Wound Dressing and Suturing

Wound Dressings

Introduction
Good wound care will minimize the inflammatory response, speed healing and minimize scarring.

Dressings for acute wounds

Sterile dressings should be applied to acute wounds, including those due to skin surgery, for the following
reasons.
 Keep the wound clean and prevent contamination by foreign bodies.
 Apply pressure to encourage haemostasis and prevent haematoma
 Immobilise the wound
 Reduce the risk of bacterial infection.
 Absorb drainage of blood or wound exudate
 Occlusion provides thermal insulation.
 Allow for oxygen entry and water vapour escape
 To cover the wound for cosmetic reasons.
These goals can be accomplished with a layered dressing comprised of a bottom, nonadherent contact
layer, a middle layer that can absorb wound exudate and exert pressure, and an outer covering of tape or a
rolled bandage. Sterile dressings come in various sizes from simple gauze pads to adhesive bandages.
Dressings for small acute wounds

Melolin® non-adherent dressing

(perforated Assorted Nexcare® plasters for acute wounds
plastic film)
If a wound is discharging fluid (serum), the dressing should be changed often to minimize bacterial growth.
After drainage has stopped, there may be no need for a dressing.
Ointments such as petroleum jelly may be applied to limit surface bacterial growth and prevent the dressing
from sticking to the wound. Topical antibiotics containing single or multiple antibiotics such as bacitracin,
neomycin, or polymyxin B may be useful in a contaminated wound but should be avoided in clean wounds
because there is an increasing rate of bacterial resistance to these agents.
Jelonet™ gauze impregnated with
petroleum jelly

Wounds may be cleansed with water, normal saline or with hydrogen peroxide several times daily
before the reapplication of ointment.
Use of topical silicone gel sheeting or polyurethane self-adhesive patches after routine
dermatologic surgery minimizes the risk of hypertrophic scars and keloids in patients at risk for those
lesions.
Dressings designed to reduce scars

Scar Reduction™
Cicacare™ silicone scar patch polyurethane
dressing scar dressing

Dressings for chronic wounds

The principles outlined for acute wounds remain true for chronic wounds including leg ulcers or
surgical wounds healing by secondary intention.
 In a full-thickness wound, the dermis must be recreated before re-epithelialization can begin.
These wounds heal from the base as well as from the edges so the development of some fibrinous exudate
in the wound bed is a positive sign.
Occlusive options
Occlusion of chronic wounds:
 Allows macrophages and fibroblasts to enter the wound
 Promotes autolysis mediated by enzymes released from leukocytes.
 Favours cell proliferation because of low pH and hypoxia.
 Enhances growth factors and cytokines within wound fluid.
The occlusive dressings may be divided into five categories:
 Hydrogels
 Hydrocolloid
 Foams
 Films
 Alginates.
Hydrogels are composed primarily of water, fixed in a cross-linked polymer (sodium
carboxymethylcellullose, or starch). They may be hydrated or in a dehydrated state requiring moistening
with water or saline. They are used to rehydrate dried-out necrotic eschar. Hydrogels are also useful for
exudative wounds because they have high absorptive capacity and are nonadherent. They cool the wound
and can provide excellent pain relief. They are also useful for partial thickness wounds from resurfacing
procedures and skin graft donor sites.
The hydrogel should be covered by an absorbent layer, made of gauze or cotton, and an outer layer of
tape, netting or roll bandage.
Hydrocolloid dressings are a mixture of a hydrophilic base and adhesive, often with an outer covering
of polyurethane. They adhere directly to the wound and do not usually require a secondary dressing to
keep them in place. In addition, they absorb mild to moderate wound exudate so they can be worn for three
to seven days without changing.
Hydrophilic foam dressings are permeable to oxygen and water vapour. They usually have a
hydrophobic backing that provides occlusion and some have an adhesive surface, which makes application
easier. They can absorb only limited amounts of wound exudate so may need to be changed every two to
three days or even more frequently during early wound healing when exudation is greatest.
 Foam dressings are ideally suited for superficial and dry wounds eg after ablative resurfacing
procedures and chronic ulcers since they provide padding that can relieve pressure over bony
prominences.
Thin transparent film dressings are not very absorptive, so they are not useful for wounds with
significant exudate. They can be used to keep other dressings in place, including as top layer of an acute
surgical wound dressing. They are often used to cover sites of IV insertion, superficial abrasions and as
temporary dressings e.g. over local anaesthetic cream prior to venepuncture.
Alginates are highly absorbent and are indicated when a wound is very exudative. They release
calcium ions, which help haemostasis so are useful applied to a surgical wound in a patient with excessive
bleeding. In chronic wounds, the exudate combines with the alginate gel to form green or yellowish goo.
The alginates are nonadherent unless the wound dries out. They can be soaked off to avoid unnecessarily
debriding the wound.

