QCan you comment on the use of a “retention suture” for complex closures?

Richard Winkelmann, DO

Richard Winkelmann, DO

Director for Dermatology and Mohs Surgery
Optum Care
Los Angeles, CA

On January 1, 2020, CMS released updated CPT coding guidelines to provide enhanced guidelines for differentiating intermediate from complex integumentary repairs. In addition to the requirements for intermediate closures, complex closures must include one of the following: exposure of bone, cartilage, tendon, or named neurovascular structure; debridement of wound edges (eg, traumatic lacerations or avulsions); extensive undermining (defined as distance equal to or greater than the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect); involvement of free margins of helical rim; vermilion border, or nostril rim; placement of retention sutures.1

In surgical texts, a retention suture classically refers to a suture placed through many tissue layers when additional support is needed for closure of the abdomen. For skin closures, retention sutures are used for surgical defects in which the skin needs to be stretched to close a wound without causing excessive tissue tension and potential for tissue necrosis. In my practice, I use a pulley stitch quite frequently as a retention suture for closing defects particularly on the scalp and shins. I may or may not leave the pulley in when the skin has stretched and I have finished the closure. Skin tension using just one 2-0 or 3-0 nylon pulley suture may at times be too great and can rip through the tissue. In these cases, there are commercially available retention sutures with their own associated medical device to enhance tissue stretching and mobility.


  1. AAD Coding Consult 2019