Running fascial plication suture

This technique is designed for wounds under marked tension, especially those on the back and shoulders, and can be conceptualized as a running variation of the fascial plication suture. Like fascial plication, it is a deep technique, permitting the tension of wound closure to shift from the dermis to the fascia, and concomitantly creating a lower-tension closure which is associated with less scar spread. In addition to tension reduction, this approach also leads to a modest increase in the apparent length to width ratio of an excised ellipse and improved dead-space minimization.

Suture choice is dependent in large part on location. Since this technique is designed to bite the fascia, generally a larger-gauge suture can be utilized. Therefore, for the back and shoulders a 2-0 or 3-0 monofilament absorbable suture may be used. As the running technique is predicated on pulling through multiple lengths of suture material, monofilament suture material should be utilized to minimize the coefficient of friction. Since suture material traverses the fascia, the incidence of suture abscess formation is vanishingly rare.

1. 
   

   The wound edges are reflected back to permit visualization of the deep bed of the wound. In deep excisions, such as those performed for melanoma or large cysts, the muscle fascia may be directly visible. Otherwise, visualizing the subcutaneous fat is appropriate as well.

   
   
2. 
   

   Starting at one pole of the ellipse, the suture needle is inserted at 90 degrees through the deep fat 2-4 mm medial to the undermined edge of the wound.

   
   
3. 
   

   The first bite is executed by entering the fascia and following the curvature of the needle, allowing the needle to exit closer to the incised wound edge. The suture material may be gently pulled to test that a successful bite of fascia has been taken.

   
   
4. 
   

   Keeping the loose end of suture distal to the first bite, attention is then shifted to the opposite side of the wound. The second bite is executed by repeating the procedure on the contralateral side.

   
   
5. 
   

   Steps (2) through (4) are then repeated sequentially in pairs moving toward the contralateral pole of the wound.

   
   
6. 
   

   Once the desired number of paired bites have been taken, the suture is then pulled tight and tied onto itself using either an instrument or hand tie (Figures 4-27A, 4-27B, 4-27C, 4-27D, 4-27E, 4-27F).