Introduction
Surgical wound closure technique significantly impacts postoperative recovery—subcuticular sutures demonstrate 23% lower risk of hypertrophic scarring compared to traditional staples. For millions of surgical patients annually, the closure method determines outcomes: minimal scarring versus permanent "train track" marks, comfortable healing versus painful staple removal appointments.
Subcuticular closure is a surgical refinement that prioritizes both functional healing and aesthetic outcomes. By placing sutures within the dermal layer rather than piercing the skin surface, surgeons can achieve superior cosmetic results while maintaining wound integrity. This approach addresses common patient concerns: visible scarring, suture marks, and the discomfort associated with removal procedures.
From Halsted's pioneering work in the 1890s to today's bioabsorbable stapler systems, subcuticular techniques have evolved significantly—driven by innovations in materials, technique refinements, and evidence-based outcomes.
TLDR
- Subcuticular placement 1-2mm below skin eliminates visible marks and surface penetration
- Match technique to wound tension—buried vertical mattress excels for high-stress closures
- Bioabsorbable stapler systems close wounds 7X faster than manual sutures with superior cosmetic results
- Subcuticular closure reduces dehiscence risk 37% and improves patient satisfaction vs. staples
- Synthetic monofilaments (polydioxanone, poliglecaprone) minimize inflammation and absorb predictably
Understanding Subcuticular Closure: Definition and Fundamentals
Subcuticular (intradermal) sutures are placed entirely within the dermal layer of skin, typically 1-2mm below the surface, without penetrating the epidermis. Unlike percutaneous (transdermal) sutures, which pass completely through all skin layers with visible knots on the surface.
Anatomical Considerations:
The technique requires precise understanding of skin anatomy. The dermis—the target layer for suture placement—varies significantly by body location.
Facial dermis measures approximately 0.98-1.30mm thick, while trunk dermis ranges from 2.01-2.09mm on the abdomen. This variation directly impacts technique selection and success.
Primary Clinical Benefits:
- Elimination of suture marks - No surface penetration means no "train track" scarring
- Superior aesthetic outcomes - Wounds heal with minimal visible scarring
- Enhanced patient comfort - Absorbable materials eliminate removal appointments and associated anxiety
- Reduced scarring rates - Evidence shows 23% lower hypertrophic scar formation compared to staples
Biomechanical Principles:
Effective subcuticular closure relies on two critical factors: tension reduction and wound edge eversion. Proper tension distribution across the dermis prevents wound dehiscence, while slight eversion counteracts the natural tendency of scars to contract and become depressed.
Sutures placed 3-4mm from the wound edge in deeper dermis achieve both objectives, creating a ridge-like eversion that flattens as healing progresses.
Evolution of Subcuticular Techniques: From Halsted to Modern Methods
Halsted's Pioneering Work (1890s)
William S. Halsted revolutionized surgical practice in 1893 by proposing buried sutures for hernia repair. His technique placed sutures within the lower skin layer rather than on the surface, dramatically reducing wound infection rates by avoiding surface contaminants.
Halsted's approach was essentially planar—achieving edge-to-edge approximation without eversion. Yet it established the fundamental principle that would guide subcuticular closure development for the next century.
The Shift to Eversion Techniques (1980s-1990s)
The field transformed in 1989 when Zitelli and Moy introduced the buried vertical mattress suture. This breakthrough technique combined the advantages of vertical mattress and buried intradermal sutures, placing the suture snugly against the epidermis 3-4mm from the wound edge to achieve deliberate wound eversion.
This marked a fundamental shift from simple approximation to biomechanically optimized closure. Building on this eversion principle, Breuninger advanced the field in 1993 with the intracutaneous butterfly suture. By using oblique scalpel excision rather than perpendicular cuts, Breuninger increased the contact area between wound edges, improving stability and eversion. The butterfly configuration—where the knot lies beside the suture loop—provided enhanced anchoring for wounds under tension.
Modern Refinements and Variations (1990s-2010s)
The subsequent decades brought practical refinements that simplified placement while maintaining benefits:
- Sadick's modification (1994) — Punctured skin directly to enhance efficiency while maintaining excellent cosmesis for wounds under tension
- Hohenleutner's intradermal approach (2000) — Advocated superficial arc placement optimized for thin facial skin, achieving excellent/good results in 89.1% of cases
- Berry's variant (2002) — Started in the subcutaneous layer for easier placement with firm anchoring
- Kantor's set-back suture (2010) — Revolutionary super-tension-reduction technique with no suture passing through incision dermis, minimizing dead space and suture spitting risk
- Meng's modified buried horizontal mattress (2017) — Designed for improved, longer-lasting tension reduction compared to vertical approaches
Types of Subcuticular Suture Techniques
Planar Suture Techniques
Planar techniques like Halsted's original buried suture and intradermal buried vertical mattress achieve simple wound edge approximation without deliberate eversion.
