Master Your Subcuticular Suture Technique for Optimal Healing

Understanding correct placement and being meticulous with your deep subcuticular suture technique can make a tremendous difference on how well your patient heals. 

I commonly get this question from students - What is the correct way on how to place subcuticular sutures?

First, ask yourself... “How much eversion am I trying to achieve?”.

This is important to understand because this will help you determine which deep suture technique to use and how much of a bite you will need to take when entering and exiting in the underside of the dermis. 

The size of the bite, or how deep you are in the dermis, is based on 3 things:

  1. Size of the needle
  2. Thickness of the dermis
  3. The need for and the tolerance of eversion (In other words, how much tension does the wound have.)

🎥 Watch VIDEO Comparing the 3 Main Deep Suture Techniques

In THIS VIDEO I created for you, I will be demonstrating the differences between the 3 main subcuticular techniques I teach in my suturing course for dermatology NPs/PAs to help better understand how to properly execute and apply each technique for optimal outcomes.  These are the 3 main suturing techniques demonstrated:

  1. the Set Back Dermal (SBD)
  2. the Buried Vertical Mattress (BVM)
  3. the Simple Buried (SB)

The case study shown in the video is a patient I took care of after performing an elliptical excision to remove a non-melanoma skin cancer on the patient’s upper lateral arm. 

The Buried Vertical Mattress

The first demonstration seen in the video is the BVM technique.  

One of the main differences for the BVM is where you first insert your needle at the underside of the dermis relative to the incised wound edge. 

Typically, you are going to be closer to the incised wound edge when compared to the SBD and the SB technique.

As you push your needle through for the BVM, you are also slightly shifting the needle from superficial dermis to deep dermis for wound eversion.

Then, exiting through the incised wound edge. 

On the contralateral side, mirror what you just did. Reinsert through the incised wound edge, not away like in the SBD. 

Then, again, as you push the needle through, shift it from deep dermis to superficial dermis.

Because of the needles subtle shift in the dermis on both sides, you are essentially creating a "heart-shaped" pattern with your sutures in which you can view in the video.

Once you perform your instrument tie, you are aiming to achieve an everted wound.  If you want to achieve more eversion, then that is when you can decide to perform the SBD technique if possible and appropriate.

Set Back Dermal Technique 

For the SBD, you are further away from the incised wound edge compared to the BVM and SB technique when first inserting the needle at the underside of the dermis.

Then, the needle exits away from the incised wound edge, which ultimately creates that more pronounced wound edge eversion.  

Eversion is beneficial because wounds contract and tend to pull inwardly with time.

Eversion helps avoid that and leaves a finer, less perceptible scar as the wound continues to heal.

Simple Buried Technique

The last demonstration in the video is the SB technique. 

This technique requires the needle to be inserted closest to the incised wound edge when first inserting the needle at the underside of the dermis when compared to the other 2 techniques.

You are not shifting your needle through the different layers of the dermis like you are in the BVM. 

This technique is the simplest technique to perform and does not provide you an inverted wound like the other 2 techniques. 

This technique would be a good technique to perform if you are not concerned about scarring, or if you are purposely wanting to cause inversion (opposed to eversion) to recreate a "pulled-in" scar line. 

This technique is great to perform when wanting to recreate a crease on the face. 

For example, when repairing a Mohs defect over the the melolabial fold or alar crease.

Summary

I really hope this video and article helped provide clarity on the subtle differences between each of the 3 main subcuticular technique.

You now know how and why you would apply each technique for your patient for the best results. 

Suturing Course OPENING JULY 1! Only For a LIMITED TIME! Save the Date!

If you found this article helpful and to improve your confidence in your surgical skills, my suturing course is opening up soon on JULY 1st! 

It will be opened only for a LIMITED TIME, so don't forget to save the date! 

The course will help leverage your skills and take you step-by-step on how to perform correct suturing technique!

If this sounds like a course that will help you, click HERE to learn more!

Serving with GRATITUDE,

Theresa Talens DNP, FNP-C(TheresaSurgDermNP)

P.U.L.S.E. Dermatology & Procedures, Inc.

Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.

_______