Dressings for chronic wounds

Curasol™ hydrogel wound dressing Duoderm™ hydrocolloid dressing Allevyn™ foam dressing

Opsite™ film dressing Sorbsan™ alginate dressing

Honey
Honey has been used as a traditional remedy for burns and wounds, and more recently several studies
have demonstrated that it has antibacterial activity. Honey can clear infection from cutaneous wounds and
improve healing. Honey from New Zealand manuka (Leptospermum spp) has enhanced antibacterial
activity. It is available in a jar (also for oral consumption), a tube, or impregnated on a wound dressing. The
antibacterial effect is labelled with its UMF (Unique Manuka Factor) according to Waikato University's
honey research unit tests.
Proposed mechanisms include:
 Physicochemical properties (eg, osmotic effects and pH)
 Antiinflammatory activity stimulates immune responses
 Hydrogen peroxide concentration.

Honey for wounds

Active UMF10+ Manuka honey Medihoney™ wound dressing Activon™ tulle wound dressing

Choice of dressing
The most suitable dressing depends on the type of wound.
 Necrotic wounds have a dry black eschar composed of dead epidermis
 Sloughy wounds contain yellow viscous adherent slough
 Granulating wounds contain deep red vascularised granulation tissue
 Epithelialising wounds have a pink margin to the wound or isolated pink islands on the surface
 Infected wounds.
It also depends on the location and size of the wound. Some dressings are easier to use and remove
than others. Modern dressings are relatively hypoallergenic and non-adherent but sensitisation may occur
to iodine, antibiotics, rubber, adhesives and preservatives. Tape cannot be applied if the skin is treated with
emollient or topical steroid creams. Cost and availability must also be considered.

Necrotic wounds
The aim is to rehydrate the dry scab so that it will separate off. Options are: Wet dressings using saline or
hypochlorite (Eusol). Hydrogel covered by perforated plastic film absorbent dressing (Melolin or Telfa) or
vapour permeable film. Hydrocolloid dressing.

Sloughy wounds
These need debriding to remove the abnormal matrix of fibrin, exudate, inflammatory cells and bacteria.
This can be done by surgical debridement or by an agent that soaks up debris and forms a moist gel.
Options are:
 Polysaccharide dressing as beads or paste.
 Hydrocolloid dressing if wound less exudative.
 Alginate dressing.
 Enzymes.

Granulating wounds
Granulation tissue is a highly vascular matrix collagen and proteoglycans.
 Cavity wounds are packed with alginate fibre ribbon, silicone foam dressing or foam chips
 Shallow but heavily exuding ulcers are dressed with alginate dressings or hydrophilic foam product
 Less exudative ulcers are dressed with hydrocolloid or thin foam dressing

Epithelialising wounds
Superficial wounds that exude fluid (burns and donor sites):
 Paraffin gauze covered with gauze and cotton tissue (Gamgee)
 Alginate
 Hydrocolloid.
Dry superficial wounds:
 Hydrocolloid
 Film dressing
 Perforated plastic film dressing
 Knitted viscose non-adherent dressings.

