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Introduction

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Video 4-43. Buried leveling suture
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Application

This technique is used to reduce the step-off between the wound edge and an area that is left open to granulate. It is a niche technique used, for example, when repairing a defect that involves the thin lower eyelid skin, where it is sometimes beneficial to allow granulation to occur while also minimizing the step-off between cheek skin and the granulated area.

Suture Choice

Since this technique is used to fine-tune the relationship between the epidermal edge and an area that will heal secondarily, it is not designed to hold tension, and a 5-0 or 6-0 absorbable suture is often appropriate.

Technique

  1. The needle is inserted through the underside of the dermis, exiting at the dermal-epidermal junction following the needle’s curvature. The needle is then reloaded.

  2. A bite is then taken through the center of the wound.

  3. The suture material is then tied off gently, with care being taken to minimize tension and avoid any pull on free margins such as the eyelid (Figures 4-43A, 4-43B, 4-43C, 4-43D).

Figure 4-43A.

Overview of the leveling suture technique.

Figure 4-43B.

The needle is inserted through the underside of the dermis. The needle exits at the dermal-epidermal junction following the needle’s curvature. The needle is then reloaded.

Figure 4-43C.

A bite is then taken through the center of the wound.

Figure 4-43D.

The suture material is then tied off gently, with care being taken to minimize tension and avoid any pull on free margins such as the eyelid.

Tips and Pearls

This suture technique is useful when repairing defects that arise from tumors that bridge the thin skin of the lower eyelid and the thicker skin of the cheek. In such cases, either linear repairs or advancement flaps (including island pedicle flaps) may be performed, but the repairs should not, ideally, bridge the boundary between the infraorbital and maxillary cheek. Therefore, it may be best to allow a small portion of the defect on the infraorbital cheek/lower eyelid skin to heal secondarily, while also obviating an overly dramatic step-off between the repaired area and the area permitted to heal secondarily.

This approach may also be useful when performing any closure that heals in part secondarily, since it may result in faster healing times and less risk of scarring or contraction. A series of leveling sutures can be ...

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