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View updated Privac Polic , effective Januar 16, 2012

Suturing Techniques
A h : J ia Mac a -Wigga ; Chief Edi U da ed: A g 5, 2010 : Di ME , MD e...

Overview
A a eh df c i gc a a e ia a d a ec f he a d e g he i g d ae he ica ea i g a d f e d , he ech i e f i gi h a d f ea d. A h gh ech i e ha e cha ged, he g a e ai he a e: c i g dead ace, i hea i g i c ea e hei e i e e g h, a i a i g i edge f a ci a e , a d i i i i g he i f b eedi g a d i fec i . e i g

P e i g ech i e i eeded e eg d e i de a gic ge . The f a bea if de ig ed c e f a ca be c i ed if a i c ec e ech i e i e ec i i . C e e , e ic i g ech i e ca f c e aef i ech i e. P i ci i ace e i h e ec e a ed i e i i e , e ce i e e i ade a e de i i g a i i he ge ' i i dc ea d e ace e f he i ei a i a i i e d hea i g. The ch ice f e ech i e de e d he ea da a ic i , he deg ee f e i , a d he de i ed c e ic e . The eci e a i ai f he d edge , hich he i i i ea e e ia a i i e he i e ih d f g d e ide a a i ai ca de e i ec da i ec ac i d i g hea i g. U d e dec ea e he i fh e hic ca i g i a i di id a ei i a i f dead ace, he e ai f a a a a ic c a i a i i e he c e ic a d f c i a e . ca i f he d, he e ace e f e d edi ib e i e i . E e i i de i ab e a ,i e i i de i iha e i f h e , a d he i i i a i

e a i e a ea a ce ch e if he e gica a f i e, . Ge e ha d i g

hic e f he e ha ce he .W dee i i i i i e he i f ab e, a d i bab hic ca . The f e a ae

I hi a ic e, he e ech i e ed i c a e ge a e e ie ed. The ech i e f e ace e f each e f i ch a e de c ibed, he a i a e f ch i g e e ech i e e a he a e e ie ed, a d he ad a age a d di ad a age f each e ech i e a e di c ed. F e e , e ha e e ech i e i eeded f i a c e fa d. Af e eadi g hi a ic e, he eade h d ha e a de a di g f h a d h a ic a e a e ch e a d a a ecia i f he ba ic e h d f aci g each e f e.[1, 2]

Basic suturing principles

Ma a ie ie f e a e ia a d eed e a e a ai ab e he c a e ge . The ch ice f e a d eed e i de e i ed b he ca i f he e i , he hic e f he i i ha ca i , a d he a f e i e e ed he d. Rega d e f he ecific e a d eed e ch e , he ba ic ech i e f eed e h di g, eed e d i i g, a d ace e e ai he a e. Need e c ci The eed e ha 3 ec i . The i i he ha e i a di ed e e a e he i e. The b d e e e he id i f he eed e. The age i he hic e i f he eed e a d he i hich he e a e ia i a ached. I c a e ge , 2 ai e f eed e a e ed: c i g a d e e e c i g. B h eed e ha e a ia g a b d . A c i g eed e ha a ha edge he i e c e f he eed e ha i di ec ed a d he d edge. A e e e c i g eed e ha a ha edge he e c e f he eed e ha i di ec ed a a f he d edge, hich ed ce he i f he e i g h gh he i e. F hi ea , he e e e c i g eed e i ed e f e ha he c i g eed e i c a e ge ( ee i age be ).

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Diagram of a needle.

Suture placement A needle holder is used to grasp the needle at the distal portion of the body, one half to three quarters of the distance from the tip of the needle, depending on the surgeon's preference. The needle holder is tightened by squeezing it until the first ratchet catches. The needle holder should not be tightened excessively because damage to both the needle and the needle holder may result. The needle is held vertically and longitudinally perpendicular to the needle holder (see image below).

The needle is placed vertically and longitudinally perpendicular to the needle holder.

Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the skin, and/or an undesirable angle of entry into the tissue. The needle holder is held by placing the thumb and the fourth finger into the loops and by placing the index finger on the fulcrum of the needle holder to provide stability (see first image below). Alternatively, the needle holder may be held in the palm to increase dexterity (see second image below).

