1. Basic Suturing Technique Robert F. Doyle, MD Michael Falgiani, MD University Of Florida Department of Emergency Medicine

2. Basic Suturing Principles  Needle Construction  The point is the sharpest portion which penetrates the tissue.  The body represents the mid portion of the needle.  The swage is the thickest portion of the needle and the portion to which the suture material is attached.

3. More on Needles  Chief distinction is between taper or "smooth" needles vs. cutting needles. Taper needles gradually taper to the point, a cross-section anywhere reveals a round shaft. Used for tissue that is easy to penetrate, such as bowel or blood vessels.  The tip of cutting needles is triangular in shape, and the apex forms a cutting surface, which facilitates penetration of tough tissue, such as skin. Much easier to penetrate tough tissue. Penetrating skin with a taper needle is difficult causing excess trauma to the skin. You should never use taper needles to suture skin.  The reverse cutting is similar to a convent. cutting, except the cutting edge faces down instead of up. Decreases the likelihood of sutures pulling through tissue in some cases.

4. Loading the Needle  The needle should be grasped in the tip of the needle holder about 2/3 of the way back from the point. At the transition of the body to the swage.  Grasping further back at the swaged end tends to weaken the needle and its attachment to the suture, and you are likely to bend the needle.

5. Suture Placement  A needle holder is used to grasp the needle at the distal portion of the body, three quarters of the distance from the tip of the needle. The needle holder is tightened by squeezing it until the first ratchet catches. The needle is held vertically and longitudinally perpendicular to the needle holder  Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the skin, and/or an undesirable angle of entry into the tissue.  The needle holder is held by placing the thumb and the fourth finger into the loops and by placing the index finger on the fulcrum of the needle holder to provide stability. Alternatively, the needle holder may be held in the palm to increase dexterity.

6. Suture Placement  The tissue must be stabilized to allow suture placement.  Avoid crushing the skin edges with the forceps. This further traumatizes the wound edge and impedes healing.  The forceps allow you to create counter traction and control the position of the skin edge to facilitate passage of the needle perpendicularly through the skin.

7. Suture Placement  The needle should always penetrate the skin at a 90° angle which promotes eversion of the skin edges. The depth and angle of the suture depends on the particular suturing technique. In general, the 2 sides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skin surface.

8. More on Eversion  If wound edges invert or rolls under the opposite side, a poorly formed, deep, noticeable scar will result.  Optimal results are achieved when the epidermis is slightly everted because most scars undergo some flattening with contraction.

9. Instrument Knot Tying  The instrument tie is most commonly used in cutaneous surgery.

10. Instrument Knot Tying  Properly squaring successive ties is important, each tie must be laid down perfectly parallel to the previous tie.  This prevents a “granny knot”, which tends to slip and is inherently weaker than a properly squared knot.

11. Instrument Knot Tying

12. Technique  Simple Interrupted Stitch Most commonly used and versatile. Easy to place, have greater tensile strength to running sutures, and have less potential for causing wound edema and impaired cutaneous circulation. Allow the surgeon to make adjustments as needed to properly align wound edges as the wound is sutured.

13. Simple Interrupted Stitch  Disadvantages of interrupted sutures Slightly increased length of time required Greater risk of crosshatched marks across the suture line

14. Simple Interrupted Stitch  Insert needle perpendicular to the epidermis, and exiting perpendicular to the epidermis on the opposite side of the wound.  Both sides of the stitch should be symmetrically placed in terms of depth and width  Stitch should be wider at its base (dermal side) than at its superficial portion (epidermal side).

15. Simple Running Stitch  Useful for long wounds, with minimal tension, in which approximation of the wound edges is good.  Theoretically, less scarring compared with interrupted sutures because fewer knots are made with simple running sutures; however, the number of needle insertions remains the same.  Advantages include quicker placement and more rapid reapproximation of wound edges, compared with simple interrupted sutures.  Disadvantages include possible crosshatching, dehiscence if the suture material ruptures, difficulty in making fine adjustments along the suture line, and puckering of the suture line when the stitches are placed in thin skin. Not good for wounds overlying joints.

16. Simple Running Stitch  Place interrupted stitch at one end, only cut the free tail of the suture.  The procession is then done with a spiral pattern encircling tissue and suture line.  After each passage of the needle, the loop is tightened slightly.  The stitch should travel perpendicularly across the wound on each pass.  The last loop is placed just beyond the end of the wound, and the suture is tied, with the last loop used as a tail in the process of tying the knot.

17. Vertical Mattress Sutures  The best for maximizing wound eversion.  Consists of a simple interrupted stitch placed wide and deep into the wound edge and a second more superficial interrupted stitch placed closer to the wound edge and in the opposite direction.  One disadvantage of this method is increased crosshatching.  Unfortunately, this stitch causes more tissue ischemia and necrosis inside its loop than either simple or continuous stitches.

18. Vertical Mattress Sutures

20. Horizontal Mattress Sutures  Useful for wounds under high tension because it provides strength and wound eversion.  Very useful for thin skinned areas that need eversion and good strength.

21. Horizontal Mattress Sutures  May also be used as a stay stitch to temporarily approximate wound edges, allowing placement of simple interrupted or subcuticular stitches.  However, they have a high risk of producing suture marks if left in place for longer than 7 days.

22. Suture Removal  Sutures should be removed within 1-2 weeks of their placement, depending on the anatomic location.  As a general rule, the greater the tension across a wound, the longer the sutures should remain in place. Face, sutures should be removed in 5-7 days Neck, 7 days Scalp, 10 days Trunk and upper extremities, 10-14 days Lower extremities, 14-21 days

23. Suture Removal  Sutures should be gently elevated with forceps, and one side of the suture should be cut. After cutting the strand, suture is gently grasped by the knot and gently pulled toward the wound or suture line until the suture material is completely removed.  Steri-Strips may be applied with a tissue adhesive to provide continued supplemental wound support after the sutures are removed.

24. Questions