Chapter 5.37: The Cross Stitch

This is a niche technique used for closure, hemostasis, and epidermal approximation of select wounds. It may be conceptualized as a simple running suture that is performed without an anchoring knot and that, when the terminus is reached, travels in the opposite direction toward the original wound apex. While it demonstrates an elegant and symmetrical postoperative appearance, it also entails the placement of a greater number of transepidermal sutures while providing little extra in terms of functional benefit, and therefore is used only infrequently.

As 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. Suture choice will depend largely on anatomic location and the goal of suture placement. The cross stitch may be utilized either to aid in wound-edge approximation or to help with hemostasis. In the latter case, slightly thicker suture material may be utilized.

On the face, a 6-0 or 7-0 monofilament suture may be used for epidermal approximation. Indeed, 5-0 or 6-0 monofilament may be used on the extremities as well, though 4-0 monofilament suture may be utilized in areas under moderate tension where the goal of suture placement is relieving tension and hemostasis as well as epidermal approximation.

1. The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.

3. The needle body is grasped with surgical forceps in the left hand, and pulled upward with the surgical forceps as the body of the needle is released from the needle driver.

4. A tail of free suture material is then left, and no knot is tied. A hemostat may be used to clamp the tail of the suture to avoid the risk of pulling it through during the subsequent steps.

5. Starting proximal to the prior knot relative to the surgeon, steps (1) through (3) are then repeated sequentially and the needle is advanced along the course of the wound until the contralateral apex is reached.

6. Once the apex is reached, steps (1) through (3) are then repeated heading in the contralateral direction, again advancing along the wound, but now with entry and exit points crossing the previously placed line of sutures, forming an X appearance.

7. Once the apex is reached, the leading end of the suture is tied to the tail end of the suture using an instrument tie (Figures 5-37A, 5-37B, 5-37C, 5-37D, 5-37E, 5-37F, 5-37G).

As with the simple running suture, it is important to enter the epidermis at 90 degrees, allowing the needle to travel slightly laterally away from the wound edge before fully following the curvature of the needle when utilizing this technique. This will allow for maximal wound eversion and accurate wound-edge approximation.

As always, care should be taken to avoid skimming the needle superficially beneath the epidermis. This results from failing to enter the skin at a perpendicular angle and to follow the curvature of the needle. This may result in wound inversion as the tension vector of the shallow bite pulls the wound edges outward and down.

In order to maintain uniformity in the length of the visible running sutures and to allow all of the suture loops to remain parallel, it is important to take uniform bites with each throw. Therefore, each subsequent loop should begin at the same point lateral to the incised wound edge and at a uniform distance closer to the surgeon than the preceding entry point.

Sutures should not be tied too tightly, and it is helpful to permit sufficient laxity between the epidermis and the suture material when using this technique. This approach will help minimize the risk of track marks that may be associated with postoperative edema.

This technique has two main drawbacks. First, the integrity of the entire suture line rests on the integrity of a single knot. When this technique is used only to fine-tune epidermal approximation, knot failure is unlikely to lead to dehiscence, but if there is significant tension across the wound this may be more problematic. Second, the additional row of simple interrupted sutures used in this technique does little to aid in wound-edge approximation or wound security, while concomitantly increasing the risk of track mark formation. Therefore, unless this approach is being utilized for its hemostatic effects, it may not be the ideal technique in most circumstances.

As with all running techniques, since each loop of the running suture material is designed to hold an equal amount of tension, it follows that areas of the wound under greater tension, such as its central portion, may tend to gape or potentially exist under greater tension leading to an increased risk of track marks.

As with any suturing technique, knowledge of the relevant anatomy is critical. When placing the cross stitch it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material. Thus, the needle may pierce a vessel leading to increased bleeding, while a tightly placed suture may lead to necrosis due to vascular compromise or even, theoretically, superficial nerve damage.

This technique may elicit an increased risk of track marks, necrosis, inflammation, and other complications when compared with techniques that do not entail suture material traversing the scar line, such as buried or subcuticular approaches. Therefore, sutures should be removed as early as possible to minimize these complications, and consideration should be given to adopting other closure techniques in the event that sutures will not be able to be removed in a timely fashion.