3 Minute Get: Real Surgical Suture Secrets

Super Practical Surgical Suture Secrets!

As the demand for healthcare has gradually increased, people need to be able to treat diseases as well as minimize wound scars. As a result, the need for cosmetic suturing has gradually increased.

Anatomy of the skin

The skin consists of two layers: the epidermis and the dermis. The epidermis consists of the stratum corneum (upper layer) and the stratum non-corneumaticum (lower layer). The color of the skin deepens as the content of melanocytes increases, and conversely, the color of the skin becomes lighter. The dermis is generally divided into the papillary layer and reticular layer, directly nourished by blood vessels and nerves, rich in elastic and collagen fibers is the reason for the elasticity of the skin and its ability to contract.

Figure 1: Anatomy of the skin

Relaxed skin tension lines

The preoperative incision should be designed to be close to the "relaxed skin tension lines" (RSTL, Figure 2) and the wrinkles of the skin. ) and wrinkles in the skin.

The wrinkle lines are perpendicular to the direction of the muscle fibers, whereas the RSTL is where the least tension is formed in the skin by the collagen, elastic fibers, etc. The RSTL corresponds to the spontaneous formation of wrinkles when the skin relaxes, and therefore they are approximately the same, although they are different in some areas, such as the area between the eyebrows, and on the side of the nose.

When the surgical incision corresponds to the direction of the RSTL, there is less tension on the wound, which results in the fastest healing and the least amount of scarring, and when there is a crease, it is important to follow the principle of "hiding scarring within the skin crease" by designing the incision within the skin crease.

Figure 2: Skin relaxation tension line

Principles of cosmetic dermatologic closure

Skin sutures should be closed with a slight flare of the wound, with enough tension in the suture to keep it from being overly tight, and with the suture knots buried deeper into the tissue to minimize irritation of the knots and avoid scarring.

Hollander wound evaluation scale Proposes that ideal wound healing should meet the following six key points:

1, no tissue dislocation;

2, wound alignment; < /p> 3, wound alignment; < /p>

4, wound alignment; < /p> 5, wound alignment; < /p> 6, wound alignment; < /p> 6, wound alignment; < /p> 6, wound alignment.

3, wound alignment spacing of no more than 2mm;

4, no skin edge inversion;

5, no excessive distortion of skin tissue;

6, overall aesthetics.

One point for each of these key points, and six points for optimal wound healing.

Standard Suture Techniques

Skin wound closure typically consists of subcutaneous and cutaneous sutures (Figure 3). Subcutaneous sutures are generally used with interrupted sutures to reduce tension on both sides of the wound and allow the knot to be buried deeper in the tissue (Figure 3A).

It is important to note that subcutaneous tissue is less resilient and does not provide adequate hypotension, so a small amount of dermal tissue can be carried with the subcutaneous suture. Additionally, subcutaneous adipose tissue can be trimmed prior to suturing to prevent tissue buildup from interfering with the alignment of the margins and insertion between the margins to interfere with healing.

Figure 3: Standard technique for skin closure

A, Knotting the suture deeper into the tissue

B, Skin is closed intermittently, with care being taken to avoid dead space, and the needle is directed away from the edge of the wound during skin closure

C, Knotting to form a hill shape

Skin closure is closed with an interrupted suture. to re-form the skin edge (Figure 3B, C). Interrupted sutures are generally considered to be the most commonly used and most effective suture for cosmetic dermatologic closure because of the ease with which local tension can be regulated, and adverse events such as poor suture performance and loose knots in a single site have less impact on overall appearance.

However, it is important to note that interrupted sutures have more knots and require more sutures, so the surgeon will have to spend more time and be patient.

Irregular Wound Suturing Techniques

1. The difference in length between the two sides of the wound is less than 1 cm (Figure 4A), and the middle of the wound is sutured first (Figure 4B), followed by suturing the middle of the wounds on both sides (Figure 4C), and then continuing to suture the middle of the individual wounds until the wounds are completely closed, i.e., middle-middle-middle. middle-middle.

Figure 4: Irregular wounds with a length gap of less than 1 cm between the two ends

A, the lower edge of the wound is longer than the upper edge when the wound is in a flaccid state

B, suture the middle of the wound

C, followed by suturing the middle of the wounds on both sides

D, closure of the wounds

2, the gap in length of the wounds on both sides of the wounds is less than 1 cm in order to avoid the emergence of small "cat ears" on both ends . "cat ears" , can also be first at both ends of the suture to confirm the flat, and then follow the tips 1 to close the wound, ie: ends - middle - middle (Figure 5).

Figure 5: Figure B: Close the ends first, then C, D, in that order

3. The difference in length between the two sides of the wound is greater than 1 cm (Figure 6A), and inevitably, a cat's ear will appear. This is accomplished by starting the suture at one end of the wound (Figure 6B) and "driving" the excess skin from the longer side to one end (Figure 6B). Subsequently, an oblique incision is made (1 2 cm, Figure 6C), and the excess skin outside the incision is excised and sutured (Figure 6D).

Figure 6: Irregular wound with a length difference of greater than 1 cm between the two ends

A. In the lax state of the wound, the lower edge is longer than the upper edge

B. Sutures are placed starting at one end of the wound and the excess skin on the side of the longer skin edge is "chased" to one end

C. This is followed by an oblique incision (1-2 cm), which expands the excess skin to clearly define the wound (Figure 6B). 2 cm), spreading the excess skin to define the portion to be excised

D. Remove the excess skin from outside the incision and suture it closed

Rules and Techniques - Proper suture results depend on:

(1) The wound edges of the skin must be similar in length, or else a "cat's ear" will be formed. Otherwise, a "cat's ear" will be formed. The latter can be eliminated by trimming or other techniques (Figures 6, 4, and 5).