Infected wounds
Infected wounds need to be covered because they may have an unpleasant odour, and to prevent the
spread of the organisms, particularly if they are resistant to standard antibiotics. Several dressings include
antibacterial agents. Their use is controversial.
 Framycetin
 Fusidic acid
 Chlorhexidine
  Povidone iodine

Bioengineered skin substitutes

Skin autografts are commonly used to cover acute surgical wounds and chronic ulcers. However,
harvesting skin grafts creates another wound that must heal, and suitable skin is unavailable in some cases
such as extensive thermal burns. Sterilised cadaver allografts provide temporary wound dressings but
eventually slough off. There has been intensive research and development in recent years to provide a
satisfactory substitute for healthy skin. Replacement of dermal matrix and epidermis is required.
Cultured keratinocyte autografts can provide permanent coverage of large area from a skin biopsy.
However, 3 weeks are needed for graft cultivation.
Keratinocyte allografts cultured from neonatal foreskins are available immediately. They can be
cryopreserved and banked, but are not currently commercially available.
Applying a substitute dermal matrix has been shown to improve the likelihood that cultured
epidermal cells (or an autologous split skin graft) will take. Several immunologically inert systems are now
under investigation for management of refractory venous and diabetic ulcers.

Bioengineered skin substitutes

Alloderm™ dermal matrix Apligraf™ artificial skin in culture

References:
 Mekkes JR, Loots MAM, van der Wal AC, Bos JD. Causes, investigation and treatment of leg
ulceration. Br J Dermatol 2003; 148: 388-401
 Simon DA, Dix FP, McCollum CN. Clinical review. Management of venous leg ulcers. BMJ
2004;328:1358-1362 (5 June), doi:10.1136/bmj.328.7452.1358
 Basic Suturing Principles

Many varieties of suture material and needles are available to the cutaneous surgeon. The choice
of sutures and needles is determined by the location of the lesion, the thickness of the skin in that location,
and the amount of tension exerted on the wound. Regardless of the specific suture and needle chosen, the
basic techniques of needle holding, needle driving, and knot placement remain the same.

Needle construction
The needle has 3 sections. The point is the sharpest portion and is used to penetrate the tissue.
The body represents the mid portion of the needle. The swage is the thickest portion of the needle and the
portion to which the suture material is attached. In cutaneous surgery, 2 main types of needles are used:
cutting and reverse cutting. Both needles have a triangular body. A cutting needle has a sharp edge on the
inner curve of the needle that is directed toward the wound edge. A reverse cutting needle has a sharp
edge on the outer curve of the needle that is directed away from the wound edge, which reduces the risk of
the suture pulling through the tissue. For this reason, the reverse cutting needle is used more often than the
cutting needle in cutaneous surgery.

Diagram of a needle.
Suture placement
A needle holder is used to grasp the needle at the distal portion of the body, one half to three
quarters of the distance from the tip of the needle, depending on the surgeon's preference. The needle
holder is tightened by squeezing it until the first ratchet catches. The needle holder should not be tightened
excessively because damage to both the needle and the needle holder may result. The needle is held
vertically and longitudinally perpendicular to the needle holder.

The needle is placed vertically and longitudinally perpendicular to the needle holder.

Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of
the skin, and/or an undesirable angle of entry into the tissue. The needle holder is held by placing the
thumb and the fourth finger into the loops and by placing the index finger on the fulcrum of the needle
holder to provide stability. Alternatively, the needle holder may be held in the palm to increase dexterity.
The needle holder is held through the loops between the thumb and the fourth finger, and the index
finger rests on the fulcrum of the instrument.

The needle holder is held in the palm, allowing greater dexterity.

The tissue must be stabilized to allow suture placement. Depending on the surgeon's preference, toothed
or untoothed forceps or skin hooks may be used to gently grasp the tissue. Excessive trauma to the tissue
being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis. Forceps are
necessary for grasping the needle as it exits the tissue after a pass. Prior to removing the needle holder,
grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in
the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the
back, where large needle bites are necessary for proper tissue approximation.

