Chapter 4.11: The Running Buried Dermal Suture

This is a hybrid technique, combining the tension relief and lack of transepidermal suture placement of a classic buried suture with the rapidity of placement and lack of resilience of a superficial running technique. This is a niche approach, since the running nature of the technique means that compromise at any point in the course of suture placement may result in wound dehiscence. Therefore, unless absolutely necessary, this approach should not be utilized as a solitary technique for the closure of most wounds.

Suture choice is dependent in large part on location, though as always the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 3-0 suture material is effective, though if there is marked tension across the wound this approach would not be appropriate as the primary closure, and would be used best for its pulley benefits. On the extremities, a 3-0 or 4-0 absorbable suture material may be used, and on the face and areas under minimal tension a 5-0 absorbable suture is adequate.

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. This first anchoring suture is then tied with an instrument tie.

7. The procedure is then repeated sequentially, repeating steps (2) through (5) in sets while moving proximally toward the surgeon for as many throws as are desired, without placing any additional knots until the desired number of loops have been placed.

8. The suture material is then tied utilizing an instrument tie (Figures 4-11A, 4-11B, 4-11C, 4-11D, 4-11E, 4-11F). The final anchoring knot is tied by leaving a loop on the penultimate throw, and tying the free end of suture material from the final throw to this loop. The ends of the suture are then trimmed.

This technique may be used as a modified winch or pulley suture, since the multiple loops help minimize the tension across any one loop and permit closure of wounds under marked tension. Because each throw is not tied off, however, it is important to adequately secure the first and final throws with a well-locked knot.

Given the theoretical susceptibility to suture material breakage or compromise, this is a technique that is probably best used in a layered fashion, either superficial to previously placed deep interrupted buried sutures, or deep to a set of more superficially placed buried sutures.

If braided absorbable suture is used, the added friction between loops may help lock the suture material in place with each throw, but caution should be taken to pull sufficient suture material with each throw, as this friction may impede the surgeon’s ability to pull suture material through the course of multiple loops. Similarly, if monofilament suture is used it may be easier to pull the additional suture material through but it may make it more difficult to lock the suture in place before tying.

It may be beneficial to place the running sutures closer together toward the center of the wound than at the poles of the incision, as this may foster a more pronounced pulley effect at the center of the wound where the tensile forces are greatest.

Given the concern regarding knot breakage, it may be helpful to attempt to better secure the first and final knots at the ends of the running series of loops. This may be done by paying particularly close attention to knot tying, tying an extra full knot, adding extra throws, or leaving a longer tail than would traditionally be executed. An additional approach is to secure the final knot with the aid of a tacking knot, which may similarly provide extra security.

As noted previously, this approach should usually not be used as a solitary closure technique, since there is no redundancy in the closure. It may be useful as an adjunct when there is either minimal tension across a wound (and therefore interrupted buried sutures may be unnecessary) or as a pulley approach to bring recalcitrant wound edges together.

Like the standard buried dermal suture, this approach provides less wound eversion than other approaches such as the set-back dermal or buried vertical mattress; therefore, a running variation of the latter two techniques may often be preferred to a buried running dermal approach, since wound eversion may be associated with improved cosmesis over the long term.