Suturing Techniques in Cutaneous Procedures
This article deals with the closure of skin wounds after elective procedures. For the treatment of traumatic wounds, see articles on
Essentials
- The choice of suturing technique depends on the type of wound, its location, and the doctor's skills.
- In many skin procedures performed by general practitioners, simple interrupted stitches are a good option.
- Absorbable intracutaneous sutures are used for good cosmetic results or in situations where the wound is subject to tension.
- It is important not to pinch the wound edges too tight together.
Wound closure
- Wounds should preferably be closed parallel to skin folds, following the direction of physiological striae (Video Determining the Direction of Skin Folds Before Minor Surgery).
- Before closing a surgical wound, it is important to undermine the wound edges to free them from the underlying tissue, and to stop bleeding.
- In most skin procedures performed by general practitioners, simple interrupted stitches are a good option.
- To close more extensive fusiform (elliptical) incisions, for cosmetically best results, absorbable intracutaneous sutures are normally used first and subsequently non-absorbable superficial sutures to close the wound edges.
- During suturing, the skin should be handled cautiously (using forceps, as necessary, as a "skin hook").
Instruments
- See picture F1.
- Needle holder
- Needle holders with smooth jaws (e.g. Webster) are the best for skin suturing. Their slight roughness will not break thin suture material.
- Forceps
- Toothed (surgical) forceps, particularly those with thinner tips, are more gentle.
- Skin hook
- To minimize tissue injury, a skin hook should be used instead of forceps to hold the skin, as necessary (necessary particularly in flap surgery).
- Scissors
- After the first incisions, it is often practical to proceed using blunt scissors with small blades (such as Metzenbaum scissors). They are often better suited than scalpels for releasing subcutaneous wound flaps and wound edges.
- Sharp-tipped suture scissors should be used for cutting the suture, since the hard suture material would damage the blades of tissue scissors.
- Scalpel
- Blade no. 15 is a small general blade for skin procedures; no. 10 is suitable for more substantial excision.
- In some cases, a no. 11 blade with sharp tip is needed (e.g. to release wound edges).
- Needles
- Needles are classified by curvature and cutting properties.
- More curved needles (3/8 or 1/2 curved) are easier to use for cutting through the skin.
- Cutting needles with triangular tip are normally used for cutting through the skin (reverse cutting).
Suture material
- Suture material is classified as absorbable or non-absorbable.
- These are further classified as mono- and multifilament materials.
- Monofilament suture material (such as Ethilon® ) is easier to handle but knots can slip and the suture can fail more easily.
- Multifilament suture material is more difficult to handle and to tighten but the knots hold better. They may be associated with an increased risk of wound infection.
- The thicknesses normally used for cutaneous suture are 3-0 (thickest) to 7-0 (thinnest).
- 3-0 or 4-0 for soles of feet, palms or scalp
- 4-0 or 5-0 for the trunk or limbs
- 5-0 or 6-0 for the face
- If there is tension on the wound, it should also be closed with intracutaneous absorbable sutures.
- The 4-0 strength, for example, can be used for intracutaneous sutures on the trunk or limbs, 3-0 for soles of feet, back and scalp.
Examples of suitable suture strengths and suture removal times
| Suture location | Non-absorbable suture | Absorbable suture | Suture removal |
|---|
| Head or scalp | 4-0 or 5-0 | 4-0 | 7-10 days |
| Face | 5-0 or 6-0 | 5-0 or 6-0 | 5-7 days |
| Trunk | 4-0-or 5-0 | 3-0 or 4-0 | 10-14 days |
| Limbs | 4-0 or 5-0 | 3-0 or 4-0 | 7-14 days; 14-21 days, if there is high tension on the wound |
Suturing techniques
General remarks
- Hold the needle holder with your thumb and ring finger, using your forefinger to stabilize and guide its tip (picture F2).
- It is most important not to tug on the suture too much.
- For optimum results, the wound edges should be well approximated and level with each other, throughout the length of the wound.
- The wound edges should be slightly raised so that the scar tissue forming when healing will not pull the skin down to form a pit.
- Pitting often occurs on convex surfaces, such as the chin or over the cheekbones.
- If undermining the edges of the wound does not reduce tension, use intracutaneous suturing with absorbable material.
- Due to increased risk of infection, any haematoma or excess fluid should be removed from the wound before closure.
