As in most locations, the set-back dermal suture or buried vertical mattress suture is generally the technique of choice on the hands and feet. Since these wounds are sometimes fairly narrow, percutaneous approaches such as the percutaneous set-back dermal suture, percutaneous buried vertical mattress, or buried horizontal mattress approaches may be useful as well (Figure 6-4).
Frequently used suturing techniques on the hands and feet.
In wounds under marked tension, the pulley set-back dermal or pulley buried vertical mattress may be useful techniques, particularly when placed toward the center of a wound under tension. The relatively robust dermis on the hands and feet of younger patients means that everting horizontally or obliquely oriented techniques, including the butterfly suture, are viable options as well.
The presence of significantly sized vessels very close to the underside of the dermis means that caution should be exerted when placing transepidermal sutures on the dorsal hands and feet. With wide undermining in the appropriate plane, these larger vessels are easily visualized when placing buried sutures. Transepidermal sutures could easily perforate a superficial vessel, and therefore unless they are necessary it may be best to avoid traditional approaches such as the simple running suture. Instead, utilizing either skin adhesive or a running subcuticular approach may be preferable, especially on the highly vascular dorsal hands. This has the added benefit of minimizing the amount of suture material extruding from the skin that could be caught when placing the hand in a pocket or purse in the postoperative period.
In select cases, purse-string approaches may be useful as well, although the postoperative cosmesis is generally not as appealing as when using linear closures.