Surgical technique for optimal outcomes

Part II. Repairing tissue: Suturing

Christopher J. Miller, MD,a Marcelo B. Antunes, MD,b and Joseph F. Sobanko, MDa

Philadelphia, Pennsylvania, and Austin, Texas

Learning objectives

After completing this learning activity, participants should be able to describe common suturing errors that lead to unaesthetic scars and identify methods to gain hemostasis efficiently

and re-approximate skin in a layered fashion with proficiency.

Disclosures

Editors

The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with

commercial interest(s).

Authors

The authors involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Planners

The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved

with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

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Sound surgical technique is necessary to achieve excellent surgical outcomes. Despite the fact thatdermatologists perform more office-based cutaneous surgery than any other specialty, few dermatologistshave opportunities for practical instruction to improve surgical technique after residency and fellowship.This 2-part continuing medical education article will address key principles of surgical technique at eachstep of cutaneous reconstruction. Part II reviews the placement of deep and superficial sutures. Objectivequality control questions are proposed to provide a framework for self-assessment and continuous qualityimprovement. ( J Am Acad Dermatol 2015;72:389-402.)

Key words: excise; excision; incise; skin; surgery; suture; technique; undermine.

INTRODUCTIONPart I of this continuing medical education

article reviewed surgical techniques that involvecutting tissue: incising, excising, and undermining.Final inspection of the wound after completingthese cutting steps should reveal cleanly incised,vertical wound edges, a wound base with auniform anatomic depth, and precisely under-mined skin flaps. Careful hemostasis should mini-mize bleeding. Strategies for effective hemostasishave been reviewed elsewhere.1,2 Precise execu-tion of these cutting steps prepares the wound foraccurate placement of buried and superficialsutures.

the Department of Dermatology,a University of Pennsylva-

a, Philadelphia, and Private Practice,b Austin.

o available at http://www.jaad.org.

ing sources: None.

licts of interest: None declared.

pted for publication August 1, 2014.

spondence to: Joseph F. Sobanko, MD, Edwin & Fannie Gray

all Center for Human Appearance, University of Pennsylvania,

REPAIRING TISSUE: PLACING BURIEDSUTURESKey pointsd The preferred caliber of the suture and sizeof the needle depend on the anatomic loca-tion, thickness of the skin, and tension of thewound

d Suture sequence and surgeon positioninginfluence the efficiency and execution ofsubcutaneous sutures

d The proper placement of buried verticalmattress sutures and atraumatic handlingof skin are critical steps that achieve optimalsurgical outcomes

3400 Civic Center Blvd, Rm 1-330S, Philadelphia, PA 19104.

E-mail: Joseph.Sobanko@uphs.upenn.edu.

0190-9622/$36.00

� 2014 by the American Academy of Dermatology, Inc.

http://dx.doi.org/10.1016/j.jaad.2014.08.006

Date of release: March 2015Expiration date: March 2018

389

Fig 1. The superficial (A) and buried vertical mattress (B) sutures each have heart-shapedloops, but the knot is at the bottom of the loop for the buried suture.

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d The buried vertical mattress suture evertsthe wound edges and allows for tension-freeapproximation of the papillary dermis andepidermis

d After the effective placement of buriedvertical mattress sutures, both wound edgesshould be clearly visible and there should beminimal bleeding from exposed dermis

The anatomic layers requiring suturing will varyby site, depth, and wound complexity.3 This articlewill focus on the most common wounds incutaneous surgery: wounds that extend through theepidermis, dermis, and subcutaneous fat. Buriedor subcutaneous sutures eliminate dead space,approximate the dermis and epidermis, and providestrength to the wound as the scar matures. Theburied vertical mattress suture is the workhorse fordeep sutures and will be the primary techniquediscussed herein.4 It creates the same heart-shapedloop as a superficial vertical mattress suture, exceptthat the knot lies at the bottom of the loop (Fig 1).Numerous other techniques for buried sutures mayalso accomplish the accurate approximation ofwound edges; however, a comprehensive discussionof these lies beyond the scope of this article.5

Judicious selection of the suture and needle, athoughtful plan for suture sequence, and positioningrelative to the wound are the first steps for effectiveexecution of the buried vertical mattress suture.

