Surgical Corner: Straight Suture Needle for Full-Thickness Skin Graft Fixation on the Ear

Nonmelanoma skin cancers occur frequently on the ear. After tumor clearance has been confirmed, a number of reconstructive options are available to the dermatologic surgeon, depending on the size, depth, and location of the surgical defect. In areas where there is intact perichondrium, a common repair is the full-thickness skin graft. Full-thickness skin graft survival depends on maintaining close approximation to the recipient wound bed while a new blood supply is established. This is usually accomplished with a bolster or tie-over dressing.¹ The intrinsic convexities of the ear often prevent full apposition within adjacent concavities. This may inhibit graft adhesion and survival. Cigna et al advocated a through-and-through tie-over bolster in the conchal bowl to avoid this complication.² Basting or tacking down the graft is another frequent maneuver used to avoid seroma or hematoma formation between the graft and the recipient bed.³ On the ear, when the tacking suture is partial thickness, a round needle may shear through the cartilage if the angle is too shallow. When creating a through-and-through basting suture, the curvature of the needle can make it difficult to be precise in placing its reentry.

We describe a simple method for full-thickness graft fixation that is applicable to the ear and any other structure that has 2 surfaces, such as the ala. We have found it especially effective within the concavities of the anterior ear, where the native topography is challenging to negotiate with a curved needle.

Once the peripheral edges of the full-thickness skin graft have been sutured into place (Figure 1), a 4-0 plain gut suture on an SC-1 needle (Ethicon, Inc, Somerville, NJ) is used for the tacking suture. An SC-1 needle is a 13-mm-long straight cutting needle (Figure 2). This straight needle allows precise entry and reentry of the suture and close approximation of the graft within any concavity of the ear (Figure 3). This procedure is then repeated as often as necessary to firmly tack the graft into place (Figure 4). The absorbable suture material provides the surgeon the option to remove it at 5 to 7 days or to allow it to spontaneously dislodge in 2 to 3 weeks. The latter time interval is another convenient benefit of this suture, since it corresponds to a critical window for graft neovascularization.

This technique is not limited to graft fixation on the ear. We have also found this suture to be helpful in tacking down grafts within the alar groove. The straight-needle, through-and-through suture fixation can also be used after harvesting of auricular cartilage for reconstruction elsewhere or cartilage resection for management of chondrodermatitis nodularis helicis. The resultant dead space created after cartilage harvest is at risk for auricular hematoma development, which can be a significant complication. By approximating this space with a running through-and-through suture, the risk is diminished.