Chapter 4.27: The Corset Plication Suture

Running fascial plication suture

This technique is designed for wounds under marked tension, especially those on the back and shoulders, and can be conceptualized as a running variation of the fascial plication suture. Like fascial plication, it is a deep technique, permitting the tension of wound closure to shift from the dermis to the fascia, and concomitantly creating a lower-tension closure which is associated with less scar spread. In addition to tension reduction, this approach also leads to a modest 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. Since 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 monofilament absorbable suture may be used. As the running technique is predicated on pulling through multiple lengths of suture material, monofilament suture material should be utilized to minimize the coefficient of friction. Since suture material traverses the fascia, the incidence of suture abscess formation is vanishingly rare.

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. Starting at one pole of the ellipse, the suture needle is inserted at 90 degrees through the deep fat 2-4 mm medial to the undermined edge of the wound.

3. The first bite is executed by entering the fascia and following the curvature of the needle, allowing the needle to exit closer to the incised wound edge. 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 distal to the first bite, 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. Steps (2) through (4) are then repeated sequentially in pairs moving toward the contralateral pole of the wound.

6. Once the desired number of paired bites have been taken, the suture is then pulled tight and tied onto itself using either an instrument or hand tie (Figures 4-27A, 4-27B, 4-27C, 4-27D, 4-27E, 4-27F).

This technique can be conceptualized as a pulley version of a fascial plication suture. The multiple loops of suture material serve to exert a pulley effect, allowing even the tightest wound to be effectively brought together. Like the fascial plication approach, this technique is very useful for wounds under marked tension, especially for large defects on the back and shoulders.

As with the fascial plication suture, 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 sufficiently tapered ellipse.

As with the fascial plication suture, 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. Corset plication may serve to help minimize this dead space by pulling deeper structures centrally and thereby filling the potential space.

Since this is a running variation of the fascial plication technique, its efficacy is predicated on both suture material integrity and adequate knot security. The value of the entire row of corset sutures would be nullified by either breakage anywhere along the row of suture material or knot failure. Therefore, its proponents have suggested utilizing a 2-0 monofilament suture in order to mitigate the risk of suture breakage, since this material has significant tensile strength. That said, since this technique is exclusively used when wounds are under marked tension, suture material failure remains a risk. Additionally, adding an extra throw when tying the knots may help mitigate the risk of knot failure.

Another important drawback of this approach is the potential for increased postoperative pain when compared with utilizing dermal sutures alone, or even when compared with placing a single fascial plication suture. 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, particularly since this technique involves the placement of multiple throws of suture material through the fascia.

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.

While there is a theoretical risk of distortion of the ellipse caused by these running fascial sutures, this is not typically seen in practice. Because this approach entails multiple passes of suture material through the fascia, the risk of pain and infection are theoretically higher than with placing one or two interrupted fascial plication sutures. While this is balanced by the theoretical benefit of the pulley effect of this technique, this pulley effect is only rarely needed even in the largest wounds. Coupled with the chance that the entire line of sutures can be annulled by breakage anywhere in the suture material or a single knot failure, this approach probably should be used less frequently than the standard fascial plication technique.