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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.
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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.
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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.
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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.
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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.
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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.