Trauma | Procedures

Suturing Techniques

Background

1. Suturing of lacerations currently are more innovative and studied (View Video)
   • Topical anesthetics, tissue adhesives, and fast-absorbing sutures has made suturing less traumatic for the patient (View Video)
     • Use of topical anesthetics should be strongly considered as an adjunct to other types of analgesia
       • 25 RCTs (3,278 patients total) showed topical anesthetics had no complications and provided effective pain control
     • Application of ice should be considered prior to local infiltration (decreases procedure-induced pain)
   • Procedural sedation for difficult lacerations or for extremely anxious children has lessened stress for patient, family, and physician
   • Many nailbed lacerations are repaired with 5.0-6.0 simple interrupted absorbable sutures
     • However, recent data suggests tissue adhesive glue may be equally efficacious
2. Goals for wound management
   • Avoid wound infection
   • Assist in hemostasis
   • Decrease deformity caused by scarring
     • Majority of studies currently focus on esthetics of wound healing
   • A recent meta-analysis including 13 randomized controlled trials totaling over 11,000 patients
     • Found no difference between surgical site infection rates after outpatient cutaneous and dental procedures using sterile versus nonsterile gloves
   • Normal saline appears to be superior to castile soap and povidone-iodine solution as a laceration irrigation fluid

Suture Types

1. Absorbable sutures were once used only for deep sutures
   • Now advocated in some patients for percutaneous closure of wounds as an alternative to nonabsorbable sutures
   • Fast-absorbing gut for skin closure of facial lacerations if suture removal difficult or tissue adhesives not an option
   • Chromic gut or Vicryl are recommended for lacerations of oral mucosa
   • Vicryl Rapide or Chromic Gut for lacerations under casts or splints
   • Simple lacerations on trunk and extremities with absorbable sutures could be considered viable alternative to non-absorbable sutures
   • Absorbable Suture Types
     • Polyglycolic (Vicryl, Dexon) strength to 21 days
     • Chromic catgut: strength 7-10 days
     • Plain catgut: strength 4-5 days
     • Alternative to nonabsorbable suture in the repair of facial lacerations
2. Non-absorbable: must be removed
   • Silk: braided, may wick water under skin
   • Nylon: monofilament, used for most skin repairs
   • Prolene: monofilament, stronger than nylon, stiffer than nylon-requires more knots
   • Dacron: as in nylon
   • Wire: very strong, primarily for closing bone
3. New Zip surgical skin closure devices
   • Shown to reduce closure times with no difference in post-operative pain or scarring to sutures
   • Small study sample size only, needs more Emergency Dept based studies
   • 2 parallel linear adhesives joined by a zipper-like reclosable piece

Suture Sizes

1. Smallest ("10-0") to Largest ("0" or "1" or "5")
2. Size 10-0: for delicate surgeries (e.g., ophthalmic surgery)
3. Size 9-0: repairing small damaged nerves
4. Size 8-0: repairing hand lacerations
5. Size 7-0: small vessels and arteries or for delicate facial plastic surgery
6. Size 6-0: vascular graft sewing such a carotid endarterectomy
7. Size 5-0: larger vessel repair such as an Abdominal Aortic Aneurysm
8. Size 4-0: skin closure
9. Size 3-0: skin closure when there is a lot of tension on the tissue, closure of muscle layers
10. Size 2-0: repair of bowel in general surgery
11. Size 0: closing of the fascia layer in abdominal surgery, the joint capsule in knee
12. Size 1: hip surgery or deep layers in back surgery
13. Size 2 or 5: For repair of tendons or other high tension structures in large orthopedic surgeries

Needle Types

1. Cutting needles for skin sutures that must pass through dense, irregular, and relatively thick dermal connective tissue
   • Standard skin needles (FS series, CE series) suitable for scalp, trunk, and extremities
   • Finer sutures of face require smaller, more sharply honed needle (P, PS, PC, and PRE series)

Stitch Types

1. Simple interrupted (View Video)
   • Most lacerations
2. Horizontal mattress (View Video)
   • Everts edges, stronger than simples
   • Good in hand, finger lacerations
3. Vertical mattress (View Video)
   • Stronger than horizontal mattress
   • Good in extremity, trunk lacerations exposed to tension
4. Subcuticular (View Video)
   • Use an absorbable suture, usually vicryl
   • To approximate wound edges prior to skin closure
   • Keep tails as short as possible
5. Running subcuticular (View Video)
   • Often with non-absorbable suture with ends externalized to be removed later
   • Better cosmetic result
   • Less advantageous in traumatic wounds: if they infect, must take out entire length
   • Require greater skill to place well
6. Corner Stitch (View Video)
   • For closing vertex of V-shaped lacerations

