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.
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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 1 View Original Step 1 View Original
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 2 View Original Step 2 View Original
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 3 View Original Step 3 View Original
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 4 View Original Step 4 View Original
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.
Step 5 View Original Step 5 View Original
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.
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 12031 Intermediate closure SATAL ≤2.5 cm $272 10 12032 Intermediate closure SATAL 2.6 " 7.5 cm $347 10 12034 Intermediate closure SATAL 7.6 " 12.5 cm $438 10 12035 Intermediate closure SATAL 12.6 " 20.0 cm $548 10 12036 Intermediate closure SATAL 20.1 " 30.0 cm $680 10 12037 Intermediate closure SATAL >30.0 cm $789 10 12041 Intermediate closure NHFG ≤2.5 cm $262 10 12042 Intermediate closure NHFG 2.6 " 7.5 cm $357 10 12044 Intermediate closure NHFG 7.6 " 12.5 cm $462 10 12045 Intermediate closure NHFG 12.6 " 20.0 cm $558 10 12046 Intermediate closure NHFG 20.1 " 30.0 cm $729 10 12047 Intermediate closure NHFG >30.0 cm $846 10 12051 Intermediate closure FEENLMM ≤2.5 cm $341 10 12052 Intermediate closure FEENLMM 2.6 " 5.0 cm $426 10 12053 Intermediate closure FEENLMM 5.1 " 7.5 cm $527 10 12054 Intermediate closure FEENLMM 7.6 " 12.5 cm $645 10 12055 Intermediate closure FEENLMM 12.6 " 20.0 cm $822 10 12056 Intermediate closure FEENLMM 20.1 " 30.0 cm $1,044 10 12057 Intermediate closure FEENLMM >30.0 cm $1,211 10 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
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