The needle should always penetrate the skin at a 90° angle, which minimizes the size of the entry wound
and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the wound edge,
depending on skin thickness. The depth and angle of the suture depends on the particular suturing
technique. In general, the 2 sides of the suture should become mirror images, and the needle should also
exit the skin perpendicular to the skin surface.

Knot tying
Once the suture is satisfactorily placed, it must be secured with a knot. The instrument tie is used
most commonly in cutaneous surgery. The square knot is traditionally used. First, the tip of the needle
holder is rotated clockwise around the long end of the suture material for 2 complete turns. The tip of the
needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the
loops of the long end by crossing the hands, such that the 2 ends of the suture material are situated on
opposite sides of the suture line. The needle holder is rotated counterclockwise once around the long end
of the suture. The short end is grasped with the needle holder tip, and the short end is pulled through the
loop again.
The suture should be tightened sufficiently to approximate the wound edges without constricting
the tissue. Sometimes, leaving a small loop of suture after the second throw is helpful. This reserve loop
allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the
tension exerted on the suture increases with increased wound edema. Depending on the surgeon's
preference, 1-2 additional throws may be added.
Properly squaring successive ties is important. That is, each tie must be laid down perfectly parallel
to the previous tie. This procedure is important in preventing the creation of a granny knot, which tends to
slip and is inherently weaker than a properly squared knot. When the desired number of throws is
completed, the suture material may be cut (if interrupted stitches are used), or the next suture may be
placed.
 Knot tying

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.
 Simple interrupted suture placement. Bottom right image shows a flask-shaped stitch, which
maximizes eversion.

In general, tissue bites should be evenly placed so that the wound edges meet at the same level to
minimize the possibility of mismatched wound-edge heights (ie, stepping). However, the size of the bite
taken from the 2 sides of the wound can be deliberately varied by modifying the distance of the needle
insertion site from the wound edge, the distance of the needle exit site from the wound edge, and the depth
of the bite taken. The use of differently sized needle bites on each side of the wound can correct
preexisting asymmetry in edge thickness or height. Small bites can be used to precisely coapt wound
edges. Large bites can be used to reduce wound tension. Proper tension is important to ensure precise
wound approximation while preventing tissue strangulation.

Line of interrupted sutures

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.

Running suture line

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
reapproximation 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.
]

Running locked suture

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.

Vertical mattress suture

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.

Half-buried vertical mattress sutures

Technique
The half-buried vertical mattress suture is a modification of the vertical mattress suture and
eliminates 2 of the 4 entry points, thereby reducing scarring. The half-buried vertical mattress suture is
placed in the same manner as the vertical mattress suture, except that the needle penetrates the skin to
the level of the deep part of the dermis on one side of the wound, takes a bite in the deep part of the dermis
on the opposite side of the wound without exiting the skin, crosses back to the original side of the wound,
and exits the skin. Entry and exit points therefore are kept on one side of the wound.
Uses
The half-buried vertical mattress is used in cosmetically important areas such as the face.

Pulley sutures
Technique
The pulley suture is a modification of the vertical mattress suture. When pulley sutures are used, a
vertical mattress suture is placed, the knot is left untied, and the suture is looped through the external loop
on the other side of the incision and pulled across. At this point, the knot is tied. This new loop functions as
a pulley, directing tension away from the other strands.

Pulley stitch, type 1

Uses
The pulley suture facilitates greater stretching of the wound edges and is used when additional
wound closure strength is desired.

Far-near near-far modified vertical mattress sutures

Technique
Another stitch that serves the same function as the pulley suture is the far-near near-far
modification of the vertical mattress suture. The first loop is placed approximately 4-6 mm from the wound
edge on the far side and approximately 2 mm from the wound edge on the near side. The suture crosses
the suture line and reenters the skin on the original side at 2 mm from the wound edge on the near side.
The loop is completed, and the suture exits the skin on the opposite side 4-6 mm away from the wound
edge on the far side. This placement creates a pulley effect.