Thematerial and caliber of the suture and the typeand size of the needle influence execution of theburied vertical mattress suture. Previous articles andeducational resources provide a comprehensivereview of suture materials.5,6 In most cases, adissolving rather than a permanent suture is idealfor buried sutures. Slowly absorbing intradermal

sutures, such as polydioxanone, may decrease scarspread in high tension wounds.7 Wound tensiondetermines the ideal size of the suture. High-tensionwounds (eg, those on the torso or proximal extrem-ities) may require a 3-0 or 2-0 suture. In moderatetension wounds, a 4-0 suture may provide sufficientstrength. For wounds under minimal tension, a 5-0suture will usually suffice. In general, using thesmallest caliber suture that provides sufficient tensilestrength is desirable to minimize the amount ofsuture material in the wound. The type and size ofthe suture needle strongly influence execution ofdeep sutures. Most surgeons prefer to place deepsutures with a reverse cutting needle. The choice ofneedle size depends primarily on the thickness of thedermis; in anatomic areas with a thin dermis, asmaller needle is required, such as a 3/8 arc P-3needle. Anatomic areas with a thicker dermis requirea larger needle, such as a 3/8 arc PS-2 needle.In locations with thick skin, such as the back, ahalf-circle reverse-cutting needle may facilitateplacement of the buried vertical mattress suture.Using a large needle in anatomic areas with a thindermis will risk tearing the skin. Using a small needlein anatomic areas with a thick dermis frequentlyleads to bent needles as the surgeon struggles torotate the needle far enough to retrieve the tip.

Suture sequence influences operative efficiencyand execution. Placing deep sutures is morechallenging in areas of high versus low tension.8

The strategy of placing the first sutures in the areaof highest tension then moving to areas ofprogressively lower tension has its advantages.First, access and visibility to the areas of greatesttension are easiest before most of the wound hasbeen closed. The alternative strategy of placing the

Fig 2. Countertraction with either forceps or a skin hook exposes the dermis for placement ofthe deep sutures. A, Ideal placement of the retracting instrument in the papillary dermismaximizes visibility of the dermis and orients the skin in an everted position. B, Suboptimalplacement of the retracting instrument in the reticular dermis compresses the dermis, whichminimizes visibility and orients the skin in an inverted position.

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initial sutures at the areas of lowest tensionmay leavea smaller space to throw the sutures in the areas ofgreatest tension, which often results in bent needles,difficulty retrieving the tip of the needle from thecenter of the wound, an inability to access thedeepest anatomic layers of thewound, and increasedtrauma and tearing of the skin. A second advantageof placing the initial sutures in the areas of greatesttension is that it provides time for tissue creep,if complete closure with the initial suture is notpossible.9,10 The first deep suture should be cinchedas much as the tension of the wound edges willallow. When complete apposition is not possibleinitially, the surgeon can continue suturing in areaswith less tension. By the time the areas with lesstension have been sutured, tissue creep may allowthe surgeon to return and completely close the areawith greatest tension. In many instances, the surgeonmay first suture areas of the wound with less tension.Whatever the suture sequence, the surgeon willbenefit from leaving sufficient space and easy accessfor accurate and efficient placement of sutures in themost critical, high-tension areas.

The position of the surgeon relative to the woundalso influences the efficiency and execution ofburied sutures. In general, it is easier to throw aburied suture when the dominant hand lies on theside of the wound where the skin is looser. Whenloaded into the needle driver, the shank of the sutureneedle (ie, the portion closest to the suture) usuallypoints to the dominant, throwing hand of thesurgeon. In tight spaces, the shank of the needlecan impede the execution of deep sutures. If thesurgeon positions him or herself so that the shank ofthe needle and dominant hand are on the same sideas the looser wound edges, the surgeon can retractthe loose skin to allow easier passage of the needle.

Countertraction to evert the skin edge with eitherthe forceps or skin hook is essential for efficient andaccurate execution of the buried vertical mattresssuture. The skin hook has the advantage of allowingretraction close to the epidermis with minimal to notrauma, but it requires frequent manipulation of asharp instrument.11 Some surgeons prefer to workwith a double- rather than single-pronged skin hookin order to reduce the risk of sharps injury and stillmaintain the benefit of atraumatic tissue handling. Bycontrast, forceps have a higher risk of trauma to thepatient’s skin but allow less exposure to sharps. Bothinstruments can be used effectively, and the surgeonmust learn to balance safety with atraumatichandling of the skin. Countertraction should occuras close to the epidermis as possible, in order to evertthe skin edge and tomaximize visibility of the dermis(Fig 2, A). If the instrument is placed too deeply, itcompresses the dermis and orients the skin edge inan inverted position (Fig 2, B). Compression of thedermis reduces the size of the target for the deepsuture, and the deep suture tends to fix the skin in aninverted position (Fig 3).

