G suture, continuous buried backstitch

This is a niche hybrid technique, combining the tension relief, eversion, and lack of transepidermal suture placement of a butterfly suture with the locking ability of a running locking suture and the rapidity of placement and lack of resilience of a superficial running technique. This approach is infrequently used, since the running nature of the technique means that compromise at any point in the course of suture placement may result in wound dehiscence.

Suture choice is dependent in large part on location, though as always the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 2-0 or 3-0 suture material is effective, though if there is marked tension across the wound this approach would not be appropriate as the primary closure, and would be used best for its pulley benefits. On the extremities, a 3-0 or 4-0 absorbable suture material may be used, and, while rarely utilized in these locations, on the face and areas under minimal tension a 5-0 absorbable suture is adequate. Braided absorbable suture has been advocated as ideal for this approach, as it helps lock each of the throws in place while still permitting sufficient slippage to take advantage of the pulley effect of the multiple throws.

1. 
   

   After incising the wound with an inward bevel, the wound edge is reflected back using surgical forceps or hooks.

   
   
2. 
   

   The suture is anchored to the undersurface of the dermis distal to the apex of the wound. This may be accomplished by taking a bite of dermis distal to the wound apex and tying off the suture material. A minimum of four throws is recommended to maximize knot security.

   
   
3. 
   

   While reflecting back the dermis on the left side of the wound, the suture needle, loaded in a backhand fashion, is inserted parallel to the skin surface into the base of the beveled undersurface of the dermis 2-mm distant from the incised wound edge.

   
   
4. 
   

   The needle is rotated through its arc, moving parallel to the skin surface toward the surgeon.

   
   
5. 
   

   The first bite is completed by following the curvature of the needle and allowing the needle to exit in the incised wound edge. The size of this bite is based on the size of the needle, the thickness of the dermis, and the need for and tolerance of eversion. The needle’s zenith with respect to the wound surface should be between the entry and exit points.

   
   
6. 
   

   Keeping the loose end of suture material distal to the preceding bite, the dermis on the side of the first bite is released. The tissue on the opposite edge is then gently grasped with the forceps.

   
   
7. 
   

   The second bite is executed by inserting the needle into the incised wound edge, parallel to the skin surface and again at the level of the superficial papillary dermis. This bite should be completed by following the curvature of the needle and avoiding catching the undersurface of the epidermis, which could result in epidermal dimpling. It then exits approximately 2 mm distal to the wound edge on the undersurface of the dermis, distal to its entry point.

   
   
8. 
   

   The procedure is then repeated sequentially, repeating steps (2) through (7) while moving proximally toward the surgeon for as many throws as are desired, without placing any additional knots until the desired number of loops have been placed. Each backstitch should overlap the preceding suture throw by approximately half of its radius.

   
   
9. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-37A, 4-37B, 4-37C, 4-37D, 4-37E, 4-37F, 4-37G, 4-37H).