Chapter 4.1: The Simple Buried Dermal Suture

Buried suture, subcuticular suture

This technique is best used in areas under moderate tension, and it remains the standard technique discussed in many plastic surgery textbooks. Its use in dermatologic and plastic surgery has, however, fallen somewhat out of favor as other techniques, such as the buried vertical mattress and set-back dermal suture, have become increasingly popular. This straightforward technique is generally reported as useful in a broad array of applications, and may be used in both facial and truncal skin, though it is particularly useful in areas where inversion is desired. This would include the nasolabial and melolabial folds as well as select areas along the antihelix and umbilicus, where restoration of anatomical inversion is desirable.

Suture choice is dependent in large part on location, though because this technique leaves residual suture material both between the incised wound edges and in the superficial dermis, care should be taken to minimize the liberal use of larger-gauge suture material. On the face and ears, a 5-0 absorbable suture may be used, and on the distal extremities a 4-0 suture is generally adequate. Using this technique, a 3-0 absorbable suture works well on the back. It may be advisable to eschew the use of 2-0 suture with this technique to minimize the risk of suture spitting.

1. The wound edge is reflected back using surgical forceps or hooks.

2. While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 2 mm distant from the incised wound edge.

3. The first bite is executed by following the curvature of the needle and allowing the needle to exit in the incised wound edge. The size of this bite is based on the size of the needle, the thickness of the dermis, and the need for and tolerance of eversion. The needle’s zenith with respect to the wound surface should be between the entry and exit points.

4. Keeping the loose end of suture between the surgeon and the patient, the dermis on the side of the first bite is released. The tissue on the opposite edge is then gently grasped with the forceps.

5. The second and final bite is executed by inserting the needle into the contralateral incised wound edge at the level of the superficial papillary dermis. This bite should be completed by following the curvature of the needle and avoiding catching the undersurface of the epidermis, which could result in epidermal dimpling. It then exits approximately 2 mm distal to the wound edge on the undersurface of the dermis. This should mirror the first bite taken on the first side of the wound.

6. The suture material is then tied utilizing an instrument tie (Figures 4-1A, 4-1B, 4-1C, 4-1D, 4-1E, 4-1F, 4-1G).

This technique is best utilized in areas where slight inversion is desirable, such as the nasolabial fold. It also may be useful toward the apices of elliptical incisions, where a slight inversion of the wound edges may reduce the tendency toward dog-ear formation by pulling the nascent dog-ear down toward the subcutaneous tissue.

A particularly well-executed traditional simple buried dermal suture is very similar to the buried vertical mattress, since the placement of the suture following the curvature of the needle results in a slight eversion of the wound edge.

The standard buried dermal suture, while seemingly a simple approach, can be difficult to execute properly. As with many buried techniques, epidermal dimpling may occur where the arc of the suture reaches its apex at the dermal-epidermal junction; on the face and areas with thin dermis this should be assiduously avoided. Similarly, areas with sebaceous skin, such as the nose, require meticulous avoidance of dimpling which has the potential to persist. In truncal areas or those with thick dermis, however, a small degree of dimpling will resolve with time as the absorbable sutures are gradually resorbed.

Given the tendency for simple buried dermal sutures to result in wound inversion, this technique should be avoided in areas where wound inversion is particularly problematic. The tendency toward wound inversion means that superficial sutures are needed more frequently with this technique than with many others, since the transepidermal sutures are utilized in order to effect eversion of the wound edges. Since obviating the need for superficial sutures may be desirable in terms of patient comfort and convenience as well as ultimate cosmetic and functional outcome, this should be considered before broadly applying this technique.