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Diagnostics2026-08-23 · 20 min read

Dog Ear Hematoma: Drainage vs Surgery vs Steroids and Why Aspiration Fails

Understand canine aural hematoma: why needle aspiration fails 80%+ of the time, 5 treatment options compared, cauliflower ear risk, and 2026 surgery costs.

Ran Chen
Ran Chen
Founder, VetMedGuide. Life-sciences operator and 10× global market-access lead.
Published

A dog's ear flap that suddenly balloons into a warm, tense, fluid-filled pouch—often described by owners as a "pillow ear" or "water balloon ear"—is a classic presentation of a canine aural hematoma (ear hematoma).

Seeing your dog's ear flap puff up overnight is distressing, and many owners immediately ask: “Can the vet just drain it with a needle today?”

While draining the fluid with a syringe is technically easy, needle aspiration alone fails in more than 80% to 90% of cases. Within 24 to 72 hours, the ear flap almost invariably refills with blood and serum. More critically, an aural hematoma is rarely a primary disease; in 75% to 90%+ of cases, it is the mechanical consequence of underlying otitis externa (ear infection) or allergic pruritus that drove violent head shaking in the first place.

Below is an evidence-based surgical and medical guide to canine aural hematomas: why simple drainage fails, what happens if left untreated (the risk of permanent "cauliflower ear"), a side-by-side comparison of the five primary treatment options, 2026 surgical costs, and how to prevent recurrence.

Direct Answer: What to Do If Your Dog Has an Ear Hematoma

If your dog has developed a swollen, fluid-filled ear flap, follow this clinical decision pathway:

[Dog Develops Swollen, Fluid-Filled Ear Flap ("Pillow Ear")]
                             │
                             ▼
         [Veterinary Clinical & Otoscopic Examination]
    - Perform ear canal cytology (identify yeast / bacteria / mites)
    - Palpate pinna for cartilage fractures and dead-space extent
    - Assess patient anesthetic risk (cardiac, renal, age)
                             │
              ┌──────────────┴──────────────┐
              ▼                             ▼
    [HEALTHY SURGICAL CANDIDATE]   [HIGH ANESTHETIC RISK / SENIOR]
              │                             │
              ▼                             ▼
    [Definitive Surgical Repair]   [Medical / Drain Management]
    - Incisional drainage (S-cut)  - Needle aspiration + Intralesional
    - Quilted mattress sutures       corticosteroids (Triamcinolone)
    - < 5%–10% recurrence rate     - OR Indwelling Teat Cannula
    - Preserves pinna anatomy      - 15%–30% recurrence rate
              │                             │
              └──────────────┬──────────────┘
                             ▼
         [Mandatory Concurrent Medical Treatment]
         1. Treat underlying otitis externa based on cytology
         2. Continuous rigid E-collar wear for 14–21 days
         3. Post-op head bandage / compress for 3–7 days
  1. Schedule a veterinary visit within 24 to 48 hours. An aural hematoma is not an instantaneous life-or-death emergency, but the accumulating blood creates painful hydraulic pressure that separates cartilage layers and fractures vascular networks.
  2. Do NOT attempt to drain the ear at home. Puncturing the ear with a sewing needle or household syringe introduces skin bacteria into a warm pool of blood, creating a severe, painful pinnal abscess and chondritis.
  3. Equip a hard Elizabethan collar (E-collar) immediately. Every time your dog shakes their head or scratches the ear, centrifugal force drives more blood into the hematoma, expanding the dead space.
  4. Treat the underlying ear infection. If you repair the hematoma but ignore the yeast or bacterial infection inside the ear canal (diagnosed via in-house ear cytology), the dog will resume head shaking the moment the bandages come off, instantly rupturing new vessels.

Pinnal Anatomy and Pathophysiology: Why Did the Ear Fill with Blood?

To understand why an aural hematoma forms and why it is notoriously difficult to heal, we must examine the micro-anatomy of the canine pinna (ear flap).

