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THE FUNDAMENTALS OF SUTURING

Tara L. Roberts MSN, RN, ANP-BC Central Texas VA Health Care System, Temple ,Texas

Presented to The University of Texas at Austin on 3/31/14, 9/9/14, 9/22/15, 3/8/17, & 4/24/18(Original presentation: November 1 , 2012)

Objectives

¨ To review the anatomy of the skin.¨ To describe the three phases of wound healing and the factors affecting wound healing and closure.¨ To describe the types of instruments needed for

suturing.¨ To describe the types of suture needles available.¨ To describe the various types of suture materials

available.¨ To discuss the types of local anesthesia, selection,

dosing, techniques for injection and potential side effects.

¨ To describe and demonstrate fundamental suturing techniques and after care.

Anatomy of Skin

q The epiderm is, derm is, subQ and deep fascia are the tissue layers o f co ncern in w o und clo sure.

q Th e ep id erm is an d d erm is form th e skin .

q The epiderm is pro tects against in jury, d isease and excessive w ater lo ss.

q Th e d erm is contain s n erve en d in gs, b lood vessels, g lan d s, co llagen an d elastin th at respond to heat, pressure, and pain .

q D erm al approxim ation provides the strength and alignm ent o f skin clo sure.

q Th e sub Q layer is m ain ly ad ipose and loose connective tissues that serves as a cush ion for the skin and helps m aintain b ody heat an d store en ergy.

q Suture w ith in the subQ layer do es no t add strength to the repair but m ay decrease tensio n o n the w o und edges im proving the co sm etic resu lt.

q Th e d eep fascia l layer includes som e m uscle

tissu e an d occasionally requires repair in deep lacerations.

EPIDERMIS

DERMIS

SUBCUTANEOUSLAYER

FASCIA/MUSCLE

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Three Phases of Wound Healing

Phase I Wound Healing

¨ Hemostasis and Inflammation:¤ Injury is followed by coagulation¤ Vasospasm is followed by

vasodilationand increased capillary permeability¤ Platelets activate and aggregate¤ Fibrous clot formation

occurs¤ Proteolytic enzymes released by neutrophils &

macrophages break down damaged tissue

Phase II Wound Healing

¨ Fibroplasia/Proliferation:¤ In f la m m a t io n d e c re a s e s a s

in f la m m a to r y s t im u li a re re m o v e d

¤ F ib ro b la s t s w it h in t h e w o u n d sy n t h e s ize a n d s e c re te p ro te o g ly c a n s , c o lla g e n a n d

e la s t in¤ E p it h e lia l iz a t io n o c c u rs in t h e

e p id e r m is , t h e o n ly la y e r

c a p a b le o f re g e n e ra t io n ; c o m p le te b r id g in g o f t h e w o u n d o c c u rs w it h in 4 8 h o u rs a f te r s u t u r in g

¤ N e w b lo o d v e s s e l g ro w t h p e a k s 4 d a y s a f te r in ju r y

¤ B y d a y 5 t h e f ib ro p la s t ic s ta g e is w e ll e s ta b lis h e d

¤ T h e w o u n d c o n t ra c t s , g ra d u a lly

d e c re a s in g in s ize

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Phase III Wound Healing

¨ Maturation/Remodeling:¤ Collagen formation is necessary to restore tensile

strength to the wound¤ This process begins within 48

hours of injury and peaks in the first week¤ Progressive increase in tensile strength

n B y 2 w e e k s w o u n d h a s h e a le d to 2 0 % o f it p re -w o u n d s t re n g t h

n B y 5 w e e k s it h a s h e a le d to 5 0 %

n B y 1 0 w e e k s it h a s h e a le d to

8 0 %n R e m o d e lin g a n d m a t u ra t io n o f

t h e s c a r c o n t in u e s fo r o n e y e a r

o r lo n g e r

Factors Affecting Wound Healing

¨ Comorbidconditions:¤ D M¤ R e n a l in s u ff ic ie n c y

¤ D is o rd e rs o f c o lla g e n sy n t h e s is (E h le r-D a n lo s/M a rfa n ’s Sy n d ro m e s)

