part II

1. Surgical technique for optimal outcomes
Part II. Repairing tissue: Suturing
Christopher J. Miller, MD,a
Marcelo B. Antunes, MD,b
and Joseph F. Sobanko, MDa
Philadelphia, Pennsylvania, and Austin, Texas
Sound surgical technique is necessary to achieve excellent surgical outcomes. Despite the fact that
dermatologists perform more office-based cutaneous surgery than any other specialty, few dermatologists
have opportunities for practical instruction to improve surgical technique after residency and fellowship.
This 2-part continuing medical education article will address key principles of surgical technique at each
step of cutaneous reconstruction. Part II reviews the placement of deep and superficial sutures. Objective
quality control questions are proposed to provide a framework for self-assessment and continuous quality
improvement. ( J Am Acad Dermatol 2015;72:389-402.)
Key words: excise; excision; incise; skin; surgery; suture; technique; undermine.
INTRODUCTION
Part I of this continuing medical education
article reviewed surgical techniques that involve
cutting tissue: incising, excising, and undermining.
Final inspection of the wound after completing
these cutting steps should reveal cleanly incised,
vertical wound edges, a wound base with a
uniform anatomic depth, and precisely under-
mined skin flaps. Careful hemostasis should mini-
mize bleeding. Strategies for effective hemostasis
have been reviewed elsewhere.1,2
Precise execu-
tion of these cutting steps prepares the wound for
accurate placement of buried and superficial
sutures.
REPAIRING TISSUE: PLACING BURIED
SUTURES
Key points
d The preferred caliber of the suture and size
of the needle depend on the anatomic loca-
tion, thickness of the skin, and tension of the
wound
d Suture sequence and surgeon positioning
influence the efficiency and execution of
subcutaneous sutures
d The proper placement of buried vertical
mattress sutures and atraumatic handling
of skin are critical steps that achieve optimal
surgical outcomes
Learning objectives
After completing this learning activity, participants should be able to describe common suturing errors that lead to unaesthetic scars and identify methods to gain hemostasis efficiently
and re-approximate skin in a layered fashion with proficiency.
Disclosures
Editors
The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with
commercial interest(s).
Authors
The authors involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).
Planners
The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved
with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).
From the Department of Dermatology,a
University of Pennsylva-
nia, Philadelphia, and Private Practice,b
Austin.
Video available at http://www.jaad.org.
Funding sources: None.
Conflicts of interest: None declared.
Accepted for publication August 1, 2014.
Correspondence to: Joseph F. Sobanko, MD, Edwin & Fannie Gray
Hall Center for Human Appearance, University of Pennsylvania,
3400 Civic Center Blvd, Rm 1-330S, Philadelphia, PA 19104.
E-mail: Joseph.Sobanko@uphs.upenn.edu.
0190-9622/$36.00
Ó 2014 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2014.08.006
Date of release: March 2015
Expiration date: March 2018
389

2. d The buried vertical mattress suture everts
the wound edges and allows for tension-free
approximation of the papillary dermis and
epidermis
d After the effective placement of buried
vertical mattress sutures, both wound edges
should be clearly visible and there should be
minimal bleeding from exposed dermis
The anatomic layers requiring suturing will vary
by site, depth, and wound complexity.3
This article
will focus on the most common wounds in
cutaneous surgery: wounds that extend through the
epidermis, dermis, and subcutaneous fat. Buried
or subcutaneous sutures eliminate dead space,
approximate the dermis and epidermis, and provide
strength to the wound as the scar matures. The
buried vertical mattress suture is the workhorse for
deep sutures and will be the primary technique
discussed herein.4
It creates the same heart-shaped
loop as a superficial vertical mattress suture, except
that the knot lies at the bottom of the loop (Fig 1).
Numerous other techniques for buried sutures may
also accomplish the accurate approximation of
wound edges; however, a comprehensive discussion
of these lies beyond the scope of this article.5
Judicious selection of the suture and needle, a
thoughtful plan for suture sequence, and positioning
relative to the wound are the first steps for effective
execution of the buried vertical mattress suture.
