Chapter 5.29: The Lembert Suture

This is a niche technique designed to encourage wound-edge inversion, and is useful primarily to recreate a natural crease. It may be used to recreate the alar creases as well as to better define the helical rim, and may also be useful when recreating the mental crease.

With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Generally, this suture is used on the face and ears, and therefore a 6-0 or 7-0 monofilament suture may be best, though fast-absorbing gut may be used to obviate the need for suture removal.

1. The needle is inserted perpendicular to the epidermis, approximately 8 mm distant to the wound edge.

2. With a fluid motion of the wrist, the needle is rotated superficially through the dermis, and the needle tip exits the skin 2 mm distant from the wound edge on the ipsilateral side.

3. The needle body is grasped with surgical forceps in the left hand and reloaded onto the needle driver.

4. The needle is then inserted perpendicular to the skin on the contralateral side of the wound edge, 2 mm distant from the wound edge.

5. The needle is again rotated superficially through its arc, exiting 8 mm from the incised wound edge.

6. The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges (Figures 5-29A, 5-29B, 5-29C, 5-29D, 5-29E, 5-29F, 5-29G).

This approach was originally developed for intestinal suturing purposes, where inversion is desirable, and indeed necessary.

No suture material traverses the incised wound edges, thus reducing the risk that foreign material could impair effective wound healing.

This approach is very useful when attempting to recreate a natural crease, especially since traditional everting sutures have a tendency to blunt natural creases. Since the eye is naturally drawn to skin folds and creases, this small change may have a dramatic effect on the ultimate outcome of the repair.

This technique may lead to dramatic wound inversion, and therefore should only be used when the goal is recreating a natural crease. Moreover, since wound inversion may be associated with inferior cosmesis over the long term, the benefit of accentuated inversion should be weighed against the possibility that the long-term cosmetic outcome of the suture scar may be less than ideal. The over-inversion of the wound edges caused by the suturing technique relaxes somewhat after suture removal, allowing the wound edges to meet and heal.

This technique does not contribute at all to epidermal-edge apposition, and therefore it should ideally be used after dermal sutures have been placed that have effectively aligned the wound edges to permit improved healing.

As with any transepidermal technique, this approach may result in residual track marks; removing sutures in a timely fashion helps mitigate this risk, and utilizing fast-absorbing gut suture may also be a reasonable option.