¤ Im m u n o c o m p ro m is e¤ N u t r it io n

¤ O b e s it y¤ M e d ic a t io n s ( c h e m o t h e ra p y, c o r t ic o s te ro id s , b io lo g ic s , a n t ic o a g u la n t &

a n t ip la te le t d r u g s )¤ S m o k in g a n d a lc o h o lis m

¨ Temperature(the higher the temperature of the anatomic area, the greater the blood supply)¨ Blood supply (the better the blood supply the more oxygen to the injured tissues improving rate of healing)¨ Ischemia¨ Infection

Principles of Wound Closure

¨ A ssessm ent of w ounds/lacerations :¤ Determine mechanism of injury¤ Age of injury¤ Possible contamination/foreign body¤ Extent of the wound¤ Neurovascular compromise or tendon injury¤ Need for tetanus prophylaxis¤ Identify risk factors that affect healing

¨ G oals o f w ound closure/healing:¤ No infection¤ Return of normal function¤ Excellent cosmetic result

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Principles of Wound Closure Continued

¨ Indications for suturing:¤ If the depth of the wound will result in excess scarring if wound edges are not approximated (i.e. extending through dermis)¤ Clean, uninfected wounds anywhere on the body may be closed primarily within 18 hours after injury w/o significant increase risk for infection¤ Facial wounds may be closed primarily 24-72 hours after injury if no s/s

infection, no risk factors for infection and wound can be easily approximated¨ Contraindications for suturing:

¤ Animal bites¤ Deep puncture wounds (cannot adequately irrigate)¤ If suturing will create too much tension along skin edges¤ Actively bleeding wounds (esp. arterial; hematoma formation increases risk of infection and delays wound healing)¤ Superficial wounds (lacerations/abrasions only involving the epidermis)

Principles of Wound Preparation

¨ Minimize bacterial contamination¤ Irrigate wound with saline or water (tap or sterile)¤ Do not irrigate wounds with antiseptics as they can impair wound healing

¨ Remove foreign bodies ¨ Debride necrotic tissue¨ Achieve hemostasis¨ Prepare intact skin for excision or biopsy (i.e. cyst, lipoma, skin lesion)

¤ Use betadineor chlorhexidinesolution¨ Handle tissues gently

¤ Recommend use of fine toothed forceps (Adson forceps) because they require less pressure to grasp tissues; smooth forceps crush tissues d/t greater force required for grasping

¨ Approximate; don’t strangulate¤ Sutures that are too tight increase scarring and cause ischemia of the

wound edges increasing risk of infection

Needles

¨ Many different needle types to choose from:¤ Curved vs. Straight¤ Curvature: 1/4, 3/8, 1/2 or

5/8 circle; most common 3/8¤ FS/CE series: standard skin needles for scalp, trunk, or

extremities; used on thick skinn (FS -fo r sk in ; C E -c u tt in g n e e d le s )

¤ P/PS/PC/PRE series: s m a lle r / s h a r p e r n e e d le s fo r fa c e & d e lic a te a re a s ; u s e d fo r c o s m e t ic

c lo s u re s n (P-plastic; PS-plastic skin; PC-precision

cosmetic; PRE-premium)

(b a s e / e y e )

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Needles Continued

¨ Taper/smooth vs. Cutting¤ Taper/smooth needles are primarily used for tissues

that are easy to penetrate (bowel or blood vessels); rounded shaft that gradually tapers to a point

¤ Cutting needles have a triangular shaft and tip forming a cutting surface used for tissues that are tough to penetrate (skin); conventional-cutting edge faces up; reverse-cutting edge faces down

Suture Materials

¨ Non-absorbable sutures¤ N o t e a s ily b ro k e n d o w n b y t h e b o d y ’s e n z y m e s o r h y d ro ly s is¤ N a t u ra lly o c c u r r in g

n silk, co tto n, stee l

¤ S y n t h e t ic

n nylo n, pro lene, m ersilene¤ U s e d fo r s k in c lo s u re ; re q u ire s re m o v a l

¨ Absorbable sutures¤ C a n b e b ro k e n d o w n o r d is s o lv e d b y t h e b o d y ’s e n z y m e s o r h y d ro ly s is ( in f la m m a to r y

re s p o n s e )