‘‘Eversion’’ is defined as upward sloping skinedges that meet perfectly at the peak without anyplateau or inversion. The buried vertical mattresssuture facilitates eversion, which helps to counteractthe contractile forces during wound healing, resistsinversion of the scar, and transfers tension to thereticular dermis so that the papillary dermis andepidermis meet with minimal to no tension.12 Theburied vertical mattress suture has a heart-shapedloop with 2 peaks at the level of the mid dermis ordeep papillary dermis and a valley at the level of thedeep reticular dermis (Fig 1). As the difference indepth between the peaks and valley of the suturepath increases, the degree of eversion will increase.

Fig 4. The ‘‘snap’’ of the wound edge toward the center of the wound after the first bite of thesuture indicates a good path of the buried vertical mattress suture. A, The first bite of the suturehas been completed and the skin hook still applies countertraction. B, The skin hook has beenreleased and the skin edge ‘‘snaps’’ back toward the center of the wound.

Fig 3. Schematic representation of the influence of countertraction on visibility of the dermisand position of the skin edge. A, Placement of the retracting instrument in the papillary dermiseverts the wound edge and maximizes visibility of the dermis, providing a larger target for thedeep suture. B, Placement of the retracting instrument in the reticular dermis inverts the woundedge and compresses the dermis, shrinking the target for the deep suture.

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To initiate a buried vertical mattress suture, theneedle is passed starting from the base of thewound to the desired location of the peak ofthe heart-shaped loop. Once the tip of the needlereaches its peak at the mid dermis or papillarydermis, the needle is rotated toward the incisedwound edge. During this maneuver, the woundedge must be retracted aggressively in an evertedposition. This will ensure that the tip of the needlewill reach the incised wound edge at a greaterdepth, usually in the reticular dermis. When thepeaks lie closer to the underside of the epidermisthan the valley of the heart-shaped loop, theepidermis and papillary dermis of the incisedwound edge naturally snap back toward the centerof the wound upon release of the retracting forcepsor skin hook (Fig 4). If the ‘‘snap’’ does not occur,

then there is a high likelihood of a gap between thewound edges. The needle is then passed in theopposite side of the wound to create a mirror imageof the first side (Fig 5). The needle enters the woundin the deep reticular dermis and must aim to create apeak of the heart-shaped loop in the more superfi-cial dermis. Extending the wrist will aim the needleupward. Once the tip of the needle reaches thepeak, the needle is rotated toward the base of thewound. Retracting the skin edge in an evertedposition with the skin hook or forceps naturallyfacilitates the proper suture path. When the suturepaths on each side are not mirror images, the woundedges will not appose each other precisely.12 As arule, the side with the more superficial bite of suturerelative to the epidermis will have a wound edgethat is depressed compared to the other side (Fig 6).

Fig 5. To achieve perfect apposition of the wound edges,each side of the completed buried vertical mattress sutureshould be a mirror image.

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The path of the buried vertical mattress suture willvary based on the thickness of the dermis. In areaswith thicker dermis (eg, the back or proximalextremities), the path of the suture must have agreater difference in height between the peaks andvalley of the buried vertical mattress suture (Fig 7,A). To achieve this greater difference, the surgeonmust take a wider bite (ie, further from the incisedwound edge) with the skin edge retracted aggres-sively in an everted position. In practice, a wide bitewith the skin edge retracted aggressively feels likethe suture needle is passing parallel to the undersideof the epidermis for as long as possible. In areaswith thinner dermis (eg, eyelid and dorsal surfacesof the hand and forearm), the ideal difference inheight between the peaks and valley of the buriedvertical mattress sutures is smaller (Fig 7, B). Toachieve this minimal difference, the surgeon musttake a narrow bite (ie, closer to the incised woundedge) with the skin edge retracted in a less aggres-sive everted position. In practice, a narrow bite witha gently retracted everted edge feels like the sutureneedle is passing parallel to the vertical face of theincised skin edge. Another way to describe thedifference in the suture path for thick versus thindermis is to conceptualize the distance of the peaksof the heart-shaped loop from the incised woundedge. In thick dermis, the peaks of the heart-shapedloop will lie further from the incised wound edgeand the path of the suture creates a broad based,heart-shaped loop. In thin dermis, the peaks of theheart shaped loop lie closer to the incised wound

edge and the path of the suture creates a narrow,tall, heart-shaped loop.

