Surgical Pearl: The dermal buried pulley suture

Abstract

We describe a suture technique helpful in the repair ofwounds under a moderate amount of tension. It is most beneficial when the surgeon is working without an assistant. The standard repair of a full-thickness elliptical surgical wound involves a layered closure. Absorbable buried dermal sutures are used to close the defect with minimal epidermal surface tension.' Nonabsorbable superficial sutures are then used to secure gentle epidermal approximation and eversion. Special maneuvers are required to close a gaping surgical wound under a moderate amount of tension. Under these circumstances, an assistant pushes the wound edges together while the surgeon is securing the dermal suture knot. Although awkward, this maneuver is sufficient to reduce tension and allow knot placement. Another maneuver involves closing the wound inward from the poles where there is a more manageable amount of tension. Subsequent sutures are placed toward the middle of the defect where greater tension exists.? This, too, can be awkward and often requires an assistant to push skin edges together until the knots are secured. Several suture techniques have been described that can generate a mechanical advantage to close gaping wounds under tension. The near-far-farnear suture as developed by ophthalmologic surgeons' and further described by Bennet and Snow et al.5 is of particular value in thin skin. A variant of the near-far-far-near suture is the pulley suture recently described by Hitzig and Sadick'' and is of great assistance in closing tight scalp-reduction defects. The disadvantage of both of these techniques is that they place significant tension on the epidermis and raise appropriate concerns about surface scarring and cosmesis. We offer the buried dermal pulley suture as an alternate suture technique that can significantly assist in closure of large gaping wounds. Because it is