De  La  Salle  Medical  and  Health  Sciences  Institute  

College  of  Medicine  
Department  of  Surgery  
 
YL4 MODULE:
WOUND SUTURING
Authors: Michael M. Lawenko, MD, Jocielle Marie Andres, Jem De Robles, Gloriana Julia Teope, Camille Allison Vidamo
Editor: Melissa Robrigado, MD
Updated: July 14, 2020

Background

As a method for closing cutaneous wounds, the technique of suturing is thousands of years old. Although
suture materials and aspects of the technique have changed, the primary goals remain the same, as follows:
Closing dead space.
Supporting and strengthening wounds until healing increases their tensile strength.
Approximating skin edges for an aesthetically pleasing and functional result.
Minimizing the risks of bleeding and infection.

The postoperative appearance of a beautifully designed closure or flap can be compromised if an incorrect
suture technique is chosen or if the execution is poor. Conversely, meticulous suturing technique cannot fully
compensate for improper surgical technique. Poor incision placement with respect to relaxed skin tension
lines, excessive removal of tissue, or inadequate undermining may limit the surgeon’s options in wound
closure and suture placement. Gentle handling of the tissue is also important to optimize wound healing.

The choice of suture technique depends on the following:

Type and anatomic location of the wound

Thickness of the skin
Degree of tension
Desired cosmetic result

Proper placement of sutures enhances the precise approximation of the wound edges, which helps minimize
and redistribute skin tension. Wound eversion is essential to maximize the likelihood of good epidermal
approximation. Eversion is desirable to minimize the risk of scar depression secondary to tissue contraction
during healing. Usually, inversion is not desirable, and it probably does not decrease the risk of hypertrophic
scarring in an individual with a propensity for hypertrophic scars

The elimination of dead space, the restoration of natural anatomic contours, and the minimization of suture
marks are also important to optimize the cosmetic and functional results.
  
De  La  Salle  Medical  and  Health  Sciences  Institute  
College  of  Medicine  
Department  of  Surgery  
 
Materials Needed

•   Suture (with needle)

•   Instruments:
o   Needle Holder
o   Tissue forceps/Adson forceps, toothed
o   Mayo scissors
•   Sterile gauze
•   Sterile cotton balls
•   Sterile gloves & Clean gloves
•   Skin disinfectant/povidone iodine
•   Adhesive tape

Basic steps in Wound suturing

1.   Introduce yourself to the patient.

2.   Explain the procedure to the patient, including benefits and complications.
3.   Secure informed consent.
4.   Prepare the materials needed for the procedure.
5.   Clean the wound using asepsis/antisepsis techniques.
6.   Put on sterile gloves and place sterile drapes.
7.   Apply local anesthesia to the wound.
8.   Do wound suturing.
9.   Check for bleeding.
10.  Clean wound and apply sterile wound dressing.
11.  Instruct patient on medications, wound care and follow-up.
12.  Thank the patient.
  
De  La  Salle  Medical  and  Health  Sciences  Institute  
College  of  Medicine  
Department  of  Surgery  
 
Different Suturing Techniques

Simple interrupted suture

Compared with running (continuous) sutures, interrupted sutures are

easy to place, have greater tensile strength, and have less potential
for causing wound edema and impaired cutaneous circulation.
Interrupted sutures also allow the surgeon to make adjustments as
needed to properly align wound edges as the wound is sutured.

Disadvantages of interrupted sutures include: the length of time

required for their placement and the greater risk of crosshatched
marks (i.e., train tracks) across the suture line. The risk of
crosshatching can be minimized by removing sutures early to prevent
the development of suture tracks.

•   Most commonly used for skin laceration repair

•   Avoid when there is great skin tension
•   Use non-absorbable suture
•   Penetrate and exit the tissue at the same 90-degree angle

Steps:
1.   The suturing needle is held using a needle holder by the dominant hand. The needle is grasped
about ¾ or 1-2mm from the eye of the needle. Toothed forceps should be held by the non-dominant
hand.
2.   Using the toothed forceps, grasp the edge of skin and lift.
3.   Place the first suture by rotating the dominant hand from pronation to supination. This should make
a 90-degree angle as the needle pierces the skin (outside to inside).
4.   While still lifting the edge of the skin, release the needle and regrasp from the pointed area.
5.   The dominated hand is in pronated form and supinates in order to turn the needle upwards.
6.   Pull the needle in order for the suture to pass through the skin.
7.   Reposition the needle holder from ¾ or 1-2mm from the eye of the needle in preparation for the
suturing of the opposite skin edge.
8.   Grasp the opposite side of the skin edge with the toothed forceps and evert.
9.   The dominant hand is in pronated form and supinates to make a 90-degree angle (inside to
outside).
10.  Release the needle and regrasp from the pointed area.
11.  The dominated hand is in pronated form and supinates in order to turn the needle upwards.
12.  Pull the needle in order for the suture to pass through the skin. Leave 2-3cm of the suture from
the far skin area.
13.  Do a square knot:
o   Use the non-dominant hand to hold the long end of the suture
o   The long end is wrapped twice around the needle holder in the dominant hand
  