The suture is now ready to be tied with theknot buried at the depth of the underminedplane. An effective instrument tie prevents an ‘‘airknot’’ and ensures snug approximation of thewound edges.13,14 The running end of the suture(needle-end) is pulled so that only a few centimetersof the trailing end remain exposed on the oppositeside of the wound. Each end of the suture should lieon the same side of the loop of the buried verticalmattress suture. The ends of the suture will form aV that points to the center of the wound, and theneedle holder will remain between both arms of theV during knot tying. With the nondominant hand,wrap the needle end of the suture once or twicearound the needle holder toward the opposite sideof the wound. Grasp the trailing end of the suturewith the needle holder and pull it parallel to the longaxis of the wound toward the same side that thesuture ends initially lay relative to the loop of theburied vertical mattress suture (video availableonline at www.jaad.org).15 Bring the needle holderback to center. To cinch the suture with a slip knot,throw another loop around the needle holder andpull the suture in the same direction as the firstthrow. To lock the knot, throw another loop with theneedle holder and pull the hands in the oppositedirection. The number of throws made by thesurgeon will be influenced by the knot security ofthe suture and the tension on the wound.

To ensure an adequate number of buried sutures,the surgeon can apply the ‘‘pull test.’’ By pulling thewound edges away from each other, the surgeonidentifies gaps that would benefit from additionalburied dermal sutures. The buried sutures shouldsupport the dermis along the entire wound and stillallow easy manipulation of the epidermal edges(Fig 8). If the buried sutures have been placed at anideal depth, the surgeon can use the skin hook orforceps to retract the epidermis and papillary dermisimmediately above the buried sutures. If the woundedges are firmly fixed above the buried suture, thenit may have been placed too superficially.

Two quality control questions allow objectiveassessment of buried suture technique. First, is bloodvisible between the edges? Assuming effectivehemostasis in the deep aspects of the wound, visibleblood between the wound edges arises when thepapillary dermis is either poorly approximated orfrankly exposed. Second, are both wound edgesclearly visible? If both wound edges are not clearlyvisible, then 1 edge is riding over the other like ashingle on a roof. Accurately placed buried verticalmattress sutures approximate the wound edges so

Fig 6. When the paths of the suture on each wound edge are not mirror images, a discrepancyin the height of the wound edges results. A, The exit point of the suture on the left side of thewound is in the reticular dermis, but the needle is entering in the papillary dermis on the rightside of the wound. B, The right side of the wound has been pulled down by the superficial bite.The exposed dermis on the high side frequently bleeds.

Fig 7. The path of the buried vertical mattress suture varies depending on the thickness of thedermis. A, Thicker dermis requires a wider bite that extends further from the incised woundedge and has a greater difference in height between the peak and valley of the heart-shapedloop. B, Thinner dermis requires a narrower bite with a smaller difference in height betweenthe peak and valley and of the heart-shaped loop.

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precisely that bleeding between the wound edges isminimal and both wound edges are clearly visible.These 2 quality control questions help to identifyseveral technical problems, which are addressed inthe troubleshooting section, but first wewill examinein detail 3 common suboptimal suture paths.

The first quality control question helps to identify2 buried suture paths that fail to approximate thewound edges and result in bleeding from theexposed dermis. One common inefficient buriedsuture has a circular path, which results in flat(ie, noneverted) wound edges, with a gap betweenthe epidermis and papillary dermis. This resultoccurs most frequently in areas with thick dermisand/or in wounds with excessive tension. A circular

path of the buried suture creates splayed woundedges with minimal to no eversion and lack thedimple often seen with a heart-shaped buriedvertical mattress suture (Fig 9, A). The circular suturepath occurs most commonly as a result of either toonarrow a bite of the buried suture or failure to retractthe skin edge in an everted position during the throwof the suture. A buried suture with a circular path willapproximate the dermis only up to the mostsuperficial point of the loop (Fig 9, B). Superficialto the loop, the wound edges splay away from eachother. Troubleshooting requires removal of the initialdeep sutures and replacement with buried verticalmattress sutures that have a wider bite and biggerdifference between the distance of the peaks and

Fig 8. The ‘‘pull test’’ identifies wound edges that will benefit from a dermal suture. A, Pullingthe wound edges identifies a gap remaining on the right side of the wound. B, After placementof another deep suture on the right side, the pull test no longer creates a gap, indicating that asufficient number of deep sutures have been placed.

