Set-Back Suture Technique – Summary for Surgery Residents

Application

- Ideal for high-tension areas: back, shoulders, thighs.

- Can be used nearly anywhere, including central face, ears, cheeks, and forehead.

- Suitable for areas prone to wound inversion.

- Easier to place than buried vertical mattress; appropriate for students and residents as a primary deep tension-relieving technique.

Suture Material Choice

- Back: 2-0 absorbable (thicker suture tolerated; rare suture spitting).

- Extremities: 3-0 or 4-0 absorbable.

- Face/low tension areas: 5-0 absorbable.

- Thicker suture acceptable as it is buried deep in dermis.

Technique Steps

1. Reflect wound edge with forceps/hooks for dermal visualization.

2. Insert needle at 90° into dermis, 2–6 mm from wound edge.

3. First bite: follow needle curve through dermis, exiting 1–4 mm from wound edge.

- Avoid epidermis to prevent dimpling.

4. Release first side; reflect opposite edge to visualize dermis underside.

5. Second bite: mirror the first; insert 1–6 mm from wound edge, exit 2–6 mm distal.

- Avoid epidermis.

6. Tie suture using an instrument tie.

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Images

Tips and Pearls

- Superior eversion and cosmesis compared to buried vertical mattress (based on randomized trial).

- Easier execution: follows needle arc; no need to change planes or perfect exit point.

- Requires broad undermining to allow full loop under dermis.

- Useful for dead space reduction (e.g., cyst/lipoma excision):

- Set first bite further back to reduce central laxity and increase wound ridge.

- Chest keloids: Combination with post-op electron beam irradiation achieved ~98% success.

- Effect attributed to tension reduction and deep suture placement away from wound edge.