          CROSS-SECTION OF CANINE PINNA (EAR FLAP)
 ┌─────────────────────────────────────────────────────────────┐
 │                                                             │
 │   Convex Skin Surface (Outer Ear)                           │
 │   ═══════════════════════════════════════════════════════   │
 │   Subcutaneous Tissue & Great Auricular Blood Vessels       │
 │   ───────────────────────────────────────────────────────   │
 │   Perichondrium (Fibrous Membrane)                          │
 │   ┌─────────────────────────────────────────────────────┐   │
 │   │                                                     │   │
 │   │         AURICULAR CARTILAGE PLATE (Central)         │   │
 │   │                                                     │   │
 │   └─────────────────────────────────────────────────────┘   │
 │   Perichondrium (Fibrous Membrane)                          │
 │   ───────────────────────────────────────────────────────   │
 │   Subcutaneous Tissue & Caudal Auricular Branches           │
 │   ═══════════════════════════════════════════════════════   │
 │   Concave Skin Surface (Inner Ear Facing Canal)             │
 │                                                             │
 └─────────────────────────────────────────────────────────────┘

The canine pinna consists of a central, flexible sheet of auricular cartilage sandwiched between two layers of skin and perichondrium (the fibrous vascular membrane covering the cartilage).

The skin on the inner (concave) surface of the ear is tightly adhered to the underlying cartilage, with minimal subcutaneous connective tissue. Traversing this interface are numerous branches of the great auricular and caudal auricular arteries and veins, which pass directly through tiny microscopic foramina (openings) in the cartilage plate.

The Mechanical Cascade of Rupture

  1. Violent Head Shaking: When a dog experiences intense ear canal pain or itchiness, they flap their ears violently. The tips and margins of the pinna accelerate to high velocities, slapping against the skull.
  2. Shearing Forces & Cartilage Fracture: This violent centrifugal whipping motion creates massive shearing forces between the tightly attached skin and the central cartilage. The cartilage plate fractures or cleaves internally, tearing the delicate blood vessels passing through it.
  3. Dead Space Expansion: Blood pours out of the severed arterioles and venules under physiological pressure. Because the skin has separated from the cartilage, an unnatural cavity (dead space) is created. Blood and inflammatory serum pool rapidly within this cavity, inflating the ear flap like a water balloon.
[Otitis Externa / Severe Pruritus]
               │
               ▼
[Violent Head Shaking & Ear Scratching]
               │
               ▼
[Shearing Forces Fracture Auricular Cartilage]
               │
               ▼
[Rupture of Great / Caudal Auricular Vessels]
               │
               ▼
[Vascular Dead Space Opens Between Skin & Cartilage]
               │
               ▼
[Aural Hematoma Fluid Accumulation ("Pillow Ear")]

The Root Cause: Why 90% of Hematomas Start Inside the Ear Canal

An aural hematoma is a physical sign, not a primary disease. In 75% to 90%+ of canine cases, the primary driver is otitis externa (inflammation or infection of the external ear canal) or generalized allergic dermatitis.

Veterinary dermatology surveys identify the following underlying etiologies:

Primary Etiology Mechanism Driving Head Shaking Diagnostic Identification
Yeast Otitis (Malassezia pachydermatis) Intense pruritus, sweet/musty odor, dark brown waxy exudate Ear cytology (budding peanut-shaped yeast)
Bacterial Otitis (Staphylococcus, Pseudomonas) Severe pain, ulceration, purulent yellow/green discharge Ear cytology & culture (cocci / rods, degenerate neutrophils)
Canine Atopic Dermatitis / Food Allergy Bilateral erythema, chronic seasonal itch, foot licking Allergy workup, elimination diet trial
Ear Mites (Otodectes cynotis) Microscopic parasites crawling in canal; classic "coffee ground" debris Mineral oil ear swab microscopy
Foreign Bodies (Grass awns / Foxtails) Sudden violent unilateral head shaking after being in tall grass Otoscopic visualization under sedation
Biting Flies / Flea Allergic Dermatitis Direct trauma and crusting at pinnal margins Physical exam, flea comb screening

The Clinical Golden Rule: Any surgical or medical treatment of an aural hematoma that fails to diagnose and treat the underlying otitis externa is doomed to relapse.

Why Needle Aspiration Alone Fails (80% to 90%+ Recurrence)

When a dog presents with a tense hematoma, inserting an 18-gauge needle attached to a syringe and withdrawing 20 to 60 mL of bloody fluid provides immediate cosmetic relief. The ear flap flattens out, and the dog feels temporary pressure relief.

However, per clinical data published by the American College of Veterinary Surgeons (ACVS) and comprehensive surgical reviews (Hewitt & Bajwa 2020, PMC7020633), simple needle aspiration carries an 80% to 90%+ recurrence rate within 24 to 72 hours.