The material and caliber of the suture and the type
and size of the needle influence execution of the
buried vertical mattress suture. Previous articles and
educational resources provide a comprehensive
review of suture materials.5,6
In most cases, a
dissolving rather than a permanent suture is ideal
for buried sutures. Slowly absorbing intradermal
sutures, such as polydioxanone, may decrease scar
spread in high tension wounds.7
Wound tension
determines the ideal size of the suture. High-tension
wounds (eg, those on the torso or proximal extrem-
ities) may require a 3-0 or 2-0 suture. In moderate
tension wounds, a 4-0 suture may provide sufficient
strength. For wounds under minimal tension, a 5-0
suture will usually suffice. In general, using the
smallest caliber suture that provides sufficient tensile
strength is desirable to minimize the amount of
suture material in the wound. The type and size of
the suture needle strongly influence execution of
deep sutures. Most surgeons prefer to place deep
sutures with a reverse cutting needle. The choice of
needle size depends primarily on the thickness of the
dermis; in anatomic areas with a thin dermis, a
smaller needle is required, such as a 3/8 arc P-3
needle. Anatomic areas with a thicker dermis require
a larger needle, such as a 3/8 arc PS-2 needle.
In locations with thick skin, such as the back, a
half-circle reverse-cutting needle may facilitate
placement of the buried vertical mattress suture.
Using a large needle in anatomic areas with a thin
dermis will risk tearing the skin. Using a small needle
in anatomic areas with a thick dermis frequently
leads to bent needles as the surgeon struggles to
rotate the needle far enough to retrieve the tip.
Suture sequence influences operative efficiency
and execution. Placing deep sutures is more
challenging in areas of high versus low tension.8
The strategy of placing the first sutures in the area
of highest tension then moving to areas of
progressively lower tension has its advantages.
First, access and visibility to the areas of greatest
tension are easiest before most of the wound has
been closed. The alternative strategy of placing the
Fig 1. The superficial (A) and buried vertical mattress (B) sutures each have heart-shaped
loops, but the knot is at the bottom of the loop for the buried suture.
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3. initial sutures at the areas of lowest tension may leave
a smaller space to throw the sutures in the areas of
greatest tension, which often results in bent needles,
difficulty retrieving the tip of the needle from the
center of the wound, an inability to access the
deepest anatomic layers of the wound, and increased
trauma and tearing of the skin. A second advantage
of placing the initial sutures in the areas of greatest
tension is that it provides time for tissue creep,
if complete closure with the initial suture is not
possible.9,10
The first deep suture should be cinched
as much as the tension of the wound edges will
allow. When complete apposition is not possible
initially, the surgeon can continue suturing in areas
with less tension. By the time the areas with less
tension have been sutured, tissue creep may allow
the surgeon to return and completely close the area
with greatest tension. In many instances, the surgeon
may first suture areas of the wound with less tension.
Whatever the suture sequence, the surgeon will
benefit from leaving sufficient space and easy access
for accurate and efficient placement of sutures in the
most critical, high-tension areas.
The position of the surgeon relative to the wound
also influences the efficiency and execution of
buried sutures. In general, it is easier to throw a
buried suture when the dominant hand lies on the
side of the wound where the skin is looser. When
loaded into the needle driver, the shank of the suture
needle (ie, the portion closest to the suture) usually
points to the dominant, throwing hand of the
surgeon. In tight spaces, the shank of the needle
can impede the execution of deep sutures. If the
surgeon positions him or herself so that the shank of
the needle and dominant hand are on the same side
as the looser wound edges, the surgeon can retract
the loose skin to allow easier passage of the needle.
Countertraction to evert the skin edge with either
the forceps or skin hook is essential for efficient and
accurate execution of the buried vertical mattress
suture. The skin hook has the advantage of allowing
retraction close to the epidermis with minimal to no
trauma, but it requires frequent manipulation of a
sharp instrument.11
Some surgeons prefer to work
with a double- rather than single-pronged skin hook
in order to reduce the risk of sharps injury and still
maintain the benefit of atraumatic tissue handling. By
contrast, forceps have a higher risk of trauma to the
patient’s skin but allow less exposure to sharps. Both
instruments can be used effectively, and the surgeon
must learn to balance safety with atraumatic
handling of the skin. Countertraction should occur
as close to the epidermis as possible, in order to evert
the skin edge and to maximize visibility of the dermis
(Fig 2, A). If the instrument is placed too deeply, it
compresses the dermis and orients the skin edge in
an inverted position (Fig 2, B). Compression of the
dermis reduces the size of the target for the deep
suture, and the deep suture tends to fix the skin in an
inverted position (Fig 3).
‘‘Eversion’’ is defined as upward sloping skin
edges that meet perfectly at the peak without any
plateau or inversion. The buried vertical mattress
suture facilitates eversion, which helps to counteract
the contractile forces during wound healing, resists
inversion of the scar, and transfers tension to the
reticular dermis so that the papillary dermis and
epidermis meet with minimal to no tension.12
The
buried vertical mattress suture has a heart-shaped
loop with 2 peaks at the level of the mid dermis or
deep papillary dermis and a valley at the level of the
deep reticular dermis (Fig 1). As the difference in
depth between the peaks and valley of the suture
path increases, the degree of eversion will increase.
