Pexing suture, ImPli, tacking suture

This is a niche technique designed to fix one or both edges of a defect to a deeper structure. This approach has also been referred to as a pexing suture or tacking suture, and is utilized typically in several situations. First, when repairing a defect that crosses a natural sulcus, it is important to tack down the skin overlying the sulcus so that the natural depression is not blunted, or bridged, by the repair. Second, it is used when working near cosmetic subunit boundaries and free margins, to avoid functional challenges such as ectropion and eclabium, as well as cosmetic distortion of sensitive areas such as the lip and eyebrows. It is also useful in order to fix a flap in place and minimize tension on the distal portion of the flap. Finally, this approach may also be used to prevent nasal valve collapse in the appropriate setting.

Suture choice is dependent in large part on location, though this technique is usually utilized on the face. While some authors have advocated for nonabsorbable clear monofilament suture to provide a lasting suspension effect, in general absorbable suture material is adequate and may mitigate some of the concerns related to leaving a nonabsorbable foreign body in place for an extended period of time. A 4-0 absorbable suture may often be utilized for this approach on the face. While utilizing smaller gauge absorbable suture material is reasonable, it may not provide sufficient tensile strength to adequately and reliably fix the tissue to the periosteum.

1. 
   

   The wound edge is reflected back using surgical forceps or hooks, and 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 2-6 mm distant from the incised wound edge.

   
   
3. 
   

   The first bite is executed by traversing the dermis following the curvature of the needle and allowing the needle to exit closer to the incised wound edge. This will minimize the risk of vascular compromise. Care should be taken to remain in the dermis to minimize the risk of epidermal dimpling. The needle does not, however, exit through the incised wound edge, but rather 1-4 mm distant from the incised edge, or, in select cases, potentially further back from the wound edge.

   
   
4. 
   

   The flap of skin may be gently pulled by the suture material so that the location of the first bite directly overlies the planned fixation point. This permits the surgeon to double-check the final position of the suspension suture. The needle is then blindly inserted through the fat and deeper structures until the bone is reached. A 3-mm bite of the periosteum is then taken, and the needle is brought back up through the soft tissues into the open center of the wound.

   
   
5. 
   

   The suture material is then tied utilizing an instrument tie. Hand tying may be utilized as well, which may be useful if the depth of the defect is significant (Figures 4-22A, 4-22B, 4-22C, 4-22D, 4-22E, 4-22F).