Suturing Techniques Technique_ General Principles, Placement of Specific Suture Types, Alternative Methods of Wound Closure.pdf

7/10/2015 Suturing Techniques Technique: General Principles, Placement of Specific Suture Types, Alternative Methods of Wound Closure

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Suturing Techniques TechniqueAuthor: Julian MackayWiggan, MD, MS; Chief Editor: Dirk M Elston, MD more...

Updated: Nov 24, 2014

General PrinciplesMany varieties of suture material and needles are available. The choice of sutures and needles is determined by thelocation 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, andknot placement remain the same.

Suture placement

A needle holder is used to grasp the needle at the distal portion of the body, one half to three quarters of thedistance from the tip of the needle, depending on the surgeon’s preference. The needle holder is tightened bysqueezing it until the first ratchet catches. The needle holder should not be tightened excessively, because damageto both the needle and the needle holder may result. The needle is held vertically and longitudinally perpendicular tothe needle holder (see the image below).

Needle is placed vertically and longitudinally perpendicular to needle holder.

Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the skin,or an undesirable angle of entry into the tissue. The needle holder is held by placing the thumb and the fourth fingerinto the loops and placing the index finger on the fulcrum of the needle holder to provide stability (see the firstimage below). Alternatively, the needle holder may be held in the palm to increase dexterity (see the second imagebelow).

Needle holder is held through loops between thumb and fourth finger, and index finger rests on fulcrum of instrument.

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Needle holder is held in palm, allowing greater dexterity.

The tissue must be stabilized to allow suture placement. Depending on the surgeon’s preference, toothed oruntoothed forceps or skin hooks may be used to grasp the tissue gently. Excessive trauma to the tissue beingsutured 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. Before removal of the needleholder, grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle inthe 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 andpromotes eversion of the skin edges. The needle should be inserted 13 mm from the wound edge, depending onskin thickness. The depth and angle of the suture depends on the particular suturing technique. In general, the twosides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skinsurface.

Knot tying

Once the suture is satisfactorily placed, it must be secured with a knot.[35] The instrument tie is used mostcommonly 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 for two complete turns (seethe image below). The tip of the needle holder is used to grasp the short end of the suture. The short end of thesuture is pulled through the loops of the long end by crossing the hands, so that the two ends of the suture are onopposite sides of the suture line. The needle holder is rotated counterclockwise once around the long end of thesuture. The short end is then grasped with the needle holder tip and pulled through the loop again.

Knot tying.

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 toexpand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the sutureincreases with increased wound edema. Depending on the surgeon’s preference, one or two additional throws maybe added.

Properly squaring successive ties is important. In other words, each tie must be laid down perfectly parallel to theprevious tie. This procedure is important in preventing the creation of a granny knot, which tends to slip and isinherently weaker than a properly squared knot. When the desired number of throws is completed, the suturematerial may be cut (if interrupted stitches are used), or the next suture may be placed.

Placement of Specific Suture Types

Simple interrupted suture

The most commonly used and most versatile suture in cutaneous surgery is the simple interrupted suture.[36] Thissuture is placed by inserting the needle perpendicular to the epidermis, traversing the epidermis and the fullthickness of the dermis, and exiting perpendicular to the epidermis on the opposite side of the wound. The twosides of the stitch should be symmetrically placed in terms of depth and width.

In general, the suture should have a flaskshaped 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 atthe base than at its apex, the resulting compression at the base forces the tissue upward and promotes eversion ofthe wound edges (see the image below). This maneuver decreases the likelihood of creating a depressed scar asthe wound retracts during healing.

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Simple interrupted suture placement. Bottom right image shows a flaskshaped stitch, which maximizes eversion.

As a rule, tissue bites should be evenly placed so that the wound edges meet at the same level; this minimizes thepossibility of mismatched woundedge heights (ie, stepping). However, the size of the bite taken from the two sidesof 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 edgethickness or height. Small bites can be used to precisely coapt wound edges. Large bites can be used to reducewound tension. Proper tension is important to ensure precise wound approximation while preventing tissuestrangulation. (See the image below.)

Line of interrupted sutures.