De  La  Salle  Medical  and  Health  Sciences  Institute  
College  of  Medicine  
Department  of  Surgery  
 
o   Open the needle holder and grasp the short end of the suture to pull it through the
loop towards you
o   Repeat steps of wrapping suture in needle holder, grasp, and pull the short end away from
you
o   Repeat steps for the third time, but pull short end towards you
o   Tighten the knot and drag it to one side of the skin edge
o   Cut the suture, leaving a tail of about 0.5cm
14.  Repeat all steps until the skin is completely closed

Simple Continuous suture

•   Less time-consuming than interrupted sutures

o   Fewer knots are tied and less suture is used
•   Continuous stitching with no knot in between
•   Enter at 90-degree angle to incision line and cross
internally under the top of incision at 45 degrees.

Advantages: Faster and more economical

Disadvantages:
•   Poorer cosmetic appearance
•   Less precise in approximated wound edges
•   Can cause inclusion cysts and suture track epithelization

STEPS:
1.   Start at the wound edge and work along the wound.
2.   For each suture, grasp and evert the skin edge.
3.   Pronate the dominant hand so that the needle will pierce perpendicular to the skin and drive the
needle through the skin by supinating the hand before picking up the needle with the needle holders. A
no touch needle technique is important, reducing sharps injury and infection risk.
4.   Place each suture, as seen above, at 1-cm interval until wound is approximated without tension.
Carry this on along the wound.
5.   Finish by carefully gathering the thread to create a long thread (with needle) and short thread
before performing a hand tie or instrument tie.
  
De  La  Salle  Medical  and  Health  Sciences  Institute  
College  of  Medicine  
Department  of  Surgery  
 
Continuous Interlocking suture

•   Useful in wounds under moderate tension

•   Should only be used in areas with good vascularization like
the scalp and post-auricular sulcus
•   Disadvantages: may cause impairment in the microcirculation
surrounding the wound

STEPS:
1.   Insert the needle in one side of the skin wound and exit on
the opposite side.
2.   Perform a square knot tie, but do not cut the suture
3.   Continue suturing the wound downwards and make sure that
the suture is made inside the loop
4.   When the wound is fully sutured, perform a square knot tie
5.   Cut the suture and leave a 0.5cm suture tail

Vertical Mattress suture

•   Also known as the far-far, near-near stitch

•   Oriented at 90-degree angle to the wound
•   Used in high-tension areas such as the back, palms, soles, etc.
•   More complex and time consuming
•   Use non-absorbable suture

STEPS:
1.   Determine four (4) landmark sites
a.   Point 1 – far right side
b.   Point 2 – far left side
c.   Point 3 –near left side
d.   Point 4 – near right side
2.   Insert the suture at Point 1 and make sure needle passes below the dermis
3.   Exit at Point 2
4.   Continue stitch as suture enters in Point 3
5.   Exit in Point 4
6.   Knot tie in between points 1 and 4 in the right side
  
De  La  Salle  Medical  and  Health  Sciences  Institute  
College  of  Medicine  
Department  of  Surgery  
 
Horizontal Mattress suture

Reinforce the subcutaneous tissue and provide more strength

•  
and support along the length of the wound, keeping tension of
the scar.
Advantages: Reinforces subcutaneous tissue, provides greater
strength and support and keeps tension away from scar.

STEPS:
1.   Determine four landmark sites (2 on each side of the wound,
making a rectangle)
a.   Point 1 – lower right side
b.   Point 2 – lower left side
c.   Point 3 – upper left side
d.   Point 4 – upper right side
2.   Insert the suture at Point 1 in the lower right side; make sure the needle passes below the dermis
3.   Exit at Point 2 in the lower left side
4.   Continue stitch suture 1cm above Point 2. The needle must enter at Point 3 in the upper left side.
5.   Exit in Point 4 in the upper right side
6.   Knot tie in between points 1 and 4 in the right side.

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