[Needle Aspiration Removes Fluid Volume]
                    │
                    ▼
[Skin Remains Separated from Cartilage (Dead Space Stays Open)]
                    │
                    ▼
[Ruptured Arterioles & Capillaries Continue Bleeding]
                    │
                    ▼
[Ear Flap Completely Refills with Blood within 24–72 Hours]
                    │
        ┌───────────┴───────────┐
        ▼                       ▼
[Repeated Unsterile Sticks]   [Chronic Fibrin Organization]
        │                       │
        ▼                       ▼
[Severe Pinnal Abscess]       [Permanent "Cauliflower Ear"]

Why Does It Refill So Fast?

  1. The Dead Space Remains Open: Suctioning fluid out does nothing to physically adhere the separated skin back to the fractured cartilage. The anatomical pocket remains wide open.
  2. Active Vascular Bleeding: The torn auricular arterioles are not cauterized or compressed. The moment the hydraulic back-pressure of the fluid is removed by aspiration, the vessels bleed freely into the empty space.
  3. Fibrin Clot Occlusion: As blood clots form, needles become clogged, preventing complete evacuation of solid fibrin organized along the cartilage wall.
  4. Infection Risk: Repeated needle aspirations without sterile surgical prep transform a clean, sterile hematoma into an aggressive bacterial abscess that can destroy the entire cartilage structure (chondritis and pinnal necrosis).

Conclusion: Needle aspiration alone is only a temporary stopgap (useful to relieve acute pressure on a Friday night until scheduled surgery on Monday), never a definitive cure.

What Happens If You Don't Treat It? The "Cauliflower Ear" Risk

Some owners, deterred by the cost of surgery, wonder if they can simply leave the hematoma alone to heal on its own.

An untreated aural hematoma will eventually stop expanding once internal tissue pressure equals arterial pressure. Over 4 to 8 weeks, the fluid component of the blood is slowly resorbed by macrophages and local lymphatics.

However, the consequences of benign neglect are cosmetically disfiguring and medically harmful:

[Untreated Aural Hematoma]
            │
            ▼
[Fibrin Clot Organization & Granulation Tissue (Weeks 1–2)]
            │
            ▼
[Fibroblastic Proliferation & Neovascularization (Weeks 2–4)]
            │
            ▼
[Chondrogenesis & Perichondrial Scar Contracture (Weeks 4–8)]
            │
    ┌───────┴───────┐
    ▼               ▼
[Permanent Shriveled       [Severe Ear Canal Stenosis]
 "Cauliflower Ear"]                 │
                                    ▼
                           [Trapped Moisture & Lifelong
                            Intractable Otitis Externa]

The Pathophysiology of "Cauliflower Ear"

  1. Fibrin Organization: The trapped blood pool forms a dense, organized fibrin matrix across the fractured cartilage.
  2. Granulation and Chondrogenesis: Fibroblasts and osteochondral progenitor cells invade the clot, depositing dense collagen and disorganized, thickened fibrocartilage.
  3. Perichondrial Contracture: As the scar tissue matures and contracts, it exerts massive inward pulling forces on the ear flap. The pinna shrivels, thickens into a heavy, hard, wrinkled mass, and rolls inward into a permanent "cauliflower ear" deformity.
  4. Ear Canal Stenosis and Chronic Disease: The heavy, crumpled pinna collapses over the external acoustic meatus (ear canal opening), causing canal stenosis. Air circulation is cut off, trapping heat, humidity, and cerumen. The dog becomes permanently predisposed to severe, painful, lifelong recurrent ear infections that frequently require salvage total ear canal ablation (TECA) surgery later in life.

The 5 Treatment Options Compared: Drainage, Drains, Steroids, and Surgery

Veterinary medicine utilizes five primary strategies to manage canine aural hematomas. Choosing the optimal approach depends on patient age, general anesthetic risk, owner compliance, and cost.

