Deep Buried Dermal Suture

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
Email

Send Email

Recipient(s) will receive an email with a link to 'Deep Buried Dermal Suture' and will have access to the topic for 7 days.

Subject: Deep Buried Dermal Suture

(Optional message may have a maximum of 1000 characters.)

×


Introduction

The deeply buried subcutaneous suture closes dead space, stops subcutaneous bleeding, reduces hematoma and seroma formation, and takes essentially all of the tension off the skin sutures and skin edges. The decreased tension in the healing scar will reduce the final width of a resultant scar. The most common suture materials used in this technique are chromic gut, polyglactin (Vicryl), polyglycolic (Dexon), polydioxanone (PDS), and polyglyconate (Maxon). These sutures are absorbable and do not need to be removed. 
Usually, both deep or buried and superficial skin sutures are placed. In multilayered closures, the deep sutures bear virtually all of the tension, and the superficial sutures approximate the epidermal edges for an optimal, cosmetically acceptable result. The eversion obtained with the buried suture carries minimal risk of leaving suture marks. The classic description of the buried suture technique emphasizes that the knot be buried downward. A buried suture allows the physician to remove superficial skin sutures earlier, because wound eversion is maintained longer. The everted wound flattens after wound contraction, providing a good cosmesis. 
Buried dermal sutures do not increase the risk of infection in clean, uncontaminated lacerations. However, animal studies suggest that deep sutures should be avoided in highly contaminated wounds. 

Equipment

  • Common skin surgery equipment and the typical skin surgery tray are listed in Appendix G.

Indications

  • Wounds needing tension reduction

  • Wounds with deep spaces that may collect blood or fluids

  • Large wounds

Contraindications

  • Inadequate subcutaneous tissue to perform the technique

  • Contaminated wounds

Consider vertical mattress sutures if tension reduction is needed. 

The Procedure

Step 1

The suture begins in the center of the wound and passes beneath the left wound edge and then back into the center of the wound through the dermis. 

Step 2

The needle is placed upside down and backward into the needle holder. It passes through the dermis into the right wound edge and down to the base of the wound. The needle then grabs a small bit of the tissue in the base of the wound. 

Step 3

Both of the suture ends need to be on the same side of the center part of the suture passing across the top of the wound (i.e., toward the operator or away from the operator). 
  • PITFALL: If a suture end is placed on either side of the center part of the suture and tied, the knot will rest on top of the center part of the suture and not be buried in the deep tissue.

Step 4

The knot is tied. Instead of pulling each throw laterally as with most ties, pull the ends of the suture parallel to the wound to deeply bury the knot. Cut the suture tails just above the knot. 
  • Pearl: There should be no more than three to four knots per suture to minimize the risk of the knot migrating through the healing wound through the incision line.

Step 5

Usually, a deeply buried suture is placed in the center and/or the ends of the wound. 
  • Pearl: In potentially contaminated wounds, the fewest number of sutures possible should be placed.

Complications

  • Bleeding

  • Infection, especially in contaminated wounds

  • Scar formation

Pediatric Considerations

Deep sutures are particularly useful in children, because they will hold the wound together even if the child picks out the superficial sutures. However, pediatric patients often find it difficult to sit and lie still during lengthy procedures. The maximum recommended dose for lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Instruct the patient to gently wash the area that has been stitched after 1 day but not to put the wound into standing water for 3 days. Have the patient dry the area well after washing. Have the patient use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to help lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. 

Coding Information and Supply Sources

If a layered closure is required, use intermediate closure codes 12031 to 12057 or complex repair codes 13100 to 13160 in addition to the simple closure codes. Place the intermediate repair code first, then the simple repair code with a -51 modifier. 
Simple repair is included in the codes reported for benign and malignant lesion excision (see Fusiform Excision) and the closure is not reported separately. 

Bibliography

Austin PE, Dunn KA, Eily-Cofield K, et al. Subcuticular sutures and the rate of inflammation in noncontaminated wounds. Ann Emerg Med .  1995;25:328. [View Abstract]
Borges AF, Alexander JE. Relaxed skin tension lines, Z-plasties on scars, and fusiform excision of lesions. Br J Plast Surg.  1962;15:242–254. [View Abstract]
Leshin B. Proper planning and execution of surgical excisions. In: Wheeler RG, ed. Cutaneous Surgery . Philadelphia: WB Saunders;  1994:171–177.
McGinness JL, Russell M. Surgical pearl: A technique for placement of buried sutures. J Am Acad Dermatol .  2006;55(1):123–124. [View Abstract]
Mehta PH, Dunn KA, Bradfield JF, et al. Contaminated wounds: infection rates with subcutaneous sutures. Ann Emerg Med .  1996;27:43. [View Abstract]
Moy RL, Lee A, Zalka A. Commonly used suturing techniques in skin surgery. Am Fam Physician .  1991;44:1625–1634. [View Abstract]
Stegman SJ, Tromovitch TA, Glogau RG. Basics of Dermatologic Surgery . Chicago: Year Book Medical Publishing;  1982:60–68.
Stevenson TR, Jurkiewicz MJ. Plastic and reconstructive surgery. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery . 5th ed. New York: McGraw-Hill;  1989:2081–2132.
Swanson NA. Atlas of Cutaneous Surgery . Boston: Little, Brown;  1987.
Vistnes LM. Basic principles of cutaneous surgery. In: Epstein E, Epstein E Jr, eds. Skin Surgery . 6th ed. Philadelphia: WB Saunders;  1987:44–55.
Zalla MJ. Basic cutaneous surgery. Cutis .  1994;53:172–186. [View Abstract]
Zitelli J. TIPS for a better ellipse. J Am Acad Dermatol.  1990;22:101–103. [View Abstract]
Zuber TJ, DeWitt DE. The fusiform excision. Am Fam Physician.  1994;49:371–376. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
×