Fig 2. Countertraction with either forceps or a skin hook exposes the dermis for placement of
the deep sutures. A, Ideal placement of the retracting instrument in the papillary dermis
maximizes visibility of the dermis and orients the skin in an everted position. B, Suboptimal
placement of the retracting instrument in the reticular dermis compresses the dermis, which
minimizes visibility and orients the skin in an inverted position.
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4. To initiate a buried vertical mattress suture, the
needle is passed starting from the base of the
wound to the desired location of the peak of
the heart-shaped loop. Once the tip of the needle
reaches its peak at the mid dermis or papillary
dermis, the needle is rotated toward the incised
wound edge. During this maneuver, the wound
edge must be retracted aggressively in an everted
position. This will ensure that the tip of the needle
will reach the incised wound edge at a greater
depth, usually in the reticular dermis. When the
peaks lie closer to the underside of the epidermis
than the valley of the heart-shaped loop, the
epidermis and papillary dermis of the incised
wound edge naturally snap back toward the center
of the wound upon release of the retracting forceps
or skin hook (Fig 4). If the ‘‘snap’’ does not occur,
then there is a high likelihood of a gap between the
wound edges. The needle is then passed in the
opposite side of the wound to create a mirror image
of the first side (Fig 5). The needle enters the wound
in the deep reticular dermis and must aim to create a
peak of the heart-shaped loop in the more superfi-
cial dermis. Extending the wrist will aim the needle
upward. Once the tip of the needle reaches the
peak, the needle is rotated toward the base of the
wound. Retracting the skin edge in an everted
position with the skin hook or forceps naturally
facilitates the proper suture path. When the suture
paths on each side are not mirror images, the wound
edges will not appose each other precisely.12
As a
rule, the side with the more superficial bite of suture
relative to the epidermis will have a wound edge
that is depressed compared to the other side (Fig 6).
Fig 4. The ‘‘snap’’ of the wound edge toward the center of the wound after the first bite of the
suture indicates a good path of the buried vertical mattress suture. A, The first bite of the suture
has been completed and the skin hook still applies countertraction. B, The skin hook has been
released and the skin edge ‘‘snaps’’ back toward the center of the wound.
Fig 3. Schematic representation of the influence of countertraction on visibility of the dermis
and position of the skin edge. A, Placement of the retracting instrument in the papillary dermis
everts the wound edge and maximizes visibility of the dermis, providing a larger target for the
deep suture. B, Placement of the retracting instrument in the reticular dermis inverts the wound
edge and compresses the dermis, shrinking the target for the deep suture.
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5. The path of the buried vertical mattress suture will
vary based on the thickness of the dermis. In areas
with thicker dermis (eg, the back or proximal
extremities), the path of the suture must have a
greater difference in height between the peaks and
valley of the buried vertical mattress suture (Fig 7,
A). To achieve this greater difference, the surgeon
must take a wider bite (ie, further from the incised
wound edge) with the skin edge retracted aggres-
sively in an everted position. In practice, a wide bite
with the skin edge retracted aggressively feels like
the suture needle is passing parallel to the underside
of the epidermis for as long as possible. In areas
with thinner dermis (eg, eyelid and dorsal surfaces
of the hand and forearm), the ideal difference in
height between the peaks and valley of the buried
vertical mattress sutures is smaller (Fig 7, B). To
achieve this minimal difference, the surgeon must
take a narrow bite (ie, closer to the incised wound
edge) with the skin edge retracted in a less aggres-
sive everted position. In practice, a narrow bite with
a gently retracted everted edge feels like the suture
needle is passing parallel to the vertical face of the
incised skin edge. Another way to describe the
difference in the suture path for thick versus thin
dermis is to conceptualize the distance of the peaks
of the heart-shaped loop from the incised wound
edge. In thick dermis, the peaks of the heart-shaped
loop will lie further from the incised wound edge
and the path of the suture creates a broad based,
heart-shaped loop. In thin dermis, the peaks of the
heart shaped loop lie closer to the incised wound
edge and the path of the suture creates a narrow,
tall, heart-shaped loop.