(2) Skin excision and skin movement can bring wound edges with depth to the same level (Figure 7).

(3) The entrance and exit depths of the subcutaneous suture area must be equal (or else deformation of the wound edge will result) (Figure 7B).

(4) Skin sutures must not be stretched too tightly or keloid contraction will develop (postoperative wound swelling must be considered).

(5) Suture ends must be left long enough for removal, but must be cut short enough to prevent them from interfering with adjacent sutures.

(6) After the suture is completed, the wound edges should be inspected. The epithelium should not be involved but should be turned outward (Figure 7C).

Figure 7: Downward sloping incision

A, Trimming the skin edge (otherwise the edge of the skin will not be easily aligned after suturing, and soft tissues will accumulate)

B, After suturing the subcutaneous tissue, after freeing the edge of the skin (freeing it at the subcutaneous fat layer)

C, Suturing the skin

4, Classical round irregular wounds (Figure 8).

Figure 8: Suture of a rounded irregular wound First, the direction and length difference of the short and long axes are clarified, and the wound is trimmed to a pike shape and then sutured

(1) If the short and long axes of the wound are equal, the wound can be trimmed to a pike shape along the line of skin relaxation tension or perpendicularly in the direction of the greater skin tension and then sutured .

(2) If there is a large difference between the short and long axes of the wound, trim the wound in the direction of the long axis as a shuttle suture. It is important to note that the initial trimming of the wound to avoid removing a large amount of skin tissue can be trimmed during suture alignment according to the linear irregularity of the wound processing method.

5. Triangular-like irregular wound (Figure 9).

Figure 9: Treatment of triangular-like irregular wounds

A, after the wound is trimmed to an obtuse triangle

B, the wound is sutured along the obtuse angle in the direction of the facing direction

(1) The triangle is obtuse or when the tension in one direction of the triangle is small, the wound can be sutured as a linear shape after the wound is trimmed to an obtuse triangle. The localized accumulation of skin tissue is reprocessed in the same way as a linear irregular wound.

(2) If the triangle cannot be trimmed or the wound tends to be triangular, the wound can be treated with triangular sutures, in which the tips of the three sides are sutured together and the rest of the wound is treated as a linear suture. To close the three-sided tip, the needle is inserted through the epidermis on side a and carries the tissue from the tip on side b (note that tip necrosis may occur with less tissue carried), followed by the needle exiting from the epidermis on side c and tying the knot (Figure 10).

Figure 10: Management of triangular-like irregular wounds

A, triangular suture method

B, triangular suture and then tie the knot, the rest of the part according to the linear suture method

Rules and tips:

1, irregular wounds suture, as far as possible, adjusting the direction of the suture to the direction of the least skin tension. direction.

2. Avoid removing too much skin tissue when trimming cat ears; smaller cat ears can improve on their own.

3. Try to avoid using the suture in Figure 10A, as it may cause ischemic necrosis of the tip and poor healing of the triangular suture.

Specialized Sutures

(A) Continuous Intracutaneous Suture

1. Advantages: The advantage of this suturing technique is that it usually requires only one entrance hole and one exit hole. This avoids excessive epithelialization of the puncture holes, especially in areas of the skin rich in sebaceous glands, and is beneficial in reducing postoperative scar formation.

2. Suture approach (Figure 11) The suture needle first enters the skin near one end of the wound and enters the wound intradermally. The suture is then passed through the other side of the wound in the dermal plane at exactly the same length to reach the distal end. The suture then leaves the skin at the distal end of the wound. The length of the wound edge is adjusted by applying slight traction to the suture, and finally the suture is secured with "buttons", sterile surgical tape , etc. to avoid inadvertent removal.

Figure 11: Continuous subcutaneous suture

A. The skin-in and skin-out points are at the ends of the wound, 1 cm from the incision margins, and are traveled intradermally at the same distance in a continuous fashion

B. After the suture is closed, the incision is closed, and the suture is adjusted to the skin margins on both sides by traction

Rules and Techniques:

Subcutaneous. Continuous suturing is only appropriate for incisions where both skin edges are similar in length:

1. Not well suited for suturing curvilinear wounds, which can lead to distortion of the wound.

2. A barbed wire can be used to improve suture stability.

(2) Vertical decubitus suture (Donati suture)

1. Advantages: Vertical decubitus suture has the advantage that it is safer to reconstruct the incision with a large difference in depth, which results in a more even margin on both sides of the skin, and that the wound flares out to avoid the formation of a furrowed scar, or even an inversion of the epithelium and poor wound healing. inversion and poor wound healing.

2. Suturing method (Figure 12) The needle entry point is located at about 4 mm from the edge of the incision, and then the needle exits at the same distance from the contralateral skin edge, and then the needle enters about 1 mm from the edge of the incision and exits at the same distance from the contralateral side. The knot can be slightly tightened to flare the incision edge.

Figure 12: Vertical mattress suture with needle entry point approximately 4mm from the incision edge

A, Suture shown to avoid dead space formation, and the skin edge can be trimmed before suturing to allow for alignment

B, Slightly flared skin edges after tying the knot

Rules and Techniques:

As an alternative it is possible to use a semi-buried vertical mattress suture (Figure 13). The horizontal decubitus suture also allows for flaring of the skin margin, but is not as stable as the vertical decubitus suture. However, decubitus sutures are used with caution because each stitch creates four suture marks and interferes with margin hemodynamics.

Figure 13: Semi-buried vertical mattress suture

A, the suture entry point on the opposite side of the needle, hanging part of the dermal tissue on the same side of the needle

B, and then tie the knot to close the incision

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