Reverse Exposure-Limiting Suture (RELS): A Technique for Defect Approximation in Constrained Anatomical Spaces

Technical note-2 illustrative cases. Suturing delicate structures risks iatrogenic damage from excessive exposure. Traditional methods, such as incisions and tissue retraction, can lead to adhesion, scarring, and impairment. We describe the reverse exposure-limiting suture (RELS) as a suture-burying maneuver facilitating controlled approximation while minimizing tissue exposure. RELS was applied to a proximal nail-bed laceration and a Zone 2 flexor tendon injury. The needle is first passed through the defect, then reversed beneath the overlying structure with the swage leading, allowing approximation without elevating protective tissues (such as eponychium) or releasing pulleys. As reversing the needle via the swage may theoretically increase tissue trauma, the technique should be applied cautiously in delicate regions. Both cases healed uneventfully: normal nail regrowth at 6 weeks (case 1) and excellent early function without pulley compromise at 3 months (case 2). Initial experience suggests that RELS is feasible in anatomically constrained regions; further study is needed to define its efficacy and stiffness, which may potentially compromise indications, safety, and outcomes.