¤ N a t u ra lly o c c u r r in g (e n z y m a t ic b re a k d o w n )n plain and chrom ic “cat gut” (derived from anim al intestines)n plain gut takes about 7 days to break dow n

n chro m ic gut is treated w ith chro m ium salts and takes 2-3 w eeks to break dow n and 3 m o nths to co m plete ly d isso lve

¤ S y n t h e t ic (n o n -e n z y m a t ic / h y d ro ly s is b re a k d o w n )n vicryl and m o no cryl (m ade fro m po lym ers)

¤ U s e d fo r s u b c u ta n e o u s c lo s u re a n d ra re ly fo r s k in c lo s u re ; d o e s N O T re q u ire re m o v a l

Suture Materials Continued

¨ Monofilament¤ A single smooth strand¤ Less traumatic; creates less friction through tissues for a better

cosmetic result¤ May have lower rates of infection¤ Knots more likely to slip (requires more “throws”; 5-6 knots)¤ Ex. nylon, Prolene, Monocryl

¨ Multifilament¤ Multiple fibers woven/braided together¤ Easier to handle and tie¤ May have higher rates of infection d/t the small, narrow spaces between the fibers that can harbor and grow bacteria¤ Knots less likely to slip (requires fewer “throws”; 3-4 knots)¤ Ex. silk, Mersilene, Vicryl

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Suture Materials Continued

¨ Suture sizes¤ Usually the bigger the suture material the bigger the

needle¤ Suture sizing is similar to needle sizing; the bigger the

number the smaller the size¤ Suture sizes range from 00 (very large, used to close abdominal wall) to 10-0 (very small, used for microvascular

surgery)¤ We generally use sizes in the middle range: 3-0 to 5-0¤ Use smaller sutures on the face: 5-0 to 6-0 (less scarring)¤ Use smaller sutures on children: 4-0 (delicate skin)¤ Larger suture can be used where cosmesis is less important

(easier to work with and stronger)

Instruments Needed

¨ Scalpel¤ The most commonly used blades are the #10, #11 & #15

n #10 is better for long, straight incisionsn #11 is better for stab incisions (I&D) and precision cuttingn #15 is better for short, tortuous incisions

Instruments Needed

¨ Needle Holder/Driver

¤ Place your thumb & ring finger slightly into the instrument’s rings.¤ A second technique is grasping the rings and body of the needle

holder in the palm of your hand w/o placing your fingers in the rings.¤ Grab the needle with the driver 1/2 to 2/3 back from the tip of the needle; you will hear a click when the clasp is engaged.

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Instruments Needed

¨ Forceps w/teeth¤ Hold like a pen¤ Be gentle

¨ Suture scissors¤ Place your thumb & ring finger in the holes¤ Cut with the tips to avoid damage to tissue

Local Anesthesia

¨ Topical Agents¤ Expensive¤ Limited usefulness (primarily for children & insertion of IV catheters)¤ Longer time to onset of action

¨ InjectableAgents¤ Local infiltration with an injectableagent is preferable for surgery on intact skin, large wounds and when immediate anesthetic effect is

required¤ Relatively quick onset of action (2-10 minutes) depending on agent¤ Duration of action 30 minutes to 6 hours depending on agent¤ Generally administered as an intradermal or subcutaneous injection blocking pain transmission from the free nerve endings in the

epidermis and dermis; intradermal injection is more painful¤ Most injectableagents are prepared in an acidic form (pH 5.0-7.0);

causing pain with injection

Local Anesthesia/Injectable Agents

¤ Amidesn Lidocaine (most commonly used agent)n Mepivacainen Bupivacaine/Marcaine

¤ Estersn Procaine/Novocainen Tetracainen Cocainen Benzocaine

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Injectable Agents Additives

¨ Sodium Bicarbonate¤ B u ffe rs t h e a c id ic p H o f in je c ta b le a g e n t s d e c re a s in g p a in a t t h e in je c t io n s ite¤ L id o c a in e (w it h o r w / o e p i) : a d d 1 m L (1 m E q / m L ) b ic a r b o n a te to 9 m L lid o c a in e

b e fo re in je c t io n

¤ B u p iv a c a in e (w it h o r w / o e p i) : a d d 1 m L o f b ic a r b o n a te to 1 9 m L b u p iv a c a in eb e fo re in je c t io n ; le s s l ik e ly to re d u c e p a in o f in je c t io n w h e n c o m p a re d to l id o c a in e