┌────────────────────────────────────────────────────────────────────────┐
│                   5 AURAL HEMATOMA TREATMENT OPTIONS                   │
├─────────────────────────┬──────────────────────────────────────────────┤
│ 1. Incisional Mattress  │ PRIMARY SURGICAL STANDARD (< 5%–10% Recurr.) │
│    Suture Repair        │ - Evacuates clots; mattress sutures seal     │
│                         │   dead space; best cosmetic preservation     │
├─────────────────────────┼──────────────────────────────────────────────┤
│ 2. Needle Aspiration +  │ MEDICAL THERAPY (15%–30% Recurrence)         │
│    Intralesional Steroid│ - Triamcinolone injection suppresses fibrin; │
│                         │   ideal for high-risk anesthetic patients    │
├─────────────────────────┼──────────────────────────────────────────────┤
│ 3. Indwelling Cannula   │ ACTIVE DRAINAGE (10%–20% Recurrence)         │
│    (Teat / Silicone)    │ - Continuous passive drain for 2–3 weeks;    │
│                         │   requires high owner hygiene & maintenance  │
├─────────────────────────┼──────────────────────────────────────────────┤
│ 4. Needle Aspiration    │ TEMPORARY STOPGAP ONLY (80%–90%+ Recurrence) │
│    Alone                │ - Refills within 48 hours; high failure      │
├─────────────────────────┼──────────────────────────────────────────────┤
│ 5. Benign Neglect       │ CONTRAINDICATED / PALLIATIVE                 │
│    (No Treatment)       │ - Results in permanent painful cauliflower   │
│                         │   ear deformity and ear canal stenosis       │
└─────────────────────────┴──────────────────────────────────────────────┘

Detailed Comparison Matrix

Treatment Modality General Anesthesia? Recurrence Rate Cosmetic Outcome Typical 2026 Cost Best Patient Candidate
1. Incisional Mattress Surgery Yes (Standard GA) < 5% – 10% Excellent (Smooth, flat pinna) $400 – $1,200 Healthy dogs; large hematomas; definitive cure
2. Intralesional Corticosteroids No (Local / Sedation) 15% – 30% Good to Moderate $150 – $350 Geriatric dogs; cardiac/renal disease; anesthetic risks
3. Indwelling Teat Cannula Mild Sedation / Local 10% – 20% Good (Slight thickening) $250 – $500 Medium/large dogs; compliant owners; moderate budget
4. Needle Aspiration Alone No (None / Local) 80% – 90%+ Poor (Repeated refill) $50 – $120 Weekend emergency stopgap until scheduled surgery
5. Benign Neglect (Untreated) None N/A (Fibrosis) Severe Deformity (Cauliflower) $0 Terminal palliative care where anesthesia is lethal

1. Incisional Surgery with Quilted Mattress Sutures (Primary Standard)

Incisional surgery remains the definitive standard surgical technique across veterinary surgery (ACVS; Hewitt & Bajwa 2020).

          INCISIONAL SURGERY & MATTRESS SUTURE PLACEMENT
 ┌─────────────────────────────────────────────────────────────┐
 │                                                             │
 │   ┌─────────────────────────────────────────────────────┐   │
 │   │      [  S-Shaped or Longitudinal Incision  ]        │   │
 │   │                   (Drainage Gap)                    │   │
 │   │                                                     │   │
 │   │     ║       ║       ║       ║       ║       ║       │   │
 │   │     ║       ║       ║       ║       ║       ║       │   │
 │   │     ║       ║       ║       ║       ║       ║       │   │
 │   │                                                     │   │
 │   │  [Through-and-through staggered mattress sutures]   │   │
 │   │  Oriented PARALLEL to longitudinal blood vessels    │   │
 │   │  (Secured with buttons or rubber tubing bolsters)   │   │
 │   └─────────────────────────────────────────────────────┘   │
 │                                                             │
 └─────────────────────────────────────────────────────────────┘
  • Surgical Technique: Under general anesthesia, a straight longitudinal or S-shaped incision is made on the concave (inner) surface of the pinna. The surgeon thoroughly curettes out all organized fibrin and blood clots, flushing the cavity with sterile saline.
  • Dead-Space Obliteration: The surgeon places multiple full-thickness, through-and-through quilted mattress sutures (using 2-0 to 3-0 non-absorbable monofilament like nylon or polypropylene) spanning the entire area of the hematoma. These sutures compress the skin against the cartilage, completely closing the dead space.
  • Suture Orientation Rule: Sutures must be oriented parallel to the long axis of the pinna and major blood vessels (never horizontally across the ear). Placing sutures horizontally strangles the auricular blood supply, causing ischemic cartilage necrosis and pinnal sloughing.
  • Bolsters / Buttons: Sutures are often placed over silicone bolsters, rubber tubing, or plastic buttons to distribute pressure evenly and prevent sutures from cutting into swollen skin.
  • Drainage: The central incision is intentionally left open to allow any new serum to drain freely by secondary intention while the tissues adhere.
  • Outcome: Recurrence is under 5% to 10%, providing the best cosmetic and anatomical preservation.

