GPsSuturing workshop

Suturing

• The skin edges should always be everted when suturing is complete.

• This results in:• Better dermal apposition• Improved healing• A finer final scar.

Cutaneous suture• The aim of this suture is to accurately appose

and evert the skin edges.

Cutaneous suture• The following may be helpful in achieving this.• When viewed in a cross-section, the suture

passage should be triangular-shaped– with its base located deeply as this will evert the

wound edges.– A triangular-shaped suture passage with the base

located superficially tends to invert the wound edges.

Trust the needle

If in doubt mattress

If in doubt mattress

Dermal suture

• Most wounds are closed by first opposing the skin edges with a dermal suture.

• This reduces the tension on the subsequent cutaneous suture and helps to limit

• stretching of the wound.• Use either monocryl (face) or pds

Dermal suture• The dermal suture should enter the deep reticular

dermis on the incised edge of the wound.• It should then pass superficially into the papillary

dermis.• The knot should be tied deeply to prevent

subsequent exposure of the suture.• This method of suture placement produces good

apposition and eversion of the skin edges.

Cheat stitch

• This combination dermal and interrupted suture is helpful with wounds under tension

• Especially when you are happy to leave the suture in for 2 weeks and stitch marks not a great concern– Backs, legs, arms

Fudging!

• If one of the wound edges lies lower than the other, the suture should be passed through the cut edge of the skin low on that side (‘low-on-the-low’).

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Fudging!

• If one of the wound edges lies higher than the other, the suture should be passed through the dermis high on that side (‘high-on-the-high’)

• Passing the suture in this way acts to flatten out any vertical step between the wound edges and ensures that the sides are on a level plane.

• Fine adjustments can be made by changing the side on which the knot lies– the knot will tend to raise the side on which it lies

Subcuticular/Intradermal

• The suture passes through the dermis, not under the skin.

• Should always be there to approximate the epithelium with no tension

• The hard work is done by the deep dermals

Another cheat stitch

• Useful for long wounds where you want to save time but still get everted skin edges

• Combination of “over and over” and horizontal mattress

What suture when?

Vicryl• Vicryl is a braided synthetic

suture• It loses its strength by 21 days

and is absorbed by 90 days.• Its braided nature may make it

more prone to bacterial colonization than monofilament alternatives.

• It may provoke a significant inflammatory reaction

• Don’t use as a dermal suture in the face.

PDS• PDS is a monofilament

synthetic suture composed of polydioxone.

• It is absorbed more slowly than either vicryl, monocryl or dexon.

• It loses its strength by 3 months and is absorbed by 6 months.

• It is primarily used as a dermal suture in areas prone to developing stretched scars.

Monocryl• Monocryl is a

monofilament synthetic suture composed of poliglecaprone 25.

• It has similar absorption characteristics to vicryl.

• Its monofilament composition may make it less prone to bacterial colonization.

What suture when?

• Sutures that retain their strength for a significant amount of time, such as a PDS, should be used in areas prone to scar stretching, such as the back, legs torso.

• Sutures that elicit a minimal tissue reaction, such as monocryl, should be used in the face.

Face

• Kids– 6.0 fastgut with

dermabond glue to waterproof

– Steristrips on top of wound

• Adults– Nylon or prolene

• Skin• 5.0 or 6.0

– Monocryl• Dermal• 5.0

– Remove sutures day 5 or 6

– No later as may leave stitch marks

Scalp

• Kids– Vicryl rapide/vicryl– monocryl

• Adults– Staples or any suture

different colour to patients hair

Rest of body

• Kids– Same as adults

• Adults– Depends on extent of

wound and depth• Usually dermal

pds/monocryl• Interrupted

nylon/prolene