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Suturing
Suturing
Suturing techniques affect the efficiency of surgical reconstruction, and suturing technique choice may also impact overall linear closure design. A detailed discussion of suturing techniques and their variations may be found in Chapter 13.
Historically, most linear closures relied on a bilayered closure approach, with sutures placed in the dermis for tension relief and transepidermally for wound-edge approximation. This paradigm has shifted over the past few years, with the realization that recruiting deeper tissue planes may have a profound effect on wound strength and cosmesis.55,56
Fascial plication is one of the most useful techniques for linear closures, as it confers several advantages simultaneously.55 First, it leads to significant tension reduction over the wound surface by shifting tension to the deep fascia. Second, it decreases the amount of undermining needed to permit effective closure, theoretically improving vascular supply to the undersurface of the advancing wound edges and reducing the risk of potential space formation that may increase the risk of hematoma formation. Finally, fascial plication has a significant effect on wound geometry, as a single fascial plication suture shifts a wound from a 3:1 fusiform shape to a 6:1 ratio and decreases the apical angles significantly.55
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.
Buried dermal sutures are the cornerstone of linear repairs. Two central suturing techniques are useful: the buried vertical mattress suture and the set-back dermal suture. The former yields significant wound-edge eversion and epidermal approximation, while the latter is easier to execute. A randomized controlled trial has suggested that the setback suture leads to cosmetically more appealing scarring than the buried vertical mattress suture.42 Its ease of use is a significant advantage as well, particularly as effective wound-edge eversion is one of the most challenging (and clinically critical) components of the linear excision and closure.38
Set-back dermal sutures result in marked wound-edge eversion, though this can be adjusted based on how far each set-back bite is taken from the incised wound edge. For a detailed discussion of step-by-step suture placement, see Chapter 13.
Though many manuscripts and chapters addressing linear closures advocate the placement of a key suture in the center of the wound followed by closure using the rule of halves, in practice this may be less desirable than starting at one edge of the woundโ typically the edge most distant from the surgeonโand moving proximally. The latter technique allows tension to be gradually relieved, minimizing the tension across any single suture. This permits tissue creep to gradually take place over the course of the closure.
The set-back or buried vertical mattress sutures may be placed closer together in the center of the wound, where tensile forces are the greatest. After placement of a full row of buried sutures, the wound edges should be well everted, and ideally drape together under no tension. With assiduous attention to detail, this layer of sutures may lead to ideal wound-edge approximation, obviating the need for transepidermal sutures.
If transepidermal sutures are placed, they may be performed in a simple interrupted or running fashion. Ideally, there should be no tension across the wound surface after deep suture placement, and therefore running sutures may be appropriate. Alternatively, some mild depth correction may be needed and in such cases depth-correcting simple interrupted suture can be used. Running horizontal mattress sutures, often with intermittent simple loops, may also be helpful for yielding excellent wound eversion and avoiding suture material crossing over the incised wound edge.57,58 Running subcuticular sutures may be used as well, though in the context of well-placed buried sutures, they often confer only minimal advantage while introducing additional foreign body material across the wound.
Most dermatologic surgeons use reverse-cutting needles; these confer several advantages, and may theoretically decrease the risk of suture material tear-through since the cut edges are on the opposite sides of the vector of maximal postoperative tension.