title: Double butterfly suture for high tension: a broadly anchored, horizontal, buried interrupted suture.
abstract: BACKGROUND
  The excision of skin lesions such as tumors, nevi, and scars frequently results in tension on surgical wound margins. This tension is commonly counteracted surgically with buried, intracutaneous, interrupted sutures of absorbable material which are anchored vertically in the corium.
  
  
  METHODS
  The horizontal, buried, intracutaneous butterfly suture has been described elsewhere. It is firmly anchored in the corium, everts wound margins, and adapts them nearly as broadly as two vertical sutures. It can also be laid as a double butterfly suture, as described here, and then has the shape of an "8." This double butterfly suture is equivalent to three vertical sutures because of its broad base in the corium. Moreover, it can cope with much greater tension because of its "pulley" effect. A single double butterfly suture usually suffices for small defects, particularly when the wound edges are cut obliquely with a longer rim of epidermis.
  
  
  METHODS
  We have laid the traditional butterfly suture in more than 35,000 skin lesion excisions since 1985 and the double butterfly suture alone or as a supplement in more than 10,000 sutures since 1992. We use 2-0 to 6-0 polydioxanone for these procedures, since it has proven in trials to be the best-absorbed suture material.
  
  
  RESULTS
  In most cases, the resulting scars were narrow and smooth in spite of high tension. Results were unsatisfactory in only 6.2% of procedures.
  
  
  CONCLUSIONS
  The double butterfly suture described here has the advantages of withstanding tension better while everting wound margins and requiring fewer stitches for wound closure. However, it is important that the suture knot be deeply anchored beneath the corium.
authors.forename: H
authors.initials: H
authors.lastname: Breuninger
mesh_terms: D062109:Dermatologic Surgical Procedures; D006801:Humans; D013536:Suture Techniques