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Basic plastic surgery techniques and principles:

How to suture
In the second article of our series, Ben Taylor and Ardeshir Bayat explain suture techniques, how to
prepare a wound, and how to get the best possible scar

Stitching (suturing) a wound is a surgical skill ondary healing to occur before the wound is thought. This article focuses on sutures, but
which also has widespread applications out- closed. The aim of a suture is to splint the there are alternatives which find a place in
side the field of surgery. We are all likely to wound edges in the best position for direct some specialties. In paediatrics, for example,
be called on to suture a wound at some primary closure to occur. If the suture has to wound glue is often used in scalp injuries, to
point in our training. Few students have pull the wound edges together under ten- save the child the stress of having his or her
enough confidence, however, to deal with sion, the sutures will act like a noose to cause head sutured.
wounds, and it can be hard to learn. In this local ischaemia of the tissues, which may Wounds can be frightening things, and
article we look at the basics of wound heal- lead to breakdown. they immediately attract attention. For larger
ing suturing technique. We discuss a few wounds, always think about airway, breath-
more advanced techniques and share the se- ing, and circulation first, and make sure that
crets of getting best possible results. Preparation and assessment the wound is an isolated injury.
When closing a wound, you need to assess it Before suturing, ensure the patient has
first (box 1 opposite).3 Many simple wounds adequate anaesthesia (either local or gen-
Wound healing will heal by themselves, without any inter- eral). Irrigate the wound, and remove any
To understand the basis of suturing, it is im- vention. A suture should be used as a splint foreign bodies and any non-viable or in-
portant to know how wounded skin heals. to hold the wound in the best possible posi- fected tissue (debridement). Debridement is
This occurs in four phases (although there is tion, rather than to hold it together. If you particularly important as dead tissue will not
some overlap). judge that there is too much tension to close heal and acts as a reservoir for infection.4
Haemostasis—Immediately after wounding, the wound directly, consider discussing the The integrity of the deep structures must be
a platelet plug forms and blood vessels vaso- case with a plastic surgeon, or leaving the checked in any wound. Refer damage to ten-
constrict. Later, a thrombus develops to seal wound for delayed primary closure. dons, nerves, viscerae, etc, to an appropriate
the wound. Many tools are available for wound clo- specialist for assessment or primary repair.
Inflammation—This occurs in the first two sure—for example, wound glue, staples, and The wound edges must have a good blood
to three days after the injury, causing sutures—and the most appropriate means of supply and be free from infection to ensure
swelling of the wound edges. White blood closing a wound must be given some healing. You must follow strict aseptic tech-
cells remove necrotic tissue, and control in-
fection.1
Proliferation—Beginning on the second or
third day after the injury, and lasting for two
to four weeks, structure forming cells called
fibroblasts proliferate into the wound, and
produce structural proteins such as gly-
cosaminoglycans, collagen, and elastin.2 New
capillaries form at this time, and epithelial
cells migrate across the top of the wound.
Areas where this is occurring are known as
“granulation tissue.”
Remodelling—After the proliferative phase
subsides, the new capillaries atrophy and
collagen changes from type III to type I and
is rearranged so that it gives the best tensile
strength. Myofibroblasts cause scar contrac-
ture. Strength of the wound increases to al-
most 80% of the original strength over this
period of up to a year.2 Because the forces
acting on the wound shape its remodelling,2
the best result is obtained when the force is
uniaxial (only acts in one direction).
Primary closure is where the wound
edges are neatly brought together. Healing
by secondary intention differs, in that the
wound heals from the base up, which takes
longer with a potentially worse cosmetic re-
SATURN STILLS/SPL

sult. Delayed primary closure is used in situ-


ations where early primary closure is
inappropriate, and allows a period of sec-

182 STUDENT BMJ VOLUME 11 JUNE 2003 studentbmj.com


niques. It may be worth delaying primary
closure if there is oedema or doubt as to the
viability of tissue. Systemic factors, such as
malnutrition, diabetes mellitus, peripheral
vascular disease, and corticosteroid therapy
may delay wound healing.2

Simple suturing
The simple suture is a technique taught to
most medical students, and often used in
wound closure. It has the advantage of being
quick and relatively easy, and usually gives
an adequate cosmetic finish. However it is
often done poorly, and can cause long last-
ing damage to a patient if care is not taken. It
is known as an “interrupted suture,” because
several individual stitches are needed to
close a wound.