Fig 9. A, After placement of the deep sutures in a location with thick dermis, a gap persistsbetween the wound edges. Note the absence of eversion. B, Narrow suture bites and a circularpath results in a gap after the deep sutures. The wound edges with this suture path do not snaptoward the center of the wound. C, Typical appearance of a wound 1 week postoperativelyafter closure with this type of deep suture. The scar is already inverted and excessive tensionfrom the top sutures has caused intense inflammation and early track marks.

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valley from the underside of the epidermis. Thehallmark of this correction will be the characteristic‘‘snap’’ of the wound edges toward each other andpossibly a dimple of the epidermis over the peaks ofthe heart-shaped loop. Failure to correct thisproblem will result in inverted scars and unduetension on the cuticular sutures, increasing the riskfor track marks (Fig 9, C).

A second pattern of buried suture that predictablyresults in visible blood between thewound edges is aburied vertical mattress suture that is placed toodeeply. The consequent degree of eversion can be sogreat that approximation of the epidermal edgesis not possible. Again, this result occurs mostfrequently in areas with thick dermis. In this extremescenario, the undersides of the dermis are effectivelysewn together and the epidermal edges cannot reacheach other (Fig 10, A). The cause of this phenome-non is an excessively wide and deep bite of theburied vertical mattress suture (ie, a broad heart-shaped loop), which results in a prominent dimplefar from the wound edge and excessive eversion (Fig

10, B). The correction for this phenomenon is usuallyreplacement of the deep sutures with buried verticalmattress sutures that have a more narrow andsuperficial bite. Once again, the hallmark of thiscorrection will be the characteristic ‘‘snap’’ of thewound edges toward each other. However, if theexposed dermis is minimal, it may be possible to trimthe splayed dermis and approximate the edgeswithout replacing the buried sutures. Failure tocorrect this issue before placing cutaneous sutureswill result in a broad scar (Fig 10, C).

The second quality control question (ie, are bothwound edges clearly visible?) identifies a suturepath that occurs most commonly in skin with thindermis. To avoid tearing of thin dermis, it is oftennecessary to throw the buried vertical mattresssuture with a wide bite that places the peak of theheart-shaped loop too far from the wound edge (ie,the heart-shaped loop is too broad). The thin dermiscannot support an upward slope to its peak, and theeverted skin plateaus or inverts when the dermiscollapses (Fig 11, A). This eversioneinversion

Fig 10. A, Appearance of a wound after deep sutures that caused eversion and inversion. Theweak dermis could not support the upward slope of the wound edges, which collapsed andinverted. B, Everted wound edges that collapse and invert because the dermis cannot supportthe upward slope to a peak. The wound edge on the right rides over the left side like shingleson a roof. C, Two-week postoperative appearance of a wound that was sutured with collapseof eversion. The lower wound edge remains fixed over the upper wound edge, especially onthe left half of the wound.

Fig 11. A, Excessive wound eversion has resulted in a persistent gap between the epidermaledges after placement of the deep sutures. B, A suture path with an excessively wide bite nearlysutures the undersurfaces of the dermis together. C, Long-term result with scar spread,hypertrophy, and suture marks from excessive tension of the top sutures.

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phenomenon creates redundant skin edges thattend to slide over and obscure visibility of theopposite side. At 1 week of follow-up, woundswith this phenomenon will have inversion anduneven wound edges (Fig 11, C). There are 2potential options for troubleshooting. First, thesurgeon can remove the initial sutures and replacethem with more narrow bites. Second, the surgeoncan trim the wound edges where the eversiontransitions to inversion (Fig 12). In thin skin, thisphenomenon is often inevitable, and the lattermethod of troubleshooting is necessary. Repeatsutures will often result with the same problem.

Goal of deep suturesThe goal of the buried vertical mattress sutures is

to transfer tension to the reticular dermis andevert the wound edges to allow for precise andtension-free approximation of the papillary dermisand epidermis.

Quality control checkpoints for placement ofdeep sutures

1. Is there blood between the wound edges?a. Troubleshooting #1—A gap between the

wound edges may result from excessivetension that prevents complete approximation.

