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Three-dimensional continuous suturing technique
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This technique is designed to bring three ends of tissue together and is generally used in the context of a flap or cleft lip repair, where it permits the tip of tissue to be inset. It is also utilized to repair V-shaped lacerations. This approach may be conceptualized as a percutaneous variation of the traditional tip stitch. Since it is used only when attempting to approximate three segments of skin, it is a niche technique.
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Suture Material Choice
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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 face, where this technique may be used for flap repairs, a 6-0 or 7-0 monofilament nonabsorbable suture is appropriate. On the trunk, extremities, and scalp, a 3-0 or 4-0 nonabsorbable suture material may be used. Fast-absorbing absorbable sutures may also be used, obviating the need for suture removal but increasing the risk of tissue reactivity.
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The flap is brought into place using buried sutures, allowing the tip to rest with only minimal tension in its desired position.
The needle is inserted into the distal nonflap section of skin at 90 degrees with a trajectory running toward the planned entry point in the center of the triangular section of skin (the tip).
The needle is inserted through the undersurface in the center of the triangular section of skin, following its curvature and exiting. As the needle is freed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to place the next throw.
The needle is then inserted into the proximal nonflap portion of skin at 90 degrees with a trajectory running toward the planned entry point in the center of the triangular section of skin (the tip), directly adjacent to its exit point.
The needle is inserted through the undersurface in the center of the triangular section of skin, following its curvature and exiting. As the needle is freed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to place the next throw.
The needle is then inserted into the distal nonflap section of skin at 90 degrees adjacent to its original entry point, now with a trajectory running toward the proximal edge of the nonflap section of skin.
The needle exits at the proximal nonflap section adjacent to its prior exit point.
The suture material is then gently tied utilizing an instrument tie. Care should be taken to minimize tension on this suture to mitigate the risk of flap tip necrosis (Figures 5-26A, 5-26B, 5-26C, ...