Far-near near-far pulley stitch

Uses
The pulley suture is useful when tissue expansion is desired, and it may be used intraoperatively
for this purpose. The suture is also useful when beginning the closure of a wound that is under significant
tension. By placing pulley stitches first, the wound edges can be approximated, thereby facilitating the
placement of buried sutures. When wound closure is complete, the pulley stitches may be either left in
place or removed if wound tension has been adequately distributed after placement of the buried and
surface sutures.

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.
 Horizontal mattress suture

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.

Buried Sutures
Half-buried horizontal sutures or tip stitches
Technique
 The half-buried horizontal suture or tip stitch begins on the side of the wound on which the flap is to
be attached. The suture is passed through the dermis of the wound edge to the dermis of the flap tip. The
needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip, and reenters the skin to
which the flap is to be attached. The needle is directed perpendicularly and exits the skin; then, the knot is
tied.

Tip stitch

Uses
The half-buried horizontal suture or tip stitch is used primarily to position the corners and tips of
flaps and to perform M-plasties and V-Y closures.

Absorbable buried sutures

Absorbable buried sutures are used as part of a layered closure in wounds under moderate-to-high
tension. Buried sutures provide support to the wound and reduce tension on the wound edges, allowing
better epidermal approximation of the wound. They are also used to eliminate dead space, or they are used
as anchor sutures to fix the overlying tissue to the underlying structures.

Dermal-subdermal sutures
Technique
The suture is placed by inserting the needle parallel to the epidermis at the junction of the dermis
and the subcutis. The needle curves upward and exits in the papillary dermis, again parallel to the
epidermis. The needle is inserted parallel to the epidermis in the papillary dermis on the opposing edge of
the wound, curves down through the reticular dermis, and exits at the base of the wound at the interface
between the dermis and the subcutis and parallel to the epidermis. The knot is tied at the base of the
wound to minimize the possibility of tissue reaction and extrusion of the knot. If the suture is placed more
superficially in the dermis at 2-4 mm from the wound edge, eversion is increased.
Uses
A buried dermal-subdermal suture maximizes wound eversion. It is placed so that the suture is
more superficial away from the wound edge.

Buried horizontal mattress suture

Technique
The buried horizontal mattress suture is a purse-string suture. The suture must be placed in the
mid-to-deep part of the dermis to prevent the skin from tearing. If tied too tightly, the suture may strangulate
the approximated tissue.
Uses
The buried horizontal mattress suture is used to eliminate dead space, reduce the size of a defect,
or reduce tension across wounds.5

Variations of Running Sutures

Running horizontal mattress sutures
Technique
A simple suture is placed, and the knot is tied but not cut. A continuous series of horizontal
mattress sutures is placed, with the final loop tied to the free end of the suture material.
Uses
The running horizontal mattress suture is used for skin eversion. It is useful in areas with a high
tendency for inversion, such as the neck. It can also be useful for reducing the spread of facial scars. If the
sutures are tied too tightly, tissue strangulation is a risk.

Running subcuticular sutures

Technique
The running subcuticular suture is a buried form of the running horizontal mattress suture. It is placed by
taking horizontal bites through the papillary dermis on alternating sides of the wound. No suture marks are
visible, and the suture may be left in place for several weeks
 Subcuticular stitch. The skin surface remains intact along the length of the suture line

Uses
The running subcuticular suture is valuable in areas in which the tension is minimal, the dead
space has been eliminated, and the best possible cosmetic result is desired. Because the epidermis is
penetrated only at the beginning and end of the suture line, the subcuticular suture effectively eliminates
the risk of crosshatching. The suture does not provide significant wound strength, although it does precisely
approximate the wound edges. Therefore, the running subcuticular suture is best reserved for wounds in
which the tension has been eliminated with deep sutures, and the wound edges are of approximately equal
thicknesses.

