Asymmetric Dermal Suture (Deep Suture of the Two-Layer Closure)

Abstract

For the ideal donor closure, surgeons should minimize follicle damage and perform a tension-free skin closure. Two-layer closure with trichophytic excision is performed routinely when the donor strip is more than 1.0 cm wide. After the trichophytic strip is excised, asymmetric dermal suturing is performed using a 4-0 Vicryl suture, with the first bite being taken in the subcutaneous fat layer of the upper lip and exiting 2 mm below the skin surface. The needle is then reinserted at the inner border of the de-epithelialized edge of the lower lip and exiting 2 mm below the skin surface. Using this suture, the excessive tension is transferred from the superficial level to the deep dermis. It also produces a faulting effect, an elevation of the upper lip, which allows sufficient concealment of the de-epithelialized lower lip edge with minimal tension in the trichophytic closure. The theoretical basis of this asymmetric dermal suture is the 2 mm difference in height between the upper and lower lips. At a 1-year follow-up assessment, trichophytic closure allowed the hair to grow through the donor scar so the linear donor scar was less visible. Several white spots along the donor scar are apparent where the knots of the asymmetric dermal sutures were placed. But this is so minimal as to be considered barely evident.