Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents     
Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 57-58
External knot for running intradermal stitch

1 Department of Surgery-Plastic Surgery, Creighton University School of Medicine, Phoenix, Arizona, USA
2 Department of Surgery-Plastic Surgery, Creighton University School of Medicine, Phoenix, Arizona, USA; Department of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona, USA

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Date of Web Publication17-Mar-2020


We describe a unique method for closure of running subcuticular/intradermal suture that minimizes potential abscess formation and maximizes cosmetic outcomes.

Keywords: Surgery, suture, technique

How to cite this article:
Leach GA, Chaffin HM, Bristyan MC, Holcombe TC. External knot for running intradermal stitch. J Cutan Aesthet Surg 2020;13:57-8

How to cite this URL:
Leach GA, Chaffin HM, Bristyan MC, Holcombe TC. External knot for running intradermal stitch. J Cutan Aesthet Surg [serial online] 2020 [cited 2022 Sep 24];13:57-8. Available from:

   Introduction Top

The standard technique for subcuticular/intradermal suturing entails placement of a buried knot at the distal apex of an incision, running the suture material with subcuticular/intradermal bites to the proximal apex where an additional buried knot is made, pulling the needle and suture material through the adjacent skin, and finally cutting it flush with the epidermis.[1]

Though this method is functionally reliable, there are several potential problems. One is that the buried knots are prone to abscess formation.[2] In addition, the bulk associated with the buried knots can leave a “dog-ear” appearance to the wound apices.[3]

Therefore, we present a technique in which the incision is closed without a buried knot mitigating the potential for abscess formation in addition to the cosmetically unappealing bulk at wound edges associated with standard subcuticular closure.

   Report Top

The technique is articulated and shown in [Figure 1] and Video 1. A standard intradermal bite at the distal apex is made leaving a long tail. Subsequent running intradermal bites are made from the distal to the proximal apex. When the proximal apex is reached, the needle and suture is brought out through the adjacent skin at a 90° angle. The suture is wrapped around the shaft of the needle driver. Using the needle driver, the suture is then grasped approximately 1cm from the skin [Figure 1]A Next, using the free, contralateral hand, the loop around the shaft is flipped over the jaws of the needle driver to create a knot with a loop [Figure 1]B. Attention is made to leave a slight air knot while securing the knot approximately 1cm above the skin. Additional throws are made using standard simple suture technique [Figure 1]C. After six total throws, the free end is cut [Figure 1]D.
Figure 1: (A–D) Steps for securing intradermal suture with external knot

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   Conclusion Top

We have seen outstanding functional and aesthetic results with this method. This technique is simple and reliable. It provides durability that is comparable to that with buried knots. Having the knot external mitigates the risk associated with granuloma and abscess formation posed by buried knots with the standard technique.[4],[5],[6],[7] Moreover, this technique maximizes cosmetic outcomes as the external knot minimizes the bulky, “dog-ear” appearance at the proximal apex commonly associated with the more common method of securement.[7],[8]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Straith RE, Lawson JM, Hipps CJ. The subcuticular suture. Postgrad Med 1961;29:164-173.  Back to cited text no. 1
Nagar H. Stitch granulomas following inguinal herniotomy: a 10-year review. J Pediatr Surg 1993;28:1505-7.  Back to cited text no. 2
Singh-Ranger D. A simple technique for the retention of a subcuticular suture. Surgeon 2003;1:149-51.  Back to cited text no. 3
Hunter DC, Logie JR. Suture granuloma. Br J Surg 1988;75:1149-50.  Back to cited text no. 4
Mahabir RC, Christensen B, Blair GK, Fitzpatrick DG. Avoiding stitch abscesses in subcuticular skin closures: the L-stitch. Can J Surg 2003;46:223-4.  Back to cited text no. 5
Rigg BM. Suture materials in otoplasty. Plast Reconstr Surg 1979;63:409-10.  Back to cited text no. 6
Du Bois JJ. A technique for subcutaneous knot inversion following running subcuticular closures. Mil Med 1992;157:255.  Back to cited text no. 7
Drake DB, Rodeheaver PF, Edlich RF, Rodeheaver GT. Experimental studies in swine for measurement of suture extrusion. J Long Term Eff Med Implants 2004;14:251-9.  Back to cited text no. 8

Correspondence Address:
Garrison A Leach
Medical Student, Department of Surgery-Plastic Surgery, Creighton University School of Medicine, Phoenix, Arizona.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCAS.JCAS_83_19

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