The needle holder is held through the loops betw een the thumb and the fourth finger, and the index finger rests on the fulcrum of the instrument.

The needle holder is held in the palm, allow ing greater dexterity.

The tissue must be stabilized to allow suture placement. Depending on the surgeon's preference, toothed or untoothed forceps or skin hooks may be used to gently grasp the tissue. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis. Forceps are necessary for grasping the needle as it exits the tissue after a pass. Prior to removing the needle holder, grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the back, where large needle bites are necessary for proper tissue approximation. The needle should always penetrate the skin at a 90 angle, which minimizes the size of the entry wound and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the
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i g c ed e ha e a i c ea ed i f i ai i g he ic ci c a i di g he d, a d he ca ca e i e a g a i if aced igh . The ef e, hi e f e h d be ed i a ea i h g d a c a i a i . I a ic a , he i g c ed e a be ef he ca i he a ic a c , e ecia he addi i a he a i i eeded. Ve ica a e e A e ica a e e i e ecia ef i a i i i g d e e i , ed ci g dead ace, a d i i i i g e i ac he d. O e f he di ad a age f hi ei c ha chi g. The i fc ha chi g i g ea e beca e f i c ea ed e i ac he d a d he 4 e a de i i f he i ch i he i . The ec e ded i e f e a f hi e i 5-7 da (bef e f ai f e i he ia e ac i c e e) ed ce he i f ca i g. If he e be ef i ace ge , b e a be aced be ee he e a d he i i i i e c ac . The e f b e i i i e a g ai f he i e he he d e i e e e a i e ede a. P aci g each i ch eci e a d a i g e ic bi e i e ecia i a i h hi e. Ha f-b ied e ica a e e The ha f-b ied e ica a e i ed i c e ica i a a ea ch a he face. P e e The e e faci i a e g ea e e chi g f he d edge a d i ed he addi i a dc e e g h i de i ed. Fa - ea ea -fa dified e ica a e e The e ei ef he i e e a i i de i ed, a d i a be ed i a e a i e f hi e. The ei a ef he begi i g he c e fa d ha i de ig ifica e i . B aci g e i che fi , he d edge ca be a i a ed, he eb faci i a i g he ace e f b ied e . Whe dc ei c e e, he e i che a be ei he ef i ace e ed if d e i ha bee ade a e di ib ed af e ace e f he b ied a d face e . H i a a e e The h i a a e ei ef f d de high e i beca e i ide e gh a d d e e i . Thi e a a be ed a a a i ch e ai a i ae d edge , a i g ace e f i ei e ed bc ic a i che . The e a i che a e e ed af e he e i i e e di ib ed ac he d. H i a a e e a be ef i ace f a fe da if d e i e i af e ace e f he e ai i g i che . I a ea f e e e high e i a i f dehi ce ce, h i a a e e a be ef i ace e e af e e a f he e ficia i e . H e e , he ha e a high i f d ci g e a if ef i ace f ge ha 7 da . H i a a e e a be aced i a ed e ci i a a i e a i ech i e ed ce e i . I ed e e i a be achie ed i h hi i ch i d ih ig ifica e i b i g a bi e a d a fi e e. I addi i he i f e a ,h i a e ha e a high i f i e a g ai a d d edge ec i if ied igh . Ta i g ge e bi e , i g b e , a d ci chi g he e a igh a ece a a i a e he d edge a dec ea e he i , a d e e i g he e a ea a ib e. P aci g e a a g ea e di a ce f he d edge faci i a e hei e a. Ha f-b ied h i a e i i che 3- i c e i che The ha f-b ied h i a e i i ch i ed i a i ii he c e a d i f fa a d ef M- a ie a d V-Y c e . The c e i ch a ide i c ea ed b d f fa i , e i g he i f ec i a d i i g ae he ic c e .[4] H e e , i a ge f a i h g ea e e i , hi ech i e ha bee e ed ii he f a i dee e ha he [5, 6] di g i e, f e e i g i a de e ed ca . Ab bab e b ied e Ab bab e b ied e a e ed a a f a a e ed c ei d de de a e- -high e i . B ied e ide he d a d ed ce e i he d edge , a i g be e e ide a a i ai f he d. The a e a ed e i i a e dead ace, he a e ed a a ch e fi he e i g i e he de i g c e . De a - bde a e A b ied de a - bde a e a i i e dee i .I i aced ha he ei e e ficia a a f he d edge. B ied h i a a e e The b ied h i a a e ei ed e i i a e dead ace, ed ce he i e f a defec ,
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ed ce e i ac d .[7] R i gh i a a e e The i gh i a a e ei ed f i ee i .I i ef i a ea i h a high e de c f i e i , ch a he ec . I ca a be ef f ed ci g he ead f facia ca . If he e a e ied igh , i e a g a i i a i . Whi e igh e i e c i g, hi ech i e a ea e i he a d f a e ca a c a ed i e i g e .[8] R i g bc ic a e The i g bc ic a e i a ab e i a ea i hich he e i i i i a , he dead ace ha bee e i i a ed, a d he be ib e c e ic e i de i ed.[9] Beca e he e ide i i e e a ed a he begi i g a d e d f he e i e, he bc ic a e effec i e e i i a e he i fc ha chi g. The ed e ide ig ifica d e g h, a h gh i d e eci e a i a e he d edge . The ef e, he i g bc ic a e i be e e ed f d i hich he e i ha bee e i i a ed i h dee e , a d he d edge a e f a i ae e a hic e e . R i g bc a e e The i g bc a e ei ed c e he dee i f gica defec de de a e e i . I i ed i ace f b ied de a e i a ge d he a ic c e i de i ed. Di ad a age f i g bc a e e i c de he i f e b ea age a d he f ai f dead ace be ea h he i face. [10] R i g bc a e c e ica i i che The c e ica i ech i e i ed i d ide ha 4 c ha a e de e ce e i . Thi e c ea e a a e e i a d be e d edge a i a i . P ace e f hi i ch ea e b e e ace e f i ade a e ,a d dia e e a d e i a e ed ced ig ifica . S e g h f he e e ie i c i f he e a i f he fa cia a e be ea h he bc a e i e. If i e ed eai e , e i d be di ib ed [10] e b ad . P e ia be i c de e b ea age a d d di i . M dified ha f-b ied h i a a e e [6] The dified c e i ch a f e a ee i f he f a i edge a d i ed ae he ic c e . Whi e i a i c ea e i f ec i if ied igh , he i cide ce f f a i ec i a f d be c a ab e i h ha f he adi i a c e i ch.[6] Dee i i ch[5] Thi i ch i ed f M- a , W- a f a , a d V-Y c e i c ea e dee i .I ide ge - e he f a ha he adi i a c e i ch a d i e a ig e f he i i h he ide f c e. Thi ech i e a a id face e , dec ea i g he i f [5] ac a . F a i ec i a d c ica i eec a ab e ha f a da d e .

