SUTURING TECHNIQUES

SIMPLE SUTURES

1. Interrupted sutures
Interrupted sutures are sutures that are placed and tied individually. For the
inexperienced this is the preferred technique due to its ability to close a wound
cleanly and securely. If infection occurs in one part of the wound only a few
interrupted sutures need be removed to treat the wound while the other sutures
remain intact. The downside is that interrupted sutures take considerably more
time to place than continuous sutures.

Individual interrupted sutures also brings a limited quantity of tissue towards

the closure margin – and thus in friable tissue it has a higher tendency to “pull
through” when tying the knot.

It is usually not the end of the world if one interrupted suture should loosen or
dehisce as the remainder of the interrupted sutures will keep the wound closed.
Thus often one would not even have to replace a single interrupted suture if it
loosens up so long as the resulting dehiscence is minimal and not in a critical
area.

Interrupted sutures will also give a good result in curved and non-linear
wounds/incisions and unlike running sutures it will not distort the form of the
wound.

Interrupted sutures offers the highest level of control over wound closure and
thus the result. If you perceive that a specific suture is not ideally placed you
can remove it and place it in a better position, unlike the running/continuous
sutures where you may need to redo the entire running suture if the result is
not pleasing. With the interrupted suture you have excellent control over the
level of wound eversion.

An unfortunate downside of using an interrupted suture is that the operator has

to push the needle through healthy skin adjacent to the wound margins with the
possibility of leaving needle marks as a visible row of small scars on either side
(cross hatching suture marks) next to the wound margin. In esthetically sensitive
areas, like the face, a surgeon will remove stitches/sutures by day 4 or 5 and
secure the wound with Steri-Strips for another couple of days in an effort to avoid
cross hatching scars. Do not leave interrupted facial sutures in for longer than
7 days!
2. Interrupted sutures with buried knots
Use the interrupted sutures with buried knots in sensitive areas. For example,
when suturing a laceration of the tongue. Do this to avoid irritating the tongue
with the 2 free ends left by a normal interrupted suture. Keep in mind that the
knots may take a bit longer to resorb due to the increased amount of suture
material left inside the wound. Always use absorbable sutures when using this
technique!

3. Subcutaneous sutures
The subcutaneous suture is very much similar to the interrupted sutures with
buried knots, but it is placed in the depth of the tissue in a surgical or traumatic
wound. This suturing technique is primarily used to eliminate dead space in the
depth of a wound. By default, always use absorbable sutures when using this
technique!

4. Figure-of-8 sutures
The (vertical) ‘Figure of 8 suture’ is a combination of a subcutaneous and a
surface skin suture. Use this suture to save a bit of time when closing a long
incision. In essence, it is a “combo-interrupted subcutaneous and skin closure
suture”.

5. Running (continuous) sutures

A running suture, also known as a continuous suture, consists of one strand of
suture material that runs for a lengthy distance along a wound, normally in a
zigzag pattern, which is tied at either end. This suture resembles those used on
baseballs, and so, they are sometimes called baseball sutures. Running
(continuous) sutures provide an adequate closure with even tension distribution
as well as saving both time and suture material. This technique is commonly
used when the wound is actively bleeding and thus where time is of essence,
such as a scalp laceration.

The disadvantage is that suture breaks can cause wound gaps to occur.

6. Running/continuous sutures
Use running sutures when esthetics are not important and when you want to
save time. Running sutures will tend to bunch-up the tissue and shorten the
wound length due to the tension needed to keep the wound margins together.
Use the running suture on an actively bleeding scalp wound, time is important
to minimize blood loss and being in the hairline in most cases the cosmetic result
is usually not critical.

Running sutures spreads the suture tension on evenly all over the wound – and
this may be important when working with tissue with a soft consistency.
If the suture material breaks in a running suture the whole wound will break
down so be sure to secure the knots on the 2 sides properly and consider adding
a couple of strategically placed interrupted sutures in addition to the running
suture.

