Suture Patterns

Simple interrupted sutures represent the most versatile suture technique and are good for realigning irregular wound edges and stellate lacerations with more meticulous approximation of the wound edges (Fig, 3Z:i4.). An advantage of interrupted sutures is that only the involved sutures need to be removed in the case of wound infections. Wound integrity is greater and the risk of premature separation (dehiscence) is less because the wound is held together with multiple individual suture loops.

Myocardial Laceration

Continuous running sutures are quick, easy, and may save time in the ED because only two knots need to be tied at each end of the laceration as opposed to individual knots for each interrupted suture loop ( Fig. 37-15). Continuous sutures are best when repairing linear wounds. However, a break in suture may ruin the entire repair and may cause permanent marks if placed too tightly. This type of suture is often used where hemostasis is important, such as the vagina and scalp, where locking the running suture aids in hemostasis (Fig..., 37-16). Another advantage of the continuous suture is that it accommodates to the developing edema of the wound edges during healing. In contrast, the dimensions of the interrupted suture remain unchanged, constricting the edematous tissue within each suture loop. For either interrupted or continuous percutaneous suture closure, a monofilament synthetic nonabsorbable suture is used.

Deep Dermal Sutures Wound Healing
FIG. 37-15. A. Linear laceration of the arm subjected to strong skin tensions, with marked retraction of wound edges. B. Three interrupted dermal sutures markedly reduce the retraction of the skin edges. C. Continuous percutaneous suture.

Continuous suture closure of a laceration can be accomplished by two different patterns. In the first pattern, the needle pathway is at a 90° angle to the wound edges and results in a visible suture that crosses the wound edges at a 45° angle ( Fig 3Z:iZ^). In the other pattern, the needle pathway is at a 45° angle to the wound edges, so that the visible suture is at a 90° angle to the wound edges ( Fig 3Z:iZ,S). In either case, the physician starts the continuous suture closure at the corner of the wound that is farthest away, and suturing progresses toward the physician, rather than away.

Types Suture Patterns

FIG. 37-17. A. Running suture crossing wound at 45°. B. Running suture crossing wound at 90°.

Dermal (subcuticular) sutures, either interrupted or continuous, may be necessary prior to skin closure to reduce tension and gaping. Interrupted dermal sutures are started by entering the skin near the base and exiting just beneath the dermal-epidermal junction. Entry into and exit from the opposite side is at corresponding levels. Tying the ends with an instrument tie "buries" the knot in the wound depth; starting the suture at the dermal-epidermal junction would leave the knot close to surface (Fig 37-18). The compound curved needle is ideal for this type of suture because the suture loop is smaller than that achieved with a simple curved needle.

Interrupted Suture Loop

FIG. 37-18. Dermal suture. A. Entry is at base of wound on one side and exit at the dermal-epidermal junction. B. Entry on the opposite side is at the dermal-epidermal junction with exit at the base. C. The tied loop has the knot buried in the wound away from the skin surface.

Continuous dermal (or subcuticular) sutures are useful in wounds subjected to strong skin tensions, patients prone to keloid formation, children frightened by suture removal, and those individuals who are unable to contact a health professional for suture removal. Absorbable synthetic braided or monofilament sutures (4-0 and 5-0 size) are ideally suited for continuous dermal sutures because they do not have to be removed. In contrast, nonabsorbable continuous dermal sutures have to exit percutaneously from the ends of the wound as well as surfacing every 3 cm through the skin, to facilitate removal. Continuous dermal sutures are begun as an interrupted dermal suture with its knot buried in the subcutaneous tissue ( Fig 3.7-1.9). After the physician cuts the free end close to the knot, the suture attached to the needle is used for the continuous closure. The next stitch is passed horizontally along the length of the wound through the superficial dermis ( Fig 37:19). After the dermis is exited, the position of the next bite is identified by pulling the suture across at right angles to the wound. Accurate positioning is assured by slight backtracking of each bite. During passage of the needle, the skin is stabilized by one arm of the toothed forceps. As the horizontal bites are taken, gentle constant traction on the fixed suture brings the wound edges together. At a point one bite from the end of the wound, a smaller horizontal bite is passed toward the end of the wound. The suture from this corner stitch is withheld, forming a loop that will be used in constructing the knot. After passing the suture horizontally through a small bite of dermis in the opposite wound edge, the fixed suture end and the long loop of the free suture are used to construct the terminal square knots. The skin edges can be approximated with either percutaneous sutures, skin staples, skin-closure tapes, or tissue adhesives.