Eq ipmen
Need e Need e h de S e a e ia

Techniq e
Si ei e The ed e c ed a d e a i e ei c a e ge i he i ei e ed [11] Thi e. ei aced b i e i g he eed e e e dic a he e ide i , a e i g he e ide i a d he f hic e f he de i , a d e i i g e e dic a he e ide i he i e ide f he d. The 2 ide f he i ch h d be e ica aced i e f de h a d id h. I ge e a , he e h d ha e a f a - ha ed c fig a i , ha i , he i ch h d be ide a i ba e (de a ide) ha a i e ficia i (e ide a ide). If he i ch e c a e a g ea e e f i e a he ba e ha a i a e , he e i gc e i a he ba e f ce he i e ada d e ee i f he d edge . Thi a e e dec ea e he i e ih d f c ea i g a de e ed ca a he d e ac d i g hea i g ( ee i age be ).

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Simple in e

p ed

e placemen . Bo om igh image ho

a fla k- haped

i ch,

hich ma imi e e e ion.

In gene al, i e bi e ho ld be e enl placed o ha he o nd edge mee a he ame le el o minimi e he po ibili of mi ma ched o nd-edge heigh (ie, epping). Ho e e , he i e of he bi e aken f om he 2 ide of he o nd can be delibe a el a ied b modif ing he di ance of he needle in e ion i e f om he o nd edge, he di ance of he needle e i i e f om he o nd edge, and he dep h of he bi e aken. The e of diffe en l i ed needle bi e on each ide of he o nd can co ec p ee i ing a mme in edge hickne o heigh . Small bi e can be ed o p eci el coap o nd edge . La ge bi e can be ed o ed ce o nd en ion. P ope en ion i impo an o en e p eci e o nd app o ima ion hile p e en ing i e ang la ion. The image belo ho a line of in e p ed e .

