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Dermatologists perform more skin cancer surgery than all other specialists combined;1 this presents a true opportunity (and duty) to perform the best possible reconstructive surgery.

Suturing techniques have seen a renaissance over the past decades, as dermatologic surgeons have increasingly appreciated the impact that precisely placed sutures have on surgical outcomes. The rise of evidence-based medicine has led to a boon in suture technique development, as surgeons have become more willing to consider changing fundamental techniques that were adopted during training in an effort to provide even better patient outcomes.

While most day-to-day procedures demand only a very few suturing techniques, recent evidence has suggested that choice of technique has the potential to impact long-term outcomes.2

Fundamental suturing techniques can have a striking impact on outcomes and patient satisfaction, and—when well placed—may mean that an exterior layer of removable sutures (and the accompanying patient visit) may be unnecessary.

Buried Suture Techniques

Three fundamental buried suture techniques include the fascial plication suture, the buried vertical mattress suture, and the set-back dermal suture.

Figure 1. Overview of the fascial plication suture technique; note that I now place my deep sutures parallel to the incised wound edge (in a horizontal mattress fashion) rather than perpendicular to it.

Fascial plication suture. This fascial plication suture (Figure 1) is designed for wounds under marked tension, especially those on the back and shoulders.3 It can also be used for facial repairs, where grasping the SMAS with this deep suture technique leads to a dramatic reduction in wound size. It is a deep technique, permitting the tension of wound closure to shift from the dermis to the fascia, thus creating a lower-tension closure. In addition to tension reduction, this approach also leads to an increase in the apparent length to width ratio of a fusiform closure and improved dead-space minimization.

Even a deep, gaping wound can be converted into a manageable fusiform defect with a single well-placed fascial plication suture. It also makes it much easier to place the more superficial buried sutures since tension has been largely removed.

Buried vertical mattress suture. The buried vertical mattress suture was first described in its current form in 1989 (Figure 2).4 This technique, if executed appropriately, leads to both excellent wound eversion and outstanding wound edge approximation. The apex of the needle should be in the papillary dermis; if the needle courses too superficially, dimpling may occur. Given the modest eversion seen with this technique, it is ideal when working towards the apices of linear closures and in areas with mild to moderate tension.

Figure 2. The buried vertical mattress suture. The needle is inserted through the underside of the dermis and moves upward and outward in the dermis before returning to exit at the incised wound edge (A). The needle is then inserted through the incised wound edge before moving upwards and outwards away from the wound edge and exiting in the deeper dermis (B). Lateral view of the buried vertical mattress suture highlighting the heart-shaped path the suture material takes through the dermis (C).

Set-back dermal suture. The set-back dermal suture (Figure 3) was first described in 2010.5 Since it is easier to place than a buried vertical mattress suture, this technique can be used by budding surgeons, medical students, and residents as a workhorse technique for deep tension-relieving sutures. This technique was compared to the buried vertical mattress suture in a randomized trial and was found to be superior in terms of eversion and cosmetic outcomes based on both physician and patient assessments.2 As with the buried vertical mattress technique, accurate suture placement is helped by having a sufficiently undermined plane, since here the entire suture loop lays on the undersurface of the dermis.

Figure 3. The set-back dermal suture. The needle is inserted through the underside of the dermis, exiting again through the underside of the dermis set back from the wound edge (A). This is repeated on the contralateral wound edge (B). Cross-sectional view demonstrating the path of the suture material through the dermis and the effect on wound eversion (C).

With all of these techniques, patients should be cautioned that they will develop a significant ridge postoperatively. Explaining that the technique is akin to placing a subcutaneous splint may help the patient develop reasonable and realistic expectations and reduce anxiety regarding the immediate postoperative appearance of the wound.6

For most linear repairs under tension, placing a single fascial plication suture followed by a series of set-back sutures (or buried vertical mattress sutures if eversion is a concern), can yield an outstanding layered closure option that does not require removable sutures.

Jonathan Kantor’s most recent book, Dermatologic Surgery, is a 1,440-page comprehensive overview of reconstructive and cosmetic surgical approaches for the face and body that was published by McGraw-Hill last month and is already in its second printing. His earlier book, Atlas of Suturing Techniques, also published by McGraw-Hill, is a perennial bestseller. Jonathan is a dermatologic surgeon with expertise in epidemiology, probability, and behavioral economics, and is in practice in St Augustine, FL.

1. Kantor J. Dermatologists perform more reconstructive surgery in the Medicare population than any other specialist group: A cross-sectional individual-level analysis of Medicare volume and specialist type in cutaneous and reconstructive surgery. J Am Acad Dermatol 2018;78:171-3 e1.

2. Wang AS, Kleinerman R, Armstrong AW, et al. Set-back versus buried vertical mattress suturing: results of a randomized blinded trial. J Am Acad Dermatol 2015;72:674-80.

3. Kantor J. The fascial plication suture: an adjunct to layered wound closure. Arch Dermatol 2009;145:1454-6.

4. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg Oncol 1989;15:17-9.

5. Kantor J. The set-back buried dermal suture: an alternative to the buried vertical mattress for layered wound closure. J Am Acad Dermatol 2010;62:351-3.

6. Kantor J. The subcutaneous splint: a helpful analogy to explain postoperative wound eversion. JAMA Dermatol 2014;150:1122.

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