Double buried dermal suture

Wounds under marked tension may be challenging to close even with well-placed buried sutures. The pulley buried dermal suture technique relies on the pulley effect of multiple loops of suture to permit the closure of wounds under even significant tension. In addition, the locking effect of placing a double loop 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. Because this technique leaves significant residual suture material both between the incised wound edges and in the superficial dermis from both loops, care should be taken to minimize the liberal use of larger-gauge suture material. On the face, while this approach is only infrequently utilized, a 5-0 absorbable suture is appropriate, and on the distal extremities a 4-0 suture is generally adequate. Using this technique, a 3-0 absorbable suture works well on the back, though when the area is under marked tension a 2-0 suture may be needed as well. 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.

   
   
2. 
   

   While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 2 mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is executed 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.

   
   
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 gently grasped with the forceps.

   
   
5. 
   

   The second bite is executed by inserting the needle into the incised wound edge 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 that could result in epidermal dimpling. It then exits approximately 2 mm distal to the wound edge on the undersurface of the dermis. This should mirror the first bite taken on the contralateral side of the wound.

   
   
6. 
   

   Steps (1) through (5) are then repeated, after moving proximally toward the surgeon, with the tail of the suture material resting deep to the loops of suture.

   
   
7. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-16A, 4-16B, 4-16C, 4-16D, 4-16E, 4-16F, 4-16G, 4-16H, 4-16I, 4-16J).