¨ Epinephrine¤ C a u s e s lo c a l v a s o c o n s t r ic t io n¤ P ro lo n g s a n e s t h e t ic a g e n t s d u ra t io n o f a c t io n (e x c e p t fo r b u p iv a c a in e )

¤ D e c re a s e s lo c a l b le e d in g d u r in g t h e p ro c e d u re

¤ D e c re a s e s sy s te m ic a b s o r p t io n o f t h e a n e s t h e t ic a g e n t¤ C o n t ra in d ic a t io n s :

n Prio r a llergic reactio n/catecho lam ine sensitiv ity (tachycard ia, H TN , palp itatio ns, anxiety)n D igital anesthesia in patient w ith PA Dn W ounds w ith irregular or ragged skin edges w ith circu latory com pro m ise

n Can be used in the face, no se, ears, d ig its o r penis; no co nvincing evidence in m edical literature o r studies to suppo rt harm w ith such use

Injectable Agents Dosing

¨ Lidocaine¤ A v a ila b le in 0 .5 % , 1 % , & 2 % s o lu t io n ; 1 % s o lu t io n (1 0 m g / m L ) is m o s t c o m m o n ly

u s e d ; h ig h e r c o n c e n t ra t io n s d o n o t im p ro v e a n e s t h e t ic e ffe c t b u t in c re a s e r is k o f to x ic it y

¤ W it h o u t e p in e p h r in e (p la in l id o c a in e ) m a x im u m to ta l d o s e o f 1 % s o lu t io n is 0 .4 m L / k g (3 0 0 m g ) o r 3 0 m L

¤ W it h e p in e p h r in e m a x im u m to ta l d o s e o f 1 % s o lu t io n is 0 .7 m L / k g (5 0 0 m g ) o r 5 0 m L¤ O n s e t o f a c t io n 2 -5 m in u te s

¤ D u ra t io n o f a c t io n 3 0 m in u te s to 2 h o u rs b u t m a y b e e x te n d e d to 3 h o u rs w it h e p in e p h r in e

¨ Bupivacaine/Marcaine¤ M o re p o te n t a n d lo n g e r d u ra t io n o f a c t io n t h a n t h e o t h e r a g e n t s (u p to 6 h o u rs )¤ A v a ila b le in 0 .2 5 % (2 .5 m g / m L ) a n d 0 .5 % (5 m g / m L ) s o lu t io n ; 0 .2 5 % s o lu t io n m o re

c o m m o n ly u s e d in m in o r p ro c e d u re s ( le s s p a in w / in j.)

¤ W it h o u t e p in e p h r in e m a x im u m d o s e o f 0 .2 5 % s o lu t io n is 0 .8 m L / k g (1 7 5 m g ) o r 7 0 m L

¤ W it h e p in e p h r in e m a x im u m d o s e o f 0 .2 5 % s o lu t io n is 1 .2 m L / k g (2 2 5 m g ) o r 9 0 m L¤ O n s e t o f a c t io n 5 -1 0 m in u te s

¤ D u ra t io n o f a c t io n u p to 6 h o u rs (e p in e p h r in e d o e s n o t in c re a s e d u ra t io n o f a c t io n )

Injectable Agents Dosing Continued

¨ Mepivacaine¤ A lte r n a t iv e to l id o c a in e b u t c o n t ra in d ic a te d in p re g n a n c y (p o o r fe ta l m e ta b o lis m )¤ A v a ila b le in 0 .5 % o r 1 % s o lu t io n ; 1 % (1 0 m g / m L ) m o s t c o m m o n ly u s e d

¤ W it h o u t e p in e p h r in e m a x im u m to ta l d o s e o f 1 % s o lu t io n is 0 .4 m L / k g (3 0 0 m g ) o r 3 0 m L

¤ W it h e p in e p h r in e m a x im u m to ta l d o s e o f 1 % s o lu t io n is 0 .7 m L / k g (5 0 0 m g ) o r 5 0 m L¤ O n s e t o f a c t io n 2 -5 m in u te s

¤ D u ra t io n o f a c t io n u p to 2 h o u rs b u t m a y b e e x te n d e d to 3 h o u rs w it h e p in e p h r in e