Closure Technique by Site

1. Scalp
   • Interrupted 4-0 or 5-0 nylon or prolene
   • Be sure to close galea first with internal 4-0 or 5-0 vicryl
   • Suturing usually controls bleeders
   • Choose color of suture that contrast hair color; blue for black or brown hair, black for blond hair
2. Face
   • Interrupted 6-0 nylon
     • Fast-absorbing catgut suture is not more effective than non-absorbable suture
   • Many, small sutures no-tension
   • Running subcutaneous prolene, later removed; also acceptable
   • Approximate vermillion border of lip with first suture
3. Mouth
   • NO betadine; saline or peroxide to cleanse
   • Chromic gut or vicryl 5-0 to close mucosal surface
4. Extremities
   • 3-0, 4-0 or 5-0 nylon or prolene based wound size
   • Internal if no tension, mattress, if under tension
   • Subcutaneous vicryl to close fascial layers prior to skin
5. Hand
   • Deep sutures
   • Explore wounds for tendon/nerve injury prior to close
   • 5-0 nylon or prolene interrupted or horizontal mattress
   • Splint finger for 3-4 days if normal movement will strain sutures
6. Trunk (View image)
   • 3-0: 5-0 nylon or prolene
   • Stitch type based on size/strain of wound
   • Subcutaneous 4-0 vicryl to approximate wound, if large
7. Recent Studies on Technique
   • Many lacerations are repaired in the ED using simple interrupted sutures
     • 5 RCTs (over 800 patients)
       • Concluded that superficial wound dehiscence may be reduced using continuous subcuticular sutures
       • Overall quality of the evidence was poor
       • Further studies with stronger quality of evidence needed before changing current practices
   • W-plasty to close facial lacerations presenting to the ED (View image)
     • Traditionally used for scar revision
     • Involves making continuous zigzag, W-shaped incisions on either side of the laceration margins
     • Results in excision of original laceration site
     • Goal to minimize scarring for lacerations which deviate > 30° from the relaxed skin tension line
     • Small study vs traditional showed
       • W-plasty had improved scores on the Stony Brook scar evaluation scale both short term and long-term follow-up
       • No increase in time to procedure completion
       • Requires further studies with larger sample size

References

1. Nicks BA, Ayello EA, Woo K, et al. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. Dec 2010;3(4): 399-407
2. Thomsen TW, Barclay DA, Setnik GS. Basic Laceration Repair. N Engl J Med oct 26, 2006;355:e18
3. Guyuron B, Vaughan C. A comparison of absorbable and nonabsorbable suture materials for skin repair. Plast Reconstr Surg. Feb 1992;89(2):pp.234-236
4. Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am. Feb 2003;21(1):pp.205-231
5. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. Sep 1999;34(3):pp.356-367
6. Forsch RT. Essentials of Skin Laceration Repair. Am Fam Physician. Oct 15, 2008;78(8):pp.945-951
7. Adams B, Anwar J, Wrone DA, Alam M. Techniques for cutaneous sutured closures: variants and indications. Semin Cutan Med Surg. Dec 2003;22(4):pp.306-316
8. Edgerton M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988
9. Lammers RL, Trott AT. Methods of Wound Closure. In Roberts, James R; Hedges, Jerris R. Clinical Procedures in Emergency Medicine, 4th ed., Philadelphia: Saunders, 2004;Chapter 36
10. McCarthy JG. Introduction to plastic surgery. In McCarthy JG (ed): Plastic Surgery, Philadelphia, W.B. Saunders, 1990, pp 48-54
11. In: Reichman EF; (eds)., Emergency Medicine Procedures, 2nd ed., Eric F. Reichman, PhD, MD, 2013; Chapter 93
12. Otterness K, Singer AJ. Updates in emergency department laceration management. Clin Exp Emerg Med. Jun 2019;6(2):97-105

Contributor(s)

1. Ho, Nghia, MD

Updated/Reviewed: December 2021