The workhorse technique for most arm closures is a vertically oriented buried suture. The set-back dermal suture is highly effective, and the buried vertical mattress suture may be utilized as well. Wide undermining is very helpful in leading to an effective closure, and undermining at the apices of the ellipse may aid in reducing the appearance of dog ears.
As always, a linear closure is preferable to a flap, and in all but the most extreme cases most defects on the arms are easily closed in a linear fashion. An s-plasty may be utilized in order to mitigate the appearance of standing cones in select cases (Figure 6-2).
Frequently used suturing techniques on the arms.
While buried vertical mattress or set-back dermal sutures are frequently used for the bulk of these closures, other techniques may also be employed. In wounds under marked tension, pulley approaches, such as the pulley set-back dermal suture or pulley buried vertical mattress may be useful; as always, however, these techniques should only be used if needed as they result in an increased volume of retained suture material when compared with their single-throw equivalents.
In wounds under very mild tension, running buried approaches may be utilized, though in general interrupted buried sutures are favored whenever possible in order to militate against the problems associated with suture material breakage.
Superficial approaches, if utilized, include the running subcuticular technique, though as noted earlier this should be avoided on the atrophic forearms. Other frequently used approaches include the simple running suture and the running horizontal mattress technique.
On atrophic forearms, patients may benefit from closures using the percutaneous set-back dermal suture, the percutaneous buried vertical mattress suture, or the buried (or percutaneous) horizontal mattress suture. When the degree of atrophy is extreme, an adhesive strip bolster technique may be most appropriate.
As in other anatomic locations, combining the set-back dermal suture for the bulk of wound closure with buried vertical mattress sutures at the wound apices may help effect marked wound eversion while concomitantly avoiding extreme eversion (and thus standing cone formation) at the apices.
In wounds under extreme tension, a pulley set-back dermal suture or pulley buried vertical mattress suture may be placed at the center of the wound, with standard set-back or buried vertical mattress sutures placed over the remainder of the wound.
Similarly, when superficial sutures are used, placing a horizontal mattress suture toward the center of the wound coupled with a simple interrupted suture at the wound apex may be a useful approach.