The Cross-Running Intradermal Suture: A Novel Method for Incision Closure

The aim of this letter is to provide details derived from our personal experience with the running intradermal suture. We have developed the cross-running intradermal suture (CRIS) to enhance the strength of closure, decrease the length of incision, and reduce the potential of complications.

We employ 5–0 Safil (B/Braun, Tuttlingen, Germany) sutures. The subdermal tissue is closed with interrupted sutures to diminish the tension on the skin. After that, the CRIS is performed to close the skin. To begin, the suture needle enters just beneath the dermis at end A of the incision for the first bite and exits from the mid-dermis ([Fig. 1a]). Next, a running intradermal closure is performed toward end B. The distance from suture to suture should be 2 to 4 mm. On reaching end B, the needle exits from the mid-dermis and is then passed through the opposing skin edge at the same level but with a direction change ([Fig. 1b]). This bite should be taken carefully so that the opposing sutures lie at an equal distance from end B. Then the running intradermal closure is continually performed toward end A, with each bite placed directly opposite to the one on the other side (generating a suture with mirror symmetry across the incision line). When back at end A, the last bite exits beneath the dermis ([Fig. 1c]). Finally, the ends of the suture are pulled tight and tied with moderate tension. The knot is then retracted beneath the skin.

Figure 1 Cross-running intradermal suture technique.

The suture of the CRIS lies symmetrically and within the same layer along each side of the incision. Compared with the conventional running intradermal suture, which is asymmetrically located, the CRIS can provide high strength closure. On the other hand, the suture loop of the CRIS is closed, so it shares characteristics of the purse-string suture. The length of incision can be reduced by pulling the suture taut ([Fig. 2], [Fig. 3]) while maintaining apposition of the skin edges. This is particularly useful when the incision is located in an obvious place such as the face. We recommend undermining the incision edge for 2 to 3 cm prior to suturing. In our experience, the CRIS is safe and can also be used to close the subdermal tissue. This technique has been applied by three surgeons in our department on 50 patients. Of these, 21 patients were followed for 3 to 8 weeks and no complications were reported. Nineteen of the 21 patients were satisfied with the scar. We are in the process of carrying out further studies on the long-term results of the CRIS technique.

Figure 2 Cross-running intradermal suture performed on pig skin model, with a 1-cm reduction in incision length.

Figure 3 Cross-running intradermal suture performed on the back of a 4-month-old male patient after hemangioma resection, with a 1-cm reduction in incision length following suture knotting.