How To Do Plastic Surgical Repair With Buried Deep Dermal Sutures

• Deep wounds, when closing just the epidermal layer might leave significant pockets of dead space

• Wounds under increased tension, which require strong dermal closure to heal optimally

• Wounds prone to keloid formation, to minimize wound skin tension

• Lacerations that require extended healing, in which a nonabsorbable dermal suture is left in place for a longer period than recommended with a surface suture

Absolute contraindications

• None

Relative contraindications

• Inadequate or thin dermal layer

• Wound that cannot be adequately cleansed (however, there is no increased risk of infection using dermal sutures in clean wounds)

Sutures of any type may be contraindicated for wounds that are contaminated, relatively old, or that would be at higher risk of infection if closed by sutures, such as small bites to hands or feet, puncture wounds, or high-velocity missile wounds.

Wounds involving deep structures (eg, nerves, blood vessels, ducts, joints, tendons, bones) and those covering large areas or involving the face or hands may require specialized techniques or referral to a surgical specialist.

• Bleeding

• Infection

• Fibrosis

Wound hygiene and closure techniques need not be sterile procedures. Although instruments that touch the wound (eg, forceps, needles, suture) must be sterile, clean nonsterile gloves as well as clean but not sterile water may be used in immunocompetent patients. Some operators prefer the better fit and better barrier protection of sterile gloves.

Clean procedure, barrier protection

• Face mask and safety glasses (or a face shield), head caps, gowns, gloves

• Sterile drapes, towels (for wound debridement and suturing)

• A standard suture tray including local anesthesia and skin suture materials

• Absorbable suture (usually monofilament and usually 4-0 or 5-0, but sometimes 3-0)

• Nonocclusive dressing

• Antibiotic ointment

• Monofilament suture material minimizes tissue reaction and inflammation, leading to better results. Monofilament is preferred to other suture types (eg, braided) except for lacerations under excessive tension (eg, in the tongue). Sizes 4-0 and 5-0 are used most often. However, size 3-0 may be needed, for example, for lacerations under tension (eg, those over joints).

• Buried, absorbable dermal sutures (also called simple deep dermal sutures) do not appear to provoke more inflammation than percutaneous running sutures.

• Because dermal sutures alone may not achieve perfect approximation of the vertical height of the wound edges, in cosmetic closures they are often followed by surface suturing (eg, running sutures).

• Consider using buried intradermal sutures for lacerations in cosmetically important areas that are subject to dynamic skin tension. (Skin tension lines in the face are shown in the figure Representative Minimal Skin Tension Lines.)

Representative Minimal Skin Tension Lines

Direction of force is along each line. Cuts perpendicular to these lines are thus under greatest tension and most likely to widen.

• Position the patient comfortably reclined or supine.

• Adjust the stretcher height so that you will be comfortable either sitting or standing at the bedside.

• The laceration should be well lit, preferably with an overhead procedure light.

(See How To Cleanse, Irrigate, Debride, and Dress Wounds for step-by-step descriptions of wound preparation, anesthesia, and dressing; see How to Repair a Laceration With Simple Interrupted Sutures for instructions on how to handle the instruments, work with needles, insert simple interrupted sutures, and tie a surgeon's knot using instruments.)

The goal is to invert each suture, which buries the knot beneath the plane of closure so that it will not interfere with epidermal healing.

• Cleanse, anesthetize, irrigate, and, if necessary, debride the wound.

• Place a sterile fenestrated drape over the wound. Place additional drapes nearby as needed to provide a large enough sterile work area.

• Insert the needle into the dermis at the bottom of the wound and direct it upward toward the skin surface, exiting near the dermal-epidermal junction on the same side.

• Insert the needle on the opposite side of the wound near the dermal-epidermal junction, directly across from the point of exit. Take small bites to avoid puckering of the skin surface.

• Exit the bite at the same dermal plane as and opposite the bite on the other side.

• Tie the knot, using 3 or fewer throws.

• Cut the suture, leaving about a 3-mm tail.

• If needed to help achieve precise skin approximation, suture the skin. Place a fine (eg, 6-0) running skin suture. At one end of the laceration tie a simple suture with a knot but leave the needle and suture attached. Evert the skin edges along the length of the laceration if possible. Advance the needle, taking small bites at a 45-degree angle to the long axis of the laceration (perpendicular to the skin) for the complete length of the laceration. After the final bite, extend a loop of suture from the wound and use this loop as one end of suture for the final tie.

Buried (Simple) Deep Dermal Suture

The suture begins and ends at the bottom of the wound so that the knot is deeply buried.

• Dress the wound (see Lacerations and How To Cleanse, Irrigate, Debride, and Dress Wounds).

• Splint joints whose movement will cause wound tension (eg, an elbow splint for a dorsal elbow laceration).

• Instruct the patient to keep the dressing dry and in place and to return in 2 days for a wound check.

• Instruct the patient to return if signs of infection develop (eg, increased pain, swelling, redness, fever, proximally spreading red streaks [infectious lymphangiitis]).

• Instruct the patient when to return for skin suture removal, which is generally based on the wound site: 3 to 5 days for the face, 6 to 10 days for the scalp and trunk, 10 to 14 days for the arms and legs, and 14 days for wounds overlying joints. Early suture removal risks wound dehiscence; however, to decrease scarring and cross-hatching of facial sutures, half of the suture line (ie, every other suture) may be removed on day 3 and the remainder are removed on day 5.

• Deep dermal sutures do not appear to increase the risk of infection in clean, uncontaminated lacerations. However, animal studies suggest that deep sutures should be avoided in highly contaminated wounds.

• Use no more than 3 throws per knot and the fewest number of sutures possible.

• Consider deep dermal sutures particularly for children, who are more likely than adults to develop suture marks.

• If surface sutures are not used, apply skin tape to correct surface unevenness and to provide more accurate apposition of the epidermis.