Video 5-43. Percutaneous dog-ear tip stitch
This is a niche technique used for reducing the appearance of dog ears, or standing cones, at the ends of elliptical excisions or local flaps. While dog-ear minimization is generally accomplished by excising lesions with fusiform incisions, this often extends the length of the wound significantly, which is undesirable. This technique was designed as an approach to mitigate the raised dog-ear appearance of the standing cone while concomitantly avoiding unnecessarily extending the length of the wound.
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.
The needle is inserted into the proximal edge of the incision line adjacent to the dog ear at 90 degrees with a trajectory running toward the planned entry point adjacent to the center of the dog ear.
The needle is inserted through the undersurface of the dog ear, 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 reinserted into the dog ear adjacent to its exit point at 90 degrees with a trajectory running toward the planned exit point on the distal edge of the incision line, parallel to the original entry point.
The needle exits at the distal exit point.
The suture material is then gently tied utilizing an instrument tie (Figures 5-43A, 5-43B, 5-43C, 5-43D, 5-43E, 5-43F, 5-43G, 5-43H).
Overview of the percutaneous dog-ear tip stitch.
The needle is inserted into the proximal edge of the incision line adjacent to the dog ear at 90 degrees with a trajectory running either toward the incised wound edge or toward the planned entry point adjacent to the center of the dog ear.
The needle is reloaded after exiting in the center of the wound. Alternatively, for smaller dog ears, the needle could be passed directly through the underside of the dog ear, combing this step with the next.