Advantages:
- Easy to master for surgeons learning subcuticular closure
- Provides precise edge-to-edge apposition
- Eliminates suture marks completely
Disadvantages:
- Less firmly anchored than eversion techniques
- Higher risk of wound dehiscence under tension
- No prevention of scar contraction, potentially leading to depressed scars
Interestingly, a randomized split-scar trial found that wound eversion achieved with buried dermal sutures did not statistically improve overall cosmetic outcome compared to planar closure in non-head/neck wounds, suggesting patient selection and wound characteristics matter more than technique alone.
Eversion Suture Techniques
When planar closure proves insufficient, eversion techniques deliberately create a raised wound edge that flattens during healing. These methods provide enhanced mechanical support for challenging wounds.
Buried Vertical Mattress
The needle enters 3-4mm from the skin edge in superficial dermis, passes deep into the dermis, crosses beneath the wound, and exits symmetrically on the opposite side.
This creates pronounced ridge-like eversion and provides superior tension relief for high-stress wounds.
Intracutaneous Butterfly
Utilizes oblique or horizontal excision to increase wound contact area. The butterfly configuration provides greater stability and anchoring, particularly beneficial for wounds under moderate tension.
The knot position beside the loop enhances mechanical advantage.
Buried Horizontal Mattress
An alternative for extremely thin dermis or shallow wounds where vertical needle passage is impractical. The horizontal path distributes tension across a broader tissue area, reducing stress concentration at any single point.
Super-Tension-Reduction Techniques
For high-tension wounds requiring maximum support, specialized techniques offer enhanced biomechanical advantages.
Wedge-shaped Excision with Modified Buried Vertical Mattress (WE-MBVMS):Combines strategic tissue excision with modified suture placement for wounds with extensive dermal involvement. The wedge shape reduces tension before suture placement, while the modified vertical mattress provides optimal eversion.
Set-Back Suture:Kantor's innovation places no suture through the incision dermis itself. Instead, sutures are set back from the wound edge, creating dramatic eversion while minimizing dead space. This approach significantly reduces suture spitting risk in thin or compromised skin.
| Technique | Best Applications | Key Advantages | Limitations | Ideal Locations |
|---|---|---|---|---|
| Halsted's Buried Suture | Low-tension wounds, precise approximation needed | Easy to learn, precise apposition | No eversion, higher dehiscence risk | Face, areas with thick dermis |
| Buried Vertical Mattress | Moderate to high tension wounds | Strong eversion, excellent tension relief | Requires practice, limited by needle size | Trunk, extremities, scalp |
| Butterfly Suture | Oblique wounds, moderate tension | Increased contact area, stable anchoring | More complex placement | Face, areas requiring precise eversion |
| Buried Horizontal Mattress | Thin dermis, shallow wounds | Distributes tension broadly | Less eversion than vertical | Face, eyelids, thin skin areas |
| Set-Back Suture | High-tension wounds, thin skin | Dramatic eversion, minimal spitting | Complex technique | High-stress areas, compromised skin |
Clinical Applications and Technique Selection
Indications for Subcuticular Closure
Subcuticular techniques excel in specific clinical scenarios:
- Clean, straight lacerations ≤6cm under minimal tension
- Cosmetically sensitive areas where scarring significantly impacts patient quality of life
- Patients prone to keloid formation who benefit from reduced inflammatory response
- Pediatric patients where avoiding traumatic suture removal improves cooperation and reduces anxiety
- Wounds beneath casts or in locations where follow-up access is problematic
- Patients unlikely to return for suture removal due to distance, mobility issues, or compliance concerns
Contraindications and Limitations
Absolute Contraindications:
- Irregular or ragged wound edges that prevent proper tissue approximation
- Wounds under marked tension exceeding dermal support capacity
- Heavily contaminated wounds or those older than 6-8 hours
- High-velocity missile injuries with extensive tissue damage
- Human or animal bites due to elevated infection risk
Relative Contraindications:
- Thin or atrophic skin with increased suture extrusion risk
- Wounds involving deep structures (nerves, vessels, joints, tendons) requiring specialist consultation
- Large wound areas exceeding 25cm requiring extensive closure
- Complex facial or hand wounds where functional outcomes demand specialist expertise
Decision-Making Framework for Technique Selection
Once you've determined subcuticular closure is appropriate, selecting the optimal technique depends on wound characteristics and anatomical location.
