Chapter 4.23: The Percutaneous Suspension Suture

Like the traditional suspension suture, this is a niche technique designed to fix the edge of a defect to a deeper structure, and may also be utilized typically in three situations: (1) When repairing a defect that crosses a natural sulcus, (2) 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, and (3) When fixing a flap in place to minimize tension on the distal portion of the flap.

Since the dermal component of the suture is percutaneous, however, it consistently results in immediate postoperative dimpling. The advocates of this technique have suggested that the dimpling resolves spontaneously over time, though unless the technique is truly necessary in order to be able to fix the tissue—which may be the case if it is challenging to insert the needle and needle driver through an undermined tunnel of skin—it would probably be preferable to perform a standard suspension suture in order to minimize the risk of long-term dimpling at the site of percutaneous suture placement.

Suture choice is dependent in large part on location, though this technique is usually utilized on the face. Since the suture is placed percutaneously, absorbable suture is preferred. A 4-0 or 5-0 absorbable suture may be used 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. Unlike the traditional suspension suture, visualization of the percutaneous tacking site on the mobile flap of skin is not necessary.

2. The suture needle is inserted at 90 degrees into the underside of the dermis at the point in the undermined flap where fixation to the underlying anchoring point is desired. The needle then pierces through the epidermis.

3. The first bite is completed by either reinserting the needle back through the epidermis with the twist of a wrist or by grasping the needle where it exits the epidermis and reintroducing it directly down through the epidermis so that it exits 2-4 mm away from the entry point.

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 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 4-23A, 4-23B, 4-23C, 4-23D, 4-23E, 4-23F).

This technique probably should be used only in cases where insertion of the needle through the undersurface of the dermis is not feasible. Thus, this approach is probably more useful in closing smaller defects in areas such as the forehead, where it may be challenging to insert the needle driver body through a small space, rather than in flaps where presumably a large amount of tissue has already been undermined.

As with the traditional suspension suture, this technique’s use demands familiarity with the underlying anatomy so that no sensitive deeper structures are injured or strangled 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 entrapped by the anchoring suture.

While a series of spaced percutaneous suspension sutures can be placed to assure that a natural crease is not bridged by a surgical repair, it may be best to minimize the number of sutures placed in order to mitigate the risk of pronounced persistent dimpling of the overlying skin.

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.

As with the traditional suspension suture, an 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 may be closed in a linear fashion if the advancing skin (the superior portion of the repair) is effectively tacked down, thus avoiding raising the ipsilateral eyebrow.

The percutaneous nature of this approach effectively guarantees an area of depression at the site of suspension suture placement. It is therefore important to utilize this approach exclusively in areas with adequate laxity, as poorly placed suspension sutures could theoretically result in an aggravated degree of distortion in cosmetically sensitive areas. Moreover, the presence of only minimal laxity increases the risk of subsequent dehiscence and ischemia. Therefore, this technique is best used in the event that placement of traditional suspension sutures is not feasible.

The anchoring portion of this suture technique carries the risk of damage to an underlying vascular or neural plexus. Familiarity with the underlying bony anatomy is therefore of paramount importance, as it also permits the surgeon to select the best location for suspension suture placement. As suture material is tacked to the periosteum—and traverses muscle and fascia—patients should be warned that they may experience more pain with this approach than would be experienced with a typical bilayered closure.