This technique is very useful when working around the eyelids and lips, though its use demands familiarity with the underling anatomy so that no sensitive deeper structures are injured or entrapped during the blind placement of the deep anchoring suture. The deep suture should also be placed parallel to the underlying vascular plexus to similarly mitigate this risk.
Placement is based on several considerations, including the degree of tension across the advanced tissue, the presence of a bony prominence, which can be used easily for suspension purposes, and the absence of underlying nerves, which could inadvertently become strangulated by the anchoring suture.
The first half of this suture technique, where the suture material is fixed to the underside of the dermis, may be conceptualized as a single throw of a set-back dermal suture. Depending on the location of the repair and the degree of suspension necessary, a single throw of this technique may be adequate. When reconstructing longer sulci, such as the mental sulcus, a series of spaced suspension sutures can be placed to assure that the natural crease is not bridged by the repair.
Pulling on the suture once it is anchored to the periosteum may help assure the surgeon that the suture is indeed tacked down to an immobile surface.
A central advantage of this technique is that it may permit the use of linear closures in areas where otherwise a flap would have been advisable to minimize free-margin distortion. Thus, for example, closures on the lower forehead or upper malar area may be closed in a linear fashion if the advancing skin (the superior and inferior portions of the repairs, respectively) is effectively tacked down.
A three-point variation of this approach is possible as well, which allows wound-edge approximation and a tacking effect to occur all with one suture placement. This is accomplished by first placing either a buried vertical mattress or set-back dermal suture at the two wound edges and then taking a bite of the underlying periosteum prior to tying the knot. The suture material thus fixes the wound edges together as well as to the underlying anchoring point. This approach, however, may result in suboptimal wound-edge eversion and places additional stress on the suture material, increasing the risk of scar spread. Moreover, it is only appropriate if the anchor target lies in the approximate midpoint of the defect, since it recreates a natural sulcus but does not permit differential pull from one side of the defect; therefore, this approach is of little utility when attempting to avoid cosmetic distortion of sensitive areas.
This technique may also be used as an alternative to cartilage grafting when reconstructing the nose. Loss of alar cartilage may lead to nasal valve collapse, which traditionally was addressed by placing an auricular cartilage graft along the reconstructed alar rim in order to maintain valve patency. A simple and elegant alternative is placing a suture in the ala and fixing it to a point superolaterally in the maxillary periosteum, permitting the nasal valve to remain open and obviating the need for a cartilage graft in many cases.
In select cases, a suspension suture may be used to fix a flap to fascia or other soft tissue structures, rather than periosteum, in order to secure its position and decrease the tension across superficial sutures at the time of final closure.