Video 4-26. The pinpoint pexing suspension suture
Like the traditional buried suspension suture, this is a niche technique designed to fix the edge of a defect to a deeper structure and may also be utilized typically in four situations: (1) when repairing a defect that crosses a natural sulcus, (2) when working near cosmetic subunit boundaries and free margins, to avoid functional challenges such as ectropion and eclabium, as well as cosmetic distortion of sensitive areas such as the lip and eyebrows, (3) when fixing a flap in place to minimize tension on the distal portion of the flap, and (4) when fixing a graft to underlying structures to minimize the risk of dead space/hematoma formation and maintain close approximation between the underside of the graft and the underlying vascular bed.
The end result of this technique is a buried suspension suture, but it begins with an initial step that is percutaneous in order to better assess the ideal location for suture placement; the percutaneous portion is removed prior to tying, as noted below.
Suture choice is dependent in large part on location, though this technique is usually utilized on the face. A 4-0 or 5-0 absorbable suture may be used.
The suture needle is inserted at 90 degrees from the outside of the skin overlying the desired tacking point directly through the dermis, exiting on the undersurface of the undermined flap at the point where fixation to the underlying anchoring point is desired.
The needle is then regrasped and inserted through the fat and deeper structures until the bone is reached (for periosteal suspension) or through more superficial structures (for simple tacking). A bite is then taken, and the needle is brought back through the soft tissues into the open center of the wound. Gentle tension can be used to ensure than an adequate bite was taken.
The needle is then reloaded, and a bite of the underside of the undermined dermis directly adjacent to the initial entry point is taken. Again, very gentle tension can be used to ensure that an adequate bite was taken.
The tail of the suture that traverses the entire thickness of the flap can then be pulled through so that the only remaining bites are the deep bite and the bite at the underside of the dermis.
The suture material is then tied using an instrument tie. Hand tying may be utilized as well, which may be useful if the depth of the defect is significant (Figures 4-26A, 4-26B, 4-26C, 4-26D, 4-26E, 4-26F, 4-26G).
Overview of the pinpoint pexing suture.