Excision of cutaneous lesions on areas such as the scalp and back can often be difficult to close primarily, even with adequate undermining of the wound edges. Using traditional suturing techniques in such high-tension areas often leads to breaking of suture, thus resulting in a highly frustrating experience for both the dermatologist and the patient. "Rotational suturing" is a simple technique that enables the cutaneous surgeon to consistently secure knots while suturing without breaking the suture.

The Rotational Suturing Method
Rotational suturing basically consists of four steps:

  1. Begin the closure by performing a simple "instrument tie." Do not tighten the knot yet.
  2. Grasp the suture with the needle driver about 1.25 inches from where the knot will form once the suture is tied (Fig. 1).
  3. While the needle driver is clasped down on the suture, rotate the needle driver two to four full turns toward the knot. This will effectively wrap a few turns of suture around the end of the needle driver (Fig. 2).
  4. Pull opposite ends of the suture to tighten the knot.

The knot will now be secured, and the suture will remain intact. Repeat steps as necessary.

Discussion
Traditional tightening of a knot to approximate wound edges involves simply clasping down on the blind end of suture with the needle driver and pulling. However, this allows a great deal of friction to occur between the suture and the serrations of the needle driver, often resulting in fraying or breaking of the suture. Although the use of a smooth-jawed needle driver can reduce the risk of fraying the suture, suture breakage may still occur due to the high tension of the wound closure.

With the method of rotational suturing described above, the energy of this frictional force is transferred to a tensional force against the smooth surface of the needle driver's outer walls, thus reducing the risk of suture breakage. Grasping the suture close to where the knot will form adds an additional mechanical advantage that will help decrease the risk of suture breakage.

Rotational suturing is a simple yet effective technique that dermasurgeons can employ in their practices to allay some of the frustration of large wound closures.

The authors have no relevant disclosures.