7. Continuous interlocking sutures

This suture technique is accomplished by passing the needle through the loop
created by the previous suture, locking it into place. Continuous locking sutures
are commonly used for breast reconstructions, intestinal surgeries, and hernias,
where soft tissue requires secure stitching. The downside when used externally
on the skin is that continuous locking sutures may leave permanent hatch
marks.

There is very little difference between the regular running and the interlocking
running sutures. The latter is supposed to seal the wound margins better – and
this may be important if one is closing a wound between two cavities e.g. closing
the incision between the oral and nasal cavities following a Le Fort 1 osteotomy.

8. Subcuticular sutures
Apposition of the wound edge is easily achieved using the subcuticular
continuous suture. Minimal scarring occurs because external sutures are not
used. Rather the subcuticular suture is applied under the epidermis using either
an absorbable suture or a non-absorbable suture leaving external knots at the
far ends of the laceration or incision so that the suture can be removed easily.
When applied correctly, subcuticular continuous sutures provide the best
outcome for cosmetic results. However, the procedure is extremely time-
consuming. These sutures are easily removed and commonly used on children
for this reason.

The subcuticular suture will allow for a very pleasing esthetic result in most
cases, but it offers very little wound eversion by itself. Surgeons will have to get
wound eversion by properly placing the subcutaneous sutures if they intend
closing the surface with subcuticular sutures. One can either use absorbable or
non-absorbable sutures when placing subcuticular sutures. If the choice is a
thin Nylon suture remember to remove the suture within 5 days to avoid having
to dissect out fragments of suture material from the semi-healed wound margin.
Strengthen the wound margins with Steri-Strips if needed when closing with
subcuticular sutures.

9. Purse-string sutures
The purse sting suture in essence is a running suture used to close round defect
wounds or openings. Predictably, the purse-string suture will not give good
cosmetic result because this suture will bunch-up the tissue. Purse-string
sutures are typically used to close circular objects such as an areola or to close
the opening after removing a chest drain (instruct the patient to take a deep
breath and forcibly exhale against closed nose and lips). The suture material is
passed in and out of the tissue as a running stitch and then drawn closed like
closing a purse or a bag.

MATTRESS SUTURES

The 3 main reasons for using mattress sutures :

Firstly, to increase the interphase or contact between the raw surface areas of
two opposing wound sides. This is especially important when you want to
optimize the time it takes for a wound to heal, especially when one closes a
fistula. For example, closing an oroantral fistula (an opening between the oral
and maxillary sinus cavities).

Secondly, to enhance eversion. You just simply have so much more eversion
when using a mattress suture up to the point where you may get opening of the
wound edges. Consider the far-near suturing technique in this instance which
is simply a variation of the vertical mattress suture.

Thirdly, the mattress suture brings a lot more volume or quantity of tissue to
the closure area, and thus the chances of dehiscence are significantly reduced.
Take care though not to tie mattress sutures too tightly as it may cause tissue
strangulation and result in necrosis of the tissue on the suture-tissue contact
areas.

10. Horizontal mattress sutures

This suturing technique is used to create moderate tension to prevent

hemostasis and to improve wound tension strength for better healing. The
horizontal mattress is also effective at everting wound edges and provides fair
approximation. However, care must be taken to not tighten excessively or tissue
ischemia can result.

11. Vertical mattress sutures

The vertical mattress technique is an excellent choice for achieving wound edge
eversion and approximation. The technique can be used on either thin or thick
skin and utilizes two bites. The first bite approximates the wound edges and the
second reduces edge tension. The downside is that vertical mattress sutures can
only remain in place for between five to seven days or risk is high for permanent
crosshatch marks.
12. Far and Near sutures
Also called the far-near-near-far suture or the pulley suture. This is a variation
of the vertical mattress suture favored by some surgeons.

The far and near suture is a modified vertical mattress stitch that uses the
tension created by a pulley action to close wound tissue. Because the pulley
stitch reduces the surface area of large wounds of which closure cannot be
accomplished completely by traditional side-to-side sutures, it is an excellent
technique for areas such as the legs and scalp. Pulley sutures can be used as
temporary assisting stitches, such as lessening tension for buried sutures, or
they can be left in for later removal. If pulley stitches are used they must be
removed promptly in order to avoid crosshatch scarring.