Simple running suture

A simple running (continuous) suture is essentially an uninterrupted series of simple interrupted sutures. The sutureis started by placing a simple interrupted stitch, which is tied but not cut. A series of simple sutures are placed insuccession, without the suture material being tied or cut after each pass. The sutures should be evenly spaced, andtension 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 tiedbetween the tail end of the suture material where it exits the wound and the loop of the last suture placed. (See theimage below.)

Running suture line.

Running locked suture

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A simple running suture may be either locked or left unlocked. The first knot of a running locked suture is tied as ina traditional running suture and may be locked by passing the needle through the loop preceding it as each stitch isplaced (see the image below). This suture is also known as the baseball stitch because of the final appearance ofthe running locked suture line.

Running locked suture.

Vertical mattress suture

A vertical mattress suture is a variation of a simple interrupted suture. It consists of a simple interrupted stitchplaced wide and deep into the wound edge and a second more superficial interrupted stitch placed closer to thewound edge and in the opposite direction (see the image below). The width of the stitch should be increased inproportion to the amount of tension on the wound—that is, the higher the tension, the wider the stitch.

Vertical mattress suture.

Halfburied vertical mattress suture

A halfburied vertical mattress suture is a modification of a vertical mattress suture that eliminates two of the fourentry points, thereby reducing scarring. It is placed in the same manner as the vertical mattress suture, except thatthe needle penetrates the skin to the level of the deep part of the dermis on one side of the wound, takes a bite inthe deep part of the dermis on the opposite side without exiting the skin, crosses back to the original side, andfinally exits the skin. Entry and exit points thus are kept on one side of the wound.

Pulley suture

A pulley suture is a modification of a vertical mattress suture. A vertical mattress suture is placed, the knot is leftuntied, and the suture is looped through the external loop on the other side of the incision and pulled across (seethe image below). At this point, the knot is tied. This new loop functions as a pulley, directing tension away from theother strands.

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Pulley stitch, type 1.

Farnear nearfar modified vertical mattress sutures

Another stitch that serves the same function as a pulley suture is a farnear nearfar modified vertical mattresssuture. The first loop is placed about 46 mm from the wound edge on the far side and about 2 mm from the woundedge on the near side. The suture crosses the suture line and reenters the skin on the original side at 2 mm fromthe wound edge on the near side. The loop is completed, and the suture exits the skin on the opposite side 46 mmaway from the wound edge on the far side (see the image below). A pulley effect is thus created.

Farnear nearfar modification of vertical mattress suture, creating pulley effect.

Horizontal mattress suture

A horizontal mattress suture is placed by entering the skin 5 mm to 1 cm from the wound edge. The suture ispassed 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 mmto 1 cm lateral of the exit point. The stitch is passed deep to the opposite side of the wound, where it exits the skin;the knot is then tied (see the image below).

Horizontal mattress suture.

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Halfburied horizontal suture

A halfburied horizontal suture (also referred to as a tip stitch or threepoint corner stitch) begins on the side of thewound on which the flap is to be attached. The suture is passed through the dermis of the wound edge to thedermis of the flap tip. The needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip, andreenters the skin to which the flap is to be attached. The needle is directed perpendicularly and exits the skin; theknot is then tied (see the image below).

Halfburied horizontal suture (tip stitch, threepoint corner stitch).

Dermalsubdermal sutures

A dermalsubdermal suture is placed by inserting the needle parallel to the epidermis at the junction of the dermisand the subcutis. The needle curves upward and exits in the papillary dermis, again parallel to the epidermis. Theneedle is inserted parallel to the epidermis in the papillary dermis on the opposing edge of the wound, curves downthrough the reticular dermis, and exits at the base of the wound at the interface between the dermis and thesubcutis 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. Ifthe suture is placed more superficially in the dermis at 24 mm from the wound edge, eversion is increased.

Buried horizontal mattress suture

A buried horizontal mattress suture is a pursestring suture. The suture must be placed in the midtodeep part ofthe dermis to prevent the skin from tearing. If tied too tightly, the suture may strangulate the approximated tissue.

Running horizontal mattress sutures

A simple suture is placed, and the knot is tied but not cut. A continuous series of horizontal mattress sutures isplaced, with the final loop tied to the free end of the suture material.[37]

Running subcuticular sutures

A running subcuticular suture is a buried form of a running horizontal mattress suture. It is placed by takinghorizontal bites through the papillary dermis on alternating sides of the wound (see the image below). No suturemarks are visible, and the suture may be left in place for several weeks.