- Deeper skin structures (such as cyst cavities) can be closed with either intracutaneous suture with absorbable material or, for example, superficial mattress suture.
Simple interrupted suture
- See pictures F3 F4.
- Insert the needle perpendicular to the skin surface about 5 mm from the wound edge. The curvature of the needle is suitable for skin, and needle rotation is usually accomplished by rotating the wrist.
- First tie a double knot and then two separate single knots on top.
- It is important to avoid excessive tightening of the suture. To avoid excessive tightening, it may sometimes be practical to use two consecutive single knots (lasso knot) and tighten these as appropriate.
- The first stitch is usually placed in the middle of the wound, the following ones in the middle of each half, and so on.
- If there is too much tension in the middle, it may be better to start closing the wound from the ends.
Intracutaneous (buried) suture
- See picture F9.
- Use absorbable suture material.
- Intracutaneous suturing is recommended whenever the wound is under high tension. It will ensure that the wound remains closed after removal of superficial sutures (simple interrupted sutures or continuous suture), and facilitate relatively early removal of superficial sutures.
- Intracutaneous suturing is used to achieve good cosmetic results, for example on the face in association with more extensive direct excision or flap surgery (picture F5) or on the back in the presence of high wound tension.
- Intracutaneous absorbable sutures should be placed deep enough not to migrate to the skin surface.
- Try to place the knot and the ends of the suture material, which have been cut short, at the centre of the wound base.
- Skin reactions to suture material are rarely seen.
- The most common complication is suture exposure (suture end appearing visible on the skin) 1 to 2 weeks after the procedure. The wound will heal well if the suture is pulled out.
- Depending on the thickness of the fat tissue, vertical or horizontal intracutaneous sutures can be placed, or the wound base can be closed by continuous suture.
- Knots in absorbable sutures will not hold as well as in superficial non-absorbable sutures and must therefore be secured more carefully.
Continuous suture
- See picture F6.
- The technique is particularly suitable for the closure of long wounds. It should not be used as the only type of suture if there is tension on the wound.
- Continuous suturing can best be used once the wound has been nearly closed with an absorbable intracutaneous suture.
- Either locked or unlocked techniques can be used for continuous suturing.
Horizontal mattress suture
- See pictures F7 F8.
- The horizontal mattress suture is suitable for situations where tension needs to be reduced in the wound area (mobile areas, such as elbows; fragile tissue at wound edge).
- It is suitable for fragile skin thinned by glucocorticoids in the elderly, for example, where ordinary sutures would cut through the skin.
- Visible scars often remain in the area with pressure applied by the suture.
- A half-buried mattress suture will leave less marks and is suitable for attaching avulsion flaps or skin flaps, in particular.
- The angle suture is a modification of this technique, where the flap corner can easily be drawn into its notch.
Intradermal (subcuticular) suture
- The suture runs from one wound edge to the other, buried immediately underneath the epidermis.
- It is suitable for cases where suture holes need to be avoided for cosmetic reasons.
Cross stitch
- See pictures F10 F11.
- This technique is used to close punch biopsy wounds, for example.
Suture removal
- The timing of suture removal depends on the area of skin involved, the surgical procedure and any complications.
- As a rule of thumb, it can be said that non-absorbable sutures should be removed from the face after 5-7 days, from the neck and limbs after 7-10 days, from the trunk after 10-14 days, and from areas with thick skin or wounds subjected to high tension after 14 days.
- To remove a suture, first use forceps to raise the knot so that the loop becomes visible. Then use a scalpel or scissors to sever either end of the loop and cautiously pull the whole suture out of the skin. See video Stitch Removal.
- After suture removal, the skin should be firmly taped for 5-7 days.
References
- Williams JA, Kimmel S, Williams JT. How to Optimize Wound Closure in Thin Skin. Cutis 2023;111(1):43-45. [PubMed]
- Ashraf I, Butt E, Veitch D, et al. Dermatological surgery: an update on suture materials and techniques. Part 1. Clin Exp Dermatol 2021;46(8):1400-1410. [PubMed]
- Butt E, Ashraf I, Veitch D, et al. Dermatological surgery: an update on suture materials and techniques. Part 2. Clin Exp Dermatol 2021;46(8):1411-1419. [PubMed]
- Yag-Howard C. Sutures, needles, and tissue adhesives: a review for dermatologic surgery. Dermatol Surg 2014;40 Suppl 9():S3-S15. [PubMed]