Friday, June 8, 2007

Basic Suture Techniques

Direct approximation of the wound margins is required for healing by primary intention. This is prefered when possible. However, if infection or excessive tension is present, then healing by secondary intention (spontaneous contraction and epithelialization) or tertiary intention (delayed surgical closure) will most likely be necessary. The following surgical axioms are important to remember in the goal of obtaining a fine-line scar that compromises neither function nor appearance:

Adequate debridement and hemostasis. All devitalized tissue and foreign bodies must be removed. Complete hemostasis should be acheived.
Atraumatic technique. Gentle handling of tissues is very important.
Alignment with relaxed skin tension line. Place elective incisions parallel to the lines of facial expression. Scars can be hidden in wrinkles.
Angle of incision. Incisions are placed perpendicular to the dermis except in the scalp and eyebrows where the incision should be parallel to the hair follicles.
Area of body. Areas of greater vascularity (head and neck, hands) usually yield better scars than areas of lesser vascularity (lower extremities).
Age of patient. Scarring is minimized in older patients due to decreases in skin tension and inflammatory response.

Critical elements include the obliteration of dead space, layered tissue closure, and eversion of skin margins. Deep dermal sutures align the skin edges and help decrease tension on the skin closure. Everting skin sutures are placed by encompassing a larger amount of deep dermis than epidermis in the closure. The suture is tied under the minimal tension necessary to appose the skin margins. Because nonabsorbable synthetic monfilament sutures (nylon, Prolene) are minimally reactive, they are preferred for skin closure when cosmesis is essential. Absorbable synthetic braided sutures (Vicryl, Dexon) are ideal for deep dermal closure, acting as transient but necessary skin splints. Absorbable natural sutures (catgut, chromic catgut) induce inflammation as they are degraded by phagocytosis. Still they are useful where suture removal is difficult and cosmesis is not critical (in the mouth, inside the nose, and non-facial wounds in children).

The simple interrupted suture is the most common skin closure method. Horizontal mattress sutures facilitate tissue eversion with the use of 50% fewer sutures. Vertical mattress sutures are useful in wounds under significant tension. Running sutures speed the closure of uncomplicated linear wounds. Subcuticular running sutures yield cosmetically pleasing results in wounds under mild tension.Optimal wound healing and epithelial migration occur in a moist environment free of coagulum or scab interposed between the healing surfaces. Epithelialization takes 2-3 days with air exposure, but only 18-24 hours with occlusion. So a light coat of antibiotic ointment and an occlusive dressing for 24-48 hours is beneficial. Most incisions may be safely cleansed with soap and water after this time. Sutures are removed after 3-5 days in the face and neck, 7-10 days in most other sites, and 10-14 days in the hands and feet. Suture marks are reduced by minimal tension on the skin closure and timely suture removal. In wounds under moderate tension, adhesive tape (Steristrips or paper tape) may be applied for 1-2 weeks to help minimize widening of the scar.


Anonymous said...

What do you think of using glue for the skin, after a verticle mattress for the subdermal layer?

rlbates said...

IF there is no tension left at the skin level, then I think using glue (ie Dermabond) would be a good choice. IF the lac or incision is very long, it can be an expensive alternative though.