The suture is now ready to be tied with the
knot buried at the depth of the undermined
plane. An effective instrument tie prevents an ‘‘air
knot’’ and ensures snug approximation of the
wound edges.13,14
The running end of the suture
(needle-end) is pulled so that only a few centimeters
of the trailing end remain exposed on the opposite
side of the wound. Each end of the suture should lie
on the same side of the loop of the buried vertical
mattress suture. The ends of the suture will form a
V that points to the center of the wound, and the
needle holder will remain between both arms of the
V during knot tying. With the nondominant hand,
wrap the needle end of the suture once or twice
around the needle holder toward the opposite side
of the wound. Grasp the trailing end of the suture
with the needle holder and pull it parallel to the long
axis of the wound toward the same side that the
suture ends initially lay relative to the loop of the
buried vertical mattress suture (video available
online at www.jaad.org).15
Bring the needle holder
back to center. To cinch the suture with a slip knot,
throw another loop around the needle holder and
pull the suture in the same direction as the first
throw. To lock the knot, throw another loop with the
needle holder and pull the hands in the opposite
direction. The number of throws made by the
surgeon will be influenced by the knot security of
the suture and the tension on the wound.
To ensure an adequate number of buried sutures,
the surgeon can apply the ‘‘pull test.’’ By pulling the
wound edges away from each other, the surgeon
identifies gaps that would benefit from additional
buried dermal sutures. The buried sutures should
support the dermis along the entire wound and still
allow easy manipulation of the epidermal edges
(Fig 8). If the buried sutures have been placed at an
ideal depth, the surgeon can use the skin hook or
forceps to retract the epidermis and papillary dermis
immediately above the buried sutures. If the wound
edges are firmly fixed above the buried suture, then
it may have been placed too superficially.
Two quality control questions allow objective
assessment of buried suture technique. First, is blood
visible between the edges? Assuming effective
hemostasis in the deep aspects of the wound, visible
blood between the wound edges arises when the
papillary dermis is either poorly approximated or
frankly exposed. Second, are both wound edges
clearly visible? If both wound edges are not clearly
visible, then 1 edge is riding over the other like a
shingle on a roof. Accurately placed buried vertical
mattress sutures approximate the wound edges so
Fig 5. To achieve perfect apposition of the wound edges,
each side of the completed buried vertical mattress suture
should be a mirror image.
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6. precisely that bleeding between the wound edges is
minimal and both wound edges are clearly visible.
These 2 quality control questions help to identify
several technical problems, which are addressed in
the troubleshooting section, but first we will examine
in detail 3 common suboptimal suture paths.
The first quality control question helps to identify
2 buried suture paths that fail to approximate the
wound edges and result in bleeding from the
exposed dermis. One common inefficient buried
suture has a circular path, which results in flat
(ie, noneverted) wound edges, with a gap between
the epidermis and papillary dermis. This result
occurs most frequently in areas with thick dermis
and/or in wounds with excessive tension. A circular
path of the buried suture creates splayed wound
edges with minimal to no eversion and lack the
dimple often seen with a heart-shaped buried
vertical mattress suture (Fig 9, A). The circular suture
path occurs most commonly as a result of either too
narrow a bite of the buried suture or failure to retract
the skin edge in an everted position during the throw
of the suture. A buried suture with a circular path will
approximate the dermis only up to the most
superficial point of the loop (Fig 9, B). Superficial
to the loop, the wound edges splay away from each
other. Troubleshooting requires removal of the initial
deep sutures and replacement with buried vertical
mattress sutures that have a wider bite and bigger
difference between the distance of the peaks and
Fig 6. When the paths of the suture on each wound edge are not mirror images, a discrepancy
in the height of the wound edges results. A, The exit point of the suture on the left side of the
wound is in the reticular dermis, but the needle is entering in the papillary dermis on the right
side of the wound. B, The right side of the wound has been pulled down by the superficial bite.
The exposed dermis on the high side frequently bleeds.
Fig 7. The path of the buried vertical mattress suture varies depending on the thickness of the
dermis. A, Thicker dermis requires a wider bite that extends further from the incised wound
edge and has a greater difference in height between the peak and valley of the heart-shaped
loop. B, Thinner dermis requires a narrower bite with a smaller difference in height between
the peak and valley and of the heart-shaped loop.
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7. valley from the underside of the epidermis. The
hallmark of this correction will be the characteristic
‘‘snap’’ of the wound edges toward each other and
possibly a dimple of the epidermis over the peaks of
the heart-shaped loop. Failure to correct this
problem will result in inverted scars and undue
tension on the cuticular sutures, increasing the risk
for track marks (Fig 9, C).
A second pattern of buried suture that predictably
results in visible blood between the wound edges is a
buried vertical mattress suture that is placed too
deeply. The consequent degree of eversion can be so
great that approximation of the epidermal edges
is not possible. Again, this result occurs most
frequently in areas with thick dermis. In this extreme
scenario, the undersides of the dermis are effectively
sewn together and the epidermal edges cannot reach
each other (Fig 10, A). The cause of this phenome-
non is an excessively wide and deep bite of the
buried vertical mattress suture (ie, a broad heart-
shaped loop), which results in a prominent dimple
far from the wound edge and excessive eversion (Fig
10, B). The correction for this phenomenon is usually
replacement of the deep sutures with buried vertical
mattress sutures that have a more narrow and
superficial bite. Once again, the hallmark of this
correction will be the characteristic ‘‘snap’’ of the
wound edges toward each other. However, if the
exposed dermis is minimal, it may be possible to trim
the splayed dermis and approximate the edges
without replacing the buried sutures. Failure to
correct this issue before placing cutaneous sutures
will result in a broad scar (Fig 10, C).
