture Technique Choice
As in most locations, the set-back dermal
suture or buried vertical mattress suture
are generally the techniques o choice on
the scalp. Since scalp wounds are o ten
airly narrow, approaches such as the
percutaneous set-back dermal suture,
percutaneous buried vertical mattress,
or percutaneous horizontal mattress may
be use ul (Figure 6-5). The percutaneous
set-back dermal technique may be the
approach o choice as it is easy to place
The Scalp
C H A P T E R 6 . 5
Closures on the scalp, like those on the
shins, o ten involve narrow wounds under
signi cant tension. Most surgical repairs
on the scalp take place on the bald scalp o
older men, where years o actinic damage
have contributed to skin cancer develop-
ment. In such cases, the skin may be slightly
atrophic, and the degree o tissue mobility
is variable, with some patients demonstrat-
ing a remarkably elastic and redundant
tissue reserve and others presenting with
a tight scalp with minimal laxity.
Closures on the hair-bearing scalp, such
as those e ected a ter a nonmelanoma skin
cancer or pilar cyst excision, o ten occur
in areas with a thicker dermis that has not
been exposed to the same degree o actinic
damage, and where the ensuing atrophy
has not taken place. In such cases, the
bene t o working with a thicker dermis
may be mitigated by the complexity o
closing a wound in a hair-bearing location.
As with all closures, it is pre erable to
utilize a linear repair when possible. Smaller
de ects are easily closed in this ashion,
though larger de ects on the scalp may
necessitate f ap or gra t closure. Secondary-
intention healing is also, o course, an option
as well, particularly or thinner de ects.
It is also important to recall that
there may be signi cant atrophy in this
sun-exposed area. Even closures under
minimal tension must contend with the
challenges o suture placement in atro-
phic areas, as the tendency toward suture
material tear through may be a problem
even in the absence o marked tension.
Purse-string
suture
Horizontal mattress
suture
Dog-ear
tacking suture
Percutaneous
set-back dermal
suture
Percutaneous
buried vertical
mattress suture
Pulley set-back
dermal suture

329
The Scalp
and has only minimal chance o tissue
tear through. The percutaneous vertical
mattress, especially when placed on the
atrophic skin o the scalp, may lead to
tear through its super cially placed arms.
In scalp wounds under marked tension,
the pulley set-back dermal or pulley bur-
ied vertical mattress may be use ul tech-
niques, particularly when placed toward
the center o a wound under tension. For
narrow low to moderate tension wounds,
a running percutaneous set-back dermal
technique may be e ective, as it is easy
to place in narrow wounds.
Since the convex sur ace o the scalp
may lead to dog-ear ormation, the
dog-ear tacking suture may be use ul
in some scalp w ounds. The postop-
erative appearance o dimpling at the
apices o the w ound is generally not
o major concern to the patient, and
as the suture is absorbed a signi cant
reduction o dimpling gradually occurs.
As in all convex areas, care should be
taken to avoid overly chasing the dog
ears, as they may remain apparent even
a ter extensive dog-ear corrections are
undertaken.
Purse-string
suture
Horizontal mattress
suture
Dog-ear
tacking suture
Percutaneous
set-back dermal
suture
Percutaneous
buried vertical
mattress suture
Pulley set-back
dermal suture
Figure 6-5. Frequently used suturing techniques on the scalp.

330
directed at xing the lower portion o the
repair in place, or maximally mobilizing
the upper portion o the repair, such as
suspension sutures, may be use ul in these
situations. Occasionally, however, espe-
cially with medially located de ects, caus-
ing a subtle brow li t may be desirable.
For larger de ects on the orehead, ver-
tically oriented repairs may be use ul
as well. As with paramedian orehead
f aps, a ull thickness incision and subga-
leal undermining may be used to urther
mobilize tissue and to permit a straight-
orward linear closure.
Suture Material Choice
For mild to moderate tension closures
on the orehead, 5-0 absorbable suture
is generally su cient. Using a small
needle, such as the P-3 reverse cutting
needle, is o ten adequate. For wounds
under greater tension, 4-0 absorbable
suture material may be used as w ell,
particularly i a deep incision has been
made and the w ound is being closed
w ith plication or deep so t tissue
sutures. Fine-gauge 6-0 or 7-0 nonab-
sorbable suture material may be used
or transepidermal sutures.
Suture Technique Choice
As with most closures on the ace, work-
horse techniques such as the set-back
dermal suture and the buried vertical
mattress suture are the usual approaches
o choice (Figure 6-6).
The Forehead
C H A P T E R 6 . 6
The orehead presents unique challenges
and opportunities to the surgeon. The
convex sur ace may increase the ten-
dency toward dog-ear ormation, as even
ellipses with high length to width ratios
may result in residual standing cone
appearance.
Additionally, the relatively immobile
skin and minimal laxity coupled with the
nearby presence o the eyebrows may
also translate into a risk o long-standing
brow asymmetry in select cases. While
this is generally addressed when design-
ing the closure, suture technique may
play a role here as well.
The natural urrows and wrinkles pres-
ent, particularly on the muscular orehead
o elderly men, also need to be consid-
ered when designing orehead closures
and when choosing suture techniques, as
blunting a dramatic wrinkle may draw
attention tow ard an otherw ise w ell-
designed repair. In such cases, an inverting
technique may be pre erable. Conversely,
those treated with neurotoxins to miti-
gate the appearance o orehead wrinkles
may bene t rom everting techniques
that will leave only barely perceptible
scars as they heal.
As always, linear closures are pre erable
to f ap and gra t techniques whenever
possible. O ten, such closures are directed
transversely across the orehead, so that
the suture line remains hidden in the
natural lines and wrinkles. This must also
be weighed against the risk o causing an
asymmetrical brow li t. Suture techniques
Dog-ear tacking
suture
Suspension
suture
Tip stitch
Purse-string
suture
Buried
vertical
mattress
suture
Set-back
dermal
suture
Pulley set-back
dermal suture