Tension may prevent immediate approxima-tion, and the exposedwound edgesmay bleed.

b. Troubleshooting #2—A gap between woundedges may result from failure to cinch theburied knot. Eliminate air knots with snug butnot strangulating buried sutures.

c. Troubleshooting #3—An insufficient numberof deep sutures will result in weak approxi-mation of the dermis and potential bleeding.Apply the ‘‘pull test’’ to the wound. If lateraltraction pulls the wound edges away andreveals a prominent gap, additional buriedsutures may be necessary (Fig 8).

d. Troubleshooting #4—A circular path of theburied suture results in bleeding fromexposed dermis superficial to the sutureloop. A circular suture path is identified bysplayed wound edges with minimal to noeversion and by the lack of the dimple oftenseen with a heart-shaped buried verticalmattress suture (Fig 9, A). The circular suturepath occurs most commonly as a result ofeither too narrow a bite of the buried sutureor failure to retract the skin edge in an evertedposition during the throw of the suture.Because of the lack of eversion, the skinedges fail the ‘‘snap test.’’ Troubleshootingrequires removal of the initial deep sutures

Fig 12. Correction of wound edges with eversion and inversion phenomenon. A, Identify thepoint of collapse where the wound edge begins to invert. B, Trim the excess skin beyondthe point of collapse. C, The newly trimmed wound edges will snap toward the center of thewound to allow tension-free approximation.

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and replacement with buried vertical mattresssutures that have a wider bite and woundedges that snap toward each other.

e. Troubleshooting #5—A buried vertical mat-tress suture that is placed too widely anddeeply can effectively sew the undersides ofthe dermis together, resulting in exposeddermis that bleeds. The hallmark of thissuture path is a prominent dimple far fromthe wound edge and excessive eversion(Fig 10, A). Because of the bulk of the splayeddermis, the wound edges fail the ‘‘snap test.’’The correction for this phenomenon is usuallyreplacement of the deep sutures with buriedvertical mattress sutures that have a morenarrow and superficial bite and wound edgesthat snap toward each other. However, if theexposed dermis is minimal, it may be possibleto trim the splayed dermis and approximatethe edges without replacing the buriedsutures.

f. Troubleshooting #6—Failure to throw theburied vertical mattress sutures with mirrorimages on both sides may result in bleeding ofthe exposed dermis on the elevated woundedge (Fig 6). The side with the deeper bite (ie,deeper relative to the epidermal edge) willride higher than the side with the moresuperficial bite and the exposed dermis willbleed readily. Correction requires replacingthe deep suture more accurately, trimming thehigh side to match the low side, or placingcuticular sutures to align the edges moreprecisely.

2. Are both wound edges clearly visible?a. Troubleshooting #1—One side of the wound

may slide over the opposite side like shingleson a roof when the bites of the deep sutureare not mirror images. The side with the moresuperficial bite (ie, closer to the epidermis)

may slide under the edge of the opposingside. Troubleshooting may include eitherreplacing the deep sutures more accuratelyor by trimming the high side to match the lowside.

b. Troubleshooting #2—Buried vertical mattresssutures with wide bites in weak dermis maycreate an upward slope that plateaus or invertsbefore reaching the wound edge (Fig 10).This eversioneinversion phenomenon createsredundant skin edges that tend to slide overand obscure visibility of the opposite side.There are 2 potential options for trouble-shooting. First, the surgeon can remove theinitial sutures and replace them with morenarrow bites. Second, the surgeon can trimthe wound edges where the eversion transi-tions to inversion (Fig 12).

REPAIRING TISSUE: PLACINGSUPERFICIAL SUTURESKey pointsd Superficial sutures correct minor heightdiscrepancies of the wound edges afterplacement of the buried sutures

d Ideally, cuticular sutures bear minimal to notension

d Skin with thin dermis requires a higherfrequency of sutures (ie, sutures placedcloser together) and suture bites that arecloser to the wound edge

Even with careful technique with deep sutures,the wound edges frequently benefit from anadditional layer of superficial sutures for preciseapproximation of the epidermal edges. If the deepsutures have been placed effectively, the epidermisand dermis should not have a gap between themand the top sutures should not need to beartension. However, minor height discrepancies afterplacement of the deep sutures are common. The

Fig 13. A, The buried vertical mattress suture has been placed with unequal bites, resulting in aheight discrepancy of the wound edges. B, To correct the height discrepancy with top sutures,it is often easiest to bite the high side first with a shallow, narrow throw. C, After biting the highside, the wound edge can be depressed to match the lower side, and a deeper, wider bite isthrown on the low side. D, The completed top suture corrects the height discrepancy.

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primary purpose of the superficial sutures is tocorrect these height discrepancies. The 2 qualitycontrol questions after placement of the deep suturesidentify wound edges that will benefit from topsutures. If both wound edges are not clearly visibleor if there is bleeding from the exposed dermis,then fine corrections with the top sutures will benecessary.

