Chapter 5.34: The Running Pleated Suture

This technique is designed to correct an imbalance in tissue length on two sides of a wound, as is commonly encountered in flap repairs. When performing advancement and rotation flaps, Burrow’s triangles are often taken at the poles of the flap in order to account for the discrepancy in tissue quantity between the two edges of the wound. This technique is designed to take advantage of forming multiple small pleats in the tissue that may be thought of as tiny Burrow’s triangles all along the wound length, leading ultimately to a shorter scar.

With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Generally this technique is used on the face, where 6-0 or 7-0 monofilament nonabsorbable suture is appropriate. On flaps on other body sites, 5-0 suture may be appropriate as well.

1. The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side.

3. The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges. This forms the first anchoring knot for the running line of pleated sutures. The loose tail is trimmed, and the needle is reloaded.

4. Starting proximal to the prior knot relative to the surgeon, the needle is inserted perpendicular to the epidermis on the side without tissue excess, approximately one-half the radius of the needle distant to the wound edge.

5. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits into the undermined space.

6. The needle is then reloaded and inserted through the superficial dermis on the contralateral wound edge, taking a more superficial bite on this side of the wound.

7. Steps (4) through (6) are then sequentially repeated until the end of the wound is reached, so that there is more space between bites on the wound side with excess.

8. For the final throw at the inferior apex of the wound, the needle is loaded with a backhand technique and inserted into the skin at a 90-degree angle in a mirror image of the other throws, entering just proximal to the exit point relative to the surgeon on the same side of the incision line and exiting on the contralateral side.

9. The suture material is only partly pulled through, leaving a loop of suture material on the side of the incision opposite to the needle.

10. The suture material is then tied to the loop using an instrument tie (Figures 5-34A, 5-34B, 5-34C, 5-34D, 5-34E, 5-34F, 5-34G, 5-34H).

While originally described for flap repairs, this technique may be used in any situation where there is a differential in tissue quantity between the two sides of a wound. Taking widely spaced superficial bites on the side with excess and narrowly spaced deep bites on the side without excess has the effect of pleating down the wound edge with excess tissue and tacking it into place against the contralateral wound edge.

A deeper layer of sutures should be placed to relieve tension across the wound edges before placing the running pleated suture.

Some visible pleating, particularly on the side with excess, is expected in the immediate postoperative period. In most areas, this will resolve with time as the wound heals.

As with all running techniques, the integrity of the entire suture line rests on two knots, and suture material compromise at any point may lead to a complete loss of the integrity of the line of sutures. Since this technique is designed for low-tension environments, however, even in the face of suture material breakage the remaining throws of suture may permit some residual epidermal approximation and wound edge length equalization.

Since all loops of suture are placed in succession, this technique does not permit the same degree of fine-tuning of the epidermal approximation as a simple interrupted suture.

As with any suturing technique, knowledge of the relevant anatomy is critical. When placing running pleated sutures it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material.

Similarly, if the knot is tied relatively tightly, structures deep to the defect may be constricted. This can lead to necrosis due to vascular compromise or even, theoretically, superficial nerve damage; again, this risk may be mitigated by maintaining some laxity in the suture throws.

This technique may elicit an increased risk of track marks, necrosis, inflammation, and other complications when compared with techniques that do not entail suture material traversing the scar line, such as buried or subcuticular approaches. Therefore, sutures should be removed as early as possible to minimize these complications.