Subcuticular stitch. Skin surface remains intact along length of suture line.

Running subcutaneous suture

A running subcutaneous suture begins with a simple interrupted subcutaneous suture, which is tied but not cut. Thesuture 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 thelast pass that was placed.

Running subcutaneous corset plication stitch

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Before the needle is inserted, forceps are used to pull firmly on at least 12 cm of tissue to ensure tissue strength.[14] The corset plication includes at least 12 cm of adipose tissue and fascia within each bite. After the first bite istied, bites are taken on opposite sides of the wound in a running fashion along the defect. The free end is pulledfirmly to reduce the size of the defect, and the suture is then tied.

Variations of tip (corner) sutures

Modified halfburied horizontal mattress suture

In a modified halfburied horizontal mattress suture, an additional vertical mattress suture is placed superficial to thehalfburied horizontal mattress suture. A small skin hook instead of forceps is used to avoid trauma of the flap.[5]

Deep tip stitch

A deep tip stitch is essentially a fully buried form of a threecorner stitch. The suture is placed into the deep dermisof the wound edge to which the flap is to be attached, passed through the dermis of the flap tip, and inserted intothe deep dermis of the opposite wound edge.[4]

Alternative Methods of Wound Closure

Wound closure tapes

Wound closure tapes (eg, SteriStrips) are composed of strips of reinforced microporous surgical adhesive tape.They are used to provide extra support to a suture line, either when running subcuticular sutures are used or aftersutures are removed.

Wound closure tapes may reduce spreading of the scar if they are kept in place for several weeks after sutureremoval. Often, they are used in conjunction with a tissue adhesive. Because they have a tendency to fall off, theyare used mainly in lowtension wounds and rarely for primary wound closure.

Staples

Stainless steel staples are frequently used in wounds under high tension, including wounds on the scalp or thetrunk. Advantages of staples include quick placement, minimal tissue reaction, low risk of infection, and strongwound closure. Disadvantages include less precise wound edge alignment and higher cost.

Tissue adhesive

Superglues that contain acrylates may be applied to superficial wounds to block pinpoint skin hemorrhages and toprecisely coapt wound edges. Because of their bacteriostatic effects and easy application, they have gainedincreasing popularity.[38, 39, 40, 41]

Tissue adhesives have demonstrated either cosmetic equivalence or superiority to traditional sutures in variousprocedures, including sutureless closure of pediatric day surgeries, saphenous vein harvesting for coronary arterybypass, and blepharoplasty.[42, 43, 44] The most commonly used adhesive, 2octyl cyanoacrylate (Dermabond), hasalso been used as a skin bolster for suturing thin, atrophic skin.[45]

Advantages of these topical adhesives include rapid wound closure, painless application, reduced risk of needlesticks, absence of suture marks, and elimination of any need for removal. Disadvantages include increased cost andless tensile strength (in comparison with sutures).

The use of tissue adhesives in dermatologic surgery is still evolving. It appears that using high viscosity 2octylcyanoacrylate in the repair of linear wounds after Mohs micrographic surgery results in cosmetic outcomesequivalent to those reported with the use of epidermal sutures.[46]

Greenhill and O’Regan reported on the use of Nbutyl 2cyanoacrylate for closure of parotid wounds and its relationto keloid and hypertrophic scar formation, as compared with the use of sutures.[47] Their results indicated a simplertechnique and a comparable result with the tissue adhesive.

In a related area, Tsui and Gogolewski reported on the use of microporous biodegradable polyurethane membranes,which may be useful for coverage of skin wounds, among other things.[48]

Barbed sutures

A barbed suture has been developed that is being evaluated for its efficacy in cutaneous surgery. The proposedadvantage 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 30 polydioxanone suturesuggests that a barbed suture has a safety and cosmesis profile similar to that of a conventional suture when usedto close cesarean delivery wounds.[49]

Barbed sutures have also been used in minimally invasive procedures to lift ptotic face and neck tissue. In onestudy, average patient satisfaction 11.5 months after a thread lift was 6.9/10.[50] By 3 months after the procedure,the skin of the neck and jawline relaxed and the final results became apparent. Overall, the barbed suture lift wasdetermined to provide sustained improvement in facial laxity.

