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Suturing Techniques

Chapter · September 2012

DOI: 10.1002/9781118412633.ch4

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 4 CHAPTER 4
Suturing techniques
Sonal Choudhary1, Keyvan Nouri1,
Ploypailin Jungcharoensukying1, and Mohamed L. Elsaie2
1
Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine,
Miami, FL, USA
2
Department of Dermatology and Venereology, National Research Center, Cairo, Egypt

Introduction Choosing appropriate

The goals of proper suturing techniques are:
• Eliminating dead space.
• Providing support to the wound so that the healing
process can strengthen the wound.
• Approximating the cutaneous edges so that cosmesis
and function are preserved.
• Minimizing the risk of infections and bleeding.1
Besides considering the conditions that affect wound
healing, the repair of wounds should always be preceded
by an evaluation of wound characteristics, their anatomic
location, thickness of the skin, degree of tension, and
desired cosmetic results.
Instruments
The instruments tray is set containing the following
items. Afterwards, a photograph should be taken;
• appropriate suture material
• surgical needle
• needle holder
• fine suture scissors
• toothed tissue forceps ± skin hook
• anesthetic solutions.
An adequate light source is important to perform
wound closure appropriately.
suture materials (Table 4.1)
A good suture material must have tensile strength to resist
breakage, good knot security, workability in handling, low
tissue reactivity, and the ability to resist bacterial infec-
tion. The two main classes of suture materials are:
• absorbable
• non-absorbable.2
Absorbable
Those sutures that are absorbed by tissue enzymes or
hydrolysis by the body’s cells and tissue fluids that they
are embedded in, during, and after the healing processes.
They are used as deep sutures and do not need to be
removed postoperatively.
I. Surgical gut: tensile strength is maintained for 7–10
days post implantation and absorption is complete
within 70 days:
a. indicated for epidermal use (required only for 5–7
days)
b. not recommended for internal use.
II. Dexon (polyglycolic acid): absorbable suture material
of a synthetic braided polymer:
a. has low rate of reactivity and infection, as well as
excellent knot security and tensile strength.
b. disadvantage: high friction.
III. Chromic gut: types A–D with increasing absorp-
tion times.

Dermatologic Surgery: Step by Step, First Edition. Edited by Keyvan Nouri.

© 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

25
26 PART 1: Dermatologic Surgery

Table 4.1 Types of sutures

Suture types

Location Subcutaneous Cutaneous

Material Usually absorbable Non absorbable : nylon (dermalon)

Organic : catgut-plain or chronic Absorbable : fast-absorbing catgut
Synthetic : polyglycolic acid (dexon, vicryl)

Advantages Decreased dead space Good approximation of tissue, good eversion of wound edges,
Decreased tension minimal tissue reaction to nylon and no need to remove if using
Homeostasis catgut suture

Disadvantages Introducing foreign body Nylon sutures require removal and can leave a mark after removed,
Risk of scar if suturing near skin surface plus more time consuming than other methods (staples and glue)
Risk of splitting of the suture

