Basic plastic surgery techniques and principles:

How to suture
In the second article of our series, Ben Taylor and Ardeshir Bayat explain suture techniques, how to
prepare a wound, and how to get the best possible scar

Stitching (suturing) a wound is a surgical skill ondary healing to occur before the wound is thought. This article focuses on sutures, but
which also has widespread applications out- closed. The aim of a suture is to splint the there are alternatives which find a place in
side the field of surgery. We are all likely to wound edges in the best position for direct some specialties. In paediatrics, for example,
be called on to suture a wound at some primary closure to occur. If the suture has to wound glue is often used in scalp injuries, to
point in our training. Few students have pull the wound edges together under ten- save the child the stress of having his or her
enough confidence, however, to deal with sion, the sutures will act like a noose to cause head sutured.
wounds, and it can be hard to learn. In this local ischaemia of the tissues, which may Wounds can be frightening things, and
article we look at the basics of wound heal- lead to breakdown. they immediately attract attention. For larger
ing suturing technique. We discuss a few wounds, always think about airway, breath-
more advanced techniques and share the se- ing, and circulation first, and make sure that
crets of getting best possible results. Preparation and assessment the wound is an isolated injury.
When closing a wound, you need to assess it Before suturing, ensure the patient has
first (box 1 opposite).3 Many simple wounds adequate anaesthesia (either local or gen-
Wound healing will heal by themselves, without any inter- eral). Irrigate the wound, and remove any
To understand the basis of suturing, it is im- vention. A suture should be used as a splint foreign bodies and any non-viable or in-
portant to know how wounded skin heals. to hold the wound in the best possible posi- fected tissue (debridement). Debridement is
This occurs in four phases (although there is tion, rather than to hold it together. If you particularly important as dead tissue will not
some overlap). judge that there is too much tension to close heal and acts as a reservoir for infection.4
Haemostasis—Immediately after wounding, the wound directly, consider discussing the The integrity of the deep structures must be
a platelet plug forms and blood vessels vaso- case with a plastic surgeon, or leaving the checked in any wound. Refer damage to ten-
constrict. Later, a thrombus develops to seal wound for delayed primary closure. dons, nerves, viscerae, etc, to an appropriate
the wound. Many tools are available for wound clo- specialist for assessment or primary repair.
Inflammation—This occurs in the first two sure—for example, wound glue, staples, and The wound edges must have a good blood
to three days after the injury, causing sutures—and the most appropriate means of supply and be free from infection to ensure
swelling of the wound edges. White blood closing a wound must be given some healing. You must follow strict aseptic tech-
cells remove necrotic tissue, and control in-
fection.1
Proliferation—Beginning on the second or
third day after the injury, and lasting for two
to four weeks, structure forming cells called
fibroblasts proliferate into the wound, and
produce structural proteins such as gly-
cosaminoglycans, collagen, and elastin.2 New
capillaries form at this time, and epithelial
cells migrate across the top of the wound.
Areas where this is occurring are known as
“granulation tissue.”
Remodelling—After the proliferative phase
subsides, the new capillaries atrophy and
collagen changes from type III to type I and
is rearranged so that it gives the best tensile
strength. Myofibroblasts cause scar contrac-
ture. Strength of the wound increases to al-
most 80% of the original strength over this
period of up to a year.2 Because the forces
acting on the wound shape its remodelling,2
the best result is obtained when the force is
uniaxial (only acts in one direction).
Primary closure is where the wound
edges are neatly brought together. Healing
by secondary intention differs, in that the
wound heals from the base up, which takes
longer with a potentially worse cosmetic re-
SATURN STILLS/SPL

sult. Delayed primary closure is used in situ-

ations where early primary closure is
inappropriate, and allows a period of sec-

182 STUDENT BMJ VOLUME 11 JUNE 2003 studentbmj.com

niques. It may be worth delaying primary
closure if there is oedema or doubt as to the
viability of tissue. Systemic factors, such as
malnutrition, diabetes mellitus, peripheral
vascular disease, and corticosteroid therapy
may delay wound healing.2

Simple suturing
The simple suture is a technique taught to
most medical students, and often used in
wound closure. It has the advantage of being
quick and relatively easy, and usually gives
an adequate cosmetic finish. However it is
often done poorly, and can cause long last-
ing damage to a patient if care is not taken. It
is known as an “interrupted suture,” because
several individual stitches are needed to
close a wound.

