Chapter 1: Introduction

For millennia, surgical and traumatic wounds have been closed with sutures and similar materials, yet it was only with the introduction of local anesthesia 130 years ago that surgeons were able to move from focusing on the most rapid suture placement technique to the most effective. From William Halsted’s promotion of the buried suture technique in the late nineteenth century to contemporary articles on the subtleties of suture placement and tissue handling, a paradigm shift has taken place, with an increasing appreciation that not only are there multiple available approaches for any single suture placement, but that this choice may impact outcomes.

Shifting tension as deep as possible in the surgical wound is the key principle of suture placement, and, indeed, adhering to this approach leads directly to improved patient outcomes, both functionally and aesthetically. Tension across the superficial dermis leads to increased scarring; shifting this tension to the deep dermis or even the fascia, and suturing in a fashion that keeps the tension deep permits wounds to heal with the subtlest of scars.

The surgical literature is rife with myriad techniques with flashy names and multiletter acronyms. While sexy and catchy technique names and acronyms are sometimes appealing, they do little to describe a technique or place it within the larger context of other fundamental and well-established approaches. Moreover, this tendency increases the risk that previously described approaches could simply be shined off, dressed up, and renamed as ostensibly novel approaches—something that only serves to increase confusion for the novice and expert alike, since developing a common language is an important step in improving techniques—and therefore outcomes. When possible, Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair utilizes descriptive names for suture techniques so that the nature of the technique is, at least somewhat, described by its name. Furthermore, when possible, techniques are explained in the context of the existing literature; for example, the “running looped suture” does not tell the reader what the technique entails, but referring to it as a “running locking horizontal mattress suture” suddenly allows the reader to understand the fundamental approach, even in the absence of a multipage description.

In the interest of consistency and developing a meaningful and translatable nomenclature, some liberty has been taken in (re)naming techniques so that they make intuitive sense. Therefore, for example, what was described in the literature as the “modified tip stitch” is referred to as the “modified vertical mattress tip stitch,” and what was originally named as the “vertical mattress tip stitch,” is instead referred to as the “hybrid mattress tip stitch.” Once the reader has an understanding of the techniques on which these approaches are based, the value of the slight shift in nomenclature should become obvious. This shift in terminology is not meant as a slight to those who have named techniques in the past, but rather as an aid to those becoming increasingly familiar with myriad suture technique variations.

Throughout the text, certain terms are used regularly. As there is significant regional variability in training and terminology, it may be worthwhile to clarify some terms. Each “bite” refers to a pass of the needle through tissue; thus a simple interrupted suture could be performed by taking a single large bite (assuming the needle is sufficiently large), starting by entering the skin on one wound edge and ending by exiting the skin on the contralateral wound edge, but it may also be closed with two separate bites, with the transition between the two bites consisting of the needle’s exit and subsequent reloading and reentry between the incised wound edges. Similarly, each “throw” refers to a single half knot, formed by the loop of the suture material around the needle driver in the case of an instrument tie.

Suture techniques are divided largely between two sections: (1) those used for deeper structures, such as the dermis or fascia, and (2) those used for superficial structures that are placed through the outside of the skin. These sections could also easily be differentiated as: (1) techniques that largely employ absorbable suture material, and (2) techniques that generally utilize nonabsorbable suture material. Ideally, since wounds heal better with tension shifted deep to the deep dermis and fascia, all closures would only be in the first category, though in real-world situations, often a layered combination of approaches is utilized.

The term “percutaneous” as used in this text refers to techniques that are largely buried but that have a small component that traverses the epidermis. Thus, the percutaneous set-back dermal suture is a buried technique wherein the suture material briefly exits and reenters the skin. While this nomenclature is generally accepted, the literature includes some publications where this term is used to mean a technique that is performed entirely through the outside of the skin, and therefore clarifying this point is necessary.

The fundamental principle of all suture techniques is simple: finely coapt the wound edges, preferably with eversion, while shifting the tension deep, away from the surface of the skin. For wounds under tension—and this would include all wounds due to excisional surgery—repairing the deeper structures, whether muscle, fascia, or deep dermis, and placing sutures in these structures, permits the wound edges to drape together under minimal tension. While it is certainly easy to close many wounds using transepidermal sutures alone, such as the simple interrupted suture, this technique alone means that the tension of the closure is held by a suture that crosses over the surface of the skin. There are two important disadvantages to such a technique: (1) Once the sutures are removed, there is no residual support for the wound, leading to an increased risk of dehiscence (and if the sutures are left in place for too long, this all but guarantees that suture track marks will be present), and (2) since a high-tension closure is effected directly across the wound edge, the scar will have a tendency to spread and may be more likely to become hypertrophic and unsightly.