Non-absorbable • 5-0: For closure on face, nose, ears, eyebrows and

Those suture materials that cannot be absorbed by the
body’s cells or fluids.
They are used for surface suturing and requires manual
removal postoperatively.
I. Nylon (Ethilon): most commonly used of all non-
absorbable suture materials.
a. Possesses minimal tissue reactivity, resists infec-
tions, high tensile strength, and good wound security.
b. Drawback: difficult to achieve a good knot (needs
four or five “throws” to get a secure knot).
II. Prolene
a. Stronger than nylon and better overall wound
security.
b. Has greater memory and hence is difficult to work
with.
III. Braided: includes cotton, silk, braided nylon and
multifilament Dacron.
a. Most workable and has excellent knot security.
b. Soft, pliable, good to use around the eyes, lips
c. Disadvantages: high reactivity and absorption of
body fluids by the braided fibers.
The choice of suture material also greatly depends on
which area is being considered for suturing. The suture
size, which is measured by its width or diameter, is deter-
mined accordingly:
• 1-0 and 2-0: for strong retention in high stress areas,
e.g., deep fascia
• 3-0: areas requiring good retention, e.g., scalp, torso,
hands
• 4-0: for areas that need minimal retention and super-
ficial closure, e.g. extremities
eyelids
• 6-0: For areas which need little or no tension, e.g.,
cosmesis.3
Surgical needles
The needle has three sections: point, body and swage.
• The point is the sharpest portion which is used to pen-
etrate the tissue.
• The body is the mid-portion.
• The suture material is attached at the swage, which is
the thickest portion.
• Curved needles with two basic configurations are used
in suturing: tapered and cutting. The former is used on
soft tissue, and when the smallest diameter hole is desired.
A cutting needle has a sharp edge directed towards the
wound edge (inner curve). A reverse cutting needle is
similar but has the sharp edge directed away from the
wound edge (outer edge) and allows for a smooth and
atraumatic penetration of tough skin and fascia. Hence,
it is used more often than the cutting needle in cutaneous
surgery.
Needle holders
Needle holders come in different shapes and sizes. The
larger and deeper the wound, the bigger the size of the
needle holder required. It is used to grasp the needle at
the distal portion of the body. It is then tightened by
CHAPTER 4: Suturing techniques
squeezing it until the first ratchet catches. Excessive tight-
ening can damage the needle and the needle holder. The
needle is held vertically and longitudinally perpendicular
to the needle holder to avoid difficulty in penetrating the
skin, bending of needle and undesirable angle of entry
into the tissue.
The needle holder is held with the thumb and fourth/
ring finger into the loops and the index finger on the
fulcrum of the needle for better stability. Alternatively, it
may be, held in the palm for an improved dexterity.
Suture scissors
Three main types of scissors are generally used:
• Iris scissors: mainly used for wound debridement and
revision. These are very delicate, and are not recom-
mended for cutting sutures except very small sutures.
• Dissection scissors: used for undermining the wound.
• Suture removal scissors: used for cutting sutures and
other dressing materials. These are single blunt-tip stand-
ard scissors which are 6 inches in length and durable
to use.
Forceps
For proper suture placement, grasping and controlling
the tissue with forceps is essential. At the same time,
gentle handling of the tissues is necessary for avoiding
tissue strangulation and necrosis. Toothed or untoothed
forceps or skin hooks are the available options for the
surgeon. The forceps are also useful in grasping the
needle, as it exits the tissue and lessens the risk of losing
the needle in the dermis and subcutaneous fat.
Important points for suturing
I. Gathering is a maneuver that should be used for every
suture to get excess line out of the way and off the table.
a. Push the needle through the skin with a needle
holder.
b. Then with the thumb and the index finger grasp the
needle and pull the suture through.
c. Now using the fifth digit pull the suture into your
hand as you re-grab the suture with your thumb and
index finger.
d. Repeat.
27
II. Wound eversion
a. Essential for good epidermal approximation and
reduces the risk of scar depression secondary to tissue
contraction during healing.
b. The needle should always penetrate the skin at 90°
angle to minimize the size of entry wound and promote
eversion.
III. Wound layers should be placed in close
approximation.
IV. Minimize the amount of tension across the suture
line.
V. Equal bites, horizontally and vertically result in a flask
shaped configuration, i.e., the stitch is wider at its base
(dermal side) than its superficial portion (epidermal
side).
VI. Small bites can be used to precisely co-apt wound
edges. Large bites can be used to reduce wound tension.
VII. Debride devitalized tissue.
Step-by-step suturing technique
I. Apply the needle to the needle holder one half to three
quarters of the distance from the tip of the needle.
II. Stabilize the wound edge and apply gentle traction
with either toothed forceps or a skin hook.
III. Insert the needle 1–3 mm from the wound edge at
90° angle to the skin surface.
IV. The needle should traverse downwards through the
epidermis and dermis and take a small bit of subcutane-
ous tissue.
V. Turn your wrist to get the needle through the
tissues.
VI. Release the needle from the needle holder and reach
into the wound and grasp the needle tip with the needle
holder and pull it free, so that you have enough suture
material to enter the opposite side of the wound.
VII. Insert needle on the opposite wound edge at
an equivalent depth to the initial placement to avoid
mismatched wound-edge heights (i.e., stepping). The
needle should follow a reverse path exiting the skin
equidistant to the opposite side, perpendicular to the
skin.
VIII. Pull the needle through the skin until you have
approximately 1 inch suture strand protruding from the
bite sites.
IX. Release the needle from the needle holder and wrap
the suture around the needle holder twice.
28
X. Grasp the end of the suture material with the
needle driver (instrument tie) and pull the two
lines across the wound site in opposite directions. This
is called a throw. It can be done using one’s hands
too.
XI. Do not position the knot directly over the wound
edge.
XII. Two throws make a “knot”. Repeat three or four
throws to ensure knot security. Over each throw, reverse