Box 1: Assessing and preparing a

wound
● Is this an isolated injury?
● Are all of the deep structures intact?
● Have I removed all dead tissue?
● Is this wound suitable for immediate
closure?
● Do the wound edges have a good blood
supply?
● Is suturing the best way to close the
wound?
● Have I anaesthetised the wound?
● Do I have the right equipment (instru-
ments and correct suture material)?
● Will the wound benefit from steri-
strips?
● Do I have an appropriate dressing to
cover and protect the wound?
Technique
When suturing, the deep layers should be
closed below if necessary. Any deep tissue
gaps may become infected. Make sure the
wound stops bleeding because if a
haematoma forms it can act as a barrier be-
tween the wound edges and be a potential
source of infection. Use a needle holder
where possible, to minimise the risk of
needlestick injury.5 The skin edges should be
accurately apposed, and not under undue
tension. If forceps are used to align the tis-
sues they should be used gently: it is better
to use the closed forceps to nudge the skin
edges together, than to grab them.6 The in-
side of the skin is delicate, as it does not have
a protective layer of keratinocytes and is also
where the blood supply is richest. Therefore
skin trauma will impair healing. A skin stitch
should gently evert the wound edges, as the
deeper layer is alive and capable of regener-
ating, whereas the superficial layers are
mostly dead keratinocytes.
The needle should be held in needle
holders two thirds of the way from the nee-
dle tip to the swage (point where the needle
becomes attached to the thread). Take a
square bite of skin, entering perpendicular
to the wound surface, and taking a smooth
semicircular course to exit at 90 degrees to
the wound edge. The needle should then be
removed from the wound, readjusted on the
needle holder, and the second half of the arc
done in the same way. This method ensures
a square bite, and good eversion of the
wound. Bites of skin should be equal on
both sides of the wound, and sutures should
be spaced evenly.
Tying
Use a surgical knot to close the wound, which
must be tied tight enough to adequately
splint the wound. However, if it is too tight,
there will be local ischaemia underneath the
suture tracks leading to an ugly crosshatched
scar. An instrument knot is shown in the fig-
ure. The concept is simple in that the long
end of the thread is wrapped around the nee-
dle holder, which is used to transfer the coil
around the short end. This cycle is repeated
to create a surgeon’s knot. Once tied, the
knot should be left to one side, so that it does
not become involved in the clot.
Variations on a simple suture
Continuous simple suture
This is similar to a simple suture, except that
there are no individual sutures, just a long
coil of material. They are used in abdominal
wall closure,7 and in places where haemosta-
sis is important, such as on the scalp, be-
cause the suture compresses the wound
edges.8
Buried simple suture
The buried suture is circular in profile, and is
used to close the deep layers of tissue. The
knot should be placed deep to prevent it
coming out. Absorbable sutures should be
used, as the suture cannot be removed from
the skin.
Vertical mattress suture
This technique produces more eversion than
a simple suture. It is similar to a simple su-
ture, but a second, superficial bite is taken in
the same vertical plane (see figure). Al-
though it may evert skin in areas with a nat-
ural tendency to invert, it does produce
more crosshatching due to increased dermal
ischaemia.8
Horizontal mattress suture
This is a similar concept to the vertical su-
ture, except that it extends along a horizon-
tal plane, almost like two simple sutures next
to each other (see figure) It is useful in areas
with thick glabrous skin, such as the soles of
the feet. But it also causes more dermal
ischaemia than simple or even vertical mat-
tress sutures, and if tied too tightly, can over-
evert the wound edges.5
Other important techniques
Subcuticular suture
Subcuticular or intradermal sutures give the
best cosmetic result, and are simple and
quick to place.9–11 They run in the dermis in
the same plane as the subdermal plexus, the
main blood supply to the skin,12 and there-
fore do not “strangle” wounds in the same
way as simple sutures. They do not cause

