You say it – but do you mean it? Remarks on dermatologic surgeons’ terminology of skin sutures

A recent discussion within an interventional dermatology chat group highlighted a critical need for clarity and precision in the terminology describing suture techniques for skin wounds. This case involved the revision of a wide, post-traumatic scar on the nasal dorsum.

The operating surgeon described an “elliptical excision;” however, the excision was more accurately fusiform with a slightly crescentic shape. A true ellipse is rounded at both poles; to minimize dog-ear formation, an acute angle is required or a skin-saving suture technique is necessary — neither of which was featured in the presented case.

The surgeon reported using “electrocauterization” for active bleeders, while the technique demonstrated was in fact electrocoagulation. Following modest undermining, horizontal sub-intradermal sutures -described by Breuninger as butterfly sutures¹ - were placed to close the defect. These were erroneously referred to as “subcutaneous sutures.” Final closure was achieved with 6-0 Ethilon transcutaneous sutures and vertical mattress (back-stitch) sutures, resulting in an acceptable outcome.

A subsequent query inquired whether “subcutaneous suture” is the optimal method for approximating wounds in areas with minimal subcutaneous tissue (e.g., the forehead, nasal bridge, and shin), where undermining is challenging. One responder correctly noted that these areas can be undermined but expressed difficulty placing subcuticular sutures in the shin due to scant subcutaneous fat, stating that “subcutaneous fat is required to absorb the sutures.”

This reflects a fundamental misconception: The subcutis is adipose tissue, which possesses no meaningful mechanical strength. Sutures placed in fat (subcutaneous/subcuticular) do not effectively approximate or hold wound edges together. While they may help reduce a dead space after lipoma excision, they do not contribute to wound stability. For that, sutures must engage the dermis – the skin’s robust, fibrous layer. This can be achieved either with a vertical suture that traverses the reticular dermis to the papillary dermis or with a butterfly suture, which engages the deep dermis from its undersurface.

Another question was whether non-absorbable 6-0 Ethilon sutures must be removed or if they “can be left to prevent stretch.” The response claimed that “Subcutaneous sutures are permanent, no need to remove it. It gives strength for long time...” This is incorrect; any non-absorbable transcutaneous suture must be removed to avoid sinus tract formation and infection.

A further assertion that “Undermining and subcutaneous sutures are (alternatives) to each other. We cannot do both” was also mistaken. As another discussant correctly noted, undermining and layered suturing are complementary techniques. Undermining reduces wound tension and mobilizes tissue, while dermal sutures provide strength and precise epidermal approximation. The technique involves undermining below the dermis, allowing for the placement of buried dermal sutures above this plane, even in areas with thin dermis, like the shin, using a horizontal bite.

This discussion also repeatedly referenced “epidermal sutures,” which is a misnomer. The epidermis is a thin, avascular layer incapable of holding suture tension. Sutures that pierce the skin and exit on the surface are more accurately termed transcutaneous or percutaneous. The belief that “subcutaneous” or “epidermal” sutures determine outcomes reveals a significant misunderstanding of skin biomechanics. As supported by evidence, undermining is not always necessary, and non-absorbable sutures can be effectively used for buried dermal stitches to minimize scar dehiscence, with a low risk of foreign body granulomas.²

While this discussion may have been clear to experienced surgeons, its inconsistent terminology can profoundly confuse trainees and beginners.

In summary, for optimal outcomes and clear communication, we advocate for the following precise terminology:

1. Most “elliptical excisions” are more accurately described as fusiform or spindle-shaped.

2. Electrocoagulation (tissue heating through high-frequency current) is distinct from electrocauterization (heating through a direct-contact hot probe).

3. The term “epidermal suture” should be abandoned. Sutures that pass through the skin are transcutaneous.

4. Buried sutures should be described by their anatomical location: Dermal or subcuticular. The butterfly suture is a specific type of intradermal suture.

5. Subcutaneous sutures (in fat) provide no significant wound strength and should not be relied upon for primary closure.

6. Layered closure with dermal sutures and undermining are complementary, not mutually exclusive, techniques.

7. Non-absorbable sutures provide long-term strength but must be removed if placed transcutaneously. Long-lasting, absorbable monofilaments, such as polydioxanone, are excellent alternatives for buried stitches.

8. A clear understanding of skin anatomy is essential: The epidermis is minute, the dermis provides strength, and the subcutis (fat) varies greatly in thickness and provides cushioning, not structural support.

Precise language is not mere semantics; it is the foundation of sound surgical technique and effective teaching.