Chapter 4.26: The Fascial Plication Suture

This technique is designed for wounds under marked tension, especially those on the back and shoulders. It is a deep technique, permitting the tension of wound closure to shift from the dermis to the fascia, concomitantly creating a lower-tension closure which is associated with less scar spread. In addition to tension reduction, this approach also leads to an increase in the apparent length to width ratio of an excised ellipse and improved dead-space minimization.

Suture choice is dependent in large part on location. As this technique is designed to bite the fascia, generally a larger-gauge suture can be utilized. Therefore, for the back and shoulders a 2-0 or 3-0 absorbable suture may be used. Since suture material traverses the fascia, the incidence of suture abscess formation is vanishingly rare. If this technique is used on the scalp or forehead, a 4-0 absorbable suture may be used.

1. The wound edges are reflected back to permit visualization of the deep bed of the wound. In deep excisions, such as those performed for melanoma or large cysts, the muscle fascia may be directly visible. Otherwise, visualizing the subcutaneous fat is appropriate as well.

2. The suture needle is inserted at 90 degrees through the deep fat 2-4 mm medial to the lateral undermined edge of the wound.

3. The first bite is executed by entering the fascia and following the curvature of the needle. The suture material may be gently pulled to test that a successful bite of fascia has been taken.

4. Keeping the loose end of suture between the surgeon and the patient, attention is then shifted to the opposite side of the wound. The second bite is executed by repeating the procedure on the contralateral side.

5. The suture material is then tied utilizing an instrument tie. Hand tying may be utilized as well, particularly if the wound is deep and the instruments cannot be easily inserted to complete the tie (Figures 4-26A, 4-26B, 4-26C, 4-26D, 4-26E, 4-26F, 4-26G).

This technique is very useful for wounds under marked tension, especially for large defects on the back and shoulders. Even a deep, gaping wound can be converted into a manageable fusiform defect with a single well-placed fascial plication suture. It can therefore be conceptualized as an alternative to pulley sutures that affords both a decrease in tension across the wound surface (by shifting tension from the dermis to the fascia) and an increase in the length-to-width ratio of the ellipse.

Indeed, this approach often leads to a more fusiform defect, even when an oval-shaped excision has been performed. Therefore, it may be useful when attempting to keep a defect as short as possible without dog-ear formation. In cases where this approach is anticipated, it may be worthwhile to create a defect with a length-to-width ratio of less than 3 to 1, as is traditionally employed, as that may be sufficient to lead to a tapered ellipse.

A single fascial plication suture may be placed in the center of the wound. This balances the benefit of dead-space minimization and tension relief with the desire to minimize suture material piercing the muscle fascia which may be associated with increased postoperative pain and a theoretical increase in infection rate.

In large wounds under marked tension, a series of spaced fascial plication sutures may be placed as well. Except for the largest wounds, typically no more than three or four sutures are needed to effectively plicate the underlying fascia.

This technique is also useful when large space-occupying lesions, such as cysts or lipomas, have been extirpated. In these cases, placing dermal sutures alone results in significant residual dead space that may be associated with a higher risk of hematoma or seroma formation, as well as subsequent infection. Fascial plication may serve to help minimize this dead space by pulling deeper structures centrally and thereby filling the potential space.

The chief drawback of this approach is the potential for increased postoperative pain when compared with utilizing dermal sutures alone. While this is not a typical occurrence, depending on how deep the suture material traverses through fascia—and the underlying muscle—pain may sometimes be experienced that is out of proportion to the defect size and depth.

As with any postoperative pain caused by sutures traversing the muscle, it is generally self-limited. That said, it is always important to minimize the risk of any pain whatsoever and therefore this technique should not be employed unless there is significant tension that cannot be relieved with standard buried dermal techniques.

The lateral bites in the fascia should be taken no closer than 1-2 mm from the undermined edge of the tissue. Taking bites too far laterally, where there is no undermined plane between fascia and dermis, may result in dimpling at the lateral edges. This dimpling occurs when the bites of fascia are directly contiguous with the overlying dermis and epidermis, and the suture's lateral tension on the fascia also pulls on the dermis. While the dimpling may resolve with time, it is best avoided if possible.