Wound Location Considerations:
- Face: Use intradermal buried vertical mattress or Hohenleutner's superficial arc technique; consider early partial removal (day 3-5) to minimize scarring
- Trunk: Buried vertical mattress provides optimal tension relief; longer suture retention (7-10 days) acceptable
- Extremities: Modified horizontal mattress distributes tension effectively; plan removal at 10-14 days
- Over joints: Set-back or super-tension-reduction techniques; retain sutures 14 days minimum
Dermal Thickness Assessment:
- Thin dermis (face, eyelids): Horizontal mattress or superficial vertical approaches minimize tissue trauma
- Thick dermis (back, buttocks): Deep vertical mattress with aggressive eversion prevents inversion
Tension Level Evaluation:
- Low tension: Simple planar techniques work well
- Moderate tension: Standard buried vertical mattress
- High tension: Set-back suture or WE-MBVMS with possible layered closure
Suture Material Selection:
Absorbable synthetic monofilaments are strongly preferred for intradermal use:
- Poliglecaprone 25 (Monocryl): Excellent for facial wounds with superior pliability and handling; loses strength by 3 weeks
- Polydioxanone (PDS): Extended support (retains 50% strength at 4 weeks); ideal for high-tension areas
- Polyglactin 910 (Vicryl): Good all-purpose option; braided structure offers excellent handling but slightly higher tissue reactivity
Nonabsorbable monofilaments (nylon, polypropylene) are reserved for situations requiring removal control or extended support beyond absorbable capacity.
Modern Advances in Subcuticular Closure
Innovations in Suture Materials
Modern synthetic absorbable sutures represent a significant advancement over natural materials like catgut. Synthetic sutures degrade via hydrolysis rather than proteolysis (enzyme breakdown), producing significantly less inflammatory reaction while maintaining predictable absorption profiles.
Polydioxanone (PDS II):This monofilament maintains 74% tensile strength at 2 weeks and 50% at 4 weeks, with minimal absorption until day 90. Its stiffness and high memory make it ideal for extended approximation under tension, though handling requires more experience.
Poliglecaprone 25 (Monocryl):Exceptionally pliable with excellent handling characteristics, Monocryl retains only 20-30% strength at 2 weeks but provides sufficient support for most soft tissue approximation. Complete absorption occurs between 90-120 days, making it ideal for facial wounds where early strength loss reduces scarring.
Bioabsorbable Stapler Systems
The most significant recent advancement combines traditional stapler speed with subcuticular cosmetic benefits. Systems like SubQ It! use bioabsorbable dermal fasteners inserted subcutaneously, completely eliminating external skin penetration.
Mechanism of Action
Adson forceps expose the sub-dermal tissue 3-4mm from the wound edge. Barbed fastener legs supported by surgical needles drive into the dermis at strategic points away from the cut edge.
The needles immediately retract, leaving bioabsorbable fasteners that engage tissue through barbs while the connecting bridge provides tensile strength to hold edges together.
Clinical Advantages
- Speed: Each fastener deploys in 7 seconds versus 42 seconds for manual subcuticular stitches—representing 7X faster closure
- Cosmetic outcomes: No train track scarring; external skin never pierced
- Patient comfort: No removal procedures required; fasteners absorbed after healing
- Versatility: Suitable for incisions up to 25cm across multiple specialties
FDA Clearance and Applications
The SubQ It! system received FDA 510(k) clearance K131563 in April 2014 for closing incisions in abdominal, thoracic, gynecologic, orthopedic, plastic, and reconstructive surgery.
Clinical applications include laparoscopic cholecystectomy, hernia repairs, cesarean sections, and various minimally invasive procedures.
Bioabsorbable fasteners are manufactured from PLGA (polylactic-co-glycolic acid), maintaining 80% strength for 21 days—the critical healing period—before gradual absorption.
Each fastener weighs only 0.0064 grams, minimizing foreign body reaction while providing adequate mechanical support.
Evidence and Outcomes
Cochrane systematic review evidence involving 66 studies and 7,487 participants demonstrates that subcuticular sutures probably decrease hypertrophic scar incidence compared to staples (RR 0.77, 95% CI 0.60-0.98). Patient satisfaction scores are consistently higher with subcuticular techniques—1.60 points higher on a 1-10 scale compared to transdermal sutures.
Wound Dehiscence and Safety Profile
Key clinical findings include:
- Subcuticular sutures may reduce wound dehiscence risk by 37% compared to staples (RR 0.63, 95% CI 0.43-0.94)
- No clear difference in surgical site infection rates between methods
- Yang's cesarean section comparison showed superior cosmetic outcomes with intradermal buried suture techniques
- A 2025 meta-analysis found no significant difference in wound complications between staples and subcuticular sutures specifically in obese cesarean patients, highlighting the importance of patient-specific factors
Best Practices, Complications, and Aftercare
Technical Execution Best Practices
Precision Placement:
Take similar-sized small bites horizontally through the dermis, maintaining consistent depth throughout. Place each successive bite 1-2mm behind the exit point of the previous suture to prevent gaps. Ensure all sutures lie on the same horizontal plane within the dermis—varying depth creates uneven tension distribution.
