Understand Placement of Deep Suture Technique

Picture 1 (above)

Picture 2 (above)

Picture 3 (above)

I commonly get this question from students - "How deep do you go when placing your subcuticular sutures?"

Here is my answer and hope this helps...

This depends on which deep suture technique you are performing. These are my 3 favorite subcuticular deep suture techniques I like to use in order (Picture 1):

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

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. Also, it will help guide you where the needle should enter and exit the skin relative to the incised wound edge.

Also, 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 (Again, how much eversion are you trying to achieve? How much tension does the wound have?)

In picture 2, you can see how I am reflecting back the skin, and the black dotted lines show you where the incised wound edges are. The arrows show you where you should first enter the needle in the underside of the dermis.  Also, where you should exit the needle on the contralateral side.

The SBD is the yellow arrow and is furthest away from the incised wound edge (6 mm away from incised wound edge. Can be closer if needed.)

The BVM is the red arrow and is closer to the wound edge (4 mm away from incised wound edge).

The SB is the green arrow and is closest to the wound edge (2 mm away away from incised wound edge).

For the BVM, reflect the skin edge back and insert the needle 90 degrees into the underside of the dermis. As you follow the curvature of the needle, you change the needle direction by twisting the needle driver so that the needle allows the apex of the bite to remain in the papillary dermis, while the needle shifts at the level of the reticular dermis as it exits through the incised wound edge (Refer to Pic 1 and 3). Mirror this on the contralateral side. The subtle shift with the needle from the papillary dermis to the reticular dermis creates a "heart shape" with the suture once knot tied off. 

For the SBD and SB, reflect the skin edge back and insert the needle 90 degrees in the underside of the dermis. As you follow the curvature of the needle, you pass at the level of the superficial papillary dermis (Refer to Pic 1 and 3). Avoid catching the undersurface of the epidermis, which can result in epidermal dimpling. For the SB, the needle continues to exit through the incised wound edge.  For the SBD, the needle exits away form the incised wound edge. Mirror what you did on the contralateral side. 

Because with the SBD technique you are exiting and entering away from the incised wound edge, you should experience less suture reactions, which is exactly why I favor the SBD over the BVM.

I hope this helps you understand how deep you place your subcuticular sutures relative to the dermis. 

Being meticulous with your deep suture technique can make a tremendous difference on how well your patient heals, leaving minimal scarring. 

All my BEST,

Theresa Talens DNP, FNP-C

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

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