The percutaneous set-back dermal approach creates significant wound eversion, and the degree of eversion elicited by this approach may be more marked than that seen with the standard set-back dermal suture approach. This pronounced eversion may lead the epidermal portion of the wound edges to separate as the dermis is brought together, as the epidermal edges fail to drape together as they would normally do with the standard set-back dermal technique.
There are two possible approaches to this situation: (1) Superficial running or interrupted sutures may be placed to better approximate the epidermal edges, and (2) The defect could be removed with an inward bevel (as is done with the butterfly suture technique), or the dermis may be incised at an inward bevel after the original defect is created, permitting the epidermal edges to come together gently even in the face of the marked eversion seen with this approach. Many clinicians favor a bilayered approach in general, and therefore placing the epidermal sutures is an easy solution and does not require the degree of preplanning associated with the bevel approach, though a combination of the two solutions may be utilized as well.
Patients should be cautioned that they might develop a significant ridge in the immediate postoperative period. Depending on the suture material used and the density of the sutures, this ridge may last from weeks to months. Explaining that the technique is akin to placing a subcutaneous splint may help the patient develop reasonable and realistic expectations and reduce anxiety regarding the immediate postoperative appearance of the wound.
Epidermal dimpling will often occur with this approach, since the suture material traverses the epidermis. A small degree of dimpling will resolve with time as the absorbable sutures are gradually resorbed, and patients should be warned that this is a likely occurrence and that it is of no long-term clinical consequence.
Since suture material traverses the epidermis, there is a theoretically greater risk of infection with this technique than with approaches that remain entirely buried on the undersurface of the dermis. Meticulous attention to sterile technique may help mitigate this theoretical risk, and anecdotally infection is seen no more frequently with this approach than with any other closure technique.