Following closure of the peritoneum and the linea alba, Scarpa's fascia may be approximated with 3/0 absorbable suture. Many feel this lessens the subcutaneous dead space within the fat (Figure 28). In thin patients, this suture may be placed in an inverted manner (as shown), with the knot at the bottom of the loop. However, in most patients, these sutures are placed upright with the knot on top.
The skin may be closed with interrupted fine 3/0 or 4/0 nonabsorbable sutures using a curved cutting needle (Figure 29). The skin edge is elevated with forceps in such a manner that the needle is introduced perpendicular to the skin on the one side and exits perpendicularly on the opposite. The sutures are spaced such that the distance between them is approximately equal to their width. This creates a pleasing uniform pattern. As the individual sutures are tied, the skin will rise, creating a slight ridge. When all sutures are tied, they are held in the surgeon's left hand and then sequentially cut with the scissors (Figure 30). Some surgeons prefer an interrupted vertical mattress suture for skin closure. The vertical mattress suture is especially well suited for circumstances where the skin edges do not lie in level approximation. The skin is grasped with the toothed forceps. A wide lateral base is created as the needle enters the skin about 1 cm or so lateral to the cut edge (Figure 31). The opposite skin edge is then grasped with forceps and the needle brought through in a symmetric manner (Figure 32). A careful approximation of the skin edges at equal levels is accomplished by a returning small bite that is approximately a millimeter or two from the skin edge and only ...