¨ Procaine/Novacaine¤ P r im a r ily u s e d in d e n ta l p ro c e d u re s o r p a t ie n t s a l le rg ic to a m id e a g e n t s

¤ L o n g e r t im e to o n s e t o f a c t io n ; s h o r te r d u ra t io n o f a c t io n b u t l it t le sy s te m ic to x ic it y w h e n c o m p a re d to l id o c a in e

¤ A v a ila b le in 0 .5 % a n d 1 % s o lu t io n ; 1 % s o lu t io n (1 0 m g / m L ) is m o s t c o m m o n ly u s e d¤ W it h o u t e p in e p h r in e m a x im u m to ta l d o s e o f 1 % s o lu t io n is 0 .7 m L / k g (5 0 0 m g ) o r 5 0 m L

¤ W it h e p in e p h r in e m a x im u m to ta l d o s e o f 1 % s o lu t io n is 0 .9 m L / k g (6 0 0 m g ) o r 6 0 m L¤ O n s e t o f a c t io n 5 -1 0 m in u te s

¤ D u ra t io n o f a c t io n u p to 1 .5 h o u rs

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Infiltration Techniques

¨ Direct infiltration¤ Appropriate if skin is intact and uninfected or clean lacerations¤ Evaluate for evidence of neurovascular compromise distal to the area to be injected¤ Cleanse area with betadine(povidone-iodine) or chlorhexidinesolution¤ Quickly insert the needle through the skin into the subQlayer; slowly inject anesthetic as the needle is advanced or insert needle to the hub and

slowly inject anesthetic as needle is with drawn (25-27 gauge needle recommended)

¤ Aspiration is not necessary prior to each infiltration unless the area is close to major blood vessels

¤ Anesthetize adjacent areas by inserting needle into previously injected skin until the entire region is infiltrated

¤ Test skin with sharp object (needle or Adsonforceps) prior to beginning procedure¤ Inform patient they will feel pressure, pulling, tugging but should not feel anything sharp or painful if adequately anesthetized

Infiltration Techniques Continued

¨ Field block¤ A p p ro p r ia te fo r c o n ta m in a te d w o u n d s / la c e ra t io n s o r I& D o f s k in

a b s c e s s / in fe c te d c y s t

¤ E v a lu a te fo r e v id e n c e o f n e u ro v a s c u la r c o m p ro m is e d is ta l to t h e a re a to b e in je c te d

¤ C le a n s e a re a w it h b e ta d in e (p o v id o n e - io d in e ) o r c h lo r h e x id in e s o lu t io n¤ In s e r t n e e d le in to s u b Q t is s u e t h ro u g h in ta c t , c le a n s k in a lo n g t h e p e r ip h e r y o f

t h e c o n ta m in a te d w o u n d o r u n in fe c te d s k in a d ja c e n t to t h e s ite (2 5 -2 7 g a u g e

n e e d le re c o m m e n d e d )¤ s lo w ly in je c t a n e s t h e t ic a s t h e n e e d le is a d v a n c e d o r in s e r t n e e d le to t h e h u b

a n d s lo w ly in je c t a n e s t h e t ic a s n e e d le is w it h d ra w n

¤ A s p ira t io n is n o t n e c e s s a r y p r io r to e a c h in f i lt ra t io n u n le s s t h e a re a is c lo s e to m a jo r b lo o d v e s s e ls

¤ A n e s t h e t ize a d ja c e n t a re a s b y in s e r t in g n e e d le in to p re v io u s ly in je c te d s k in a lo n g t h e m a rg in s o f t h e w o u n d o r c irc u m fe re n t ia l ly a ro u n d t h e a b s c e s s u n t il t h e e n t ire re g io n is in f i lt ra te d

¤ Te s t s k in w it h s h a r p o b je c t (n e e d le o r A d s o n fo rc e p s ) p r io r to b e g in n in g p ro c e d u re

¤ In fo r m p a t ie n t t h e y w il l fe e l p re s s u re , p u ll in g , t u g g in g b u t s h o u ld n o t fe e l a n y t h in g s h a r p o r p a in fu l if a d e q u a te ly a n e s t h e t ize d