Box 1: Assessing and preparing a


wound
● Is this an isolated injury?
● Are all of the deep structures intact?
● Have I removed all dead tissue?
● Is this wound suitable for immediate
closure?
dle tip to the swage (point where the needle Buried simple suture
● Do the wound edges have a good blood
becomes attached to the thread). Take a The buried suture is circular in profile, and is
supply? square bite of skin, entering perpendicular used to close the deep layers of tissue. The
● Is suturing the best way to close the to the wound surface, and taking a smooth knot should be placed deep to prevent it
wound? semicircular course to exit at 90 degrees to coming out. Absorbable sutures should be
● Have I anaesthetised the wound? the wound edge. The needle should then be used, as the suture cannot be removed from
● Do I have the right equipment (instru- removed from the wound, readjusted on the the skin.
ments and correct suture material)? needle holder, and the second half of the arc
done in the same way. This method ensures Vertical mattress suture
● Will the wound benefit from steri-
a square bite, and good eversion of the This technique produces more eversion than
strips? wound. Bites of skin should be equal on a simple suture. It is similar to a simple su-
● Do I have an appropriate dressing to both sides of the wound, and sutures should ture, but a second, superficial bite is taken in
cover and protect the wound? be spaced evenly. the same vertical plane (see figure). Al-
though it may evert skin in areas with a nat-
Tying ural tendency to invert, it does produce
Technique Use a surgical knot to close the wound, which more crosshatching due to increased dermal
When suturing, the deep layers should be must be tied tight enough to adequately ischaemia.8
closed below if necessary. Any deep tissue splint the wound. However, if it is too tight,
gaps may become infected. Make sure the there will be local ischaemia underneath the Horizontal mattress suture
wound stops bleeding because if a suture tracks leading to an ugly crosshatched This is a similar concept to the vertical su-
haematoma forms it can act as a barrier be- scar. An instrument knot is shown in the fig- ture, except that it extends along a horizon-
tween the wound edges and be a potential ure. The concept is simple in that the long tal plane, almost like two simple sutures next
source of infection. Use a needle holder end of the thread is wrapped around the nee- to each other (see figure) It is useful in areas
where possible, to minimise the risk of dle holder, which is used to transfer the coil with thick glabrous skin, such as the soles of
needlestick injury.5 The skin edges should be around the short end. This cycle is repeated the feet. But it also causes more dermal
accurately apposed, and not under undue to create a surgeon’s knot. Once tied, the ischaemia than simple or even vertical mat-
tension. If forceps are used to align the tis- knot should be left to one side, so that it does tress sutures, and if tied too tightly, can over-
sues they should be used gently: it is better not become involved in the clot. evert the wound edges.5
to use the closed forceps to nudge the skin
edges together, than to grab them.6 The in-
side of the skin is delicate, as it does not have Variations on a simple suture Other important techniques
a protective layer of keratinocytes and is also
where the blood supply is richest. Therefore Continuous simple suture Subcuticular suture
skin trauma will impair healing. A skin stitch This is similar to a simple suture, except that Subcuticular or intradermal sutures give the
should gently evert the wound edges, as the there are no individual sutures, just a long best cosmetic result, and are simple and
deeper layer is alive and capable of regener- coil of material. They are used in abdominal quick to place.9–11 They run in the dermis in
ating, whereas the superficial layers are wall closure,7 and in places where haemosta- the same plane as the subdermal plexus, the
mostly dead keratinocytes. sis is important, such as on the scalp, be- main blood supply to the skin,12 and there-
The needle should be held in needle cause the suture compresses the wound fore do not “strangle” wounds in the same
holders two thirds of the way from the nee- edges.8 way as simple sutures. They do not cause

