In addition to the several conventional facelift procedures, the Scarless Suture Method (SSM) facelift, also known as the Serdev Scarless Suture Method, offers patients contemplating facelift surgery a further level of choice. Once deep sutures have been placed, the epidermis can be closed in the usual fashion. Surgery of the skin procedural dermatology. During a slow shift, you decide to take a look at the suture cart in minor treatment, and realize you can only recognize two of the types available. They are generally used for skin surface sutures and do require removal postoperatively. Macerated wound edges were associated with increased rate of infection [7]. The knot is tied deep at the subcutaneous level and the free ends cut short. On the second throw in the opposite margin of the wound, the needle first enters the dermis and exits the deep dermal layer (superficial-to-deep). Debridement of devitalized tissue to provide smooth wound edges is preferable for wound healing. See Figure 2. DermNet NZ does not provide an online consultation service. After local anesthesia and irrigation, you notice that the laceration extends deep to adipose tissue. The number of deep sutures should be kept to a minimum since each suture is a foreign body and a possible nidus of infection [2]. Absorbable – lose the majority of their tensile strength in less than 60 days. See smartphone apps to check your skin. Cutting needles move through the tissue more easily and may have their primary cutting edge on the inside of the curve (conventional cutting) or outside of the curve (reverse cutting). Thomsen, T. W., Barclay, D. A., & Setnik, G. S. (2006). The implantation and tying of a suture decreases its tensile strength. The benefit of this suture is the minimal epidermal puncture points allowing the suture to be left in place longer without suture-track scarring. The type of suture used depends on the size and location of the wound, the strength and period of use required, cosmetic effect desired, and/or other clinical or physical needs. Rosen’s Emergency Medicine Concepts and Clinical Practice. During a slow shift, you decide to take a look at the suture cart in minor treatment, and realize you can only recognize two of the types available. Ed Robinson JK, Hanke CW, Sengelmann RD, Siegel DM. Following examination you are confident there is no tendon, nerve, or vascular involvement in this clean, 6 cm laceration. To obtain the best results, it is important to have good quality instruments that are the correct size for the location and nature of the wounds being closed. These are essential techniques for the new learner to master, as almost any traumatic laceration can be repaired with knowledge of these techniques alone. » When choosing sutures veterinary surgeons should always consider which is the appropriate suture material, surgical needle and suture size for a given tissue and be familiar with suture characteristics and tissue requirements. 3-0, 4-0 or 5-0 may be appropriate for other areas including torso, arms, legs, hands and feet[1] [4]. “Michele’s Wound”. DermNet NZ does not provide an online consultation service. Surgical suture, types of sutures, sizes, how to suture & suture … Collective risk of complications is 15 to 20%, but all are minor and easily corrected. The rate at which a suture loses its tensile strength over time is not the same as its absorption and varies among suture materials. Jared is also a UBC Royal College Emergency Medicine resident based in Kelowna, BC. Topics A–Z Tejani, C., Sivitz, A.B., Rosen, M.D, Nakanishi, A.K., Flood, R.G., Clott, M.A., …& Luck, R.P. To review common suture types used in the ED. This technique is also used to better approximate edges of skin of varying texture or thickness. Is there a role for deep sutures? Non-cutting round needles cause even less tissue tearing and may be especially useful in delicate areas and fascia. An otherwise healthy 34-year-old female presents to the ED after cutting the anterior surface of her left leg in a kitchen accident. Dry, unused, absorbable suture loses 4-13% of its initial strength after being soaked in sodium chloride solution for 24 hours. It is generally accepted that if one uses sutures to repair an uncomplicated laceration, the best choice is a monofilament non-absorbable suture. Do you think that was a good idea? Pacemaker Essentials: How to Interpret a Pacemaker ECG, Nice threads: a guide to suture choice in the ED, Tiny Tip: C BIG K DROP (Management of Hyperkalemia…, 2020 CanadiEM Year in Review and Editor’s Choice Awards, Virtual Retreat 2020: The Future of CanadiEM, First Year Diaries E04: Dr. Daniel Ting & Dr. Jared Baylis – Transitioning to EM Practice, Tiny Tips: SALTR for Pediatric Growth-plate Fractures. The needle position is then reversed in the needle holder, and the needle is reintroduced 1-3mm from the second side of the wound and a smaller bite of tissue is taken before exiting on the first side of the wound. Simple Interrupted Suture - OSCE guide | Wound Suturing | … In your first Emergency Department (ED) rotation, you are keen to practice your suturing technique. To learn the basics of suturing prior to trying these out click here.. Horizontal bites of dermis are then taken from alternating sides of the wound working towards the other wound apex. The suture can then be pulled out of the tissue by pulling towards the opposite side of the wound as seen in Figure 13. (2014). 7th Ed. Another prospective study found no cosmetic difference for facial wounds repaired by fast-absorbing gut, nylon or tissue adhesive, although the study lost almost half its cohort in follow-up [13]. 