Complications of Local Anesthesia

¨ Avoid direct intravascular injection of anesthetic agents¨ Do not exceed the maximum total dose¨ Systemic toxicity/CNS effects: metallic taste, tinnitus, tingling of lips, agitation, seizures

¤ Tre a t m e n t in c lu d e s : o x y g e n a t io n , a ir w a y s u p p o r t , a d m in is t ra t io n o f a b e n zo d ia ze p in e ( lo ra ze p a m 0 .0 5 m g / k g )

¨ Systemic toxicity/Cardiovascular effects: bradycardia, decreased myocardial contractility, atrioventricularblock, vasodilation, ventricular arrhythmias, cardiac arrest¤ F o llo w B C L S /A C L S p ro to c o ls

¨ Catecholamine sensitivity (epinephrine): tachycardia, HTN, palpitations, anxiety¨ Vasovagalsyncope: bradycardiaand pallor¨ Allergic reactions:

¤ C o n ta c t d e r m a t it is - s w e ll in g , lo c a lize d e c ze m a to u s a n d p r u r it ic ra s h w it h in 7 2 h o u rs a ffe c t in g t is s u e s d ire c t ly in c o n ta c t w it h t h e a n e s t h e t ic a g e n t ; v e s ic le s , b l is te r in g a n d w e e p in g c a n o c c u r

¤ U r t ic a r ia a n d a n a p h y la x is -h iv e s , fa c ia l o r in t ra o ra l s w e ll in g , s t r id o r, w h e e z in g , h y p o te n s io n ( s e e k e m e rg e n c y c a re im m e d ia te ly )

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Suturing Techniques

¨ When suturing it is important to evertthe skin edges so that the dermal layer on both sides touch ensuring that the wound will achieve optimal healing.

¨ Suture placement:¤ F a c e : 2 -3 m m fro m s k in e d g e a n d 3 -5 m m a p a r t

¤ E v e r y w h e re e ls e : 3 -4 m m fro m s k in e d g e a n d 5 -1 0 m m a p a r t(A V O ID U S IN G T O O M A N Y S U T U R E S A S IT C A N IN C R E A S E S C A R R IN G . A G O O D

R U L E O F T H U M B IS T O U S E T H E M IN IM U M N U M B E R O F S U T U R E S N E E D E D T O A C H IE V E G O O D A P P R O X IM AT IO N O F T H E S K IN E D G E S W IT H O U T G A P S .)

¨ The needle tip should enter the tissue perpendicular to the skin or at a 90 degree angle.¨ Start on the side of the wound opposite and farthest from you; always sewing toward yourself.¨ The suture loop should be at least as wide at the base as it is at the skin surface.¨ The width and depth of the suture loop should be the same on both sides of the wound.

Suturing Techniques Continued

¨ Simple sutures¤ Can be used for most skin suturing¤ Start from the outside of the skin, go through the epidermis into the subcutaneous tissue from one side, then enter the subcutaneous tissue

on the opposite side, and come out the epidermis above¤ Interrupted vs. Continuous

n Interruptedsimple sutures are individually placed and tiedn Ta ke s m o re t im e

n Te c h n iq u e o f c h o ic e if th e re is co n c e rn fo r w o u n d in fe c t io n ; a fe w ca n b e re m o ve d to a llo w d ra in a g e w ith o u t d is ru p t in g th e e n t ire c lo su re

n Continuous/Runningsimple suture n Ta ke s le ss t im e

n Te c h n iq u e o f c h o ic e to h e lp sto p b le e d in g fro m sk in e d g e s (e x . S ca lp la c e ra t io n )n W o u n d sh o u ld b e c le a n w ith c le a n /sm o o th e d g e s

n P ro v id e s e ve n d istr ib u t io n o f te n s io n a lo n g th e le n gth o f th e w o u n d / in c is io n

Simple Suture Technique

The pro per technique fo r everting the edges o f a w ound is illustrated in the panels on the left. A ) The needle has been inserted at a 90 degree angle . B ) The suture lo o p is as w ide at the base as it is

at the skin surface. The w idth and depth o f the suture lo o p are the sam e o n bo th sides o f the w ound. In the panels on the right, im proper technique has resu lted in inversion o f the w ound edges, w hich w ill interfere w ith w o und healing. C ) The needle has entered the skin at an angle . D ) The base

o f the w o und is narrow er than the skin surface.

