Buried suture, subcuticular suture

This technique is best used in areas under moderate tension, and it remains the standard technique discussed in many plastic surgery textbooks. Its use in dermatologic and plastic surgery has, however, fallen somewhat out of favor as other techniques, such as the buried vertical mattress and set-back dermal suture, have become increasingly popular. This straightforward technique is generally reported as useful in a broad array of applications, and may be used in both facial and truncal skin, though it is particularly useful in areas where inversion is desired. This would include the nasolabial and melolabial folds as well as select areas along the antihelix and umbilicus, where restoration of anatomical inversion is desirable.

Suture choice is dependent in large part on location, though because this technique leaves residual suture material both between the incised wound edges and in the superficial dermis, care should be taken to minimize the liberal use of larger-gauge suture material. On the face and ears, a 5-0 absorbable suture may be used, 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. It may be advisable to eschew the use of 2-0 suture with this technique to minimize the risk of suture spitting.

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 and final bite is executed by inserting the needle into the contralateral 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, which 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 first side of the wound.

   
   
6. 
   

   The suture material is then tied utilizing an instrument tie (Figures 4-1A, 4-1B, 4-1C, 4-1D, 4-1E, 4-1F, 4-1G).