The second quality control question (ie, are both
wound edges clearly visible?) identifies a suture
path that occurs most commonly in skin with thin
dermis. To avoid tearing of thin dermis, it is often
necessary to throw the buried vertical mattress
suture with a wide bite that places the peak of the
heart-shaped loop too far from the wound edge (ie,
the heart-shaped loop is too broad). The thin dermis
cannot support an upward slope to its peak, and the
everted skin plateaus or inverts when the dermis
collapses (Fig 11, A). This eversioneinversion
Fig 8. The ‘‘pull test’’ identifies wound edges that will benefit from a dermal suture. A, Pulling
the wound edges identifies a gap remaining on the right side of the wound. B, After placement
of another deep suture on the right side, the pull test no longer creates a gap, indicating that a
sufficient number of deep sutures have been placed.
Fig 9. A, After placement of the deep sutures in a location with thick dermis, a gap persists
between the wound edges. Note the absence of eversion. B, Narrow suture bites and a circular
path results in a gap after the deep sutures. The wound edges with this suture path do not snap
toward the center of the wound. C, Typical appearance of a wound 1 week postoperatively
after closure with this type of deep suture. The scar is already inverted and excessive tension
from the top sutures has caused intense inflammation and early track marks.
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8. phenomenon creates redundant skin edges that
tend to slide over and obscure visibility of the
opposite side. At 1 week of follow-up, wounds
with this phenomenon will have inversion and
uneven wound edges (Fig 11, C). There are 2
potential options for troubleshooting. First, the
surgeon can remove the initial sutures and replace
them with more narrow bites. Second, the surgeon
can trim the wound edges where the eversion
transitions to inversion (Fig 12). In thin skin, this
phenomenon is often inevitable, and the latter
method of troubleshooting is necessary. Repeat
sutures will often result with the same problem.
Goal of deep sutures
The goal of the buried vertical mattress sutures is
to transfer tension to the reticular dermis and
evert the wound edges to allow for precise and
tension-free approximation of the papillary dermis
and epidermis.
Quality control checkpoints for placement of
deep sutures
1. Is there blood between the wound edges?
a. Troubleshooting #1—A gap between the
wound edges may result from excessive
tension that prevents complete approximation.
Tension may prevent immediate approxima-
tion, and the exposed wound edges may bleed.
b. Troubleshooting #2—A gap between wound
edges may result from failure to cinch the
buried knot. Eliminate air knots with snug but
not strangulating buried sutures.
c. Troubleshooting #3—An insufficient number
of deep sutures will result in weak approxi-
mation of the dermis and potential bleeding.
Apply the ‘‘pull test’’ to the wound. If lateral
traction pulls the wound edges away and
reveals a prominent gap, additional buried
sutures may be necessary (Fig 8).
d. Troubleshooting #4—A circular path of the
buried suture results in bleeding from
exposed dermis superficial to the suture
loop. A circular suture path is identified by
splayed wound edges with minimal to no
eversion and by the lack of the dimple often
seen with a heart-shaped buried vertical
mattress suture (Fig 9, A). The circular suture
path occurs most commonly as a result of
either too narrow a bite of the buried suture
or failure to retract the skin edge in an everted
position during the throw of the suture.
Because of the lack of eversion, the skin
edges fail the ‘‘snap test.’’ Troubleshooting
requires removal of the initial deep sutures
Fig 10. A, Appearance of a wound after deep sutures that caused eversion and inversion. The
weak dermis could not support the upward slope of the wound edges, which collapsed and
inverted. B, Everted wound edges that collapse and invert because the dermis cannot support
the upward slope to a peak. The wound edge on the right rides over the left side like shingles
on a roof. C, Two-week postoperative appearance of a wound that was sutured with collapse
of eversion. The lower wound edge remains fixed over the upper wound edge, especially on
the left half of the wound.
Fig 11. A, Excessive wound eversion has resulted in a persistent gap between the epidermal
edges after placement of the deep sutures. B, A suture path with an excessively wide bite nearly
sutures the undersurfaces of the dermis together. C, Long-term result with scar spread,
hypertrophy, and suture marks from excessive tension of the top sutures.
