Dermal buried pulley suture; modified buried dermal suture

This technique is best used in areas under very significant tension, and can be conceptualized as existing on the spectrum between single and double buried vertical mattress sutures. Wounds under marked tension may be challenging to close even with well-placed buried sutures. The half pulley buried dermal suture technique relies on the pulley effect of an additional single loop of suture to permit the closure of wounds under even significant tension. In addition, the effect of placing an extra bite of suture leads the suture material to lock in place after the first throw of the surgical knot, obviating the need for an assistant maintaining the alignment of the wound edges.

Suture choice is dependent in large part on location. Since some suture material traverses the papillary dermis and the incised wound edge, 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 theoretically the risk of suture spitting or suture abscess formation is greater with the thicker 2-0 suture material. This needs to be weighed against the benefit of utilizing a larger CP-2 needle, which will almost never bend even in the thickest dermis, and the benefit of adopting the 2-0 suture material, which is less likely to snap under tension or fail during tension bearing activities, leading to attendant dehiscence. On the extremities, 3-0 or 4-0 absorbable suture material may be used, and on the face and areas under minimal tension, though this technique would only rarely be used, a 5-0 absorbable suture is adequate.

Braided suture tends to lock more definitively than monofilament, though monofilament suture allows for easy pull through when taking advantage of the pulley effect.

1. 
   

   The wound edge is reflected back using surgical forceps or hooks. Adequate visualization of the underside of the dermis is desirable.

   
   
2. 
   

   While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 4 mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is executed by following the needle initially at 90 degrees to the underside of the dermis and then changing direction by twisting the needle driver so that the needle exits in the incised wound edge. This allows the apex of the bite to remain in the papillary dermis while the needle exits in the incised wound edge at the level of the reticular dermis.

   
   
4. 
   

   Keeping the loose end of suture between the surgeon and the patient, the dermis on the side of the first bite is released. The tissue on the opposite edge is then reflected back in a similar fashion as on the first side.

   
   
5. 
   

   The second bite is executed by inserting the needle into the incised wound edge at the level of the reticular dermis. It then angles upward and laterally so that the apex of the needle is at the level of the papillary dermis. This should mirror the first bite taken on the contralateral side of the wound.

   
   
6. 
   

   Keeping the tail of the suture material between the surgeon and the first set of loops, the needle is then inserted into the undersurface of the dermis slightly further set-back from the wound edge than the first throw.

   
   
7. 
   

   The needle then exits in the deep reticular dermis, just deep to the exit point of the first loop of suture.

   
   
8. 
   

   With both ends of the suture material now exiting from the same side of the wound (generally the surgeon’s left), the suture material is then tied utilizing an instrument tie (Figures 4-19A, 4-19B, 4-19C, 4-19D, 4-19E, 4-19F).