Advanced Suturing

Steri strips

surgical tape that can be used to close fragile skin; used as an adjunct to sutures

Scalp Sutures

4-0 suture or staple, with removal in 7-14 days

Forehead sutures

5-0/6-0 sutures, with removal in 5 days

Eyebrow Sutures

•5-0/6-0 sutures, with removal in 3-5 days

Face/eyelid sutures

6-0/7-0 sutures, with removal in 3-5 days

Nose Sutures

5-0 sutures, with removal in 3-5 days

Ear sutures

5-0/6-0 sutures, with removal in 7-10 days

Lip sutures

•5-0/6-0 sutures (mucosa, muscle 4-0), with removal in 3-5 days

trunk sutures

3-0 or 4-0, remove in 7-14 days

arm/leg sutures

3-0 or 4-0, remove in 7-14 days

foot sutures

•3-0 or 4-0, remove in 10-14 days

Proline

non-absorbable primarily used for general tissue approximation and ligation in various surgical procedures

Silk

non-absorbable suture primarily used for general soft tissue approximation and ligation, including in cardiovascular, ophthalmic, and neurological procedures. It's also used for securing surgical tubes, such as chest tubes, and in dentistry for mucosal surfaces.

Ethilon/Nylon

primarily used for general soft tissue approximation and ligation, including in cardiovascular, ophthalmic, and neurological procedures. They are a non-absorbable, monofilament suture known for their strength and smooth tissue passage

Vicryl Rapide

soft tissue approximation where short-term wound support is needed. This includes skin closure (not external) , closure of oral mucosa, and sometimes in pediatric surgery, episiotomies, and conjunctival sutures in ophthalmic procedures. It's a synthetic, absorbable suture that mimics the performance of surgical gut

What is a suture bite

the area of tissue grabbed by the needle when stitching the wound

Interrupted Sutures

Simple, vertical mattress, horizontal mattress

Continuous sutures

running, running locked, subcuticular

Vertical Mattress

used in creases and areas of natural inversion; uses a 2nd mini suture in the same line as the main suture to ensure eversion of skin edges

Horizontal mattress

pulling edges together over great distances, initial suture anchors the wound and hold the 2 wound edges together

Purse string

technique ideal for use of securing indwelling lines that will be repeatedly in use for long periods of time (chest tube)

What is the best suture for attempting to gain control of a hemorrhaging arterial vessel

horizontal mattress

Layered closing

Closing a wound on multiple layers using different types of sutures to minimize tension, reduce dehiscence, and improve cosmetic outcomes

Layered closing technique

Deep tissue: absorbable sutures

Dermal: absorbable sutures using a vertical mattress

Epidermal: sutures or skin adhesives

Considerations of layered closures

Wound Type - The layered closure technique is particularly useful for wounds under moderate to high tension or those with significant depth. 

Surgeon Preference - While layered closure is a common technique, some surgeons may prefer other methods depending on their experience and the specific wound characteristics. 

Potential complications - Layered closure may increase the risk of postoperative pain, infection, or dimpling of the skin in some cases

Patient has a left leg laceration, deep, 12cm long?

Which of the following would be the appropriate selection of suture materials to close the wound?

4-0 Fascia, 4-0 subcutaneous, 2-0 skin

4-0 Fascia, 4-0 subcutaneous, 4-0 skin

12-0 Fascia, 2-0 subcutaneous, 5-0 skin

2-0 Fascia, staple subcutaneous, steri-strip skin

4-0 fascia, 4-0 subq, 4-0 skin

Facial Lacerations special cases

extremely vascular, copious irrigation needs to be used to clean, explore for foreign bodies, gross asymmetry may signify underlying nerve damage

Evaluation of the pt

Hx: mechanism of injury!

Physical: location, size, depth, shape, foreign body, palpate, neurological eval

Facial Laceration procedure

• Generally, may be closed up to 24 hours after injury

• Initial care: as like any other injury cleanse and evaluate thoroughly

• Because of excellent blood supply of the face, tissue that seems ischemic often survives

• Anesthesia: generally, lidocaine with epinephrine is best choice (except areas where contraindicated: around nose, ears, flaps)

• Suture choice: Nylon – skin and chromic/vicryl – mucosal lacerations

• Suture placement: generally closer together than usual (1-2mm from skin edges and 3mm apart)

• Removal around 5-7 days

Anatomy of a lip laceration

• Vermilion border

• Mucosal surface

  • Wet

  • Dry

It is very important to align the border between these surfaces to prevent noticeable irregularities

Mucosal laceration procedure

• Important to realign the wet-dry mucosal border

• Place the first stitch at the border between the wet and dry surfaces

• Absorbable 4-0 suture

• sew wet mucosa to wet and dry to dry

• Evert the edges (mattress if necessary

• Tie at least 4 or 5 knots

Partial thickness that crosses the vermilion border procedure

• Important to approximate the vermillion border as well as possible

• Align the red/white margin first. Place initial suture just outside the vermilion border using 5-0/6-0 suture

• Remaining sutures lip skin 5-0/6-0 and lip mucosa 4-0/5-0

This laceration is of highest cosmetic importance

Full thickness lip laceration procedure

• Outer skin, lip muscle, and mucosa

• Repair the mucosa: repair the inner aspect of the lip first absorbable 4-0 suture try to evert the edges

• Irrigate the wound

• Repair the muscle: absorbable 3-0/4-0 figure of eight suture in the muscle

• Repair the skin

Indications for repair of intraoral lacerations

• Mucosal laceration that creates a flap that interferes with chewing

• Mucosal flap that is large enough to trap food particles

• Wounds longer than 2 cm

Intraoral mucosal laceration procedure

• Avoid injury to the opening of the parotid duct (opening of the duct into the mouth is a small, raised mound of mucosa inside the cheek across from the upper second molar) during repair

