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11/13/24, 7\:19 PM Guide | Deep dermal suture

Deep dermal suture

Table of contents

Introduction

This guide demonstrates how to perform a deep dermal suture, including step-by-step images of the key stages involved. This
workhorse suture is frequently used by plastic surgeons, utilising the strength of the dermis to provide the foundations of a
robust wound closure.

Equipment

Needle holder (a.k.a. Driver)

Needle holders should be held with your dominant hand.
Put your thumb through one handle and place your ring
they feel you have greater dexterity and range of movement (this is referred to as "palming").
Needle holder closed

Toothed forceps (a.k.a. Pickups)

Hold the forceps with your non-dominant hand in the same way you would hold a pen.
Be gentle when using toothed forceps to manipulate skin, do not grip it too tightly or you may damage the wound's edges.
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Hold the forceps with your non-dominant hand in the same way you would hold a pen

Scissors

Scissors are used for cutting sutures.
Position your index
Rest the blades on your index
Use scissors to cut sutures

Suture

An absorbable suture is always used for deep dermal sutures, to allow hiding of the knot beneath the dermis in the
subcutaneous tissue.
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The choice of suture material is dependent on the anatomical site and surgeon preference. Monocryl (3-0 or 4-0) and undyed
Vicryl (3-0 or 4-0) are most commonly used.
On the back where the dermis is very thick, some surgeons use PDS as it takes longer to absorb, however many advocate that
this risks suture extrusion.
On the face, a smaller deep dermal suture should be used such as 5-0 or 6-0 Monocryl. Vicryl Rapide can also be used in areas
that heal quickly, such as the face.

Principles of wound management

All wounds should have local anaesthetic in
the lip as this may distort the normal anatomy.
Following this, they should be thoroughly washed and the wound bed should be examined for internal damage. Patients
should be up to date with their tetanus immunisation and contaminated wounds warrant a course of an antibiotic such as co-
amoxiclav or a suitable alternative if allergic.
X-rays should be performed if there is suspicion of a fracture or foreign body.
Wound edges should be debrided if the wound is contaminated. If there is no damage deep to the skin, then primary closure
can be performed.
Use intuition, some patients have much thicker skin than others and will require a larger suture to facilitate wound closure.
BODY AREA SIZE MATERIAL REMOVAL TIME
Face/Lip 6-0 Mono
Scalp 3-0, 4-0 Mono
Chest/Abdomen/Back 3-0, 4-0 Mono
Limbs 3-0 to 5-0 Mono
Hands 4-0 or 5-0 Mono
Nailbed 6-0 Braided, rapidly absorbable Absorbable

Setup

This is a sterile procedure, and therefore the wound and surrounding skin must be prepared with antiseptic solution before
placing a drape around the sterile
during the procedure. Although you may not need a surgical gown, you must don gloves taking care not to touch the external
surface.
Wash the wound and debride the skin edges if ragged or dirty and if you are certain there is no deep tissue damage you may
proceed to close the skin.
Load your needle holder by placing the needle in the tip of the holder, two-thirds of the distance from the tip to the thread.
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Load the needle between the apex of its curvature and two-thirds from the needle tip

Deep dermal suture

Deep dermal sutures are utilised when closing large or gaping wounds that require a robust, layered closure. They are useful in
reducing tension over the length of a wound, relying on the strength of the dermis (containing collagen and elastin
opposed to the epidermis.
The aim is to hide the suture beneath the skin. To bury the knot, one must
, then,
from 'super
. This places the suture ends deep in the wound and thus hides the knot beneath the dermis.
The technique can be thought of as an 'upside-down' interrupted suture. As the suture is to be underneath the skin surface it is
favourable for the knot to be deep in the wound, this avoids extrusion of the suture material.
1. Load the suture as detailed above and use the toothed forceps to gently evert the skin edge (without crushing the tissues).
2. Pronate your wrist and place the suture at the deep aspect of one side of the wound, this should be at the bottom of the
dermis but not incorporating subcutaneous fat.
3. Supinate your wrist to bring the needle from deep in the wound towards the surface. Aim for the needle to emerge
underneath the epidermis taking care not to puncture the skin surface.
4. Push the needle through with the needle holders, then grasp with the toothed forceps and pull the needle and thread
through, leaving enough to tie on to at the base of the wound.
5. Re-mount the needle, this time in a position to enter the opposing side of the wound.
6. This time the needle should enter just below the epidermis at the same level as the suture exited on the
7. Again, supinate your wrist so the needle passes from super
stitch.
8. Pull the needle through.

Knot tie

When performing a deep dermal suture the knot should sit at the deep aspect of the wound.
9. Put down the forceps.
10. Pull the suture through so there is approximately 3cm of length on the opposing side.
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11. Hold the suture in your non-dominant hand and the needle holder in your dominant hand.
12. Loop the suture away from you around the needle holder twice, then grasp the suture end with your needle holder. Lay the

perpendicular to the wound (as you would do in a simple interrupted, external suture).
13. Let go of the suture with your needle holder but keep hold of it in your non-dominant hand.
14. Now loop the suture back towards you around the needle holder once and grasp the suture end with your needle holder.
Pull your suture ends parallel to the wound again, this time in the opposite direction to lay the second knot. Pulling the suture
ends in the opposite direction will secure your surgical ‘reef’ knot.
15. Finally, loop the suture away from you around the needle holder once, then grasp the suture end with your needle holder.
Lay the
16. Cut your suture
completely hidden on the skin surface.
Tips
Your needle must enter and exit the dermis at symmetrical heights on each side of the wound to ensure the skin edges
oppose at the same level.
If you place your deep dermal suture slightly deeper in the dermis, it will reduce the chances of suture extrusion and
evert the wound edges nicely.
When laying your
1. Evert the skin edge, aim to pass your needle from deep (below the dermis) to super

Wound care

Once you have completed suturing, you must ensure that you account for and dispose of your sharps immediately in a sharps
bin.
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The wound should be washed and dried, then dressed appropriately. Dressings depend on the site of the body and
professional preference, below are some examples\:
Face\: Cover with steristrips and Micropore tape or provide chloramphenicol 1% ointment.
Limb\: Cover with a non-adhesive dressing such as Jelonet, Mepetel, or Sil
wound may be covered with an OpSite or a Mepore waterproof dressing.
Torso\: Cover with non-adhesive then Opsite or Mepore. If large you may consider gauze and Me

Follow-up

All wounds should be reviewed in 5-7 days and sutures removed (if non-absorbable) as per the table above.

Authors

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