Beyond the Basics: Simple buried suture

Indications, step-by-step procedures, common errors, and training with UpSurgeOn SkinPad


As a medical student or surgical resident, proficiency in suturing techniques is paramount for your future career. While the simple interrupted and simple running suture serves as a cornerstone for wound closure, mastering the simple buried suture elevates your skillset.

This blog post is your guide to mastering this technique. We will delve into:

  • Step-by-step instructions: Learn the precise execution of each step, ensuring proper wound closure, knot burial, and minimal scarring.
  • Considerations and potential challenges: Identify key points to keep in mind.
  • Benefits of practicing on a suture pad: Understand the invaluable role of practicing on a suture pad before applying your skills to real-world scenarios.

What is a simple buried suture?

A  simple buried suture is a specialized suturing technique designed to close wounds by approximating the deeper layers of the skin (subcuticular tissue – if deeper) or superficial (dermis) while keeping the suture material itself hidden beneath the surface.

Image from Cleveland Clinic

Steps for Mastering the Simple Buried Suture Technique:

1) Preparation

  • Gather your materials: needle driver, absorbable suture material (e.g., Monocryl, Vycril, Prolene), tissue forceps, and scissors.
  • Secure the UpSurgeOn SkinPad on a stable surface.

2) Needle Entry and Path:

  • Grasp the needle holder near the base with your dominant hand and grasp the needle at 1/3–1/2 of its length from the swaged end.
  • Use the toothed forceps to gently evert (flip outwards) the skin edge at the entry point, providing better visibility and preventing tissue damage.
  • Hold your hand palm-down (pronated position) and insert the needle deep within the wound.

3) Exiting under the epidermis

Rotate your hand palm-up (supinated position) to guide the needle upwards, ensuring it exits 2-3 mm just below the surface of the skin (epidermis) without puncturing it.

This “inverted” approach helps conceal the knot beneath the skin.

4) Grasping and passing the suture

  • Use the tissue forceps to grasp the tissue near the needle and gently pull the needle and thread entirely through the skin.

Leave sufficient suture length at the wound base for knot tying.

5) Repositioning the Needle and Deep Re-entry

  • Reattach the needle to the needle driver.
  • On the opposite side of the woundre-enter the needle just below the epidermis, at the same depth where the suture exited on the first side.

6) Deep Exit and Knot Burial

  • Similar to step 3, supinate your wrist to direct the needle from superficial to deep, exiting at the same level as the first stitch on the other side. This deep exit facilitates burying the knot beneath the skin later.

7) Completing the Suture and Knot Tying

  • Gently pull the needle and suture completely through the skin.
  • Tie a secure knot (e.g., square knot or surgeon’s knot) with the remaining suture ends at the wound.

8) Repeat again, and again and again

Additional Tips

  • Visualize the deep dermal layer as your target during needle placement.
  • You can practice both at a superficial and deep layer
  • Good subcuticular sutures are paramount for a nice skin closure even with staplers
Deep and superficial buried suture on SkinPad

Common Errors to Avoid

  • Incorrect needle angulation: Ensure the needle enters and exits perpendicular to the wound edge.
  • Uneven bites and throws: Maintain consistent size and avoid excessive tension
  • Leaving gaps between stitches: Ensure complete wound closure without bunching tissues.
  • Errors to avoid: 
    • Improper needle placement: Placing the needle too deep can damage underlying structures, while placing it too shallow can lead to suture extrusion and poor wound closure.
    • Tension issues: Excessive tension can cause skin ischemia and compromise wound healing, while insufficient tension can lead to wound dehiscence (reopening).
    • Incomplete knot burial: Leaving the knot visible can compromise aesthetics and potentially increase the risk of infection.

By following these steps and practicing diligently with UpSurgeOn SkinPad, you can effectively learn and refine your skills. Remember the keys to improve :

  • Repetitive practice: Exercise every day
  • Recording Progress: Record your progress and practice sessions to track improvements and identify areas for further development. 
  • Seeking Feedback: If possible, when practicing ask for the guidance of experienced practitioners who can provide feedback and tips for improvement.

Mastering simple interrupted dural closure with Mycro

Mastering continous dural closure with Mycro

Mastering the Horizontal Mattress Suture

Beyond the Basics: Simple buried suture