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Suturing Techniques Continued

¨ Mattress Sutures¤ Technique of choice when skin edges are difficult to evert;

especially when there is tension on the wound¤ Vertical Mattress

n Starting on the side opposite you insert needle at a 90 degree angle through the epidermis and into the subQtissue then enter the subQtissue on the opposite side and come out through the epidermis (Far-Far; approximates the dermal layer)

n Turn the needle in the opposite direction and insert the needle through the epidermis on the same side you just exited and come out the dermis, then enter the dermis on the opposite side and come out the epidermis above (Near-Near; evertswound edges)

n The short hand technique is when the superficial Near-Near bites are completed first, followed by the deeper Far-Farbites (can be done quicker than the traditional technique)

Vertical Mattress Technique

To p la c e a v e r t ic a l m a tt re s s s u t u re , t h e n e e d le is in it ia l ly in s e r te d a t a

d is ta n c e f ro m t h e w o u n d e d g e , e x it in g t h ro u g h t h e s k in o n t h e o p p o s ite s id e , a t a n e q u a l d is ta n c e f ro m t h e w o u n d e d g e ( fa r-fa r ) . T h e

n e e d le is t h e n ro ta te d 1 8 0 d e g re e s in t h e n e e d le h o ld e r a n d t h e d ire c t io n o f t h e s u t u re lo o p is re v e rs e d . O n t h e re t u r n , s m a ll b ite s a re

ta k e n a t t h e e p id e r m a l/ d e r m a l e d g e s (n e a r-n e a r ) .

Suturing Techniques Continued

¤ Horizontal mattressn Insert needle at a 90 degree angle through the epidermis and

dermal/subQtissues and bring the needle back out the epidermis

on the opposite side; take your second bite on the same side

approx. 5mm from the exit site and bring the needle back through

the dermal/subQtissues and then the epidermis on the opposite side approx. 5mm from the initial entry point

Vertical (left) and horizontal (right) mattress suture patterns.

Slatter D, Textbook of Small Animal Surgery, Saunders, 2002

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Suturing Techniques Continued

¨ Buried intradermalsutures¤ T h is te c h n iq u e is u se d fo r w id e ,

ga p in g w o u n d s w h e re th e re is h ig h te n s io n o n th e w o u n d m a k in g it d iff ic u lt to c lo se a n d e ve rt th e sk in e d g e s

¤ M a ke s sk in c lo su re m u c h e a s ie r¤ A lig n s th e d e rm is to e n h a n c e h e a lin g

¤ R e q u ire s a c u tt in g n e e d le a n d a b so rb a b le su tu re m a te ria l

¤ S ta rt in th e d e e p d e rm a l lay e r a n d

co m e o u t ju st b e lo w th e e p id e rm is (g o in g fro m d e e p to su p e rf ic ia l) th e n y o u w a n t to in se rt th e n e e d le o n th e o p p o s ite s id e a t th e sa m e d e p th d o w n th ro u g h a n d o u t th e d e rm a l lay e r (g o in g fro m su p e rf ic ia l to d e e p ); try to avo id th e su b Q lay e r; f in a lly t ie th e

su tu re , th e k n o t sh o u ld b e b u rie d d e e p so it d o e s n o t co m e u p th ro u g h th e sk in ca u s in g irr ita t io n a n d p a in

Absorbable suture material should be used for dermal sutures. The knot is buried by placing the suture using an inverted technique in which the suture loop begins in the dermis. The needle is

directed toward the skin surface, exiting near the dermal-epidermal junction. It is then inserted into the opposite side of the wound directly across from the point of exit. The loop is completed in the dermis at the level where the needle was initially placed.