Common Errors to Avoid:
- Suture ends exiting on opposite sides of the wound, causing the knot to sit superficially rather than buried
- Starting the initial knot too superficially instead of deep in the dermis
- Taking bites too close to the wound edge (less than 3mm), risking tissue tear-through
- Excessive tension causing tissue strangulation and ischemia
Wound Preparation Protocol:
Proper wound preparation involves several key steps:
- Thorough cleansing with normal saline or antiseptic solution to remove surface contaminants
- Adequate local anesthesia (lidocaine with epinephrine for hemostasis) for patient comfort and surgical precision
- Copious irrigation to remove debris and foreign material
- Conservative debridement of devitalized (non-viable) tissue to optimize healing without excessive tissue loss
Clean gloves are sufficient for uncomplicated laceration repair—sterile gloves don't reduce infection risk.
Complications and Management
Wound Dehiscence:
This complication occurs most commonly when technique doesn't match wound characteristics—such as using planar closure for high-tension wounds or inadequate deep layer closure before subcuticular placement.
Prevention strategies include:
- Accurate assessment of wound tension before technique selection
- Adequate deep layer closure to reduce superficial tension
- Matching closure method to anatomical location and wound characteristics
Infection:
Subcuticular techniques show no significant difference in surgical site infection rates compared to other methods (RR 1.10 for transdermal sutures, RR 0.81 for staples). Proper wound preparation and patient selection are more important than closure technique for infection prevention.
Suture Extrusion:
This occurs primarily in thin or atrophic skin when sutures are placed too superficially.
Risk reduction strategies:
- Use finer suture material (5-0 or 6-0)
- Ensure adequate depth (1-2mm minimum)
- Consider set-back techniques, which virtually eliminate spitting by avoiding the incision dermis entirely
Reactive Inflammation:
Synthetic absorbable sutures cause significantly less inflammation than natural materials. Monofilaments produce less reaction than braided sutures. When inflammation occurs, it typically resolves spontaneously as suture absorption progresses.
Modern bioabsorbable stapler systems like SubQ It! address several traditional suture complications by eliminating the need for removal, reducing procedure time by up to 7X compared to manual sutures, and avoiding train-track scarring associated with metal staples.
Aftercare and Follow-up Protocols
Wound Dressing:
Cover wounds with gauze or semiocclusive polymer film dressing for at least 24 hours to maintain moist healing environment. Topical antibiotic ointment is beneficial for traumatic lacerations. Patients should avoid prolonged soaking (swimming, extended baths) to prevent premature tensile strength loss.
Suture Removal Timeline (when using nonabsorbable sutures):
| Location | Days | Rationale |
|---|---|---|
| Face | 3-5 | Early removal minimizes scarring |
| Scalp/trunk | 7-10 | Standard healing timeframe |
| Extremities | 10-14 | Higher tension areas |
| Over joints | 14 | Longer support needed for movement |
Patient Instructions:
Provide patients with clear guidance:
- Keep dressing dry for first 24-48 hours
- Monitor for infection signs: increasing pain, redness, warmth, purulent drainage, or fever
- Return immediately if wound edges separate or infection signs develop
- For absorbable subcuticular sutures: no removal needed; expect gradual absorption over 60-120 days depending on material
Frequently Asked Questions
What is the main difference between subcuticular and traditional suturing techniques?
Subcuticular sutures sit 1-2mm below the skin surface without penetrating the epidermis, while traditional sutures pass completely through all layers with visible surface knots. This placement eliminates suture marks and produces superior cosmetic results.
Which subcuticular technique is best for facial wounds?
Intradermal buried vertical mattress or Hohenleutner's superficial arc technique work best due to thin facial dermal thickness. Early partial removal at day 3-5 further minimizes scarring.
How long do absorbable subcuticular sutures take to dissolve?
Polyglactin (Vicryl) absorbs in 56-70 days, poliglecaprone (Monocryl) in 90-120 days, and polydioxanone (PDS) in 182-238 days. Tensile strength is lost by 3-6 weeks, allowing proper healing before full absorption.
Can subcuticular sutures be used for all types of surgical wounds?
No. They work best for clean, straight lacerations under minimal tension. Avoid using them for irregular wounds, contaminated wounds, high-velocity injuries, or wounds under marked tension.
What are the advantages of bioabsorbable stapler systems compared to traditional sutures?
Systems like SubQ It! deploy fasteners in 7 seconds versus 42 seconds per stitch—7X faster closure. They deliver superior cosmetic outcomes without train track scarring, eliminate removal procedures, and absorb naturally during healing.
What are the most common complications with subcuticular closure techniques?
Wound dehiscence occurs when technique doesn't match wound tension characteristics. Infection rates are similar to other closure methods (no significant difference). Suture extrusion happens occasionally in thin skin when placed too superficially, and mild inflammation to suture material resolves as absorption progresses.