STUDENT BMJ VOLUME 11 JUNE 2003 studentbmj.com 183


crosshatching, and mechanically provide the Box 2: Getting a fine scar Box 3: Removing sutures
best internal splinting of a wound.
● Ensure that an elective incision runs ● Give oral analgesia or topical
Monofilament sutures are used, as they
along a line of relaxed skin tension, anaesthesia if necessary
do not exhibit as much tissue drag as
where possible8 (RSTL—also known as ● Clean the wound with antiseptic
braided sutures. There are many different
wrinkle lines or natural skin lines are solution
ways to start and finish such a suture,10 13–15
lines of minimal tension and lie perpen- ● Use forceps, fine scissors, or a suture
but generally, non-absorbable sutures
should enter the skin at the apex of the dicular to axis of underlying muscle) cutting blade
wound, and absorbable sutures are often tied ● Debride the wound, remove any foreign ● For removing interrupted sutures, lift
in the dermis. Bites should be parallel to the bodies, and irrigate it4 one end lightly, and then cut under the
wound edges, and through the dermis. Take ● Ensure the wound edges are not under knot
care to ensure that all bites are placed in the tension, that they have a good blood ● Pull suture out across rather than away
same vertical plane, otherwise the wound supply, and that they are viable5 from the wound as you may make the
edges will be misaligned with poor healing. ● Obtain early primary closure where wound bleed or dehisce if not careful
Long wounds should have bridges (loops of possible ● If in doubt, apply steristrips or tissue
suture) brought out over the wound.16 ● Avoid infection4 glue to protect the wound after
● Ensure that the wound edges are well removing sutures
Half buried mattress suture (Barron apposed6 ● Time to remove non-absorbable
suture) and three corner suture ● Ensure that the forces acting on the sutures depends on location: face (5-7
This is used where either a single wound wound only act in one direction, and days), scalp (7-10 days), and limbs and
edge is friable, or the knots can be hidden on minimise distracting forces trunk (12-14 days)
one side (such as the areola of the breast). It ● Minimise tissue trauma when suturing6
is a combination of a mattress suture and a
● Suture neatly with a gently everting
subcuticular suture (see figure). Surg Clin North Am 1991;71:371-84.
wound edge
A variation where the subcuticular com- 5 Skinner I. Basic surgical skills manual. Sydney: McGraw-
● Avoid materials that cause a bad tissue Hill, 2000.
ponent is used to close the corners of several
different lacerations is known as a three-cor- reaction for example, silk on the face18 6 Singer AJ, Quinn JV, Thode HC, Hollander JE. Deter-
minants of poor outcome after laceration and surgical
ner suture (see figure). ● Make sure you immobilise the wound incision repair. Plast Reconstr Surg 2002;110:429-35.
with steri-strips, tapes, and even ther- 7 Wadström J, Gerdin B. Closure of the abdominal wall:
moplastic splints and plaster casts how and why? Acta Chir Scand 1990;156:75-82.
8 Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and
Complications of suturing, and where necessary Smith’s plastic surgery. 5th ed. Philadelphia: Lippincott-
how to minimise them Raven, 1997.
9 Angelini GD, Butchart EG, Armistead SH, Brecken-
ridge IM. Comparative study of leg wound closure in
Infection used for skin closure, as they have a better coronary artery bypass graft operations. Thorax
Infection was a significant problem when su- cosmetic result. 1984;39:943-5.
10 Taube M, Porter RJ, Lord PH. A combination of subcu-
tures were carried in the buttonholes of sur- ticular suture and sterile micropore tape compared
geons. Today it can be a problem if there are Dehiscence with conventional interrupted sutures for skin closure:
breaks in aseptic technique or from hospital Dehiscence is the term used for the break- a controlled trial. Ann R Coll Surg Engl 1983;65:164-7.
11 Onwuanyi ON, Evbuomwan I. Skin closure during ap-
acquired infection. Wounds must be ade- down of a wound postoperatively. Common pendicectomy: a controlled clinical trial of subcuticular
quately debrided to remove any contami- causes include lack of surgical experience,6 and interrupted transdermal sutures. J R Coll Surg Ed-
nated tissue, and may need to be irrigated or (implying that poor technique is to blame). inb 1990;35:353-5.
12 Richards AM. Key notes on plastic surgery. Oxford: Black-
cleaning with abrasion under anaesthetic Other important factors are wound tension well Science, 2002
may be required.4 and infection. Dehiscence is associated with 13 La Padula A. A new technique to secure an entirely
a mortality of 25% in the case of general buried subcuticular suture. Plast Reconstr Surg
1995;95:423-4.
Tattooing surgical wounds. Other complications in- 14 Smoot EC. Method for securing a subcuticular suture
This is a rare complication of using dyed su- clude chronic wounds and infection of deep with a minimal buried knot. Plast Reconstr Surg
tures, and it is best to avoid dyed sutures on structures. 1998;102:2447-9.
15 St John HM. Knot-free subcuticular suture. Br J Surg
the skin. Other sources of tattooing are grit 1997;84:872.
and dirt. Abrasions are particularly liable to 16 Tantawy HS. New technique for subcuticular suture in
tattoo, and should be thoroughly scrubbed An important skill lengthy wounds. Br J Surg 1996;83:66-7.
17 Carr T, Harris D, James C. The Derriford appearance
with a wire brush, under anaesthetic of Suturing is an important skill for any med- sale (DAS-59): A new scale to measure individual re-
course. ical student or junior doctor to learn. There sponses to living with problems of appearance. Br J
are a few key messages to remember to Health Psychol 2000;5:201-15.
18 Gabrielli F, Potenza C, Puddu P, Sera F, Masini C,
Scarring suture effectively and avoid damaging your Abeni D. Suture materials and other factors associated
Scarring is a natural process, and occurs as patient. with tissue reactivity, infection and wound dehiscence
the result of any wound. However, large, among plastic surgery outpatients. Plast Reconstr Surg
2001;107:38-45.
stretched or hypertrophic scars can look Ben Taylor third year medical student
ugly and are occasionally a source of psy-
chological trauma, even if the scar looks ac- Ardeshir Bayat specialist registrar in plastic surgery Key points
ceptable to the medical professional.17 Scars University of Manchester
contract, which is troublesome around ardeshir.bayat@man.ac.uk ● Always assess, clean, and debride the
joints. It is very important to minimise scar- wound before suturing
ring, and take every effort to do so (box 2). 1 Hart J. Inflammation 1: its role in the healing of acute ● Use aseptic technique at all times
The simple suture does an adequate job wounds. J Wound Care 2002;11:205-9. ● Suture neatly
2 Cotran RS, Kumar V, Collins T, eds. Robbins pathologic
of internally splinting the wound but in do- basis of disease. 6th ed. Philadelphia: WB Saunders, ● Get as much supervised practice as you
ing so can create lines of traction and 1999. can before you have to do it on your
counter traction, which can result in a poor 3 Benbow M. The skin 2: skin and wound assessment.
Nurs Times 2002;98:41-4.
own
scar. Ideally, subcuticular sutures should be 4 Fildes J, Bannon MP. Soft-tissue infections after trauma.

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