Running subcutaneous sutures

Technique
The running subcutaneous suture begins with a simple interrupted subcutaneous suture, which is
tied but not cut. The suture is looped through the subcutaneous tissue by successively passing through the
opposite sides of the wound. The knot is tied at the opposite end of the wound by knotting the long end of
the suture material to the loop of the last pass that was placed.
Uses
The running subcutaneous suture is used to close the deep portion of surgical defects under
moderate tension. It is used in place of buried dermal sutures in large wounds when a quick closure is
desired. Disadvantages of running subcutaneous sutures include the risk of suture breakage and the
formation of dead space beneath the skin surface.
Suture Removal and Alternative Methods of Wound Closure
Suture removal
Sutures should be removed within 1-2 weeks of their placement, depending on the anatomic
location. Prompt removal reduces the risk of suture marks, infection, and tissue reaction. The average
wound usually achieves approximately 8% of its expected tensile strength 1-2 weeks after surgery. To
prevent dehiscence and spread of the scar, sutures should not be removed too soon.
As a general rule, the greater the tension across a wound, the longer the sutures should remain in
place. As a guide, on the face, sutures should be removed in 5-7 days; on the neck, 7 days; on the scalp,
10 days; on the trunk and upper extremities, 10-14 days; and on the lower extremities, 14-21 days. Sutures
in wounds under greater tension may need to be left in place slightly longer. Buried sutures, which are
placed with absorbable suture material, are left in place because they dissolve.
Proper suture removal technique is important to maintain good results after sutures are properly
selected and executed. Sutures should be gently elevated with forceps, and one side of the suture should
be cut. Then, the suture is gently grasped by the knot and gently pulled toward the wound or suture line
until the suture material is completely removed. If the suture is pulled away from the suture line, the wound
edges may separate. Steri-Strips may be applied with a tissue adhesive to provide continued supplemental
wound support after the sutures are removed.

Alternative methods of wound closure

Steri-Strips
Wound closure tapes, or Steri-Strips, are reinforced microporous surgical adhesive tape. Steri-
Strips are used to provide extra support to a suture line, either when running subcuticular sutures are used
or after sutures are removed. Wound closure tapes may reduce spreading of the scar if they are kept in
place for several weeks after suture removal. Often, they are used with a tissue adhesive. These tapes are
rarely used for primary wound closure.
Staples
Stainless steel staples are frequently used in wounds under high tension, including wounds on the
scalp and trunk. Advantages of staples include quick placement, minimal tissue reaction, low risk of
infection, and strong wound closure. Disadvantages include less precise wound edge alignment and cost.
Tissue adhesive
 Superglues that contain acrylates may be applied to superficial wounds to block pinpoint skin
hemorrhages and to precisely coapt wound edges. The usefulness of rapidly polymerizing plastics is limited
because of the difficulty in handling the adhesive and the potential for tissue toxicity and inflammation. The
use of tissue adhesives in dermatologic surgery is still evolving. As new and improved products are
developed, the use of adhesives for skin closure may increase. Greenhill and O'Regan reported on the use
of N-butyl 2-cyanoacrylate (Indermil) for closure of parotid wounds and its relationship to keloid and
hypertrophic scar formation versus using sutures. Their results indicated a simpler technique and a
comparable result. In a related area, Tsui and Gogolewski report on the use of microporous biodegradable
polyurethane membranes, which may be useful for coverage of skin wounds, among other things.

Barbed sutures
A barbed suture has been developed and is being evaluated for its efficacy in cutaneous surgery.
The proposed advantage of such a suture is the avoidance of suture knots. Suture knots theoretically may
be a nidus for infection, are tedious to place, may place ischemic demands on tissue, and may extrude
following surgery. A randomized controlled trial comparing a barbed suture with conventional closure using
3-0 polydioxanone suture suggests that a barbed suture has a safety and cosmesis profile similar to the
conventional suture when used to close cesarean delivery wounds. Additional studies are likely needed
before the barbed suture is accepted for widespread use.