Shifting tension to the deep dermis or fascia permits the epidermal and superficial dermal closure to occur under minimal to absent tension. Since the scar response results from, and is exacerbated by, tension, this approach permits not only a functional closure, but an aesthetically pleasing one as well.

The accomplished surgeon should move from simply attempting to coapt wound edges to designing closure techniques that will maximize the chance of outstanding healing and a return to “normal” as much as possible. For example, suture material left between the incised wound edges may serve as a barrier to healing; this may be conceptualized as an iatrogenic eschar phenomenon. The importance of debriding eschar that rests between wound edges is clear to most surgeons, as the mechanical blockade of tissue healing cofactors by the mass of eschar clearly impairs the rapidity with which a wound can heal and, ultimately, its functional and cosmetic outcome. Therefore, buried suture techniques that minimize the placement of suture material between the incised wound edges, such as the set-back suture and its variants, may confer a clinical advantage. Since no suture material is present between the incised wound edges, nothing impedes the cellular migration necessary for healing.

The goal of surgical procedures on the skin and soft tissues is to return the skin as close to “normal” as possible. By definition, every wound heals with a scar. Wound edges should in most cases be smooth and perpendicular to the surface (some repairs, such as the butterfly suture, call for a beveled edge). Tissue must be handled as atraumatically as possible. Careful attention to hemostasis is a must. A thorough understanding of anatomy, tissue mechanics, flap mechanics and geometry, and other considerations is imperative before approaching complex repairs. The cornerstone of every closure, however, is simple. If there is minimal tension across the surface of a wound—if the wound is splinted or cast in place by the presence of precisely placed, meticulously designed sutures through the deep dermis—then it will heal with a nearly imperceptible scar.

Since all tissues are not created equal, all body sites do not respond to the same techniques, and technical challenges in suture placement are a reality, there is no single suture technique that will be appropriate in every situation. Certain workhorse techniques that effectively reduce tension across the surface of the wound, such as the set-back dermal suture or buried vertical mattress suture, may be used in almost every surgical case. Others, such as the pulley versions of the previously mentioned techniques, may be used occasionally, while still others, such as percutaneous running suturing techniques, may be niche approaches that are used only infrequently by most surgeons.

Lacerations in the context of the emergency department, urgent care center, or primary care office may be addressed in a number of ways. All of the techniques described in this book may be used for any repair, from a simple laceration to a multi-layered flap. That said, approaches to a laceration—as opposed to a surgical wound purposely caused by the surgeon—may differ subtly from iatrogenic incision repairs. First, lacerations, of course, need to be properly prepped via debridement and irrigation, as appropriate. Second, lacerations, like skin incisions (but unlike excisional defects), generally do not involve removal of skin, and therefore the wound is under only modest tension, as tissue does not need to be recruited in order to effect a closure. Thus, suturing techniques designed for high-tension closures (such as pulley techniques) may be needed only infrequently. Third, undermining is often not performed when closing lacerations, so that certain techniques predicated on a well-undermined dermis (such as the butterfly suture) may be less appropriate, though select lacerations may benefit from undermining in order to reduce final closure tension.

Many practitioners close lacerations with only transepidermal sutures, whether for presumed ease of placement, minimization of infection risk by avoiding the theoretical risk of bacterial contamination of absorbable suture material, or a sense that deep sutures are only needed in wounds under marked tension. Still, as with any wound, closing a laceration so that there is minimal tension across the wound’s surface will yield the most cosmetically-acceptable scar in the long run. Therefore, placing deep sutures, such as the buried vertical mattress suture or set-back dermal suture, may both reduce the tension across the surface of the wound and (when used as a single-layer closure without transepidermal sutures) allow for avoidance of suture removal visits. Other frequently used techniques in laceration repair include the simple interrupted suture, simple running suture, running locking suture, depth-correcting simple interrupted suture, horizontal mattress suture, running subcuticular suture, and the various iterations of the tip stitch. Half-buried variations of the horizontal or vertical mattress suture are also occasionally used adjacent to hair-bearing areas, so that the non-hair bearing edge is not marred by the presence of transepidermal sutures. The full range of suture techniques are available to those involved in laceration repair; given the substantial clinical variation seen in these wounds, familiarity and comfort with high-level suturing techniques may yield markedly improved outcomes for patients in the acute setting.

All of surgery is both art and science; it is the goal of this text to break down some of the art of surgical technique, distil it to its essence, and convey this information in as straightforward a way as possible. This Atlas also serves to catalogue some fundamental techniques that may be useful to both the novice and virtuoso surgeon alike. Perspective is simplified when standing on the shoulders of giants, and, indeed, while there is nothing new under the sun, it may be helpful to shine its rays on a variety of approaches that may serve to expand the armamentarium of all of those involved in improving outcomes for he or she who is always the most important person in the surgical suite—the patient.