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9. and replacement with buried vertical mattress
sutures that have a wider bite and wound
edges that snap toward each other.
e. Troubleshooting #5—A buried vertical mat-
tress suture that is placed too widely and
deeply can effectively sew the undersides of
the dermis together, resulting in exposed
dermis that bleeds. The hallmark of this
suture path is a prominent dimple far from
the wound edge and excessive eversion
(Fig 10, A). Because of the bulk of the splayed
dermis, the wound edges fail the ‘‘snap test.’’
The correction for this phenomenon is usually
replacement of the deep sutures with buried
vertical mattress sutures that have a more
narrow and superficial bite and wound edges
that snap toward each other. However, if the
exposed dermis is minimal, it may be possible
to trim the splayed dermis and approximate
the edges without replacing the buried
sutures.
f. Troubleshooting #6—Failure to throw the
buried vertical mattress sutures with mirror
images on both sides may result in bleeding of
the exposed dermis on the elevated wound
edge (Fig 6). The side with the deeper bite (ie,
deeper relative to the epidermal edge) will
ride higher than the side with the more
superficial bite and the exposed dermis will
bleed readily. Correction requires replacing
the deep suture more accurately, trimming the
high side to match the low side, or placing
cuticular sutures to align the edges more
precisely.
2. Are both wound edges clearly visible?
a. Troubleshooting #1—One side of the wound
may slide over the opposite side like shingles
on a roof when the bites of the deep suture
are not mirror images. The side with the more
superficial bite (ie, closer to the epidermis)
may slide under the edge of the opposing
side. Troubleshooting may include either
replacing the deep sutures more accurately
or by trimming the high side to match the low
side.
b. Troubleshooting #2—Buried vertical mattress
sutures with wide bites in weak dermis may
create an upward slope that plateaus or inverts
before reaching the wound edge (Fig 10).
This eversioneinversion phenomenon creates
redundant skin edges that tend to slide over
and obscure visibility of the opposite side.
There are 2 potential options for trouble-
shooting. First, the surgeon can remove the
initial sutures and replace them with more
narrow bites. Second, the surgeon can trim
the wound edges where the eversion transi-
tions to inversion (Fig 12).
REPAIRING TISSUE: PLACING
SUPERFICIAL SUTURES
Key points
d Superficial sutures correct minor height
discrepancies of the wound edges after
placement of the buried sutures
d Ideally, cuticular sutures bear minimal to no
tension
d Skin with thin dermis requires a higher
frequency of sutures (ie, sutures placed
closer together) and suture bites that are
closer to the wound edge
Even with careful technique with deep sutures,
the wound edges frequently benefit from an
additional layer of superficial sutures for precise
approximation of the epidermal edges. If the deep
sutures have been placed effectively, the epidermis
and dermis should not have a gap between them
and the top sutures should not need to bear
tension. However, minor height discrepancies after
placement of the deep sutures are common. The
Fig 12. Correction of wound edges with eversion and inversion phenomenon. A, Identify the
point of collapse where the wound edge begins to invert. B, Trim the excess skin beyond
the point of collapse. C, The newly trimmed wound edges will snap toward the center of the
wound to allow tension-free approximation.
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10. primary purpose of the superficial sutures is to
correct these height discrepancies. The 2 quality
control questions after placement of the deep sutures
identify wound edges that will benefit from top
sutures. If both wound edges are not clearly visible
or if there is bleeding from the exposed dermis,
then fine corrections with the top sutures will be
necessary.
The type and size of the suture and the size of
the needle influence execution of the top sutures. A
few general principles apply. First, smaller caliber
sutures have a lower risk of leaving track marks
compared to thicker caliber sutures. The effective
placement of buried vertical mattress sutures nearly
eliminates tension on the wound edges and allows
the surgeon to use lower caliber sutures. Second,
smaller suture needles (eg, P-3) should be used to
suture delicate wound edges to avoid tearing.
Finally, sutures should be removed as early as
possible to avoid track marks. In wounds with
effective placement of deep sutures, the top sutures
do not bear tension and can be removed within 5 to
7 days in most cases, especially on the head and
neck. Leaving superficial sutures for a longer time
offers little advantage, because the deep sutures
bear the tension that keeps the wound from
dehiscing.16,17
Once the surgeon has chosen the suture materials,
the key decisions that the surgeon must make are the
spacing between the epidermal sutures and the
distance of the suture bites from the wound edge.
In general, skin with a thinner dermis requires a
higher frequency of sutures (ie, sutures placed closer
together) and suture bites that are closer to the
wound edge. The ideal distance from the wound
edge supports eversion to a peak without collapse. If
the bite of the superficial suture is too far from
the wound edge, it can create the same eversione
inversion phenomenon as seen with an excessively
wide bite with a deep suture.
