SubcuticularEdit
Subcuticular closure is a wound-closure method in which sutures are placed in the dermal layer just beneath the epidermis to approximate wound edges. By burying the knots and placing the stitches parallel to the skin surface, this technique aims to produce a discreet scar and minimize visible suture tracks. It is commonly employed in dermatologic and plastic procedures as well as general surgery for incisions in areas where cosmetic appearance matters, though it is also useful for certain functional closures. The method often relies on absorbable threads so that external suture removal is not required, a factor that can reduce follow-up visits and patient inconvenience.
The approach is valued for its cosmetic advantages and for reducing wound tension across the skin, which can contribute to flatter scars. However, the technique is not universally superior; tissue characteristics, incision location, and surgeon experience all influence its suitability. In settings where tissue is thick, infected, or under high mechanical stress, alternative closure methods may be preferred. Given these trade-offs, subcuticular closure is one option among a spectrum of wound-closure strategies used in modern medicine and is selected based on balancing cosmetic outcomes, healing dynamics, and practical considerations for the patient and the healthcare system.
Techniques and materials
Pattern and placement
Subcuticular closure typically involves two stages: first, deeper dermal sutures are placed to reapproximate tissue planes and distribute tension away from the surface; second, epidermal closure is achieved with a subcuticular pattern in which the needle runs within the dermal layer parallel to the incision line, burying the knot. The goal is to create a smooth surface with minimal surface punctures or visible knots. The exact pattern—whether running, interrupted, or purse-string variations—depends on the incision, tissue quality, and practitioner preference.
Dermal and epidermal layers
In practice, sutures are placed in the dermis to align tissue planes and reduce blanching or puckering at the surface. The epidermis is then approximated by a buried subcuticular pass, leaving little or no suture material exposed. This approach contrasts with traditional epidermal closures that rely on external knots or surface stitches, which can leave more conspicuous marks.
Suture materials
A common choice for subcuticular closure is an absorbable suture material so that removal is unnecessary. Examples include materials such as polydioxanone and monocryl (a fast-absorbing monofilament), as well as other monofilament options like poliglecaprone and polyglycolic acid depending on surgeon preference and tissue needs. The needle type is often a slender, curved taper needle designed for precise enter-and-exit through the dermal layer, minimizing tissue trauma.
Alternatives and complements
In some cases, a surgeon may combine a subcuticular dermal layer closure with an additional skin-level closure using adhesives, non-absorbable sutures, or skin staples in areas where cosmetic considerations are balanced against functional demands. For quick closures or in high-moisture or contaminated environments, alternative methods such as surgical staple or adhesive skin closures may be used, either as primary closure or as adjuncts. The choice of method often reflects local practice patterns, equipment availability, and patient-specific factors.
Indications and contraindications
Indications: Subcuticular closure is particularly favored for incisions in cosmetically sensitive regions (e.g., face, neck, breast, or extremities where scarring is a concern) and for wounds where a buried closure can reduce surface irritation and scarring. It is also used in procedures where minimizing follow-up visits is desirable, given the potential for reduced need for suture removal.
Contraindications: Infected or contaminated wounds, tissue that is under high tension, or wounds with poor perfusion may not tolerate buried dermal sutures well. In such cases, alternative closure methods may be preferred to ensure reliable wound apposition and healing.
Safety, outcomes, and comparisons
Outcomes: When performed appropriately, subcuticular closure can yield low rates of wound dehiscence and favorable cosmetic results. Aesthetic outcomes are frequently cited as a major benefit, with a flatter scar and reduced likelihood of visible external suture tracks.
Complications: Possible complications include stitch granuloma, infection, or tissue necrosis if suture material is too tight or if tissue perfusion is compromised. Appropriate aseptic technique and patient selection are essential to minimize risks.
Comparisons: Compared with surface-only closures or staples in suitable incisions, subcuticular closure can offer comparable strength with superior cosmetic appearance in many settings. The technique may require greater precision and training relative to simpler closures, which is a factor in debates about standardization and practice patterns across medical environments.
Controversies and debates
Cosmetic emphasis versus functional priority: Critics argue that a focus on cosmetic outcomes can drive procedure choices beyond what is necessary for healing, potentially increasing procedure time or costs. Proponents counter that improved scars can enhance patient satisfaction, reduce stigma associated with surgical scars, and lower long-term psychosocial costs.
Training and skill requirements: Some observers worry that subcuticular techniques demand higher levels of training and experience. Advocates contend that with proper instruction, the technique can be reliably implemented in many surgical settings, and that the long-term benefits in scar quality justify the investment in training.
Absorbable versus non-absorbable sutures: The choice between absorbable and non-absorbable dermal sutures remains debated. Absorbables reduce follow-up visits for removal but may have different handling characteristics or tissue reactions. Non-absorbables can be removed after a short interval, offering some control to the surgeon but requiring an extra visit for the patient. Evidence suggests both approaches can be effective when matched to tissue type and wound conditions.
Resource utilization and policy considerations: In some health systems, the adoption of buried dermal closures intersects with policies on cost-efficiency, reimbursement, and access to trained personnel. Supporters emphasize that efficient, cosmetically favorable closures can lower revision rates and improve patient throughput, while critics warn against privileging cosmetic metrics over universal access and core surgical safety.