Surgical Corner. Modified Buried Suture Technique for the Scalp

June 2013 | Volume 12 | Issue 6 | Features | 692 | Copyright © June 2013

Phillip C. Hochwalt MD, Adam Asarch MD, John C. Selby MD PhD, and Marta VanBeek MD MPH

Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, IA

Large surgical defects on an actinically damaged scalp are notoriously difficult to close primarily. Not only is the skin weak and friable, but the underlying bone often limits the size of “bite” that the surgeon can take with their deep suture. We describe a technique that maximizes the ability to grasp adequate deep tissue with the suture, decreasing the likelihood of tearing through the tissue when the wound edges are brought together.

J Drugs Dermatol. 2013;12(6):692-693.


Clinical Bottom Line

The standard buried suture technique limits the surgeon’s ability to grasp adequate deep tissue on the scalp, which often results in the suture tearing through the tissue as the surgeon attempts to bring the wound edges together. The modified buried suture technique of the scalp maximizes gripping of dermal and subcutaneous tissue and often allows for primary closure of large scalp defects.

Clinical Issue

Large surgical defects on the scalp can be difficult to close. When primary closure is not possible, secondary intention healing can be utilized. Unfortunately, secondary intention healing can take several weeks, requires meticulous wound care, and may be considered aesthetically suboptimal in certain cases.1,2 The difficulty in scalp wound closure often rests in the limited depth of soft tissue above the periosteum, which restricts the surgeon’s ability to grasp adequate deep tissue with a standard buried suturing technique. This difficulty can be compounded by weak or friable surrounding tissue from actinic damage or previous surgical scars. We utilize a buried suture technique that maximizes gripping of dermal and subcutaneous tissue and often allows for primary closure of scalp tissue. Our technique, which is easy to perform, significantly limits the likelihood of tearing through deep tissue when compared to traditional techniques.


Large braided absorbable suture with a high tensile strength such as 2-0 or 3-0 Dexon® or Vicryl® is typically used for this closure. The suture first enters the deep tissue similar to standard suturing technique. However, the needle then exits the epidermis 1-2cm adjacent to the wound, and the excess suture is pulled through. The needle is then directed into the same epidermal exit point (taking care not to cut the exiting suture with the needle point), guided through the dermis, and pulled through the wound margin in the upper dermis (Figure 1a). As the excess suture is brought through the free margin of the wound, the suture loop will bury within the deeper tissues (Figure 1b, left). Additionally, because the needle is directed through the same epidermal exit point, deep suture will not be exposed to the epidermal surface. The needle is then brought through the upper dermis on the opposite side