the order of the wrap (squaring). Proper squaring of suc-
cessive ties prevents creation of a granny knot which
tends to slip and is inherently weaker than a properly
squared knot.
XIII. Cut the ends of the suture one-quarter inch from
the knot.
Types of suturing technique
Simple interrupted sutures
• Interrupted sutures are individually placed and tied.
• The technique involved is mentioned above and needs
to be repeated for however many times is required
depending on wound length.
• Sutures should be placed 0.5– cm apart.
• Less potential for causing wound edema.
• Allow the surgeon to make adjustments as needed to
properly align wound edges.
• Technique of choice, if cleanliness of wound is doubt-
ful. If the wound appears to become infected, a few
sutures can be removed without interrupting the entire
closure.
• Disadvantage: more time required to place interrupted
sutures and more risk of crosshatching (train tracks)
across the suture line. The latter can be minimized by
early suture removal.1
Running sutures
Simple running sutures
• Uninterrupted series of simple interrupted sutures.
• Suture is started by placing a simple interrupted
stitch which is tied but the line leading to the needle
is not cut.
• Reinsert the needle the same distance from the wound.
Once inserted, push the needle perpendicular to the
wound and out of the other side.
PART 1: Dermatologic Surgery
• Instead of tying, reinsert the needle down the wound
and so that the suture crosses over the top of the wound.
Now, go through the wound perpendicular again.
• Repeat until the end of the wound, then tie off (like
mentioned in the technique).
• Useful for long wounds in which tension has been
minimized with already placed deep sutures, and in
which wound approximation is good.
• Can be used to secure a split- or full-thickness skin
graft.
• Causes lesser scarring due to lesser number of knots
than interrupted sutures.
• Advantage: quicker placement
• Disadvantages: wound dehiscence if suture material
fails, can cause crosshatching, adjustments along the
suture line can be difficult, puckering of suture line can
occur in patients with thin cutaneous tissue.1
Running locked sutures
• Also known as baseball sutures due to its final
appearance.
• The first knot of a running suture is tied as mentioned
earlier and is then locked by passing the needle through
the loop preceding it as each stitch is placed.
• Useful in wounds that need more hemostasis (oozing
from skin edges), e.g., scalp and post-auricular sulcus.
• Can impair microcirculation and cause strangulation.
• Should only be used in areas that are adequately
vascularized.1
Mattress sutures
Vertical mattress sutures
• Variation of simple interrupted sutures.
• Goes both deep and superficial, and constrains minor
blood vessels.
• For placing this suture go in and out of the wound,
narrow and shallow. Then reinsert needle on same side
as the exit, but further from the wound. Push needle
back to the other side of the wound going deeper
than the first pass. Pull suture tight, and tie the ends as
before.
• The width of the stitch should be made directly pro-
portional to the amount of tension on the wound.
• Useful in achieving maximum wound eversion, reduc-
ing dead space and minimizing tension across the
wound.
 CHAPTER 4: Suturing techniques
• Disadvantage: cross-hatching
• Early suture removal (5–7 days), should be done to
reduce scarring.1
• Pulley suture/far-near near-far modified vertical mat-
tress sutures: variation of vertical mattress suture. Facili-
tates greater stretching of wound edges. Useful when
additional wound closure strength is desired.
Horizontal mattress sutures
• Begins as a deep simple interrupted stitch by entering
the skin 5 mm to 1 cm from the wound edge, passing
through the dermis and exiting on the opposite side at
an equidistant point. Now, the needle is re-inserted on
the same side of suture line 5 mm to 1 cm lateral to the
exit point emerging from the opposite side. The ends are
tied to complete the knot.
• Useful for wounds under high tension, and can be used
as a stay stitch where risk of dehiscence is high. Improved
wound strength and wound eversion.
• Disadvantage: high risk of tissue strangulation.1
Buried sutures
Buried sutures are a useful technique for wide gaping
wounds and wounds where eversion is difficult. The
purpose of this stitch is to line up the dermis and thus
enhance healing. The knot needs to be as deep into tissues
as possible (buried), so that it does not present through
the epidermis and cause irritation and pain.
Variations of running sutures
Running horizontal mattress sutures
After placing a simple suture, the horizontal mattress is
placed. The final loop is tied to the free end of the suture
material.
Useful at places where wound inversion chances are
high, e.g. neck, and also useful for reducing spread of
facial scars.1
Running subcuticular sutures
• Useful in situations with minimal would tension
and dead space, and when the best cosmetic result
is desired.
• Can result in minimal visible suture marks, little cross-
hatching, as well as closely approximated wound edges.
• Does not contribute to wound strength.1
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29
Table 4.2 Length of suture maintenance, by body region
Region Approximate number of
days for suture removal
Face 5–7 days
Scalp 10 days
Neck 7 days
Trunk and upper extremities 10–14 days
Lower extremities 14–21 days
Running subcutaneous sutures
• Begins as a running subcutaneous suture. The knot is
tied but not cut. The suture is looped through the sub-
cutaneous tissue by successively passing through the
opposite sides of the wound.
• Next, the knot is tied at the opposite end of the wound
by knotting the long end of the suture material to the
loop of the last pass that was placed.
• It is used to close deep portion of surgical defects under
moderate tension.
• Disadvantages: suture breakage can create dead space
underneath the cutaneous surface.1
Suture removal
• Rule: the greater the tension across a wound, the longer
the suture needs to be left in place (Table 4.2).
• Buried sutures that utilize absorbable suture material
are dissolved by tissue fluids and do not require removal.
References
1. Mackay-Wiggan J, Ratner D, Sambandan DR.
Suturing techniques.
http://emedicine.medscape.com/article/1128240-print
2. Gunson T. Suturing techniques.
http://www.dermnetnz.org/procedures/suturing.html
3. Suture materials and techniques.
http://www.brooksidepress.org/Products/
OperationalMedicine/DATA/operationalmed/Manuals/
FMSS/SUTUREMATERIALSANDTECHNIQUES.htm