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Wound closure of superficial lacerations by tissue adhesives is quicker and less painful compared with conventional suturing, with similar outcome on appropriate wounds (Aukerman et al., 2005) (SOR: A).

Figure 28-9 A, Facial relaxed skin tension lines (RSTLs). B, RSTLs of the entire body.

(From Trott A. Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St Louis, Mosby, 1997; and Burns JL, Blackwell SJ. Plastic surgery. in Townsend CM, Beauchamp RD, Evers BM, Mat-tox KL [eds]. Sabiston Textbook of Surgery, 18th ed. Saunders-Elsevier, Philadelphia, 2008.)

Figure 28-9 A, Facial relaxed skin tension lines (RSTLs). B, RSTLs of the entire body.

(From Trott A. Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St Louis, Mosby, 1997; and Burns JL, Blackwell SJ. Plastic surgery. in Townsend CM, Beauchamp RD, Evers BM, Mat-tox KL [eds]. Sabiston Textbook of Surgery, 18th ed. Saunders-Elsevier, Philadelphia, 2008.)

I Dermis

Subcutaneous layer

B Start here

Figure 28-10 Inverted subcutaneous stitches.

(From Lammers RL. Methods of Wound Closure. in Roberts JR, Hedges JR [eds]. Clinical Procedures in Emergency Medicine, 5th ed. Elsevier, Philadelphia, 2010.)

B Start here

Figure 28-10 Inverted subcutaneous stitches.

(From Lammers RL. Methods of Wound Closure. in Roberts JR, Hedges JR [eds]. Clinical Procedures in Emergency Medicine, 5th ed. Elsevier, Philadelphia, 2010.)

Suture Placement Interrupted Sutures

Individually placed single sutures are the most common form of closure. Although slower than using a running suture, single sutures usually appear better cosmetically and have a reduced risk for dehiscence. Slightly everting skin edges will result in the best wound appearance. Enter the skin 2 to 3 mm from the skin edge with the needle perpendicular to the skin plane, and rotate the wrist smoothly. Go an equal distance in depth as the horizontal distance from the wound edge. If unable to obtain an equidistant bite on the opposite side in one step, use an additional step. Bring the needle out through the laceration, then enter at the same level within the laceration, and come out through the skin at a symmetric distance from the wound's edge (Fig. 28-11). (See Tuggy Video: Instrument Tie.)

One may reduce the risk for dog-ears by placing a suture in the middle of a laceration and then another in the middle of the remaining gaps until equal tension and alignment approximate the skin edges in a cosmetic and hemostatic fashion. If bleeding persists, ligate or cauterize the vessel before further closing. If suturing a landmark such as vermillion borders on lip edges, consider marking opposing points before instilling anesthesia, then place an aligning suture there first.

Planning excision of an ellipse with a 3:1 to 4:1 length/ width ratio has been the standard recommendation, but recent data suggest less tissue removal and better healing if a round excision is used, with adequate margins and repair of any subsequent dog-ears that develop. With this technique, 59% of the repairs required dog-ear repair (Seo et al., 2008).

I Dermis

Subcutaneous layer

Figure 28-11 Suture technique and methods. A, Sutures are placed through the entire thickness of the dermis at right angles to the skin and suture line while everting the wound edge. B, Sutures are placed 2 to 3 mm apart and 2 to 3 mm from the wound edge. C, The subcuticular stitch prevents crosshatch scarring. D, Intradermal sutures help preserve peninsular flaps in this stellate wound.

(Modified from Wright CV, Ronaghan JE: Office surgery. in Rakel R. Textbook of Family Practice, 5th ed. Philadelphia, Saunders, 1995.)

Skin surface

Wound edge

Figure 28-12 View from above stellate laceration, showing closure with half-buried mattress stitches. For some stellate lacerations, it is best to cover with Steri-Strips and revise the scar later or, if small, excise the laceration and convert it to a linear repair.

