The percutaneous set-back dermal suture Jonathan Kantor, MD, MSCE, MA Philadelphia, Pennsylvania, and Saint Augustine, Florida
SURGICAL CHALLENGE Dermatologists are frequently called on to reconstruct wounds in narrow areas of minimal skin laxity or body sites with marked atrophy and actinic damage. Placing traditional buried vertical mattress or set-back dermal sutures in these conditions may be challenging due to either access limitations or the absence of a robust dermis.
SOLUTION One approach is the use of the percutaneous set-back dermal technique, a percutaneous variation of the setback dermal suture1 that permits placement of buried everting sutures in tight spaces. The technique is executed as follows: the needle is inserted from inside the wound directly through the undersurface of the undermined dermis, exiting through the surface of the intact skin just lateral to the cut wound edge (Fig 1, A). The needle is then reloaded and reinserted using a backhand technique just medial to the exit point of the suture material, directly through the epidermis, exiting on the undersurface of the dermis in the undermined space (Fig 1, B). The needle is then inserted from the undersurface of the dermis directly through the skin on the contralateral side (Fig 1, C ). A single movement may be used to execute both of the previous 2 steps. Finally, the needle is reloaded and inserted just lateral to its exit point perpendicularly through the skin, exiting the underside of the dermis in the undermined space (Fig 1, D). The suture material is then tied. Other techniques have been proposed for closing narrow wounds,2 but they have significant drawbacks: they may be challenging to execute, generally leave suture material between the incised wound edges, and are not suited for atrophic skin. The percutaneous approach allows the clinician to glean the advantages of the set-back dermal suture— outstanding wound eversion and approximation coupled with ease of execution—while permitting closure in a narrow space that would otherwise not permit the insertion of traditional buried sutures.
Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and the Florida Center for Dermatology, PA, Saint Augustine. Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jonathan Kantor, MD, MSCE, MA, Florida Center for Dermatology, PA, 105 Southpark Blvd, Suite A-103, Saint Augustine, FL 32086. E-mail: [email protected]
J Am Acad Dermatol 2015;72:e61-2. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.09.033
J AM ACAD DERMATOL
Fig 1. A, First throw. The needle is inserted through the underside of the dermis. B, Second throw. The needle is reinserted just medial to the exit point, exiting at the undersurface of the dermis. C, Third throw. The needle is inserted at the contralateral wound edge through the undersurface of the dermis. D, Fourth throw. The needle is reinserted just lateral to the exit point, exiting in the undermined space between the dermis and subcutaneous tissue. E, Appearance of the wound after 2 percutaneous set-back dermal sutures have been placed. REFERENCES 1. Kantor J. The set-back buried dermal suture: an alternative to the buried vertical mattress for layered wound closure. J Am Acad Dermatol 2010;62:351-3. 2. Collins SC, Whalen JD. Surgical pearl: percutaneous buried vertical mattress for the closure of narrow wounds. J Am Acad Dermatol 1999; 41:1025-6.