Suture technique

The goal is to tightly match the edges of the wound, preventing their turning in and the formation of closed spaces in the wound, to minimize the tension of each individual suture, leaving a minimum of foreign material in the subcutaneous tissue. Sutures can be applied and tied individually (interrupted sutures) or continuously (continuous suture). They can be completely located under the skin (intradermal suture) or tie the edges of the skin on its surface (percutaneous suture).

If the wound is slit-like, subcutaneous sutures are applied first, then cutaneous ones. Wounds on the face are closed with sutures, placing them at a distance of 2-3 mm from each other, mainly subcutaneously (except for the nose and eyelids). For a nodal suture, as a rule, a braided, absorbable (for example, based on polyglactinic acid) 4-0 or 5-0 thread is used (the smaller the number, the thinner the material). They are applied with the knot immersed in the bottom of the wound to avoid the formation of a palpable protrusion, the knot should not be too tight. A continuous subcutaneous suture (intradermal) is sometimes used for cosmetic purposes.

The epidermis is usually closed with a simple, interrupted suture using a nonabsorbable monofilament suture (such as nylon). Over large joints and on the scalp, 3-0 suture is used, on the face, 6-0, and in most other areas, 4-0 or 5-0. Sutures are placed at a depth approximately equal to the width and spaced equally apart, equal to the distance from the needle entry to the wound line. Small stitches are used for cosmetic purposes and on thin skin, usually 1 to 3 mm from the wound edge. In other cases, wider stitches are used, depending on the thickness of the tissue.

The suture begins and ends deep in the wound so that the knot remains at its bottom.

Suture materials

Category	Material	Comment
Non-absorbable		Preferred for skin sutures
Monofilament	Nylon	Durable, tough, relatively difficult to work with
	Polypropylene	Doesn't hold a knot well and is the most difficult to use.
	Polybutester	It is quite elastic, so it stretches when tissue edema occurs and contracts after it decreases.
Wicker	Polyester	Low reactivity, worse than monofilament for skin sutures
	Silk	Soft, easy to use, holds the knot well, high tissue reactivity. Use is limited, mainly in the mouth area, on the lips, eyelids, oral mucosa
Absorbable suture material		Preferred for subcutaneous sutures
Monofilament	Polydioxanone	Very strong and long-lasting in tissues (absorbed within 180 days); more rigid, more difficult to use for manual suturing compared to other absorbable materials
Natural	Catgut, chromic catgut	From the inner vascular membrane of sheep. Weak, does not hold the knot well; quickly absorbed (1 week); high tissue reactivity. Not recommended for use
Wicker	-	Easy to tie, holds a knot well, low reactivity
	Based on polyglycolic acid	It dissolves quickly and remains effective for a week.
	Based on polyglycolic acid	Currently the most preferred

The interval between stitches is usually equal to the distance from the needle entry to the wound edge. The needle entry and exit should be at the same distance from the wound edge.

The vertical mattress suture is sometimes used instead of layered suturing in cases where there is no noticeable tension on the skin; it also helps to properly evert the wound edges in loose tissues. The running suture can be placed more quickly than the interrupted suture and is used on wounds with well-applied edges.

In all cases, skin sutures should orient the wound edges horizontally, taking into account natural skin landmarks (folds, furrows, edges of the lips). Vertical alignment of sutures is no less important to avoid step deformation.

Excessive tension after wound suturing is indicated by a "sausage-like" skin surface deformation. Such suturing should be redone, adding, if necessary, subcutaneous or percutaneous sutures, or both.