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Video 5-03. Leveling suture
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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 a significant amount of tension, and a 5-0 or 6-0 fast-absorbing suture is often appropriate.


  1. The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant from the wound edge.

  2. A shallow bite is taken, with the needle skimming the dermal-epidermal junction and exiting in the center of the wound.

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

  4. The needle is reloaded on the needle driver, and the needle is inserted into the open portion of the defect directly adjacent to the epidermal edge, and a small bite of the deep portion of the wound is taken.

  5. The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid any pull on free margins such as the eyelid (Figures 5-3A, 5-3B, 5-3C, 5-3D, 5-3E).

Figure 5-3A.

Overview of the leveling suture technique.

Figure 5-3B.

First throw of the leveling suture technique. The needle passes superficially through the epidermis.

Figure 5-3C.

The needle exits in the center of the wound.

Figure 5-3D.

The needle is reloaded.

Figure 5-3E.

The needle is inserted into the open portion of the wound.

Figure 5-3F.

The needle exits the deep portion of the wound and is regrasped.

Figure 5-3G.

The suture is tied with an instrument tie. Note that there is reduced discrepancy between the depth of the defect and the epidermal edge.

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