Chapter 4.9: The Percutaneous Set-Back Dermal Suture

Synonym

Percutaneous Kantor suture

Application

This technique is designed primarily for the closure of narrow wounds. In anatomic locations such as the scalp and lower leg, there is often insufficient laxity to permit the effective visualization of the undersurface of the undermined wound edge that would be ideal for the placement of set-back dermal sutures.

This technique could theoretically be utilized in other areas, though in practice the standard buried set-back dermal suture should probably be utilized if at all possible to effect better wound-edge approximation.

Suture Material Choice

On the scalp, a 3-0 or 4-0 absorbable suture is probably best, as it allows for robust closure in this area where tension is occasionally moderate to severe. On the lower legs, 3-0 or 4-0 absorbable suture material may be used as well, as this area is sometimes under marked tension. As always, utilizing the smallest gauge suture material that will permit adequate closure under tension is best.

Technique

1. If possible, the wound edge is reflected back using surgical forceps or hooks. Adequate visualization of the underside of the dermis is not required.

2. While gently grasping the skin edge, the suture needle is inserted at 90 degrees into the underside of the dermis 2-4 mm distant from the incised wound edge.

3. The first bite is executed by traversing the dermis and piercing directly up through the epidermis, with the needle exiting the epidermis 2-4 mm from the incised wound edge.

4. The needle is then reloaded on the needle driver in a backhand fashion and inserted at 90 degrees just medial to the exit point. The needle exits the undermined surface of the dermis into the undermined space between the undersurface of the dermis and the deeper subcutaneous tissue, medial to its entry point.

5. The needle is then reloaded, again in a backhand fashion, and inserted into the undersurface of the dermis on the contralateral wound edge, 2-4 mm distant from the incised wound edge. Depending on needle size and the breadth of the wound, this step may be combined with the prior step, saving the need to reload the needle. The needle should traverse the dermis and exit through the epidermis 2-4 mm distant from the incised wound edge.

6. The needle is then reloaded in a standard fashion and inserted in the epidermis just lateral to the exit point at 90 degrees, exiting the undersurface of the dermis in the undermined space.

7. The suture material is then tied utilizing an instrument tie (Figures 4-9A, 4-9B, 4-9C, 4-9D, 4-9E, 4-9F, 4-9G, 4-9H, 4-9I, 4-9J, 4-9K).