Line of in e

p ed

e .

Simple nning e The imple nning e i an nin e p ed e ie of imple in e p ed e . The ei a ed b placing a imple in e p ed i ch, hich i ied b no c . A e ie of imple e a e placed in cce ion i ho ing o c ing he e ma e ial af e each pa . S e ho ld be e enl paced, and en ion ho ld be e enl di ib ed along he e line. The line of i che i comple ed b ing a kno af e he la pa a he end of he e line. The kno i ied be een he ail end of he e ma e ial he e i e i he o nd and he loop of he la e placed. The image belo ho a nning e line.

R nning

e line.

R nning locked e The imple nning e ma be locked o lef nlocked. The fi kno of a nning locked ei ied a in a adi ional nning e and ma be locked b pa ing he needle h o gh he loop p eceding i a each i ch i placed. Thi e i al o kno n a he ba eball i ch ( ee image belo ) beca e of he final appea ance of he nning locked e line.

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R nning locked

e.

Ve ical ma e e The e ical ma e e i a a ia ion of he imple in e p ed e. I con i of a imple in e p ed i ch placed ide and deep in o he o nd edge and a econd mo e pe ficial in e p ed i ch placed clo e o he o nd edge and in he oppo i e di ec ion. The id h of he i ch ho ld be inc ea ed in p opo ion o he amo n of en ion on he o nd. Tha i , he highe he en ion, he ide he i ch ( ee image belo ).

Ve ical ma e

e.

Half-b ied e ical ma e e The half-b ied e ical ma e e i a modifica ion of he e ical ma e e and elimina e 2 of he 4 en poin , he eb ed cing ca ing. The half-b ied e ical ma e e i placed in he ame manne a he e ical ma e e, e cep ha he needle pene a e he kin o he le el of he deep pa of he de mi on one ide of he o nd, ake a bi e in he deep pa of he de mi on he oppo i e ide of he o nd i ho e i ing he kin, c o e back o he o iginal ide of he o nd, and e i he kin. En and e i poin he efo e a e kep on one ide of he o nd. P lle e The p lle e i a modifica ion of he e ical ma e e. When p lle e a e ed, a e ical ma e e i placed, he kno i lef n ied, and he e i looped h o gh he e e nal loop on he o he ide of he inci ion and p lled ac o . A hi poin , he kno i ied. Thi ne loop f nc ion a a p lle , di ec ing en ion a a f om he o he and ( ee image belo ).

P lle

i ch,

pe 1.

Fa -nea nea -fa modified e ical ma e e Ano he i ch ha e e he ame f nc ion a he p lle e i he fa -nea nea -fa modifica ion of he e ical ma e e. The fi loop i placed app o ima el 4-6 mm f om he o nd edge on he fa ide and app o ima el 2 mm f om he o nd edge on he nea ide. The eco e he e line and een e he kin on he o iginal ide a 2 mm f om he o nd edge on he nea ide. The loop i comple ed, and he e e i he kin on he oppo i e ide 4-6 mm a a f om he o nd edge on he fa ide. Thi placemen c ea e a p lle effec ( ee image belo ).

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H T T ( 5 ). , 1 5 1 ). T .T ( .

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i c ea ed. B ied h i a a e e The b ied h i a a e ei a e- i g e. The e be aced i he id-dee a f he de i e e he i f ea i g. If ied igh , he e a a g a e he a i a ed i e. R i gh i a a e e A i e ei aced, a d he i ied b c .Ac i e ie f h i a [12] a e e i aced, i h he fi a ied he f ee e d f he e a e ia . R i g bc ic a e The i g bc ic a e i a b ied f f he i gh i a a e e. I i aced b a i g h i a bi e h gh he a i a de i a e a i g ide f he d. N e a a e i ib e, a d he e a be ef i ace f e e a ee ( ee i age be ).