Suturing Techniques Continued

¨ Subcuticularrunning suture¤ T h is t e c h n iq u e is u s e d t o c lo s e

w o u n d s fo r b e t t e r c o s m e t ic e f fe c t

¤ R e q u ir e s c u t t in g n e e d le a n d a b s o r b a b le s u t u r e

¤ A n c h o r t h e s u t u r e a t t h e e n d f u r t h e s t f r o m y o u t h e n c h o s e a p la n e w it h in t h e d e r m is ; r u n t h e

s u t u r e h o r iz o n t a l ly t a k in g m ir r o r im a g e b it e s w it h in t h e t is s u e p la n e a lo n g t h e f u l l le n g t h o f t h e w o u n d / in c is io n ; a t r a i l in g lo o p o f

s u t u r e is le f t a t t h e e n d t o t ie t h e f in a l k n o t w h ic h c a n t h e n b e b u r ie d b e fo r e c u t t in g t h e s u t u r e

¤ A p p ly s t e r is t r ip s o r d e r m a b o n dt o t h e s k in t o r e in fo r c e a n d p r o t e c t t h e h e a l in g s k in e d g e s

Tying the Suture

¨ Instrument tie¤ Simplest way to tie the suture¤ Pull the suture through the skin until there is a short “tail” (a few centimeters) on one side of the wound/incision ¤ Taking the longer end of the suture (be careful, the needle is still attached), wrap the suture around the end of the needle driver 1-2 times in a clockwise direction (2 loops for first throw, 1 loop for

additional throws)¤ Grab the short end of the suture with the needle driver and pull it

through the loops and have the knot lay flat¤ The short end of the stitch should now be on the opposite side¤ Let go of the short end and repeat the steps 4 more times for a total of

5 throws/knots; be sure to alternate between clockwise and counterclockwise when making your loops¤ Cut the suture about 1cm from the knot¤ For subcutaneous sutures be sure to cut as close to the knot as

possible; usually 1mm or less from the knot.

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After Care

¨ Most wounds/incisions should be covered with a thin layer of antibiotic ointment and a non-adherent dressing following repair¤ Reco m m end bacitracin o r bacitracin/po lym yxin B co m binatio n o intm ent; neo m ycin can also be used

but patients tend to have h igher rates o f local skin reaction w ith addition o f neom ycin

¨ Leave dressing in place at least 24-48 hours¨ After 24 hours most wounds/incisions should be gently cleaned with soapy water daily; if crusting develops along the sutures use soapy water or ½ strength hydrogen peroxide to clean¨ Some providers will have pt. reapply the antibiotic onitment1-2 times per day and cover the site with non-adherent dressing for several days after the procedure then

d/c the ointment, leave the site open to air, and keep clean¨ Some providers will continue to have pt. reapply the antibiotic ointment 1-2 times

per day until suture removal¨ Avoid too much moisture if pt. has external absorbable sutures¨ Avoid dirty water such as swimming pools, hot tubs, lake, ocean, etc. until sutures

removed (increased risk for infection)¨ Prophylactic antibiotics generally not required in healthy patients with NON-BITE wounds

Suture Removal

¨ Face: 3-5 days

¨ Neck: 7 days

¨ Scalp, chest, abdomen, arms: 7-10 days

¨ Back, legs, feet: 10-14 days; up to 20 days in some cases

¤ Rate of healing can be affected by co-morbid conditions and the

amount of tension on the wound. Take these factors into account when determining if sutures should be left in for a shorter or

longer period of time.

¤ Clean skin with alcohol swab or saline prior to suture removal to

remove any crusting.

¤ Gently lift the knot away from the surface of the skin and only cut on one side of the knot.

¤ Gently remove suture by pulling the cut stitch across the surface of

the wound instead of away from the wound.

References

¨ Alguire, P.C.; Mathes, B.M. Skin biopsy techniques. Up To Date September 2011.

¨ deLemons, D. Closure of skin wounds with sutures. Up To Date August 2011.

¨ Hsu, D.C. Infiltration of local anesthesia. Up To Date August 2011.¨ LaMorte, W. Basics of Wound Closure and Healing. August 2012.

www.bumc.bu.edu/generalsurgery/technical-training/suturing-basics. ¨ Semer, N. Practical Plastic Surgery for Nonsurgeons. Chapter 1 Suturing:

The Basics. August 2012. http://practicalplasticsurgery.org/the-book.¨ Semer, N. Practical Plastic Surgery for Nonsurgeons. Chapter 3 Local

Anesthesia. August 2012. http://practicalplasticsurgery.org/the-book.¨ Sherris, D.A. Basic Surgical Skills. Mayo Clinic, Mayo Foundation for

Medial Education and Research. 1999.¨ The Free Dictionary by Farlex. September 2012. http://medical-

dictionary.thefreedictionary.com/mattress+suture+pattern.