These positive findings notwithstanding, painful dysesthesias and suture migration distant to the insertion site havebeen reported.[51, 52] Although the longterm efficacy of barbed suspension sutures remains unclear, they may allowa minimally invasive facial lift with few adverse effects.[53]

Novel punch biopsy closure

Placing sutures lateral to a punch biopsy causes the defect to taper, allowing a more linear closure and yieldingimproved cosmetic outcomes.[54] A simple interrupted stitch is placed 13 mm lateral to a wound edge, a second

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stitch is placed 13 mm lateral to the opposite wound edge, and a final stitch is placed at the center of the wound.Sites larger than 4 mm may require additional interrupted stitches. Disadvantages include extended procedure timeand increased risk of suture marks.

Contributor Information and DisclosuresAuthorJulian MackayWiggan, MD, MS Assistant Professor, Department of Dermatology, Columbia UniversityNewYork Presbyterian Hospital

Julian MackayWiggan, MD, MS is a member of the following medical societies: American Academy ofDermatology, Society for Investigative Dermatology, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)Desiree Ratner, MD Director, Comprehensive Skin Cancer Center, Continuum Cancer Centers of New York;Director of Dermatologic Surgery, Beth Israel Medical Center and St Luke's and Roosevelt Hospitals; Professorof Clinical Dermatology, Columbia University College of Physicians and Surgeons

Desiree Ratner, MD is a member of the following medical societies: American Academy of Dermatology,American College of Mohs Surgery, American Medical Association, American Society for Dermatologic Surgery,Phi Beta Kappa

Disclosure: Nothing to disclose.

Divya R Sambandan Columbia University College of Physicians and Surgeons

Divya R Sambandan is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief EditorDirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

AcknowledgementsDaniel G Becker, MD Assistant Professor, Department of OtorhinolaryngologyHead and Neck Surgery, Divisionof Facial Plastic and Reconstructive Surgery, University of Pennsylvania School of Medicine

Daniel G Becker, MD is a member of the following medical societies: American Academy of Facial Plastic andReconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery, and American College ofSurgeons

Disclosure: Nothing to disclose.

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor ofSurgery, Division of OtolaryngologyHead and Neck Surgery, Faculty of Medicine, Université de Sherbrooke,Canada

Disclosure: Nothing to disclose.

Richard F Edlich, MD, PhD, FACS, FASPS, FACEP Distinguished Professor Emeritus of Plastic Surgery,Biomedical Engineering and Emergency Medicine, University of Virginia Health Care System

Richard F Edlich, MD, PhD, FACS, FASPS, FACEP is a member of the following medical societies: AlphaOmega Alpha, American Association of Plastic Surgeons, American Burn Association, American College ofEmergency Physicians, American College of Surgeons, American Society of Plastic and Reconstructive Surgery,American Spinal Injury Association, American Surgical Association, American Trauma Society, Plastic SurgeryResearch Council, Society ofUniversity Surgeons, and Surgical Infection Society

Disclosure: Nothing to disclose.

Stephen Y Lai, MD, PhD Associate Professor, Department of Head and Neck Surgery, University of Texas MDAnderson Cancer Center

Stephen Y Lai, MD, PhD is a member of the following medical societies: American Academy of OtolaryngologyHead and Neck Surgery, American Association for Cancer Research, American Head and Neck Society, andSociety of University OtolaryngologistsHead and Neck Surgeons

Disclosure: GlaxoSmithKline Grant/research funds None; Neoprobe Grant/research funds clinical trial

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of ColoradoSchool of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plasticand Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery, and American Headand Neck Society

Disclosure: Axis Three Corporation Ownership interest Consulting; Medvoy Ownership interest Managementposition; Cerescan Imaging Honoraria Consulting

Anthony P Sclafani, MD Director of Facial Plastic Surgery and Surgeon Director, New York Eye and EarInfirmary; Professor of Otolaryngology, New York Medical College

Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic andReconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery, and American College of

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Surgeons

Disclosure: Contura None Board membership; Aesthetic Factors, Inc. Salary Consulting; Meditech MedicalEnterprises Consulting fee Independent contractor

Shobana Sood, MD Assistant Professor, Department of Dermatology, University of Pennsylvania Hospital

Shobana Sood, MD is a member of the following medical societies: American Academy of Dermatology andAmerican Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; EditorinChief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health SciencesCenter, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy ofDermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

References

1. Adams B, Anwar J, Wrone DA, Alam M. Techniques for cutaneous sutured closures: variants andindications. Semin Cutan Med Surg. 2003 Dec. 22(4):30616. [Medline].

