Simple Interrupted Sutures

Technique
The most commonly used and versatile suture in cutaneous surgery is the simple
interrupted suture. This suture is placed by inserting the needle perpendicular to
the epidermis, traversing the epidermis and the full thickness of the dermis, and
exiting perpendicular to the epidermis on the opposite side of the wound. The 2
sides of the stitch should be symmetrically placed in terms of depth and width.
In general, the suture should have a flask-shaped configuration, that is, the stitch
should be wider at its base (dermal side) than at its superficial portion
(epidermal side). If the stitch encompasses a greater volume of tissue at the base
than at its apex, the resulting compression at the base forces the tissue upward
and promotes eversion of the wound edges. This maneuver decreases the
likelihood of creating a depressed scar as the wound retracts during healing

Uses
Compared with running sutures, interrupted sutures are easy to place, have greater tensile
strength, and have less potential for causing wound edema and impaired cutaneous
circulation. Interrupted sutures also allow the surgeon to make adjustments as needed to
properly align wound edges as the wound is sutured.
Disadvantages of interrupted sutures include the length of time required for their
placement and the greater risk of crosshatched marks (ie, train tracks) across the suture
line. The risk of crosshatching can be minimized by removing sutures early to prevent the
development of suture tracks.

Running Sutures
Simple running sutures
Technique
The simple running suture is an uninterrupted series of simple interrupted sutures. The
suture is started by placing a simple interrupted stitch, which is tied but not cut. A series
of simple sutures are placed in succession without tying or cutting the suture material
after each pass. Sutures should be evenly spaced, and tension should be evenly
distributed along the suture line. The line of stitches is completed by tying a knot after the
last pass at the end of the suture line. The knot is tied between the tail end of the suture
material where it exits the wound and the loop of the last suture placed.

Uses
Running sutures are useful for long wounds in which wound tension has been minimized
with properly placed deep sutures and in which approximation of the wound edges is
good. This type of suture may also be used to secure a split- or full-thickness skin graft.
Theoretically, less scarring occurs with running sutures compared with interrupted
sutures because fewer knots are made with simple running sutures; however, the number
of needle insertions remains the same.
Advantages of the simple running suture include quicker placement and more rapid re-
approximation of wound edges, compared with simple interrupted sutures. Disadvantages
include possible crosshatching, the risk of dehiscence if the suture material ruptures,
difficulty in making fine adjustments along the suture line, and puckering of the suture
line when the stitches are placed in thin skin.

Running locked sutures

Technique
The simple running suture may be locked or left unlocked. The first knot of a running
locked suture is tied as in a traditional running suture and may be locked by passing the
needle through the loop preceding it as each stitch is placed. This suture is also known as
the baseball stitch because of the final appearance of the running locked suture line.

Uses
Locked sutures have increased tensile strength; therefore, they are useful in wounds
under moderate tension or in those requiring additional hemostasis because of oozing
from the skin edges. Running locked sutures have an increased risk of impairing the
microcirculation surrounding the wound, and they can cause tissue strangulation if placed
too tightly. Therefore, this type of suture should be used only in areas with good
vascularization. In particular, the running locked suture may be useful on the scalp or in
the postauricular sulcus, especially when additional hemostasis is needed.

Mattress Sutures
Vertical mattress sutures
Technique
The vertical mattress suture is a variation of the simple interrupted suture. It consists of a
simple interrupted stitch placed wide and deep into the wound edge and a
second more superficial interrupted stitch placed closer to the wound edge and
in the opposite direction. The width of the stitch should be increased in
proportion to the amount of tension on the wound. That is, the higher the
tension, the wider the stitch

Uses
A vertical mattress suture is especially useful in maximizing wound eversion, reducing
dead space, and minimizing tension across the wound. One of the disadvantages of this
suture is crosshatching. The risk of crosshatching is greater because of increased tension
across the wound and the 4 entry and exit points of the stitch in the skin. The
recommended time for removal of this suture is 5-7 days (before formation of epithelial
suture tracks is complete) to reduce the risk of scarring. If the suture must be left in place
longer, bolsters may be placed between the suture and the skin to minimize contact. The
use of bolsters minimizes strangulation of the tissues when the wound swells in response
to postoperative edema. Placing each stitch precisely and taking symmetric bites is
especially important with this suture.

