Figure 1. A, First throw, cross-sectional view; B, second throw, cross-sectional view; C, first throw, surgeon’s-eye view; D, second throw, surgeon’s-eye view.
Figure 2. A, Final wound appearance, cross-sectional view; B, final wound appearance, surgeon’s-eye view.
Figure 3. Defect before (A) and after (B) placement of single fascial plication suture; note enhanced fusiform appearance of the wound. Scale bar measures 6 cm in both panels.
Kantor J. The Fascial Plication Suture: An Adjunct to Layered Wound Closure. Arch Dermatol. 2009;145(12):1454-1456. doi:10.1001/archdermatol.2009.311
Minimizing surgical wound tension is generally accomplished by combining buried dermal sutures with an epidermal closure of choice. Several improvements on the buried dermal suture have been proposed over the years, from the buried vertical mattress technique1 and its many variants2 to the setback dermal suture.3
Despite the unique nature of wound closure from excisional surgery, most surgeons approach these closures as repairs of simple incisions. The added wound tension resulting from the extirpation of the excised tissue, over and above the tension across the surface of the wound that would be expected even from incisional surgery, may not be fully alleviated with standard layered-closure techniques. In excisions of large cysts or tumors, significant dead space may remain even with wounds closed using dermal sutures, potentially increasing the risk of hematoma formation or wound infection.
The plication of superficial muscle fascia has been used as a technique of choice in rhytidectomy surgery for decades. The popularity of this technique stems from the ability to effect long-lasting tissue drag. Extending the application of this technique to reconstructive procedures, Dzubow4 described the use of multiple fascial plication sutures using nonabsorbable sutures in lieu of dermal sutures for select Mohs defects on the head and neck. Other authors have suggested fascial imbrication for select scalp and forehead defects.5
The fascial plication technique described herein is best suited to high-tension repairs on the trunk, neck, and shoulders—areas where general dermatologists perform the bulk of their procedures. Further study is needed to assess whether this technique confers a significant benefit over standard layered closure techniques.
After the excision is accomplished, the wound is widely undermined in the level of the superficial fat, and adequate hemostasis is obtained. For all but the deepest excisions, the muscle fascia will not be visible at this point. With absorbable suture (I favor 2-0 Vicryl; Ethicon Inc, Somerville, New Jersey), the first throw is accomplished by inserting the cutting or reverse-cutting needle gently into the fat and through the superficial fascia approximately 2 to 5 mm from the undermined edge of the wound (Figure 1A and B). A successful bite of the fascia may be tested by gently pulling on the suture and watching for characteristic uplifting of the area. The second throw is then performed by repeating the procedure on the opposite edge and at the same depth (Figure 1C and D). The knot is then tied, which results in a visible pleat and leads to a more fusiform appearance of the wound (Figure 2 and Figure 3). Placing the sutures at the far lateral undermined edges should be avoided owing to a tendency for dimpling of the overlying skin. If 1 fascial plication suture is used, this may be placed in the vertical midline of the wound; otherwise, a series of multiple evenly spaced plication sutures may be placed.
While this technique might theoretically increase risk of postoperative pain from deep tissue trauma or infection through the breach in the superficial muscle fascia, these issues have not been a problem in my experience. In hundreds of wound closures using this technique on the shoulders and trunk, I have found improved outcomes with less spread-scar formation, less dehiscence, and less tendency toward hematoma formation, especially on large defects. A randomized controlled trial is needed to determine whether this technique truly offers a clinically and statistically significant benefit over standard layered wound closure techniques. This technique shifts the burden of tension from the dermis to the fascia, theoretically resulting in a lower-tension closure, dramatically improved dead-space minimization, and, hopefully, a cosmetically and functionally improved reconstruction.
Correspondence: Dr Kantor, North Florida Dermatology Associates, 1551 Riverside Ave, Jacksonville, FL 32082 (email@example.com).
Accepted for Publication: July 14, 2009.
Author Affiliation: North Florida Dermatology Associates, Jacksonville, Florida.
Financial Disclosure: None reported.