2. Ratner D, Nelson BR, Johnson TM. Basic suture materials and suturing techniques. Semin Dermatol. 1994Mar. 13(1):206. [Medline].

3. Kandel EF, Bennett RG. The effect of stitch type on flap tip blood flow. J Am Acad Dermatol. 2001 Feb.44(2):26572. [Medline].

4. Chan JL, Miller EK, Jou RM, Posten W. Novel surgical technique: placement of a deep tip stitch. DermatolSurg. 2009 Dec. 35(12):20013. [Medline].

5. Bechara FG, AlMuhammadi R, Sand M, Tomi NS, Altmeyer P, Hoffmann K. A modified corner stitch forfixation of flap tips. Dermatol Surg. 2007 Oct. 33(10):12779. [Medline].

6. YagHoward C. Novel surgical approach to subcutaneous closure: the subcutaneous inverted cross mattressstitch (SICM Stitch). Dermatol Surg. 2011 Oct. 37(10):15035. [Medline].

7. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures. J Am Acad Dermatol. 2004 Jan.50(1):736. [Medline].

8. Moody BR, McCarthy JE, Linder J, Hruza GJ. Enhanced cosmetic outcome with running horizontalmattress sutures. Dermatol Surg. 2005 Oct. 31(10):13136. [Medline].

9. Chacon AH, Shiman MI, Strozier N, Zaiac MN. Horizontal running mattress suture modified withintermittent simple loops. J Cutan Aesthet Surg. 2013 Jan. 6(1):546. [Medline]. [Full Text].

10. Eleftheriou LI, Weinberger CH, Endrizzi BT, et al. The Victory stitch: a novel running vshaped horizontalmattress suturing technique. Dermatol Surg. 2011 Nov. 37(11):16635. [Medline].

11. Alam M, Posten W, Martini MC, Wrone DA, Rademaker AW. Aesthetic and functional efficacy ofsubcuticular running epidermal closures of the trunk and extremity: a raterblinded randomized control trial.Arch Dermatol. 2006 Oct. 142(10):12728. [Medline].

12. Maher IA, Bingham J, Mellette R. A running modification of the percutaneous buried vertical mattress.Dermatol Surg. 2012 Sep. 38(9):15602. [Medline].

13. YagHoward C. Zipper stitch: a novel aesthetic subcutaneous closure. Dermatol Surg. 2013 Sep.39(9):14002. [Medline].

14. Tierney E, Kouba DJ. A subcutaneous corset plication rapidly and effectively relieves tension on largelinear closures. Dermatol Surg. 2009 Nov. 35(11):18068. [Medline].

15. Edlich RF, Long WB 3rd, Gubler KD, Rodeheaver GT, Thacker JG, Borel L, et al. Citizen's Petition toFood and Drug Administration to ban cornstarch powder on medical gloves: Maltese cross birefringence.Am J Emerg Med. 2009 Feb. 27(2):22735. [Medline].

16. Edlich RF, Wind TC, Heather CL, Thacker JG. Reliability and performance of innovative surgical doubleglove hole puncture indication systems. J Long Term Eff Med Implants. 2003. 13(2):6983. [Medline].

17. Lin KY, Farinholt HM, Reddy VR, Edlich RF, Rodeheaver GT. The scientific basis for selecting surgicalsutures. J Long Term Eff Med Implants. 2001. 11(12):2940. [Medline].

18. Drake DB, Rodeheaver PF, Edlich RF, Rodeheaver GT. Experimental studies in swine for measurement ofsuture extrusion. J Long Term Eff Med Implants. 2004. 14(3):2519. [Medline].

19. Sanz LE, Patterson JA, Kamath R, Willett G, Ahmed SW, Butterfield AB. Comparison of Maxon suturewith Vicryl, chromic catgut, and PDS sutures in fascial closure in rats. Obstet Gynecol. 1988 Mar. 71(3 Pt1):41822. [Medline].

