Chapter 4.35: The Bootlace Suture

Like traditional running buried sutures, this is a hybrid technique, combining the tension relief and lack of transepidermal suture placement of a classic buried suture with the rapidity of placement and lack of resilience of a superficial running technique. This is therefore a niche approach, since the running nature of the technique means that compromise at any point in the course of suture placement may result in wound dehiscence. It does afford the advantage of the knot resting in the center of the wound, which may reduce the tendency for the central portions of the wound to gape open. Still, unless truly needed, this approach should not be utilized as a solitary technique for the closure of most wounds.

Suture choice is dependent in large part on location, though as always the smallest gauge suture material appropriate for the anatomic location should be utilized. On the back and shoulders, 2-0 or 3-0 suture material is effective, though if there is marked tension across the wound this approach would not be appropriate as the primary closure, and would be used best for its pulley benefits. On the extremities, a 3-0 or 4-0 absorbable suture material may be used, and on the face and areas under minimal tension a 5-0 absorbable suture is adequate. Since the technique requires easy pull through of suture material, monofilament absorbable suture is probably preferable.

1. At the midpoint of the wound, 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 bite is executed by inserting the needle into the 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 that 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 contralateral side of the wound.

6. Instead of tying the suture, a tail is left protruding from this first set of sutures and may be secured with a hemostat.

7. Moving superiorly toward the distal pole of the wound, the procedure is then repeated sequentially, repeating steps (2) through (5) while moving distally toward the apex for as many throws as are desired, without placing any additional knots.

8. Once the superior-most set of throws is placed, the needle is passed beneath all of the previously placed sets of sutures until it exits proximal to the starting point at the midpoint of the wound. Only then are the ends of the suture material pulled to effect partial closure of the distal portion of the wound.

9. Starting at the inferior or proximal apex, steps (2) through (5) are then repeated, with the pairs of sutures moving upward toward the center of the wound.

10. Once the desired number of throws have been placed, and the midpoint of the wound has been reached, the suture material is then pulled taut, leading to complete closure of the wound, and tied utilizing an instrument tie (Figures 4-35A, 4-35B, 4-35C, 4-35D, 4-35E, 4-35F, 4-35G, 4-35H, 4-35I, 4-35J).

This technique was designed as an alternative to other running dermal techniques that would solve one of their chief drawbacks, the tendency toward differential scar-spread in the center of the wound as a function of the increased tension in this central area.

While originally described as a modification of the buried dermal suture, it may be easily modified as a buried vertical mattress or set-back suture technique as well, with the same principle that suture material is tied in the central portion of the wound.

Like other running dermal techniques, this technique may be used as a modified winch or pulley suture, since the multiple loops help minimize the tension across any one loop and permit closure of wounds under marked tension. Because each throw is not tied off, however, it is important to adequately secure the knot.

Given the theoretical susceptibility to suture material breakage or compromise, this is a technique that is probably best used in a layered fashion, either superficial to previously placed interrupted buried sutures, or deep to a set of more superficially placed buried sutures.

It may be beneficial to place the running sutures closer together toward the center of the wound than at the poles of the incision, as this may foster a more pronounced pulley effect at the center of the wound where the tensile forces are greatest.

Given the concern regarding knot breakage, it may be helpful to attempt to better secure the central (and only) knot. This may be done by paying particularly close attention to knot tying, tying an extra full knot, adding extra throws, or leaving a longer tail than would traditionally be executed. An additional approach is to secure the final knot with the aid of a tacking knot, which may similarly provide extra security.

Unlike other running dermal techniques, this approach leaves an additional bolus of suture material in the wound from the suture material traversing from the superior apex to the inferior apex at the halfway point of the closure. This added foreign-body material increases the theoretical risk of foreign-body reaction, suture abscess formation, and infection. That said, these theoretical disadvantages should be weighed against the real benefit of tying the knot centrally and better securing the central, highest tension portion of the wound.

As noted previously, this approach should usually not be used as a solitary closure technique, since there is no redundancy in the closure. It may be useful as an adjunct when there is either minimal tension across a wound (and therefore interrupted buried sutures may be unnecessary) or as a pulley approach to bring recalcitrant wound edges together.

Like the standard buried dermal suture, this approach as originally described provides less wound eversion than other approaches such as the set-back dermal or buried vertical mattress; therefore, a bootlace variation of the latter two techniques, as discussed earlier, may often be preferred to a bootlace running dermal approach, since wound eversion may be associated with improved cosmesis over the long term.