In the field of procedural dermatology, the primary concerns when performing surgical excisions include adequate control of surgical margins and cosmetic outcome. The ideal repair combines perfect wound approximation, tensile strength, and minimal scarring. Various techniques and suture materials are utilized by dermatologic surgeons to achieve this goal, depending on wound size, location, surgeon preference, and surgeon comfort level.
A 2006 prospective survey of 101 members of the Association of Academic Dermatologic Surgeons (now known as the Procedural Dermatology Section) found that epidermal layers were closed most often, in descending order, by simple interrupted sutures (38%-50%), simple running sutures (37%-42%), and vertical mattress sutures (3%-8%), with subcuticular sutures used more often on the trunk and extremities (28%).1 The most commonly used superficial sutures were nylon (51%) and polypropylene (44%), and the most common absorbable suture was polyglactin 910 (73%). Bilayered closures, undermining, and electrocoagulation were used in at least 90% of sutured repairs. With such an array of techniques, we would like to share our approach to achieving excellent and cost-effective results for wound closure on the trunk and extremities using a poliglecaprone 25 (Monocryl; Ethicon, Inc, San Angelo, TX) alone for layered closures.
Traditionally, nonabsorbable sutures, such as nylon or prolene, are used for superficial closure because of their high tensile strength, minimal tissue reactivity, and low capillary attraction.2 Recent studies have challenged the superiority of nonabsorbable sutures for cutaneous wound closure. A prospective study compared simple running sutures using the absorbable suture 5-0 poliglecaprone 25 (Monocryl) with the nonabsorbable suture 6-0 polypropylene (prolene) in primary closures of 57 facial Mohs defects.3 The authors blindly evaluated the wounds at 1 week and at 4 months postprocedure and found no statistically significant difference (P=.03) in cosmetic outcome. A bilayered closure with poliglecaprone (Monocryl) has many advantages for both patients and surgeons. Monocryl is a monofilament that elicits minimal inflammatory reaction and is absorbed by hydrolysis in vivo, retaining approximately 50% to 60% of its original strength 7 days postimplantation, 20% to 30% at 14 days, and absorption is essentially complete between 91 and 119 days.4
In the appropriate clinical setting, we favor using Monocryl for deep dermal approximation, followed by subcuticular running. A subcuticular running approach has several advantages: first, it leads to wound eversion not always achieved by superficial running sutures. Everted wound edges tend to heal with flatter scars, whereas an initially flat closure may become depressed following wound contracture.5 A running subcuticular suture also avoids track marks, which can accompany superficial running or interrupted epidermal suturing that can lead to patient dissatisfaction with cosmesis. A Monocryl-alone approach is most frequently implemented for closures below the neck, as sutures used on the face are typically removed in 1 week, resulting in minimal risk of track marks. Another advantage of using absorbable Monocryl for bilayer repairs on the trunk and extremities vs absorbable dermal sutures with nonabsorbable suture for the cutaneous layer is that once the superficial sutures are removed, stretching occurs and only the deep layer remains to keep the wound intact, whereas an intradermal Monocryl layer will retain 20% to 30% of its tensile strength at 14 days to combat stretching.
Using a Monocryl-only approach, patients are spared the financial costs and time of returning to the office for a follow-up visit for suture removal. A cost-analysis study using a single suture package of coated absorbable polyfilament suture (polyglactin 910) for deep and superficial layers saved approximately 50%