(From Lammers RL. Methods of wound closure. in Roberts JR, Hedges JR [eds]. Clinical Procedures in Emergency Medicine, 5th ed. Elsevier, Philadelphia, 2010.)

Skin surface

Wound edge

Figure 28-11 Suture technique and methods. A, Sutures are placed through the entire thickness of the dermis at right angles to the skin and suture line while everting the wound edge. B, Sutures are placed 2 to 3 mm apart and 2 to 3 mm from the wound edge. C, The subcuticular stitch prevents crosshatch scarring. D, Intradermal sutures help preserve peninsular flaps in this stellate wound.

(Modified from Wright CV, Ronaghan JE: Office surgery. in Rakel R. Textbook of Family Practice, 5th ed. Philadelphia, Saunders, 1995.)

Running Sutures

If rapid suture placement is needed and an area is not over a joint with movement, the physician can use a running suture. If the suture breaks, however, the entire wound would open up. If the running sutures are left too long, "baseball lacing" tracks may remain visible on the skin. In one study (not funded by manufacturers), deeply buried absorbable suture used along with running subcuticular polyglactin 910 (Vicryl) suture left in place resulted in the best results on trunk and extremity scar healing from elective excision of atypical moles (Alam et al., 2006).

Subcuticular Sutures

Halstead first described the subcuticular suturing technique in 1889 as a way to approximate wound edges with the least scarring. A running intradermal, buried subcuticular suture is useful in places where the dermis is shallow and when skin edges are well approximated under minimal tension, such as on the face. Placing subcuticular sutures on the back, chest, and other areas under tension without deep interrupted sutures may give poor results.

For subcuticular suture placement, use either absorbable or nonabsorbable 4-0 suture and anchor it on one end external to the wound. Enter the skin and come out in the apex of one end of the wound. Place horizontal subcuticular zigzagging sutures with symmetric bites and level entry and reentry sites on each side of the wound. If using absorbable suture, tie and bury a knot at the end of the wound by tying the knot and then placing a stitch to come out through the skin near the wound, then cut the suture flush with the skin while pulling upward on the suture. The knot will be retracted below the skin. Alternatively, with either absorbable or nonabsorbable suture, enter and exit the skin away from the wound, and tie off the suture externally. A nonabsorbable suture may be removed after 1 to 3 weeks by cutting one end of suture and gently pulling with countertraction from the other end of the wound. (See Tuggy Video: Subcuticular Running Stitches.)

Figure 28-12 View from above stellate laceration, showing closure with half-buried mattress stitches. For some stellate lacerations, it is best to cover with Steri-Strips and revise the scar later or, if small, excise the laceration and convert it to a linear repair.

(From Lammers RL. Methods of wound closure. in Roberts JR, Hedges JR [eds]. Clinical Procedures in Emergency Medicine, 5th ed. Elsevier, Philadelphia, 2010.)

Half-Buried Mattress or Tip Sutures

Half-buried mattress sutures can be used on stellate edges and on triangular defects to reapproximate the skin edges with reduced tension on the tips (Fig. 28-12). Tip sutures are similar and used to secure a laceration tip with minimal tension. This tension can reduce blood and oxygen flow to the distal tip. (See Tuggy Video: Mattress Stitches.)

Pulley Sutures

The far-near, near-far pulley sutures are a modification of the vertical mattress suture and may be used as a temporary measure to reduce tension and approximate skin edges to place interrupted sutures. These sutures are used for longer repairs, but do not leave them in too long or place them too tightly because cross-hatching scars may occur. Enter with the needle 4 to 6 mm back from the wound edge, come out on the opposite side 2 mm from the wound, and loop back across the wound opening, then enter the skin 2 mm from the edge and come out on the opposite side 4 to 6 mm back from the edge (Wu, 2006).

Modified pulley sutures offer some mechanical advantage in vitro by requiring less force to achieve closure compared with horizontal mattress or single interrupted sutures. These pulley sutures are generally used when a wound is under moderate tension (Austin and Henderson, 2006).

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