11/13/24, 7\:27 PM Guide | Subcuticular suture

Subcuticular suture

Table of contents

Introduction

This guide demonstrates how to perform a subcuticular suture, including step-by-step images of the key stages involved. This
guide focuses on a buried continuous dermal suture which is typically used to approximate the most super

Equipment

Needle holder (a.k.a. Driver)

Needle holders should be held with your dominant hand.
Put your thumb through one handle and place your ring
they feel you have greater dexterity and range of movement (this is referred to as "palming").
Needle holder closed

Toothed forceps (a.k.a. Pickups)

Hold the forceps with your non-dominant hand in the same way you would hold a pen.
Be gentle when using toothed forceps to manipulate skin, do not grip it too tightly or you may damage the wound's edges.
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Hold the forceps with your non-dominant hand in the same way you would hold a pen

Scissors

Scissors are used for cutting sutures.
Position your index
Rest the blades on your index
Use scissors to cut sutures

Suture

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The suture of choice in this scenario tends to be Monocryl as it is a smooth absorbable mono
strength and doesn't cause much irritation to the skin. Monocryl loses 50% of its tensile strength at approximately 3 weeks and
completely absorbs within 8 weeks. Care must be taken, if knots are not tied deep under the skin they can erode through the
wound whilst healing.
Prolene or nylon can also be used as these are smooth and cause minimal skin irritation. These mono
absorbable and therefore have to be removed, which is viewed as an advantage by some. Be sure not to leave too long a
length of suture within the skin or it may snap when attempting to remove it, leaving non-absorbable suture within the skin.
Vicryl Rapide is a braided absorbable suture which loses 50% of its tensile strength at 7 days and is completely absorbed at 21
days. Braided sutures are thought to induce a more signi

Principles of wound management

This is a sterile procedure, and therefore the wound and surrounding skin must be prepared with antiseptic solution before
placing a drape around the sterile
during the procedure. Although you may not need a surgical gown, you must don gloves taking care not to touch the external
surface.
Wash the wound and debride the skin edges if ragged or dirty and if you are certain there is no deep tissue damage you may
proceed to close the skin.
Load your needle holder by placing the needle in the tip of the holder, two-thirds of the distance from the tip to the thread.

Setup

This is a sterile procedure, and therefore the wound and surrounding skin must be prepared with antiseptic solution before
placing a drape around the sterile
during the procedure. Although you may not need a surgical gown, you must don gloves and take care not to touch any
external surfaces.
Wash the wound and debride the skin edges if ragged or dirty. If you are certain there is no deep tissue damage you may
proceed to close the skin.
Load your needle holder by placing the needle in the tip of the holder, two-thirds of the distance from the tip to the thread.
Plan the entry and exit of your suture on either side of the wound. The suture should lie perpendicularly across the wound
with equal depth and distance from the wound edge.
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Load the needle between the apex of its curvature and two-thirds from the needle tip

Subcuticular sututre

This technique generally follows dermal suturing to complete a layered closure. It is often performed with an absorbable
suture, however, non-absorbable material can be used and removed once the wound has reached an adequate strength. The
technique can be thought of as a buried continuous suture.

Procedure

1. The suture is started at one apex of the wound. It can either be started with a buried dermal knot or a free length of suture
out of the skin which can later be trimmed (if absorbable) or removed (if non-absorbable).
At the apex of the wound, pass your need from deep to super
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2. It is easier to suture from 'far to near' or from your dominant side towards your non-dominant side (right to left assuming
right-handedness).
3. Starting from the chosen apex, take a bite deep to the epidermis that should curve parallel to the skin surface and exit in the
same plane approximately 5-10mm along the wound, taking care to stay at the same level. It is useful to evert the skin edge
with the toothed forceps to help. Ensuring that your suture is not too super
4. Remove the needle and pull the stitch through.
5. Perform a mirror image on the opposing side keeping the bites the same depth and length. If one side of your wound is
longer than the other, bigger bites must be taken on the longer side of the wound to compensate for excess skin at the apex of
the wound (called a 'dog ear').
6. Continue this down the length of the wound, pulling the suture taut as you oppose the skin edges.
Pass your needle from deep to super
7. Once the distal apex is approached a knot needs to be secured (if not leaving the ends free).
8. Two deeper opposing bites are taken and then a knot can be instrument tied using a loop of suture or, more commonly, an
'Aberdeen knot'
.
9. To do this bring the needle out at the apex of the wound, pull this through with your non-dominant hand leaving behind a
loop big enough for the thumb and index
and index
non-dominant hand, pull the loop down to form a knot. Repeat this 2-3 times and on the
loop to secure the knot. If you create too many loops the knot will increase in size and is more likely to erode through the skin.
10. Once a secure knot is formed in the apex, pass the needle back deep through the wound emerging adjacent to the wound,
this will bury the knot.
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To bury the
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