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The Four-Step Subcuticular Suture Technique

Retzlaff, Kelly A.P.N.; Agarwal, Shailesh B.S.; Song, David H. M.D., M.B.A.; Dorafshar, Amir H. M.B.Ch.B.

Plastic and Reconstructive Surgery: July 2010 - Volume 126 - Issue 1 - p 50e-51e
doi: 10.1097/PRS.0b013e3181dab592

Section of Plastic and Reconstructive Surgery; University of Chicago; Chicago, Ill.

Correspondence to Dr. Dorafshar; Section of Plastic and Reconstructive Surgery; University of Chicago; 5841 South Maryland Avenue, MC 6035; Chicago, Ill. 60637;

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One of the primary missions of an academic medical center is to train future physicians. However, because of ever-increasing economic pressures, the drive to maximize efficiency in our practices is being emphasized. Unfortunately, this can threaten our role as teachers. As a result, a simple, reproducible method of teaching medical students and junior surgical residents how to perform a basic running subcuticular (or intracuticular) suture was developed.

Although the running subcuticular suture is well described in surgical textbooks,1 the “four-step method” is unique in that it separates and quantifies each component. With the first step, the skin is gently everted using an Adson forceps to visualize the dermal-epidermal junction (Fig. 1, above, left). Step two consists of introducing the needle at a 90-degree angle at the dermal-epidermal junction and pronating the wrist to take a deep horizontal bite parallel to the skin surface (Fig. 1, above, right). In step three, the needle is stabilized with the Adson forceps, being mindful of not touching the tip, and advanced through the skin (Fig. 1, below, left). In this step, it is important to emphasize to the student that the Adson forceps can be used more effectively by firmly gripping the needle at more of a right angle to it, allowing more contact and thus success with grasping the needle, without dulling the needle by manipulating the tip. Finally, in step four, while continuing to stabilize the needle with the Adson forceps, the needle is replaced in the needle holder in the appropriate position for the next throw (Fig. 1, below, right). It should be highlighted that in this step the operator should stabilize the hand holding the needle with the Adson forceps on the patient's body close to the area from the last throw while releasing and reloading with the needle holder, to minimize the difficulty in reloading the needle holder in the correct position for the next throw.

Fig. 1.

Fig. 1.

Once the student grasps the concept of each of the four steps, the instructor begins to count aloud as the student performs each of the four steps. Each movement performed by the student is given a number (i.e., 1, 2, 3, 4, 5, and so on), illustrating extraneous movements. The immediate feedback provided by having the instructor count aloud has been critical in helping students at our institution master this skill and improve their efficiency by removing extraneous movements. Once the basic concept is grasped, the four-step method can be modified as necessary for the advancing surgeon.

In conclusion, the four-step method is a quick, simple, and easily reproducible method of teaching medical students and junior residents how to perform a basic running subcuticular suture. We believe that its simplicity will serve as a valuable tool for surgeons to maintain their efficiency in the operating room while still fulfilling their role as teachers.

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The authors have no financial interests to disclose and there were no external sources of funding provided for this project.

Kelly Retzlaff, A.P.N.

Shailesh Agarwal, B.S.

David H. Song, M.D., M.B.A.

Amir H. Dorafshar, M.B.Ch.B.

Section of Plastic and Reconstructive Surgery

University of Chicago

Chicago, Ill.

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1. Thorne CH. Techniques and principles in plastic surgery. In: Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007:5–6.
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