Horizontal mattress suture

Technique
The horizontal mattress suture is placed by entering the skin 5 mm to 1 cm from the
wound edge. The suture is passed deep in the dermis to the opposite side of the suture
line and exits the skin equidistant from the wound edge (in effect, a deep simple
interrupted stitch). The needle reenters the skin on the same side of the suture line 5 mm
to 1 cm lateral of the exit point. The stitch is passed deep to the opposite side of the
wound where it exits the skin and the knot is tied.

Uses
The horizontal mattress suture is useful for wounds under high tension because it
provides strength and wound eversion. This suture may also be used as a stay stitch to
temporarily approximate wound edges, allowing placement of simple interrupted or
subcuticular stitches. The temporary stitches are removed after the tension is evenly
distributed across the wound.
Horizontal mattress sutures may be left in place for a few days if wound tension persists
after placement of the remaining stitches. In areas of extremely high tension at risk for
dehiscence, horizontal mattress sutures may be left in place even after removal of the
superficial skin sutures. However, they have a high risk of producing suture marks if left
in place for longer than 7 days.
Horizontal mattress sutures may be placed prior to a proposed excision as a skin
expansion technique to reduce tension. Improved eversion may be achieved with this
stitch in wounds without significant tension by using small bites and a fine suture.
In addition to the risk of suture marks, horizontal sutures have a high risk of tissue
strangulation and wound edge necrosis if tied too tightly. Taking generous bites, using
bolsters, and cinching the suture only as tightly as necessary to approximate the wound
edges may decrease the risk, as does removing the sutures as early as possible. Placing
sutures at a greater distance from the wound edge facilitates their removal.
Suture materials
Polyglycolic Polydioxanone
. Plain catgut Chromic catgut
acid (P.G.A.) (PDS)
USP 6-0 (1 USP 6-0 (1
Size USP 6-0 (1 metric) to USP 6-0 (1 metric) to
metric) to USP metric) to USP 2
available USP 3 (7 metric). USP 3 (7 metric).
2 (5 metric) (5 metric)
High initial
tensile
strength,
Very high knot-pull guaranteed
tensile strength, good holding power
knot security due to through the
Very high knot-pull
special surface finish, critical wound Tensile strength
tensile strength, good
improved healing period. retention,
Advantages knot security due to
smoothness due to Smooth guaranteed
special excellent
the dry presentation passage holding power
handling features
of the thread, through tissue,
excellent handling easy handling,
features excellent
knotting
ability, secure
knot tying
PDS is
particularly
For all surgical useful where the
procedures especially combination of
when tissues that Subcutaneous, an absorbable
regenerate faster are For all surgical intracutaneous suture and
involved. General procedures, closures, extended wound
Indications
closure, ophthalmic, especially for tissues abdominal and support is
orthopedics, that regenerate faster. thoracic desirable,
obstetrics/gynecology surgeries pediatric
and gastro-intestinal cardiovascular
tract surgery. surgery,
ophthalmic
surgery
CI Incisions that require Incision that requires Extended Where prolonged
the sustaining of the sustaining of the approximation approximation of
tissues for a tissues for a of tissue is tissues under
 stress is required
prolonged period of prolonged period of and/ or in
required.
time. time. conjunction with
prosthetic devices

U.S.P. Needle Pull Specifications

U.S.P. Average Minimum Individual Minimum
Suture Size (kgf) (kgf)
11-0 0.007 0.005
10-0 0.014 0.010
9-0 0.021 0.015
8-0 0.050 0.025
7-0 0.080 0.040
6-0 0.170 0.080
5-0 0.230 0.110
4-0 0.450 0.230
3-0 0.680 0.340
2-0 1.100 0.450
0 1.500 0.450
1 1.800 0.600
2+ 1.800 0.700