STUDENT BMJ VOLUME 11 JUNE 2003 studentbmj.com 183

crosshatching, and mechanically provide the
best internal splinting of a wound.
Monofilament sutures are used, as they
do not exhibit as much tissue drag as
braided sutures. There are many different
ways to start and finish such a suture,10 13–15
but generally, non-absorbable sutures
should enter the skin at the apex of the
wound, and absorbable sutures are often tied
in the dermis. Bites should be parallel to the
wound edges, and through the dermis. Take
care to ensure that all bites are placed in the
same vertical plane, otherwise the wound
edges will be misaligned with poor healing.
Long wounds should have bridges (loops of
suture) brought out over the wound.16
Half buried mattress suture (Barron
suture) and three corner suture
This is used where either a single wound
edge is friable, or the knots can be hidden on
one side (such as the areola of the breast). It
is a combination of a mattress suture and a
subcuticular suture (see figure).
A variation where the subcuticular com-
ponent is used to close the corners of several
different lacerations is known as a three-cor-
ner suture (see figure).
Complications of suturing, and
how to minimise them
Infection
Infection was a significant problem when su-
tures were carried in the buttonholes of sur-
geons. Today it can be a problem if there are
breaks in aseptic technique or from hospital
acquired infection. Wounds must be ade-
quately debrided to remove any contami-
nated tissue, and may need to be irrigated or
cleaning with abrasion under anaesthetic
may be required.4
Tattooing
This is a rare complication of using dyed su-
tures, and it is best to avoid dyed sutures on
the skin. Other sources of tattooing are grit
and dirt. Abrasions are particularly liable to
tattoo, and should be thoroughly scrubbed
with a wire brush, under anaesthetic of
course.
Scarring
Scarring is a natural process, and occurs as
the result of any wound. However, large,
stretched or hypertrophic scars can look
ugly and are occasionally a source of psy-
chological trauma, even if the scar looks ac-
ceptable to the medical professional.17 Scars
contract, which is troublesome around
joints. It is very important to minimise scar-
ring, and take every effort to do so (box 2).
The simple suture does an adequate job
of internally splinting the wound but in do-
ing so can create lines of traction and
counter traction, which can result in a poor
scar. Ideally, subcuticular sutures should be
184
Box 2: Getting a fine scar
● Ensure that an elective incision runs
along a line of relaxed skin tension,
where possible8 (RSTL—also known as
wrinkle lines or natural skin lines are
lines of minimal tension and lie perpen-
dicular to axis of underlying muscle)
● Debride the wound, remove any foreign
bodies, and irrigate it4
● Ensure the wound edges are not under
tension, that they have a good blood
supply, and that they are viable5
● Obtain early primary closure where
possible
● Avoid infection4
● Ensure that the wound edges are well
apposed6
● Ensure that the forces acting on the
wound only act in one direction, and
minimise distracting forces
● Minimise tissue trauma when suturing6
● Suture neatly with a gently everting
wound edge
● Avoid materials that cause a bad tissue
reaction for example, silk on the face18
● Make sure you immobilise the wound
with steri-strips, tapes, and even ther-
moplastic splints and plaster casts
where necessary
used for skin closure, as they have a better
cosmetic result.
Dehiscence
Dehiscence is the term used for the break-
down of a wound postoperatively. Common
causes include lack of surgical experience,6
(implying that poor technique is to blame).
Other important factors are wound tension