Fig 13. A, The buried vertical mattress suture has been placed with unequal bites, resulting in a
height discrepancy of the wound edges. B, To correct the height discrepancy with top sutures,
it is often easiest to bite the high side first with a shallow, narrow throw. C, After biting the high
side, the wound edge can be depressed to match the lower side, and a deeper, wider bite is
thrown on the low side. D, The completed top suture corrects the height discrepancy.
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11. Table I. Review of checkpoints and methods of error correction
Surgical technique Quality control checkpoint Technical error Correction of errors
Incising 1. Has the incision achieved uniform release to the
desired anatomic plane?
Incomplete incision, or skin edges not
released
Complete the incision to the desired depth to get
uniform release
Incision extends more deeply than the
intended depth of excision and
undermining
Ensure that the subsequent steps of excision and
undermining occur in the more superficial, correct
anatomic plane
2. Do the incised wound edges have a sharp
perpendicular edge and no bevel?
Beveled dermis a. Ensure that the angle of the scalpel is
perpendicular to the plane of the skin during
the incision
b. Stabilize the skin during the incision with
downward pressure rather than lateral traction
c. Consider using a no. 10 scalpel blade for
anatomic locations with thick dermis
d. Correct the bevel by gripping the redundant
tissue with a forceps, apply gentle traction into
the wound, and incise through the beveled
dermis to create a clean and perpendicular edge
Beveled subcutaneous fat Use tissue scissors to trim the fat flush with the
vertical face of the incised dermis
3. Are the wound edges cut cleanly without jagged
edges?
Jagged wound edges a. Use a sharp scalpel and pass it lightly over the
skin, allowing [1 pass to achieve desired depth,
if necessary
b. Stabilize the skin with gentle downward pressure
while incising
Excising 1. Is the excision effortless with minimal bleeding? Excision is difficult or causes excessive
bleeding
Evaluate the surgical plane and redirect excision to
optimal plane as necessary
2. Does the excision specimen have a uniform
thickness without scalloped edges of its base?
Excision specimen has uneven
thickness
Assess base of wound to identify transitions of
surgical planes. Consider using scissors, rather
than a scalpel, in order to gain the tactile
feedback that helps to maintain a uniform
anatomic plane
The base of the excision specimen has
scalloped edges
Consider using scissors, rather than a scalpel, in
order to gain the tactile feedback that helps to
maintain a uniform anatomic plane during the
excision
3. Does the base of the wound have a uniform
depth at the desired anatomic plane?
The base of the wound is too shallow Excise the remaining superficial tissue to the desired
anatomic plane
The base is deeper than the intended
surgical plane
Be careful that undermining occurs in the more
superficial, preferred anatomic plane
Continued
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12. Table I. Cont’d
Surgical technique Quality control checkpoint Technical error Correction of errors
Undermining 1. Does undermining occur effortlessly and with
minimal bleeding?
Undermining is difficult or causes
excessive bleeding
Evaluate the surgical plane and redirect excision to
optimal plane as necessary
Undermining is difficult because of
poor stabilization of the skin edge
Apply countertraction with the skin hook directly
over the point of undermining
2. Can the incised skin edge be retracted in an
everted position?
The incised wound edge cannot be
retracted in an everted position
Undermine effectively to allow easy eversion of the
skin edge
3. Are the wound edges sharply perpendicular
along the full thickness of the skin flap from
epidermis to the plane of undermining?
The wound edges are not perpendicular
because of beveled dermis or fat
If the wound edges are not perpendicular after
undermining, identify and correct any bevel of the
dermis or fat
Placing deep
sutures
1. Is there blood between the wound edges? Blood is visible between the wound
edges
a. Excessive tension may prevent complete wound
edge approximation
b. Eliminate air knots with cinched but not
strangulating buried sutures
c. Ensure an adequate number of deep sutures
to close all gaps. If a circular path of a buried
suture is identified, remove the initial deep
sutures and replace with buried vertical mattress
sutures that have a wider bite and wound edges
that snap toward each other
d. If the papillary dermis is splayed from deep
sutures with excessively wide bites, replace the
deep sutures with buried vertical mattress
sutures that have a more narrow and superficial
bite. If the exposed dermis is minimal, it may be
possible to trim the splayed dermis and
approximate the edges without replacing the
buried sutures
e. If profile of the buried sutures does not have a
mirror image and 1 dermal edge rides higher,
replace the deep suture more accurately, trim the
high side to match the low side, or place cuticular
sutures to align the edges more precisely
2. Are both wound edges clearly visible? One wound edge overlaps and
obscures the other
a. One side of the wound overlaps the other if the
bites of the deep suture are thrown at different
depths. If the difference is marked, replace the
buried suture with symmetrical bites. If the
difference is minimal, consider trimming the high
side to match the lower side
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13. The top sutures should be thrown with minimal
tension. Excessive tension may cause pleating of the
wound edges and increases the risk for wound
necrosis and suture marks. As a quality control
measure, the surgeon should be able to slide 1 arm
of the forceps under the suture loop without diffi-
culty. If the top sutures are thrown with tension, a gap
will form at the points of entry and exit. The process
of reepithelialization begins immediately,16,18
so
track marks are likely to occur, even if the top sutures
are removed before 1 week postsurgery.
