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Fascial Plication Suture Step-by-Step
Fascial Plication Suture Step-by-Step
a. The wound edges are reflected back to permit visualization of the deep bed of the
wound. In deep excisions, such as those performed for melanoma or large cysts, the muscle fascia may be directly visible. Otherwise, visualizing the subcutaneous fat is appropriate as well. b. The suture needle is inserted at 90 degrees through the deep fat 2 to 4 mm medial
to the lateral undermined edge of the wound. c. The first bite is executed by entering the fascia and following the curvature of the
needle. The suture material may be gently pulled to test that a successful bite of fascia has been taken. d. Keeping the loose end of suture between the surgeon and the patient, attention is
then shifted to the opposite side of the wound. The second bite is executed by repeating the procedure on the contralateral side. e. The suture material is then tied utilizing an instrument tie. Hand-tying may be
utilized as well, particularly if the wound is deep and the instruments cannot be easily inserted to complete the tie.
This technique is very useful for wounds under marked tension, especially for large defects on the back and shoulders.7,8 Even a deep, gaping wound can be converted into a manageable fusiform defect with a single well-placed fascial plication suture. It can, therefore, be conceptualized as an alternative to pulley sutures that affords both a decrease in tension across the wound surface (by shifting tension from the dermis to the fascia) and an increase in the length-to-width ratio of the ellipse.
Indeed, this approach often leads to a more fusiform defect, even when an ovalshaped excision has been performed. Therefore, it may be useful when attempting to keep a defect as short as possible without dog-ear formation. In cases where this approach is anticipated, it may be worthwhile to create a defect with a length-to-width ratio of less than 3 to 1, as is traditionally employed, as that may be sufficient to lead to a tapered ellipse.
Fascial plication sutures need not be used for all linear closures. This technique is most appropriate for areas under significant tension, or large excisions where minimizing the postoperative wound length is desirable. On the face, recruiting the SMAS may be very helpful. When designing the closure of a round defect, the fascial plication suture should be placed prior to removing the dog ears. The risks of fascial plication sutures include possible pain, a theoretically increased infection risk (since the fascial envelope has been pierced by suture), and a theoretical risk of vascular compromise through inadvertent pressure-induced ligation of perforating vessels. In practice, these complications are infrequent, though patients may experience transient
pain during needle entry and immediately after the fascial plication suture is tied. If pain persists for more than 5 minutes, the suture should be removed.