The type and size of the suture and the size ofthe needle influence execution of the top sutures. Afew general principles apply. First, smaller calibersutures have a lower risk of leaving track markscompared to thicker caliber sutures. The effectiveplacement of buried vertical mattress sutures nearlyeliminates tension on the wound edges and allowsthe surgeon to use lower caliber sutures. Second,smaller suture needles (eg, P-3) should be used tosuture delicate wound edges to avoid tearing.Finally, sutures should be removed as early aspossible to avoid track marks. In wounds with

effective placement of deep sutures, the top suturesdo not bear tension and can be removed within 5 to7 days in most cases, especially on the head andneck. Leaving superficial sutures for a longer timeoffers little advantage, because the deep suturesbear the tension that keeps the wound fromdehiscing.16,17

Once the surgeon has chosen the suture materials,the key decisions that the surgeon must make are thespacing between the epidermal sutures and thedistance of the suture bites from the wound edge.In general, skin with a thinner dermis requires ahigher frequency of sutures (ie, sutures placed closertogether) and suture bites that are closer to thewound edge. The ideal distance from the woundedge supports eversion to a peak without collapse. Ifthe bite of the superficial suture is too far fromthe wound edge, it can create the same eversioneinversion phenomenon as seen with an excessivelywide bite with a deep suture.

Table I. Review of checkpoints and methods of error correction

Surgical technique Quality control checkpoint Technical error Correction of errors

Incising 1. Has the incision achieved uniform release to thedesired anatomic plane?

Incomplete incision, or skin edges notreleased

Complete the incision to the desired depth to getuniform release

Incision extends more deeply than theintended depth of excision andundermining

Ensure that the subsequent steps of excision andundermining occur in the more superficial, correctanatomic plane

2. Do the incised wound edges have a sharpperpendicular edge and no bevel?

Beveled dermis a. Ensure that the angle of the scalpel isperpendicular to the plane of the skin duringthe incision

b. Stabilize the skin during the incision withdownward pressure rather than lateral traction

c. Consider using a no. 10 scalpel blade foranatomic locations with thick dermis

d. Correct the bevel by gripping the redundanttissue with a forceps, apply gentle traction intothe wound, and incise through the beveleddermis to create a clean and perpendicular edge

Beveled subcutaneous fat Use tissue scissors to trim the fat flush with thevertical face of the incised dermis

3. Are the wound edges cut cleanly without jaggededges?

Jagged wound edges a. Use a sharp scalpel and pass it lightly over theskin, allowing[1 pass to achieve desired depth,if necessary

b. Stabilize the skin with gentle downward pressurewhile incising

Excising 1. Is the excision effortless with minimal bleeding? Excision is difficult or causes excessivebleeding

Evaluate the surgical plane and redirect excision tooptimal plane as necessary

2. Does the excision specimen have a uniformthickness without scalloped edges of its base?

Excision specimen has uneventhickness

Assess base of wound to identify transitions ofsurgical planes. Consider using scissors, ratherthan a scalpel, in order to gain the tactilefeedback that helps to maintain a uniformanatomic plane

The base of the excision specimen hasscalloped edges

Consider using scissors, rather than a scalpel, inorder to gain the tactile feedback that helps tomaintain a uniform anatomic plane during theexcision

3. Does the base of the wound have a uniformdepth at the desired anatomic plane?

The base of the wound is too shallow Excise the remaining superficial tissue to the desiredanatomic plane

The base is deeper than the intendedsurgical plane

Be careful that undermining occurs in the moresuperficial, preferred anatomic plane

Continued

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Table I. Cont’d

Surgical technique Quality control checkpoint Technical error Correction of errors

Undermining 1. Does undermining occur effortlessly and withminimal bleeding?

Undermining is difficult or causesexcessive bleeding

Evaluate the surgical plane and redirect excision tooptimal plane as necessary

Undermining is difficult because ofpoor stabilization of the skin edge

Apply countertraction with the skin hook directlyover the point of undermining

2. Can the incised skin edge be retracted in aneverted position?

The incised wound edge cannot beretracted in an everted position

Undermine effectively to allow easy eversion of theskin edge

3. Are the wound edges sharply perpendicularalong the full thickness of the skin flap fromepidermis to the plane of undermining?