20. Demyttenaere SV, Nau P, Henn M, Beck C, Zaruby J, Primavera M, et al. Barbed suture forgastrointestinal closure: a randomized control trial. Surg Innov. 2009 Sep. 16(3):23742. [Medline].

7/10/2015 Suturing Techniques Technique: General Principles, Placement of Specific Suture Types, Alternative Methods of Wound Closure

http://emedicine.medscape.com/article/1824895technique?src=emailthis 10/11

21. PinerosFernandez A, Drake DB, Rodeheaver PA, Moody DL, Edlich RF, Rodeheaver GT. CAPROSYN*,another major advance in synthetic monofilament absorbable suture. J Long Term Eff Med Implants. 2004.14(5):35968. [Medline].

22. Szarmach RR, Livingston J, Edlich RE. An expanded surgical suture and needle evaluation and selectionprogram by a healthcare resource management group purchasing organization. J Long Term Eff MedImplants. 2003. 13(3):15570. [Medline].

23. Tera H, Aberg C. Tissue holding power to a single suture in different parts of the alimentary tract. ActaChir Scand. 1976. 142(5):3438. [Medline].

24. Van Winkle W Jr, Hastings JC. Considerations in the choice of suture material for various tissues. SurgGynecol Obstet. 1972 Jul. 135(1):11326. [Medline].

25. Salthouse TN, Williams JA, Willigan DA. Relationship of cellular enzyme activity to catgut and collagensuture absorption. Surg Gynecol Obstet. 1981. 129:6916.

26. Regan T, Lawrence N. Comparison of poliglecaprone25 and polyglactin910 in cutaneous surgery.Dermatol Surg. 2013 Sep. 39(9):13404. [Medline].

27. Faulkner BC, Gear AJ, Hellewell TB, Mazzarese PM, Watkins FH, Edlich RF. Biomechanical performanceof a braided absorbable suture. J Long Term Eff Med Implants. 1996. 6(34):16979. [Medline].

28. Murtha AP, Kaplan AL, Paglia MJ, Mills BB, Feldstein ML, Ruff GL. Evaluation of a novel technique forwound closure using a barbed suture. Plast Reconstr Surg. 2006 May. 117(6):176980. [Medline].

29. Edlich RF, Drake DB, Rodeheaver GT, Winters KL, Greene JA, Gubler KD, et al. Syneture stainlessSTEEL suture. A collective review of its performance in surgical wound closure. J Long Term Eff MedImplants. 2006. 16(1):10110. [Medline].

30. Rodeheaver GT, Nesbit WS, Edlich RF. Novafil. A dynamic suture for wound closure. Ann Surg. 1986 Aug.204(2):1939. [Medline]. [Full Text].

31. Rodeheaver GT, Shimer AL, Boyd LM, Drake DB, Edlich RF. An innovative absorbable coating for thepolybutester suture. J Long Term Eff Med Implants. 2001. 11(12):4154. [Medline].

32. Rosenzweig LB, Abdelmalek M, Ho J, Hruza GJ. Equal cosmetic outcomes with 50 poliglecaprone25versus 60 polypropylene for superficial closures. Dermatol Surg. 2010 Jul. 36(7):11269. [Medline].

33. Kaulbach HC, Towler MA, McClelland WA, Povinelli KM, Becker DG, Cantrell RW, et al. A beveled,conventional cutting edge surgical needle: a new innovation in wound closure. J Emerg Med. 1990 MayJun. 8(3):25363. [Medline].

34. Abidin MR, Towler MA, Thacker JG, Nochimson GD, McGregor W, Edlich RF. New atraumatic roundededge surgical needle holder jaws. Am J Surg. 1989 Feb. 157(2):2412. [Medline].

35. Richey ML, Roe SC. Assessment of knot security in continuous intradermal wound closures. J Surg Res.2005 Feb. 123(2):2848. [Medline].

36. Adams B, Levy R, Rademaker AE, Goldberg LH, Alam M. Frequency of use of suturing and repairtechniques preferred by dermatologic surgeons. Dermatol Surg. 2006 May. 32(5):6829. [Medline].

37. Wong NL. Review of continuous sutures in dermatologic surgery. J Dermatol Surg Oncol. 1993 Oct.19(10):92331. [Medline].