6 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts USP 4 - for temporal, mid-face lifts, buttocks & breast lifts USP 6 - for bigger buttocks & large breast lifts USP 8 - for bigger buttocks lifts (mostly used in Latin America) Polycon surgical sutures are absorbed in the human body within 2-3 years, i.e. He is the author of the awesome emergency medicine wound care website, www.lacerationrepair.com. This suture is especially good for distributing wound tension across larger wounds particularly for the initial sutures. Made in Germany. Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. The instruments also need to be correctly sterilised and handled carefully. See figure 11. If you have any concerns with your skin or its treatment, see a dermatologist for advice. These include tensile strength required for wound closure, site anatomic location of the wound closure, and ability to return for follow up. In: Tintinalli, J., Stapczynski, J., Ma, O., et al. to suture material properties and surgical needle characteristics. The best suture for a given laceration is the smallest diameter suture, which will adequately counteract static and dynamic tension forces on the skin. Retrieved from http://www.med.uottawa.ca/procedures/wc/e_treatment.htm#c3 October 16, 2014. The basic suturing kit includes: 1. needle holder 2. fine suture scissors 3. toothed tissue forceps +/- skin hook 4. appropriate suture material See figure 10. To remove sutures, one tail of the suture should be grasped with forceps and pulled gently towards one side to the wound, elevating the knot. I know layered suture is the best, one in the dermal, and one on the surface. In general, the smallest diameter that can effectively support the tension on the wound is preferable. Vicryl is often a good choice here because it provides long-term tensile strength and has a mid-range absorption time, which reduces foreign body infection risk (Table 1). An interrupted suture is performed, but only the free suture end is cut before the needle is reintroduced and directed diagonally across the wound to exit the skin on the other side. He tweets about medicine and FOAM @tingdan. Suture types available in the Kelowna General Hospital ED, divided by type. Basic Airway Assessment: It’s as easy as… 1-2-3? Join our community of educators by submitting a blog post, opinion piece, chalk talk, or lecture. Because the epidermis is penetrated only at the beginning and end of the suture line, the subcuticular suture effectively eliminates the risk of crosshatching. Wound management principles. What is the right suture choice? Non-absorbable – maintain the majority of their tensile strength for more than 60 days. This principle is especially important when considering the use of buried sutures (such as interrupted deep dermal sutures) or planned non-removal of epidermal sutures (as discussed in Case 3). This article was co-written by Dr. Daniel Ting (@tingdan) and Dr. Jared Baylis (@baylis_jared). The horizontal half-buried mattress, or 3-corner suture, is used to close flapped or V-shaped wound edges. See Figure 12. Two (or three) further single throws are then added in a similar fashion to secure the knot. A common mistake is to enter the skin at a flatter angle resulting in much less wound edge eversion as shown in Figure 4. But my doctor everted the surface suture where it looked like a caterpillar. There are many factors that go into selecting a suture type. Tintinalli’s Emergency Medicine: A comprehensive study guide. The knot is then tied as seen in Figure 2. This is demonstrated in figure 6. For interrupted sutures, thinnest possible (3/0 or 4/o) silk or prolene is used. We can use this knowledge in the following cases! This may be generalizable to adult populations, although further research is needed (see case 3). Single-layer versus double-layer closure of facial lacerations: a randomized controlled trial. involving over 5,000 patients with traumatic lacerations, there was a 3.5% wound infection rate [5]. In cosmetically sensitive areas, sutures are often preferable to skin glue, because they provide more precise apposition of tissue, especially in the pediatric population, whose high skin elasticity predisposes to scar widening over time [9]. Using a continuous suture rather than multiple interrupted sutures offers a significant time saving. Elsevier Saunders, Philadelphia. The first double knot is then pulled gently tight. By mi.a. Bottom Line: Lacerations with macerated edges are associated with higher risk of infection. In Medical Concepts by Daniel TingFebruary 5, 20155 Comments, In your first Emergency Department (ED) rotation, you are keen to practice your suturing technique. We use a few cases to illustrate, and have searched the literature for the best-available evidence. Most simple suture to use and suitable for almost all situations; Needle is inserted in one side of the wound and out through the wound itself A wound under suspicion of contamination should be closed without deep stitches. He has a clean-appearing 6 cm laceration. 313201001, 277581000, 257932009, 302415002. 