2. Needle Aspiration Combined with Intralesional Corticosteroids

Pioneered by Dr. Romatowski (JAVMA 1994), this medical approach is the preferred alternative for dogs who cannot undergo general anesthesia due to advanced age, heart failure, or severe kidney disease.

  • Technique: The ear is aseptically prepped. The hematoma is completely drained using an 18-to-20 gauge needle. Without removing the needle hub, the syringe is swapped for one containing Triamcinolone acetonide (0.5 to 2 mg) or Dexamethasone sodium phosphate, which is injected directly into the empty dead space. A short course of tapering oral prednisone is frequently added.
  • Mechanism: High-potency local corticosteroids suppress local inflammatory cascades, inhibit fibrinolysis, reduce capillary permeability, and stimulate rapid fibroblastic adhesion between the perichondrium and cartilage.
  • Outcome: Success rates range from 70% to 85% (recurrence 15% to 30%). A second aspiration and injection may be required 7 to 10 days later.

3. Indwelling Teat Cannula / Active Vacuum Drains

For active dogs where anesthesia is undesirable but medical steroid therapy is contraindicated (e.g., severe diabetic dogs or patients on NSAIDs for arthritis), a mechanical drain tube provides continuous evacuation.

  • Technique: Under local anesthesia and sedation, a small stab incision is made at the ventral (bottom) aspect of the hematoma. A sterile plastic teat cannula or soft silicone butterfly catheter is inserted into the cavity and sutured to the skin.
  • Mechanism: The cannula remains open for 14 to 21 days, allowing fluid to drain out continuously whenever the dog moves. The perichondrium gradually forms tight fibrous adhesions against the cartilage, closing the dead space from the top down.
  • Maintenance: The owner must milk the ear flap twice daily to clear fibrin plugs, clean the cannula opening with antiseptic solution, and ensure the dog wears an E-collar 24/7.
  • Outcome: Recurrence rate is 10% to 20%.

2026 Treatment Costs and Itemized Fee Schedule

The cost of treating an aural hematoma depends on whether surgical correction under general anesthesia or medical management under local anesthesia is chosen, as well as whether ear cytology and infection medications are included.

Nationally in 2026, surgical repair at a general practice clinic typically costs between $400 and $900, while specialty or emergency surgical care ranges from $800 to $1,400+.

Itemized Fee Schedule (2026 National Benchmarks)

Clinical Procedure / Line Item GP Veterinary Clinic Specialty / ER Hospital Clinical Purpose
Comprehensive Physical Exam & Otoscopy $55 – $95 $125 – $225 Full physical and deep ear canal otoscopic examination
In-House Ear Cytology (Bilateral) $35 – $65 $55 – $95 Identifies yeast, bacteria, or mites triggering head shaking
Pre-Anesthetic Blood Chemistry & CBC $80 – $150 $135 – $240 Ensures liver and kidney safety before general anesthesia
General Anesthesia & Dedicated Monitoring $175 – $350 $350 – $650 IV catheter, propofol induction, isoflurane, pulse ox, ECG
Surgical Repair (Incision + Mattress Sutures) $225 – $450 $450 – $850 Clot curettage, dead space quilting, bolster placement
Topical & Oral Otic Medications $45 – $90 $65 – $120 Antibiotic/antifungal ear drops (daily vs single-dose otic medications), NSAIDs
Elizabethan Collar (Hard Cone) $20 – $35 $25 – $45 Prevents destructive scratching during 2–3 week recovery
Post-Operative Suture Removal (Day 14–21) $0 – $40 $45 – $75 Suture snipping and final otoscopic re-check
TOTAL ESTIMATED SURGICAL COST $400 – $850 $850 – $1,400+ Definitive surgical repair + infection treatment
TOTAL MEDICAL / STEROID PROTOCOL $150 – $325 $275 – $450 Needle drainage + intralesional triamcinolone

Post-Operative Care, Bandaging, and Suture Removal

The surgical procedure is only half the battle. Preventing post-operative complications requires rigorous adherence to the following three recovery rules for 14 to 21 days:

