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Suspension Suture Step-by-Step
Suspension Suture Step-by-Step
a. First, the surgeon determines the desired location for fixing the suspension suture,
as discussed below. The wound edge is reflected back using surgical forceps or hooks, and adequate visualization of the underside of the dermis is desirable. b. While reflecting back the dermis, the suture needle is inserted at 90 degrees into
the underside of the dermis 2 to 6 mm distant from the incised wound edge. c. The first bite is executed by traversing the dermis following the curvature of the
needle and allowing the needle to exit closer to the incised wound edge. This will minimize the risk of vascular compromise. Care should be taken to remain in the dermis to minimize the risk of epidermal dimpling. The needle does not, however, exit through the incised wound edge, but rather 1 to 4 mm distant from the incised edge, or, in select cases, potentially further back from the wound edge. d. The flap of skin may be gently pulled by the suture material so that the location of
the first bite directly overlies the planned fixation point. This permits the surgeon to double-check the final position of the suspension suture. The needle is then blindly inserted through the fat and deeper structures until bone is reached. A 3-mm bite of periosteum is then taken, and the needle is brought back up through the soft tissues into the open center of the wound. e. The suture material is then tied utilizing an instrument tie. Hand-tying may be
utilized as well, which may be useful if the depth of the defect is significant.
This technique is very useful when working around the eyelids and lips, though its use demands familiarity with the underling anatomy so that no sensitive deeper structures are injured or entrapped during the blind placement of the deep anchoring suture. The deep suture should also be placed parallel to the underlying vascular plexus to similarly mitigate this risk.
Placement is based on several considerations, including the degree of tension across the advanced tissue, the presence of a bony prominence, which can be used easily for suspension purposes, and the absence of underlying nerves, which could inadvertently become strangulated by the anchoring suture.
Pulling on the suture once it is anchored to the periosteum may help assure the surgeon that the suture is indeed tacked down to an immobile surface.
A three-point variation of this approach is possible as well, which allows woundedge approximation and a tacking effect to occur all with one suture placement. This is accomplished by first placing either a buried vertical mattress or set-back dermal suture at the two wound edges and then taking a bite of the underlying periosteum prior to tying the knot. The suture material thus fixes the wound edges together as well as to the underlying anchoring point. This approach, however, may result in suboptimal woundedge eversion and places additional stress on the suture material, increasing the risk of scar spread. Moreover, it is only appropriate if the anchor target lies in the approximate
midpoint of the defect, since it recreates a natural sulcus but does not permit differential pull from one side of the defect.
This technique may also be used as an alternative to cartilage grafting when reconstructing the nose. Loss of alar cartilage may lead to nasal valve collapse, which traditionally was addressed by placing an auricular cartilage graft along the reconstructed alar rim in order to maintain valve patency. A simple and elegant alternative places a suture in the ala and fixes it to a point superolaterally in the maxillary periosteum, permitting the nasal valve to remain open and potentially obviating the need for a cartilage graft. Since the underside of the dermis is tacked to periosteum, this technique may result in an area of depression at the site of suspension suture placement.