38. Nahas FX, Solia D, Ferreira LM, Novo NF. The use of tissue adhesive for skin closure in body contouringsurgery. Aesthetic Plast Surg. 2004 MayJun. 28(3):1659. [Medline].

39. Nitsch A, Pabyk A, Honig JF, Verheggen R, Merten HA. Cellular, histomorphologic, and clinicalcharacteristics of a new octyl2cyanoacrylate skin adhesive. Aesthetic Plast Surg. 2005 JanFeb. 29(1):538. [Medline].

40. Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. Am J Emerg Med. 2008May. 26(4):4906. [Medline].

41. Quinn JV, Osmond MH, Yurack JA, Moir PJ. N2butylcyanoacrylate: risk of bacterial contamination with anappraisal of its antimicrobial effects. J Emerg Med. 1995 JulAug. 13(4):5815. [Medline].

42. Hasan Z, Gangopadhyay AN, Gupta DK, Srivastava P, Sharma SP. Sutureless skin closure with isoamyl 2cyanoacrylate in pediatric daycare surgery. Pediatr Surg Int. 2009 Dec. 25(12):11235. [Medline].

43. Krishnamoorthy B, Najam O, Khan UA, Waterworth P, Fildes JE, Yonan N. Randomized prospective studycomparing conventional subcuticular skin closure with Dermabond skin glue after saphenous veinharvesting. Ann Thorac Surg. 2009 Nov. 88(5):14459. [Medline].

44. Perin LF, Helene A Jr, Fraga MF. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl2cyanoacrylate. Aesthet Surg J. 2009 MarApr. 29(2):8792. [Medline].

45. Bain MA, Peterson EA, Murphy RX Jr. Dermabond bolsterassisted primary closure of atrophic skin. PlastReconstr Surg. 2009 Apr. 123(4):147e149e. [Medline].

46. Sniezek PJ, Walling HW, DeBloom JR 3rd, Messingham MJ, VanBeek MJ, Kreiter CD. A randomizedcontrolled trial of highviscosity 2octyl cyanoacrylate tissue adhesive versus sutures in repairing facialwounds following Mohs micrographic surgery. Dermatol Surg. 2007 Aug. 33(8):96671. [Medline].

47. Greenhill GA, O'Regan B. Incidence of hypertrophic and keloid scars after Nbutyl 2cyanoacrylate tissueadhesive had been used to close parotidectomy wounds: a prospective study of 100 consecutive patients.Br J Oral Maxillofac Surg. 2009 Jun. 47(4):2903. [Medline].

48. Tsui YK, Gogolewski S. Microporous biodegradable polyurethane membranes for tissue engineering. JMater Sci Mater Med. 2009 Aug. 20(8):172941. [Medline].

7/10/2015 Suturing Techniques Technique: General Principles, Placement of Specific Suture Types, Alternative Methods of Wound Closure

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Medscape Reference © 2011 WebMD, LLC

49. Murtha AP, Kaplan AL, Paglia MJ, Mills BB, Feldstein ML, Ruff GL. Evaluation of a novel technique forwound closure using a barbed suture. Plast Reconstr Surg. 2006 May. 117(6):176980. [Medline].

50. Kaminer MS, Bogart M, Choi C, Wee SA. Longterm efficacy of anchored barbed sutures in the face andneck. Dermatol Surg. 2008 Aug. 34(8):10417. [Medline].

51. Lee CJ, Park JH, You SH, Hwang JH, Choi SH, Kim CH. Dysesthesia and fasciculation: unusualcomplications following facelift with cog threads. Dermatol Surg. 2007 Feb. 33(2):2535; discussion 255.[Medline].

52. SilvaSiwady JG, DíazGarza C, OcampoCandiani J. A case of Aptos thread migration and partialexpulsion. Dermatol Surg. 2005 Mar. 31(3):3568. [Medline].

53. Villa MT, White LE, Alam M, Yoo SS, Walton RL. Barbed sutures: a review of the literature. PlastReconstr Surg. 2008 Mar. 121(3):102e108e. [Medline].

54. Skvarka CB, Greenbaum SS. A novel surgical technique: placement of the suture lateral to the punchbiopsy defect. Dermatol Surg. 2007 Feb. 33(2):2224. [Medline].