The first step in placing accurate top sutures is to
recognize which side of the wound is riding higher
than the other. The high side either obscures
visibility of the lower wound edge by sliding over
it like shingles on a roof or it bleeds because its
papillary dermis is exposed. The high side of the
wound is usually slightly more delicate and can be
more challenging to manipulate. It is often more
efficient to correct height discrepancies of the
wound edge by biting the high side first. The general
guideline to correct height discrepancies with top
sutures is: ‘‘Bite high on the high side, and bite low
on the low side.’’ In other words, the needle should
approach the high side with a shallow bite in the
papillary dermis (ie, close to parallel to the plane of
the epidermis) that is relatively close to the wound
edge. After showing the tip of the needle between
the wound edges, the surgeon has control of this side
of the wound. The surgeon must then depress the
wound edge until it matches the height of the
opposite side. The needle is then passed with a
deeper and wider bite that precisely matches the
wound edges (Fig 13). The principles to achieve
precise wound approximation apply to various
methods of placing superficial sutures.
Goal of superficial sutures
The goal of superficial sutures is to align the
papillary dermis and epidermis with precision.
Quality control checkpoints for the placement
of cuticular sutures
1. Is there blood between the wound edges?
a. Troubleshooting #1—When the bites of the
superficial sutures have asymmetric distances
from the wound edge, the side with the wider
bite tends to slide over the opposite side like
shingles on a roof, and the opposite edge may
not be visible. This exposed dermis on the
high side may bleed. Placing an interrupted
suture may be necessary to realign the wound
edges.
b.Redundantskinedgesoverlapifthebitesofthe
buriedsuturearetoowide.Ifthedifferenceis
marked,repeattheburiedsutureswithmore
narrowbites.Ifthedifferenceisminimal,
considertrimmingtheoverlappingwoundedges
Placingtopsutures1.Istherebloodbetweenthewoundedges?Bloodisstillpresentbetweenthewound
edges
a.Checkwhetherthebitesofthesutureare
asymmetricdistancesfromthewoundedge.
Placeaninterruptedsuturetorealignthewound
edgesprecisely
b.Checkforpleatingofthesuturefromexcessive
tension.Relievethetensionuntilpleating
diminishes.Checkforinsufficienttensionand
interruptedsuturestocloseanyremaininggaps
2.Arebothwoundedgesclearlyvisible?Onewoundedgeoverlapsandobscures
theother
a.Checkwhetherthebitesofthesutureare
asymmetricdistancesfromthewoundedge.
Placeaninterruptedsuturetorealignthewound
edges.precisely
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14. b. Troubleshooting #2—Excessive tension on
the superficial sutures, especially in skin
with a thin dermis, can lead to pleating of
the wound edges between the loops of
suture. Pleating often causes height dis-
crepancies, and the exposed dermis on the
high side may bleed. Replacing the cuticular
sutures with less tension will correct bleeding
from pleating. The sutures should be loose
enough to allow the surgeon to slide 1 arm of
the forceps under the loop without difficulty.
c. Troubleshooting #3—Insufficient tension of
the cuticular sutures can lead to small gaps
betweenthewoundedgesanddermalbleeding.
Cutaneous sutures should align the wound
edges snugly but without strangulation.
2. Are both wound edges clearly visible?
a. Troubleshooting—When the bites of the
cuticular sutures have asymmetric distances
from the wound edge, the side with the wider
bite tends to slide over the opposite side like a
shingle on a roof, and the opposite edge may
not be visible. Placing an interrupted suture
may be necessary to realign the wound edges.
CONCLUSION
This continuing medical education series
provided quality control questions to assess the
technical precision of each step of cutaneous
surgery: incising, excising, undermining, placing
buried sutures, and placing cuticular sutures. These
quality control questions provide a methodology for
objective self-evaluation and help to identify
common technical errors and potential solutions to
obtain reproducibly excellent surgical outcomes
(Table I).
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