Technique of suturing

The goal is to closely match the edges of the wound, eliminating their tucking 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. Seams can be applied and tied individually (nodal seams) or continuously (continuous seam). They can be completely located under the skin (intradermal suture) or bind the edges of the skin on its surface (percutaneous suture).

If the wound is slit, first place subcutaneous sutures, and then dermal seams. Wounds on the face are closed with sutures, placing them 2-3 mm apart, mostly subcutaneously (with the exception of the nose and eyelids). For the nodal suture, as a rule, use a woven, absorbable (for example, based on polyglactic acid) yarn 4-0 or 5-0 (the smaller the number, the thinner the material). They are applied with the immersion of the node on the bottom of the wound to avoid the formation of a palpable protrusion, the knot should not be too tight. Continuous subcutaneous suture (intradermal) is sometimes used for cosmetic purposes.

The epidermis is usually sutured with a simple, nodular suture that does not dissolve with a monofilament strand (for example, nylon). Above the large joints and on the scalp use a thread 3-0, on the face - 6-0, in most other areas - 4-0 or 5-0. The sutures are applied to a depth approximately equal to the width, at the same distance equal to the distance from the needle insertion to the wound line. Small stitches are used for cosmetic purposes and on thin skin, usually 1 -3 mm from the edge of the wound. In other cases, wider stitches are used, depending on the thickness of the tissues.

The suture begins and ends in the depth of the wound, so that the knot remains on its bottom.

Suture materials

Category	Material	A comment
Not absorbable		Preferred for skin seams
Monofilament	Nylon	Durable, hard, working with it is relatively difficult
	Polypropylene	Poor holding the knot, the most difficult to use
	Polybutester	It is elastic enough, therefore it is stretched when swelling of tissues and is reduced after its reduction
Wicker	Polyester	Low reactivity, for skin seams worse than monofilament
	Silk	Soft, easy to use, well-kept knot, high reactivity of tissues. The use is limited, mainly in the mouth area, on the lips, eyelids, oral mucosa
Dissolving suture material		Preferred for subcutaneous sutures
Monofilament	Polydioxanone	Very durable and long lasting in tissues (resorption for 180 days); more rigid, it is more difficult to use for a hand weld in comparison with other absorbable materials
Natural	Catgut, chrome-plated catgut	From the inner vasculature of the sheep. Unstable, poorly held knot; quickly resolves (1 week); high tissue reactivity. Undesirable for use
Wicker	-	It is easily tied, keeps well the knot, low reactivity
	Based on polyglycolic acid	Rapidly resolves, remains effective for a week
	Based on polyglactic acid	Currently, the most preferable

The interval between the sutures is usually equal to the distance from the injection of the needle to the edge of the wound. Injection and removal of needles should be at the same distance from the edge of the wound.

Vertical mattress suture is sometimes used instead of layer-by-layer suturing in cases where there is no noticeable skin tension; it also helps to correctly twist the edges of the wound in loose tissues. A continuous seam can be applied faster than a nodular seam and used on wounds with well-aligned edges.

In all cases, skin seams should orient the edges of the wound horizontally, taking into account the natural skin marks (folds, furrows, lip edges). Vertical alignment of seams is equally important in order to avoid step deformation.

To excessive tension after suturing the wound indicates deformation of the skin surface in the form of a "bundle of sausages". Such suturing should be remade, adding, if necessary, subcutaneous or dermal sutures, or both.