Corner Stitch Sutur

Continuous dermal sutures can be used by themselves when percutaneous sutures might cause cosmetic problems. They are ideal for linear facial lacerations, where sutures placed completely below the surface of the skin minimize scaring. One disadvantage is that complete suture removal may be required if local infection demands wound reopening. Wound integrity is dependent on only one piece of suture as opposed to multiple loops if interrupted sutures were used. For the best cosmetic results, a compound-curved, reverse cutting-edge precision-point needle is recommended.

Vertical mattress sutures allow for precise edge to edge alignment and are especially good to match thick to thin skin ( Fig.; 3.7.-2.0.). This suture enhances skin edge eversion and avoids the tendency for inversion common with deep nonlinear lacerations. When placing the sutures, care must be taken not to make them too tight, which might strangulate the tissues. The resulting scar may be inferior to that from some of the other suturing techniques; therefore this approach should be used for areas that are not cosmetically important. For conventional vertical mattress sutures, the first bite is a large one starting approximately 1 to 1.5 cm away from the wound edge and crossing through the wound to an equal distance on the opposite side. The needle is then reversed and a very small, shallow bite (1 to 2 mm) at the epidermal/dermal edge is placed in order to closely approximate the epidermal layer. The ends are tied with the knot falling on one side of the wound. The vertical mattress suture is useful in areas of lax skin (elbow, dorsum of hand), where the wound edges tend to fall or fold into the wound and eversion of the skin is harder to obtain. The vertical mattress suture can also act as a deep as well as superficial suture—an "all in one" suture; avoiding the need for a layered closure. The modified vertical mattress suture places the small bite first and then uses elevation on the suture ends to raise the wound edges, to make placing the larger and deeper second bite easier. This modification allows faster placement of individual stitches. 17

Vertical Suture
FIG. 37-20. Vertical mattress suture.

Horizontal mattress sutures are faster and better at eversion than vertical mattress ( Fig 37:21). The repair may look poor early on, but with good eversion, the scar will have a better cosmetic effect in 2 to 3 months. This suturing technique may be faster because it covers more linear distance. It is especially useful in areas of increased tension such as fascia, joints, and callused skin. Individual sutures must be tied loosely to avoid tissue strangulation. The first throw is similar to a simple interrupted suture but instead of tying the suture a second bite is taken approximately 5 mm adjacent to the first exit on the same side and directed back to the initial side. This second bite exits approximately 5 mm from the initial entry point. The knot is tied leaving an everted edge.

Half Buried Vertical Mattress

Horizontal half buried sutures are good for repairing flaps and triangular wounds ( Fig 37-22). It minimizes tissue tension so it doesn't strangulate the interposed tissue. Similar to vertical mattress sutures, horizontal half buried sutures are also useful to approximate thick to thin edges. To accomplish this, it is important to bury the suture in the thicker edge and tie the suture on the thinner side to allow eversion and reapproximation of the skin edges.

Buried Suture
FIG. 37-22. Horizontal half-buried suture.

Purse-string suture is very useful at reapproximating multiple flap tips and corner wounds back together ( Fig 37:23). This technique is used in these areas in order to preserve the blood supply and minimize tissue destruction at the tips of the skin edges.

Purse String Suture
FIG. 37-23. Purse-string suture.

The dog-ear maneuver is a technique used to handle excess tissue at one end of the wound ( Fig 37-24). Basically the wound is extended from the apex toward the long side in the form of a hockey stick. Then the triangular piece of excess skin is removed and the skin edges are sewn together. Undermining may be necessary to help remove the excess tissue and suture the edges closed.

Dog Ear Suture

FIG. 37-24. Dog-ear maneuver. A. Incision is carried off one end of the wound at 45° toward the side with excess tissue. B. The excess tissue is pulled over the incision and cut away. C. The sutured laceration now has a "hockey stick" angulation.

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