331
The Forehead
As brief y noted earlier, an important
exception to this approach w ould be
utilizing inverting techniques w hen
attempting to hide a closure w ithin
pronounced skin olds or wrinkles on
the orehead. This should be reserved
or use in wrinkles that are pro ound
and in cases where the patient has no
plans to utilize neurotoxins or other
approaches to mitigate the appearance
o their wrinkles in the uture. Utilizing
a simple buried dermal suture technique
or the deep sutures combined with an
inverting horizontal mattress or Lembert
suture or the transepidermal compo-
nent may aid in promoting wound-edge
inversion.
Given the tendency or orehead closures
to resist dog-ear correction, the dog-ear
tacking suture may be considered in such
cases. The immediate postoperative dim-
pling e ect generally resolves with time,
permitting closures to remain relatively
short while avoiding the exaggerated dog
ears that would otherwise be present. When
advancement f aps are utilized, the tip stitch,
or one o its variants, is requently utilized.
For larger de ects in the upper orehead,
occasionally the purse-string technique or
one o its modi cations may be use ul as
well; while this does not result in a ne
linear scar, it may permit more rapid heal-
ing than would be seen with secondary
intention healing alone.
Figure 6-6. Frequently used suturing techniques on the forehead.
Dog-ear tacking
suture
Suspension
suture
Tip stitch
Purse-string
suture
Buried
vertical
mattress
suture
Set-back
dermal
suture
Pulley set-back
dermal suture

332
material breakdown by hydrolysis. Fine
P-3 needles are generally adequate or
these repairs.
When transepidermal sutures are used,
6-0 or 7-0 monof lament is o ten the best.
These locations may also heal well using
ast-absorbing gut suture (or the newer
rapidly absorbing synthetic sutures),
where the disadvantage o higher tissue
reactivity should be weighed against the
benef t o utilizing a rapidly absorbing
suture material that obviates the need
or suture removal.
Suture Technique Choice
Despite the o ten thin dermis present on
the eyelids, standard approaches such as
the set-back dermal suture and the bur-
ied vertical mattress technique are o ten
utilized. Care should be taken to avoid
skimming the needle too superf cially,
leading to an essentially percutaneous
repair (Figure 6-7).
In patients with a very thin dermis or
with marked atrophy, placing absorbable
sutures may be particularly challenging.
In such cases, simple interrupted sutures
may be used to easily approximate eye-
lid skin. Running variations, such as the
simple running suture, may be used as
well. While over-eversion o the eyelid
skin should be avoided, transepidermal
everting techniques, such as the running
horizontal mattress or running diagonal
mattress, may be used as well. Unlike
repairs in anatomic locations under ten-
sion, the transepidermal closures may
The Eyelids
C H A P T E R 6 . 7
The eyelids present unique challenges
to the surgeon—the dermis is very thin,
with a near absence o subcutaneous at
in some areas. This provides only mini-
mal tissue volume to aid in absorbable
suture material breakdown, potentially
increasing the chance o suture spitting
or suture abscess ormation. Moreover,
the highly elastic eyelid skin also means
that a disf guring residual pull is pos-
sible, so that ectropion—while something
to avoid at all costs—is only the most
extreme outcome along a spectrum o
lid pull abnormalities.
The unique challenges associated
with eyelid repair means that some o
the standard buried suturing techniques
may be less use ul in these locations,
and the lack o signif cant tension along
most eyelid repairs means that running or
transepidermal techniques, which should
be used sparingly in many locations to
minimize the risk o scar spread, may be
appropriate. Medial canthal eyelid repairs
should sometimes be avoided altogether,
as this area tends to heal well by second-
ary intention.
Suture Material Choice
When absorbable suture material is
used in eyelid repairs, 5-0 or 6-0 braided
or monof lament suture material may
be used. It is important to avoid using
thicker suture material on the eyelids,
as the large volume o suture material
in knots relative to the thickness o the
dermis may impede the process o suture
Simple
running
suture
Depth-correcting
simple interrupted
suture
Simple
interupted
suture
Buried vertical
mattress
suture
Set-back
dermal
suture

333
The Eyelids
be used as a solitary approach or some
eyelid closures under minimal tension.
When working on the lower eyelid
at the eyelid-cheek junction, a marked
di erence in dermal thickness may be
appreciated betw een the thin eyelid
skin and the thicker dermis o the
upper cheek. In such cases, the depth-
correcting simple interrupted suture may
be help ul to maintain precise wound-
edge apposition.
Finally, the Frost suture may be used to
mitigate the risk o developing ectropion
due to tissue edema in the immediate
postoperative period. It is important to
recall that this approach will not help
when ectropion is present; rather it is
designed to minimize the chance that
the postoperative edema and ecchymosis
seen a ter lower lid surgery will lead to
an iatrogenic ectropion. The benef t o
placing a Frost suture should be weighed
against the risk o the patient traumatiz-
ing the suture material, where an acci-
dental pull could lead to a pain ul and
possibly damaging outcome. There ore,
Frost sutures should only be le t in place
or a minimum period o time and should
be covered with a wound dressing to
avoid accidental tugging.
Figure 6-7. Frequently used suturing techniques on the eyelids.
Simple
running
suture
Depth-correcting
simple interrupted
suture
Simple
interupted
suture
Buried vertical
mattress
suture
Set-back
dermal
suture