You are closing a linear defect under high tension on the back and want to provide deep dermal support while minimizing tension on the epidermis and optimizing cosmetic outcome. You review several suturing techniques including those shown in the images provided.
Which of the following suturing techniques best offers deep tension relief?
A. 
B. 
C. 
D. 
Rationale:
When closing surgical defects under tension, choosing the appropriate deep suturing technique is critical to ensure wound stability, minimize scar spread, and reduce risk of dehiscence. There are multiple potential options for wound closure and multiple appropriate techniques. Minimizing trauma to superficial layers and reducing epidermal strangulation risk/suture marks is important in high tension areas.
Correct answer: C. Set-back suture
The set-back dermal suture, also called the Kantor suture, places the suture in the deep undersurface of the dermis, several millimeters from the wound edge. This creates a broad platform of support and avoids the superficial dermis or epidermis. Compared to the buried vertical mattress, which requires careful depth transitions and may risk superficial suture placement, the set-back technique follows the natural curve of the needle and is easier for learners to master. It also minimizes the risk of suture spitting and epidermal puckering. In high-tension areas such as the back, this technique has been shown in controlled trials to provide better cosmetic outcomes. It is also helpful in preventing keloids and in minimizing dead space (e.g., after cyst removal) by allowing the dermis to cinch down centrally.
Below is an example of each step:
Incorrect answer choices:
A. Buried vertical mattress suture
This is a deep-to-superficial-to-deep stitch that does enter the dermis and is excellent for wound edge eversion. It offers both support and precise approximation, but it is not placed deep enough to be considered a true set-back suture and does not avoid dermal penetration.
B. Tip stitch
Used for flap tips or standing cones, this suture starts in the deeper tissue and travels through the undersurface of a flap tip to the other side. It's ideal for preserving vascularity and contour at the tip of a flap, but it does not provide widespread deep tension relief, and its design is specific to flap geometry, not general linear closures.
D. Running horizontal mattress suture
This suture travels in a continuous loop-like pattern that passes horizontally through the dermis on either side of the wound. It’s good for edge eversion and tension distribution across a longer wound, but it engages the dermis and sits superficially compared to a set-back dermal suture.
Additional reading at Atlas of Suturing Techniques Chapter 4.10: The Percutaneous Set-Back Dermal Suture