• Absorbable 4-0 suture

• 2-3 mm from the edge of the wound and include only the mucosa

• Evert the edges

Full thickness cheek laceration procedure

• Cheek skin, underlying subcutaneous tissue/muscle and intraoral mucosa

• Intraoral mucosa should be repaired first once closed re-irrigate the wound

• Skin and sub q tissue/muscle

  • Repair the skin using 5-0 nylon sutures

    • Generally bring the skin edges together will allow the sub q tissue to fill in, but if it does not then place one or two 4-0 absorbable simple sutures to approximate the sub q/muscle

      • These sutures can increase the risk to the facial nerve

Post procedure care

• Make sure tetanus is up to date

• NSAIDs and cold packs can help with swelling

• If wound involves the oral mucosa suggest a bland diet to avoid irritation

• Post-procedure prophylactic antibiotic for through and through and intra oral lacerations

Which tongue lacerations should you close

• Large Lacerations (>1-2 cm)

• Large gaping wounds, esp with the tongue at rest

• Wounds requiring suturing for hemostasis

• Anterior split tongue

Which tongue wounds do you not close

Small lacerations (<1-2 cm)

non-gaping wounds

Tongue laceration procedure

• Lidocaine with epinephrine

• Irrigate

• Absorbable 3-0/5-0 suture in a figure of eight fashion in the inner muscle

• If unable to suture the inner muscle the take larger and deeper bites approx 4-5 mm from edge using 3-0/4-0 absorbable suture

Full thickness nasal laceration procedure

• External skin, cartilage, and nasal mucosa

• Skin-plain lidocaine, small 5-0 non-absorbable suture, align the alar rim

• Cartilage-suture directly in the cartilage is usually not recommended

• Nasal mucosa-small absorbable 5-0 chromic sutures

• Once repaired loosely pack the affected nostril with gauze coated with antibiotic ointment. Leave gauze in place for a few days

• Oral antibiotic as long as packing is in place

Eyelid laceration procedure

• Full thickness-skin, muscle, tarsal plate, and underlying conjunctiva -> REFER

• Place a small 6-0 (subcuticular?) suture to reapproximate the gray line (lash margin)- watch the placement of the knot

• Close skin loosely with 5-0 or 6-0 suture

Eyebrow laceration procedure

• recreate the natural curvature of the eyebrow

• do not shave the eyebrow

Ear laceration procedure

• Inspect the TM and external auditory canal and facial nerve

• Primary goal of wound management

  • Coverage of exposed cartilage

  • Minimization of hematoma

Scalp laceration pneumonic

S=Skin

C=subCutaneous tissue

A=epicranial Aponeurosis (muscle layer)

L=Loose connective tissue

P=Periosteum (pericranium)

Full thickness scalp laceration

Must close the galea and the skin to control bleeding and prevents infection spread

Scalp laceration procedure

• Lidocaine with epi (when possible)

• Suture the aponeurosis layer with 3-0 or 4-0 Vicryl (simple or figure of eight)

• Close the skin with a continuous locking suture 3-0 nylon or Vicryl, or skin stapler

Indications for a nerve block

• Local anesthesia at the site of the incision may not be effective (infected tissue)

• When edema from the local injections would distort anatomy landmarks

• When edema from the local injection would make it difficult to palpate deep tissue to be excised

• When repairs/excisions are quite large and prohibit the use of large amounts of anesthetic**

Nerve block contraindications

• Need to inject through infected tissue

• Presence of septicemia

• Allergy to medication

  • Relative Contraindication

    • Neurologic Damage before procedure

    • Previous epi contraindication

Nerve block risks/benefits

•No anesthesia vs. local anesthesia vs. nerve block vs. general anesthesia

•In rare instances trauma to the nerve could occur but long term consequences are rare

•The possibility of parasthesia during injection should be explained

•Infection

Nerve block procedure

• Before beginning perform a neurological examination and document the results

• Identify the nerve area

• Obtain informed consent

• Clean site in sterile fashion

• Draw up medication

• Inject-aspirate

• Allow 5-15 minutes before procedure

Mental nerve block

• Innervated the lower lip and skin below the lip

• The nerve exits the mandible just inferior to the second mandibular bicuspid midway between the upper and lower edges of the mandible approx 2.5 cm from the midline of the jaw

• Needle is introduced at the gingival buccal margin aspirate and inject 2 ml

Buccal nerve block

anesthetizes the mucous membrane of the cheek and vestibule and, to a lesser extent, a small patch of skin on the face

Infraorbital nerve block

• Nerve exits just beneath the notch at the infaorbital rim

• Used to repair upper lip laceration and lacerations of the lower lateral nose and eye lid

Infraorbital nerve block technique

• Direct infiltration through the skin over the area

• Intraoral technique: introduce needle at gingival buccal margin over the maxillary canine and inject approx 2 ml at the infaorbital foramen

Lingual Nerve block

• located on the lingual side of the second mandibular molar

• anesthetizes the anterior two thirds of the tongue

Supraorbital nerve block

• Innervate the forehead and the anterior scalp

• Nerve exits at the supraorbital ridge

• Infiltrate just above the bone beneath the entire medial eyebrow

Do you ever use staples on the face

NO! leads to extreme cosmetic issues

Dermabond

uses independent chemical reaction to seal the skin, can be used to close low tension wounds