The wound edges are not perpendicularbecause of beveled dermis or fat

If the wound edges are not perpendicular afterundermining, identify and correct any bevel of thedermis or fat

Placing deepsutures

1. Is there blood between the wound edges? Blood is visible between the woundedges

a. Excessive tension may prevent complete woundedge approximation

b. Eliminate air knots with cinched but notstrangulating buried sutures

c. Ensure an adequate number of deep suturesto close all gaps. If a circular path of a buriedsuture is identified, remove the initial deepsutures and replace with buried vertical mattresssutures that have a wider bite and wound edgesthat snap toward each other

d. If the papillary dermis is splayed from deepsutures with excessively wide bites, replace thedeep sutures with buried vertical mattresssutures that have a more narrow and superficialbite. If the exposed dermis is minimal, it may bepossible to trim the splayed dermis andapproximate the edges without replacing theburied sutures

e. If profile of the buried sutures does not have amirror image and 1 dermal edge rides higher,replace the deep suture more accurately, trim thehigh side to match the low side, or place cuticularsutures to align the edges more precisely

2. Are both wound edges clearly visible? One wound edge overlaps andobscures the other

a. One side of the wound overlaps the other if thebites of the deep suture are thrown at differentdepths. If the difference is marked, replace theburied suture with symmetrical bites. If thedifference is minimal, consider trimming the highside to match the lower side

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The top sutures should be thrown with minimaltension. Excessive tension may cause pleating of thewound edges and increases the risk for woundnecrosis and suture marks. As a quality controlmeasure, the surgeon should be able to slide 1 armof the forceps under the suture loop without diffi-culty. If the top sutures are thrownwith tension, a gapwill form at the points of entry and exit. The processof reepithelialization begins immediately,16,18 sotrack marks are likely to occur, even if the top suturesare removed before 1 week postsurgery.

The first step in placing accurate top sutures is torecognize which side of the wound is riding higherthan the other. The high side either obscuresvisibility of the lower wound edge by sliding overit like shingles on a roof or it bleeds because itspapillary dermis is exposed. The high side of thewound is usually slightly more delicate and can bemore challenging to manipulate. It is often moreefficient to correct height discrepancies of thewound edge by biting the high side first. The generalguideline to correct height discrepancies with topsutures is: ‘‘Bite high on the high side, and bite lowon the low side.’’ In other words, the needle shouldapproach the high side with a shallow bite in thepapillary dermis (ie, close to parallel to the plane ofthe epidermis) that is relatively close to the woundedge. After showing the tip of the needle betweenthe wound edges, the surgeon has control of this sideof the wound. The surgeon must then depress thewound edge until it matches the height of theopposite side. The needle is then passed with adeeper and wider bite that precisely matches thewound edges (Fig 13). The principles to achieveprecise wound approximation apply to variousmethods of placing superficial sutures.

Goal of superficial suturesThe goal of superficial sutures is to align the

papillary dermis and epidermis with precision.

Quality control checkpoints for the placementof cuticular sutures

1. Is there blood between the wound edges?a. Troubleshooting #1—When the bites of the

superficial sutures have asymmetric distancesfrom the wound edge, the side with the widerbite tends to slide over the opposite side likeshingles on a roof, and the opposite edge maynot be visible. This exposed dermis on thehigh side may bleed. Placing an interruptedsuture may be necessary to realign the woundedges.

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b. Troubleshooting #2—Excessive tension onthe superficial sutures, especially in skinwith a thin dermis, can lead to pleating ofthe wound edges between the loops ofsuture. Pleating often causes height dis-crepancies, and the exposed dermis on thehigh side may bleed. Replacing the cuticularsutures with less tension will correct bleedingfrom pleating. The sutures should be looseenough to allow the surgeon to slide 1 arm ofthe forceps under the loop without difficulty.

c. Troubleshooting #3—Insufficient tension ofthe cuticular sutures can lead to small gapsbetween thewoundedges anddermal bleeding.Cutaneous sutures should align the woundedges snugly but without strangulation.

2. Are both wound edges clearly visible?a. Troubleshooting—When the bites of the

cuticular sutures have asymmetric distancesfrom the wound edge, the side with the widerbite tends to slide over the opposite side like ashingle on a roof, and the opposite edge maynot be visible. Placing an interrupted suturemay be necessary to realign the wound edges.

CONCLUSIONThis continuing medical education series

provided quality control questions to assess thetechnical precision of each step of cutaneoussurgery: incising, excising, undermining, placingburied sutures, and placing cuticular sutures. Thesequality control questions provide a methodology forobjective self-evaluation and help to identifycommon technical errors and potential solutions toobtain reproducibly excellent surgical outcomes(Table I).

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