Clinical Challenge
Hemodynamic stability, skin approximation (especially in high-tension areas), and achieving an ideal esthetic outcome are the goals of a cutaneous closure. The objectives can challenge those performing dermatologic procedures. While dermatologists are familiar with the figure 8 suture technique, also known as the cruciate mattress suture, as a means to achieve the first 2 objectives, this crossed horizontal mattress can be less esthetic and potentially can catch on fingernails or clothing.
Solution
The inverse figure 8 suture, also known as the “hidden X suture,”1 solves this conundrum. Exiting the epidermis in a diagonal direction opposite its entrance, the hidden X is achieved by reentering the initial epidermal side, again exiting obliquely. The visible result entails 2 suture lines perpendicular to the linear closure, with the knot tied at the initial entrance site (Fig 1).
Fig 1.
A, Step-by-step guide to needle insertion and exit. 1. First point of needle insertion. 2. First point of needle exit. 3. Second point of needle insertion. 4. Second point of needle exit (to approximate the closure, the loose suture from point 1 is tied in several successive standard knots to the suture exiting from point 4.). B, Closure by inverse figure 8 technique.
The inverse figure 8 addresses hemodynamic stability and skin approximation just as the standard figure 8. Furthermore, with the suture crossing buried beneath the wound surface, it is not only more esthetic and less prone to accidental manipulation but depending on the tension, could cause further slight wound eversion and result in a better long-term outcome. While a typical horizontal mattress relies on adequate distance and tissue support between the entrance and exit points, an inverse figure 8 allows for excellent skin approximation when closing a small circular defect, such as from a punch biopsy, and defects with friable tissue. The inverse figure 8 suture technique has been utilized successfully by periodontists and surgeons for years.1,2 Maybe it’s time we teach the inverse of a surgical technique mainstay to our trainees too.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
IRB approval status: Not applicable.
Patient consent: Patient consent is unnecessary in this case as photos are specifically of suture on non-marked (non-tattooed) skin and therefore the source is unidentifiable.
References
- 1.Park J.C., Koo K.T., Lim H.C. The hidden X suture: a technical note on a novel suture technique for alveolar ridge preservation. J Periodontal Implant Sci. 2016;46(6):415–425. doi: 10.5051/jpis.2016.46.6.415. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Gomes O.M., Campos do Amaral A.S., Villar Goncalves A.J., Brito A.S., Monteiro E.L. New suture techniques for best esthetic skin healing. Acta Cir Bras. 2012;27(7):505–508. doi: 10.1590/s0102-86502012000700013. [DOI] [PubMed] [Google Scholar]