8-23
(6) Silk: Not absorbable. Fair tensile strength, excellent handling/knot tying. Moderate tissue reaction.
b. Use wire sutures on bone and tendons. Stainless steel is the strongest suture material, with the most
secure knots, and is well tolerance by tissue unless corroded. Stiffness of the metal can cause
irritation and tissue damage.
c. Tissue reaction to suture: localized acute, aseptic inflammation. Suture, especially braided suture,
can provide a wick through the skin allowing pathogens access to a wound.
- Suture the patient. Thread needles with desired suture if not using pre-packaged needle/suture
combinations.
HINTS: Align the edges of the wound, and stitch the middle of the wound first, if possible. Use the needle
holder to clamp on the back of the needle near but not ON the suture material, with the needle perpendicular
to the holder. Some recommend grasping the needle half way around the curve. Insert the point of the needle
perpendicular to the skin and then follow the curve of the needle through when piercing tissue. Suture an equal
width of tissue on each side of the wound. Go deeper rather than wider with the stitches if need to achieve
greater wound closure. Do not have stitches too tense - make sure tissue is not blanched by the stitch. Keep
stitches uniform approximately 5-10mm apart and 5-10mm from the wound edge, with knots away from the
wound edge.
a. Simple interrupted suture: Puncture the skin with the needle and exit into the wound, traversing
the skin only. Pull the needle out through the wound, and enter the opposite side of the wound at
the same depth. Curve the needle up through the skin, positioning it as described above. Tie a
square knot plus an additional throw, then clip excess suture material. This is the most common
suture used. Advantages: strength; successive sutures can be placed following the path of the
laceration; distance, depth and tissue eversion can vary from stitch to stitch (see Figure 8-1).
b. Vertical mattress suture: Puncture the skin with the needle at least 1 cm from the edge of the
wound, and exit into the wound, traversing the skin and subcutaneous tissue (at least 1 cm deep).
Pull the needle out through the wound, and enter the opposite side of the wound at the same depth
(subcutaneous tissue). Curve the needle up through the skin at least 1 cm from the edge of the
wound, positioning it as on the other side. Reverse the orientation of the needle, as if to sew with
the opposite hand. Point the sharp tip away from yourself and insert the needle approximately 5mm
from the wound. Make the return suture either subcutaneous or a skin closure. Tie a knot as above
and clip the excessive suture material. Advantages: more tissue eversion, broad wound contact,
watertight. Useful for preventing broad scar formation (see Figure 8-1).
Disadvantage: constricts blood supply at wound edges, possibly causing necrosis and dehiscence.
c. Continuous suture: Insert the needle and exit through the subcutaneous tissue. Tie a knot as for
a simple interrupted stitch, but do not clip the suture end. Suture continuously the entire length of the
wound without tying any additional knots until the end. This method can be modified to ‘lock’ each
stitch by bringing the suture back across the wound after the stitch and passing it under the piece of
suture coming from the previous stitch. All the locks should be aligned on the same side of the wound.
Tie the final knot on the opposite side of the wound. Clip the excessive material. Advantages: aligns
perpendicular to the wound, distributing tension evenly; allows watertight, rapid closure; locking
feature prevents continuous tightening of the stitches as suturing progresses. Disadvantages: not
able to adjust to tension from edema; should not be used on areas of existing tension
(see Figure 8-1). - Eliminate the dead space by rolling the wound proximally to distally with a rolled gauze pad.
- Apply bacitracin or other topical antibiotic as appropriate and then bandage the wound.
- Tell the patient when to return to have the sutures removed or to return earlier if the wound shows signs
of infection (red, hot, swollen, wound draining pus; fever; red streaks from wound). Remove stitches from
eyelid in 3 days; cheek in 3-5 days; nose, forehead and scalp in 5-7 days; arm, leg, hand, foot in 7-10+
days; and chest, back, and abdomen in 7-10+ days.
What Not To Do:
Do not suture opposite sides of the wound at different depths or distances from the wound edge. This will create
uneven skin alignment, overriding edges and poor or delayed healing, as well as a poor cosmetic result.
Do not tie sutures too tight, so as to compromise blood flow to the wound edges, which need it most.