and infection. Dehiscence is associated with
a mortality of 25% in the case of general
surgical wounds. Other complications in-
clude chronic wounds and infection of deep
structures.
An important skill
Suturing is an important skill for any med-
ical student or junior doctor to learn. There
are a few key messages to remember to
suture effectively and avoid damaging your
patient.
Ben Taylor third year medical student
Ardeshir Bayat specialist registrar in plastic surgery
University of Manchester
ardeshir.bayat@man.ac.uk
1 Hart J. Inflammation 1: its role in the healing of acute
wounds. J Wound Care 2002;11:205-9.
2 Cotran RS, Kumar V, Collins T, eds. Robbins pathologic
basis of disease. 6th ed. Philadelphia: WB Saunders,
1999.
3 Benbow M. The skin 2: skin and wound assessment.
Nurs Times 2002;98:41-4.
4 Fildes J, Bannon MP. Soft-tissue infections after trauma.
STUDENT BMJ VOLUME 11
Box 3: Removing sutures
● Give oral analgesia or topical
anaesthesia if necessary
● Clean the wound with antiseptic
solution
● Use forceps, fine scissors, or a suture
cutting blade
● For removing interrupted sutures, lift
one end lightly, and then cut under the
knot
● Pull suture out across rather than away
from the wound as you may make the
wound bleed or dehisce if not careful
● If in doubt, apply steristrips or tissue
glue to protect the wound after
removing sutures
● Time to remove non-absorbable
sutures depends on location: face (5-7
days), scalp (7-10 days), and limbs and
trunk (12-14 days)
Surg Clin North Am 1991;71:371-84.
5 Skinner I. Basic surgical skills manual. Sydney: McGraw-
Hill, 2000.
6 Singer AJ, Quinn JV, Thode HC, Hollander JE. Deter-
minants of poor outcome after laceration and surgical
incision repair. Plast Reconstr Surg 2002;110:429-35.
7 Wadström J, Gerdin B. Closure of the abdominal wall:
how and why? Acta Chir Scand 1990;156:75-82.
8 Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and
Smith’s plastic surgery. 5th ed. Philadelphia: Lippincott-
Raven, 1997.
9 Angelini GD, Butchart EG, Armistead SH, Brecken-
ridge IM. Comparative study of leg wound closure in
coronary artery bypass graft operations. Thorax
1984;39:943-5.
10 Taube M, Porter RJ, Lord PH. A combination of subcu-
ticular suture and sterile micropore tape compared
with conventional interrupted sutures for skin closure:
a controlled trial. Ann R Coll Surg Engl 1983;65:164-7.
11 Onwuanyi ON, Evbuomwan I. Skin closure during ap-
pendicectomy: a controlled clinical trial of subcuticular
and interrupted transdermal sutures. J R Coll Surg Ed-
inb 1990;35:353-5.
12 Richards AM. Key notes on plastic surgery. Oxford: Black-
well Science, 2002
13 La Padula A. A new technique to secure an entirely
buried subcuticular suture. Plast Reconstr Surg
1995;95:423-4.
14 Smoot EC. Method for securing a subcuticular suture
with a minimal buried knot. Plast Reconstr Surg
1998;102:2447-9.
15 St John HM. Knot-free subcuticular suture. Br J Surg
1997;84:872.
16 Tantawy HS. New technique for subcuticular suture in
lengthy wounds. Br J Surg 1996;83:66-7.
17 Carr T, Harris D, James C. The Derriford appearance
sale (DAS-59): A new scale to measure individual re-
sponses to living with problems of appearance. Br J
Health Psychol 2000;5:201-15.
18 Gabrielli F, Potenza C, Puddu P, Sera F, Masini C,
Abeni D. Suture materials and other factors associated
with tissue reactivity, infection and wound dehiscence
among plastic surgery outpatients. Plast Reconstr Surg
2001;107:38-45.
Key points
● Always assess, clean, and debride the
wound before suturing
● Use aseptic technique at all times
● Suture neatly
● Get as much supervised practice as you
can before you have to do it on your
own
JUNE 2003 studentbmj.com