Video 4-40. Stacked backing out subcuticular suture
This is a niche technique that may be conceptualized as a backing out subcuticular approach with the first row of subcuticular sutures placed in the deep dermis or as a variation of the stacked double purse-string technique. It is useful for wounds under mild to moderate tension and may be used overlying deeper tension-relieving sutures.
As with any technique, it is best to utilize the thinnest suture possible for any given anatomic location. As this technique is not designed to hold marked tension irrespective of anatomic location, generally a 4-0 or 5-0 suture may be used. This is especially important since a large volume of suture material is left in situ when utilizing this approach. It is best to utilize a monofilament suture material to minimize the coefficient of friction at the time of suture removal, though this technique may also be finessed for use with absorbable suture material.
The needle is inserted at the far right corner of the wound, parallel to the incision line, beginning approximately 2-5 mm from the apex. The needle is passed from this point, which is lateral to the incision apex, directly through the epidermis, exiting into the interior of the wound just medial to the apex.
With the tail of the suture material resting lateral to the incision apex and outside the wound, the wound edge is gently reflected back, and the needle is inserted into the deep dermis or fascia on the far edge of the wound with a trajectory running parallel to the incision line. The needle, and therefore the suture, should pass through the deep dermis or fascia at a uniform depth. Bite size is dependent on needle size, though in order to minimize the risk of necrosis, it may be prudent to restrict the size of each bite. The needle should exit the deep dermis or fascia at a point equidistant from the cut edge from where it entered.
The needle is then grasped with the surgical pickups and simultaneously released by the hand holding the needle driver. As the needle is freed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to repeat the previously mentioned step on the contralateral edge of the incised wound edge.
A small amount of suture material is pulled through, and the needle is inserted into the deep dermis or fascia on the contralateral side of the incised wound edge after reflecting back the skin, and the same movement is repeated. The needle should enter slightly proximal (relative to the wound apex where the suture line began) to the exit point, thus introducing ...