S bc ic a

i ch. The

face e ai

i ac a

g he e g h f he

e i e.

i g bc a e e The i g bc a e e begi iha i ei e ed ied b c . The ei ed h gh he bc a e i h gh he i e ide f he d. The i ied a he i g he g e d f he e a e ia he f he a a i g bc a e c e ica i i che [10] Bef e i e i g he eed e, f ce a e ed fi a ea i e e g h. The c e ica i i c de a ea 1-2 c f adi each bi e. Af e he fi bi e i ied, bi e a e a e i e ide fa hi a g he defec . The f ee e d i ed fi ed ci g he i i he ied.

bc a e e, hich i eb cce i e a i g i e e d f he db ha a aced. 1-2 c f i e e e e i e a d fa cia i hi f he di a i g e f he defec , a d he e

Va ia ion of ip (co ne )

e
e e [6] a e ica a e i h i ead f f ce e i e ficia he ha f-b ied h i ed a id a a f he f a . a

M dified ha f-b ied h i a a Thi i ch ace a addi i a e e. A a Dee i i ch[5] The dee i i ch i e e he dee de i f he he f a i , a d i e ed i

ia a f -b ied f f he 3-c e i ch. The ei aced i d edge hich he f a i be a ached, a ed h gh he de i he dee de i f he ie d edge.

e emo al
S e h d be e ed i hi 1-2 ee f hei ace e , de e di g he a a ic ca i . P e a ed ce he i f e a , i fec i , a d i e eac i . The a e age d a achie e a i a e 8% f i e ec ed e i e e g h 1-2 ee af e ge . T e e dehi ce ce a d ead f he ca , e h d be e ed . A a ge e a e, he g ea e he e i ac a d, he ge he e h d e ai i ace. A a g ide, he face, e h d be e ed i 5-7 da ; he ec , 7 da ; he ca , 10 da ; he a d e e e i ie , 10-14 da ; a d he e e e i ie , 14-21 da . S e i d de g ea e e i a eed be ef i ace igh ge . B ied e , hich a e aced i h ab bab e e a e ia , a e ef i ace beca e he di e. P e e e a ech i e i i a ai ai g d e af e e ae e e ec ed a d e ec ed. S e h d be ge e e a ed i h f ce , a d e ide f he e h d be c . The , he e i ge g a ed b he a d ge ed a d he d e i e i he e a e ia i c ee e ed. If he ei ed a a f he e i e, he d edge a e a a e. S e i-S i a be a ied i h a i e adhe i e ide c i ed e e a d af e he e ae e ed.

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Alternative Methods of Wound Closure

S -S W , S . W .O , S S .A , . T S , , .[17] [18, 19] T , , , ). T 2G O'R N2.I G , B A .S , . A .[24] B .[25] I 6.9/10.[25] B 3 .O .[25] H , .[26, 27] A N P , .S .D .A 1-3 4 .
[29] [13, 14, 15]

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Contributor Information and Disclosures

A Julian Macka -Wiggan MD, A
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Presbyterian Hospital, Columbia University College of Physicians and Surgeons Julian Mackay-Wiggan is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society for Investigative Dermatology Disclosure: Nothing to disclose. Coauthor(s) D sir e Ratner, MD Director of Dermatologic Surgery, Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center, New York Presbyterian Hospital D sir e Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, and Phi Beta Kappa Disclosure: Nothing to disclose. Divya R Sambandan Columbia University College of Physicians and Surgeons Divya R Sambandan is a member of the following medical societies: Phi Beta Kappa Disclosure: Nothing to disclose. Specialty Editor Board Shobana Sood, MD Assistant Professor, Department of Dermatology, University of Pennsylvania Hospital Shobana Sood, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Dermatologic Surgery Disclosure: Nothing to disclose. Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association Disclosure: Nothing to disclose. Mary Farley, MD Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center Disclosure: Nothing to disclose. Glen H Crawford, MD Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons Disclosure: Nothing to disclose. Chief Editor Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology Disclosure: Nothing to disclose.

References
1. Adams B, Anwar J, Wrone DA, Alam M. Techniques for cutaneous sutured closures: variants and indications. Semin C an Med S rg. Dec 2003;22(4):306-16. [Medline].
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2. R D, N BR, J 1994;13(1):20-6. [M ]. 3. R F ML, R SC. A 2005;123(2):284-8. [M

TM. B

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