┌────────────────────────────────────────────────────────────────────────┐
│                   POST-OPERATIVE RECOVERY ROADMAP                      │
├──────────────┬─────────────────────────────────────────────────────────┤
│ Days 1 – 3   │ Active Drainage & Head Wrap Management                  │
│              │ - Ear is bandaged flat against head to absorb drainage  │
│              │ - Change outer gauze if soaked; administer oral NSAIDs  │
│              │ - Hard E-collar on 24/7                                 │
├──────────────┼─────────────────────────────────────────────────────────┤
│ Days 4 – 7   │ Head Bandage Removal & Otic Treatment                   │
│              │ - Clinic removes head wrap; pinna exposed to air        │
│              │ - Clean crusts with warm chlorhexidine diluted solution │
│              │ - Begin topical ear canal drops for underlying infection│
├──────────────┼─────────────────────────────────────────────────────────┤
│ Days 8 – 14  │ Tissue Consolidation & Fibrous Adhesion                 │
│              │ - Skin adheres tightly to cartilage plate               │
│              │ - Incision site contracts by secondary intention        │
│              │ - Leash walks only; absolutely no rough play            │
├──────────────┼─────────────────────────────────────────────────────────┤
│ Days 14 – 21 │ Suture Removal & Final Otoscopic Re-Check               │
│              │ - Veterinarian cuts and removes all mattress sutures    │
│              │ - Re-check cytology confirms infection is resolved      │
└──────────────┴─────────────────────────────────────────────────────────┘
  1. The Rigid E-Collar Is Mandatory: A dog recovering from ear surgery will experience intense tickling and itching as the mattress sutures heal. A single scratch from a hind claw will rip the sutures through the ear flap, lacerating the pinna and destroying the repair. The hard plastic cone must stay on 24/7 until the sutures are removed.
  2. Head Bandages (Compresses): In many clinics, the ear is folded flat across the top of the dog's skull and wrapped in a soft padded bandage for 3 to 7 days. This prevents the ear flap from flapping if the dog shakes their head and absorbs bloody serous drainage.
  3. Suture Removal Timeline: Mattress sutures must remain in place for a minimum of 14 to 21 days. Removing sutures too early (e.g., at Day 7) allows the incomplete fibrous adhesions to tear open, causing an immediate relapse.
  4. Treating the Ear Canal: Never stop ear drops early. Complete the full 14-to-21-day course of prescribed antimicrobial/antifungal otic medication to guarantee the underlying yeast or bacterial population is eradicated.

Frequently Asked Questions

Can a dog ear hematoma heal on its own without treatment?

Technically, yes, but with severe permanent damage. Over 4 to 8 weeks, the fluid component of the hematoma is slowly resorbed, but the resulting scar tissue contracts into a thick, deformed, shriveled "cauliflower ear." This deformity narrows the ear canal, permanently predisposing the dog to chronic, painful ear infections.

Can I drain my dog's ear hematoma at home with a needle?

No. Draining an ear hematoma at home with a household needle is unsafe. It introduces skin bacteria directly into a warm pool of blood, creating a severe, painful abscess and cartilage infection (chondritis). Furthermore, because the dead space remains open, the ear will refill with blood within 24 to 48 hours.

How much does dog ear hematoma surgery cost in 2026?

At a general practice veterinary clinic, comprehensive surgical repair under general anesthesia typically costs between $400 and $850, including pre-op bloodwork, anesthesia, surgical mattress suturing, ear cytology, and medications. At specialty or emergency hospitals, costs range from $850 to $1,400+. Medical management with intralesional steroids ranges from $150 to $350.

How do you prevent an ear hematoma from coming back?

The only way to prevent recurrence is to identify and treat the underlying cause of head shaking. In 90% of dogs, this means treating an active yeast or bacterial ear infection with cytology-guided ear drops, managing chronic environmental/food allergies, and using regular veterinary ear cleansers to prevent future wax buildup.

Why do vets put buttons or rubber tubes on the ear during surgery?

Veterinarians place plastic buttons or soft rubber tubes under the suture loops to distribute pressure evenly across the skin. Without buttons, thin suture wire can cut into swollen, edematous skin like a cheese slicer, causing tissue necrosis and scarring.

Sources

Topics
DermatologyAnesthesia & AnalgesiaClinical Pathology
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