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  • While most day-to-day procedures demand only a few suturing techniques, recent evidence has suggested that choice of technique has the potential to impact long-term outcomes.

  • Suturing techniques can be dichotomized as buried versus transepidermal techniques, though the use of percutaneous approaches may make this distinction unclear.

  • While the dermatologic surgeon does not need to incorporate a vast array of techniques into daily practice, precise placement of sutures coupled with an appreciation of the subtle variations in individual patients that may benefit from particular niche techniques is very helpful and may result in improved surgical outcomes.

image Beginner Pearls

  • Deep suture techniques, such as the buried vertical mattress or set-back dermal suture, are fundamental techniques for all wound closures, as they lead to wound eversion, wound-edge approximation, and shift tension to the dermis.

  • Fascial plication sutures are very useful to reduce dead space and reduce tension, and serve to shift tension even deeper, ultimately leading to a possibly improved outcome.

image Expert Pearls

  • When suturing a tight location, such as the scalp or lower leg, either percutaneous approaches or a buried horizontal mattress suture may be used for the deeper layer of sutures.

  • With meticulous suture placement, no transepidermal sutures are needed for many closures, as the deep sutures lead to both tension reduction and wound-edge approximation.

image Don’t Forget!

  • When working on the back, use thicker suture such as a 2-0 absorbable suture with a large needle.

  • To reduce the risk of suture material spitting, consider using set-back sutures that leave no suture material at the incised wound edge.

image Pitfalls and Cautions

  • Pulley variations may be useful for wounds under significant tension, but always using a pulley approach may needlessly increase the amount of suture material left in the wound, leading to an increased risk of foreign body reactions and suture material spitting.

  • Fascial plication sutures may increase the risk of pain or infection; if pain after suture placement persists for more than 30 seconds, the suture should be removed.

image Patient Education Points

  • The dramatic eversion seen after dermatologic surgery should be explained to patients ahead of time and reviewed repeatedly.

  • Using the analogy of a subcutaneous splint (or cast) may be helpful when explaining that the goal is to reduce tension temporarily but that the eversion will not persist.

image Billing Pearls

  • An intermediate or complex repair code is predicated on the wound being closed in a layered fashion.

  • Fascial plication followed by dermal sutures would be considered a layered closure for these purposes.


Suturing techniques have seen a renaissance over the past decades, as dermatologic surgeons have increasingly appreciated the impact that precisely placed sutures have on surgical outcomes. The rise of evidence-based medicine has led to a boon in suture technique development, ...

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