5 Best Suture Kits For Life Threatening Medical Emergencies One size larger may be used for deep layers and one size larger should be used for areas of increased tension. Is the use of an absorbable suture acceptable? Retrieved from http://tinyurl.com/nl26mfd January 15, 2015. “Such Fragile Beings”. The suture is then brought across perpendicular to the wound edge and reintroduced on the first side again with each bite. Simon, B.C., Hern, H.G. Often, suture choice is not explicitly taught in medical school and is learned informally. A suture may consist of only one thread (i.e., monofilament) or several threads (i.e., multifilament) that are frequently twisted or braided. A knot can then be secured as shown in Figure 7. Sponsored content: melanomas are notoriously difficult to discover and diagnose. A series of cases designed to dive into choosing the right suture material! Learn the best basic suture techniques from board-certified and world-renowned plastic surgeon Dr. Michael Zenn. Prolene is a polypropylene nonabsorbable suture that is used in other EDs for similar applications as Ethilon/nylon. Luck, R.P., Flood, R., Eyal, D., Saludades, J., Hayes, C., & Gaughan, J. A literature search revealed little evidence outside of surgical and military literature regarding traumatic lacerations. Learn more about our submission and editorial process on the, The ‘Top Five Changes’ Project: 2015 AHA guidelines on CPR + ECC update infographic series. This page includes the following topics and synonyms: Suture Material, Suture Needle, Suture Removal Timing, Suture Selection, Suture. While peering in to a suture cart and envisioning how to perform a closure can be intimidating for the new learner, the process is much simpler if some basic tenets are kept in mind: The authors briefly discuss the techniques of simple interrupted suturing, both for superficial skin closure and for deep dermal placement. Note that this may not provide an exact translation in all languages, breadcrumbs Further study is likely required. Transparent face shield of high quality by Durable. Daniel is UBC Royal College Emergency Medicine resident at Kelowna General Hospital. Horizontal Half Buried Mattress or 3-Corner Sutures. The traditional teaching has held that the use of non-absorbable sutures provide a better cosmetic result because they are less inflammatory and reduce the risk of “railroad track” scarring in the skin. This is particularly useful in areas that heal more rapidly than the suture dissolves (i.e., the face). The wound edge is everted with a skin hook and then an absorbable suture is introduced at the subcutaneous level and brought back out at dermal level on the same side of the wound. He completed the CanadiEM Digital Scholarship Fellowship in 2017-18. McGraw-Hill Medical, New York. (2008). In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face. The needle should enter perpendicular to the skin 3-5mm from the wound edge. Share, teach, and receive feedback. Suture size should be tailored to the amount of tension and the need for cosmesis (Table 1‐3). A trio of studies performed in Pediatric EDs showed absorbable catgut sutures provided similar cosmesis to nonabsorbable nylon after several months, with no differences in parental satisfaction or wound complications [10-12]. A 41 year-old male presents to the ED after he caught his hand on an exposed nail causing a 3 cm laceration with macerated edges that are not well approximated. Curved needles are almost exclusively used in dermatological surgery. A technique of using absorbable sutures in the dermis and subcutaneous layers can allow the relief of tension and approximate wound edges. Small vessel repair/grafting, fine suturing on the hand/nailbed & face: 5-0 & 4-0: 0.1 & 0.15: Larger vessel repair, skin closure (hands/limbs, face) tendon repair: 3-0 & 2-0: 0.2 & 0.3: Closure of thick skin, fascia, muscle, tendon repair: 0 & 1: 0.35 & 0.4: Closure of fascia, drain stitches: 2 and above >0.5 The opposite side of the suture should then be cut with stitch-cutters or fine suture scissors immediately under the knot. The needle is introduced 5-10mm from the wound edge and exited on the opposite side of the wound. Retrieved from http://tinyurl.com/jwxulhf January 15, 2015. Contact us to sponsor a DermNet newsletter. 2011, 306-310. after the final Avoid suturing adipose tissue as it does not provide good purchase (grip) and only increases the risk of infection [2,14]. The needle then enters the same dermal level on the opposite side of the wound and exits the in the same subcutaneous level as it was initially entered into on the first side of the wound. N.B., “Ethilon” is a nylon nonabsorbable suture. Suturing techniques. For the absorbable types, long-lasting sutures provide durable tensile strength but again, have higher infection rates. It provides longer-term support to the healing wound and improves the cosmetic result. Bottom line: When sutures are indicated for a clean wound on a child’s face, fast-absorbing catgut sutures allow similar cosmesis to non-absorbable sutures. The long end of the suture is wrapped around the tip of the closed needle holder twice before grasping the short end of the suture with the needle holder. In a 2001 cross-sectional study by Hollander et al. The stronger an absorbable suture is, the greater its absorption time, and the greater its risk of causing a foreign body reaction within a wound. The needle is introduced 10mm distal to one wound end and brought out inside the apex of the wound within the dermis. The time to suture removal depends on the location and the degree of tension the wound was closed under. What is the right suture choice?Â. The suture exits in the same position on the first side of the wound and the suture is tied as shown in Figure 8. Bleeding at the time of the procedure causing a hematoma (accumulation of blood) in the temple, infection of the threads, granuloma (suture reaction), snapping of threads, migration, extrusion, localized pain when thread end abuts against underside of the skin (which is easy to locate, shorten ,or remove completely). Thus, they are an acceptable alternative, especially if the provider perceives the child may have significant anxiety with suture removal. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. What is the difference between these sutures and how can you apply them to different presentations? Great Evidence in Medical education Summary (GEMeS). Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. A 6-year-old girl presents with a 3 cm clean-appearing laceration over the left cheek after falling against a metal table. In general, when proven infection or contamination is a concern, monofilament, nonbraided suture is preferred. The wound edge should be gently stabilised with either toothed forceps or a skin hook. Suture can be monofilament or multifilament, braided or nonbraided, and dissolvable or nondissolvable. Suturing techniques. Retrieved, from http://www.who.int/hac/techguidance/tools/guidelines_prevention_and_management_wound_infection.pdf October 16, 2014. » When wounds extend to the deep dermis, they are often subject to higher tension. The running subcuticular suture is valuable in areas where tension is minimal, dead space has been eliminated, and the best possible cosmetic result is desired. In patients presenting with lacerations to the ED, how should physical characteristics of the suture type influence choice for primary closure? Closing a deep wound under tension increases the risk of scarring as well as complications, such as dehiscence [2,14]. A horizontal mattress suture can also be used to achieve wound eversion in areas of high skin tension . They are generally used for buried sutures and do not require removal. Most current wound care practices are empirical or based on animal models. Recently, a small ED study examined cosmetic outcomes for extremity repair in adults and found similar cosmesis between Vicryl Rapide and Prolene, although the Vicryl Rapide group had an 11% risk of infection [6].  The are both residents at the University of British Columbia. If the child will not easily and calmly tolerate suture removal, the presence of the absorbable sutures allows for the suture removal procedure to be aborted. (1999). Once the entire wound is closed, a loop is made with the last pass of suture, and this loop is grasp by the needle holder to tie the knot. Singer A.J., Gulla J., Hein, M., Marchini, S., Chale, S., & Arora, B.P. Luck, R.P., Tredway, T., Gerard, J., Eyal, D., Krug, L., & Flood, R. (2013). To obtain the best results, it is important to have good quality instruments that are the correct size for the location and nature of the wounds being closed. DermNet provides Google Translate, a free machine translation service. Bottom line: General consensus has been that, when using sutures to repair an uncomplicated laceration in an adult patient, a monofilament non-absorbable suture is preferable (e.g., Ethilon). Author: Dr Todd Gunson, Dermatology Registrar, Greenlane Clinical Centre, Auckland, New Zealand, 2008. The free end of suture can be tied off on itself, or secured with a bead or crimp. This suture is extremely important for distributing wound tension to the dermis rather than the epidermis and also for closing dead space. A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures. The plastic surgeon's skin closure technique might include traditional stitches, or perhaps a "subcuticular" technique, where the suture is completely beneath the surface. Best Suture Kits To Purchase in 2021 Every person living in a city or town has to face many serious conditions sometimes. BoringEM has been 'bringing the boring' to emergency medicine since 2012. [Sponsored content]. In facial lacerations, an ED study found that using deep sutures in simple wounds smaller than 3 cm did not result in a cosmetically superior outcome than simply closing the skin with nonabsorbable suture [15]. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. The needle holder should be held with the palm grip as illustrated in Figure 1. Laceration Management. This allows the knot to be buried deep in the wound, which prevents the knot from forming an uncomfortable bump and from interfering with dermal healing [2,14]. Conceptually, suture types can be divided into four categories: absorbable braided, absorbable monofilament, nonabsorbable braided and nonabsorbable monofilament. The second free end can be secured in the same way as the first. (2004). Karounis H., Gouin S., Eisman H., Chalut, D., Pelletier, H., & Williams, B. The realistic tissue is specially made with the advisory of a surgeon by a movie effect artist. (2014). Daniel Ting is an Emergency Physician and Clinical Instructor at the University of British Columbia, based in Vancouver. See figure 9. Deep sutures can be done in an interrupted fashion. The authors postulated that debriding contaminated, macerated tissue to provide smoother wound edges may reduce risk of infection. Home 2014, 756-763. This post aims to explain differences between basic suture types as well as how key patient and wound factors may influence choice. How should physical characteristics of the wound was closed under of this suture provides excellent wound,! Of dermis are then taken from alternating sides of the wound of their tensile strength for more efficient and closure... Double knot is then brought across perpendicular to the ED NZ does not provide an exact translation all... Not as strong as interrupted sutures, thinnest possible ( 3/0 or 4/o ) silk or prolene is a,. After cutting the anterior surface of her left leg in a kitchen accident, permanent closure with nondissolvable seems... 10Mm distal to one wound end and brought out inside the apex the. 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