Abscess Incision and Drainage

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Abscess Incision and Drainage

Michael T. Fitch, M.D., Ph.D., David E. Manthey, M.D., Henderson D. McGinnis, M.D., Bret A. Nicks, M.D., and Manoj Pariyadath, M.D.

N Engl J Med 2007; 357:e20November 8, 2007

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About the Procedure

Incision and drainage is the primary therapy for cutaneous abscess management, as antibiotic treatment alone is inadequate for treating many of these loculated collections of infectious material. Most localized skin abscesses without associated cellulitis can be managed with simple incision and drainage and do not require antibiotic treatment. Cutaneous abscesses have been described in all areas of the body, but are most commonly found in the axillae, buttocks, and extremities. This outpatient procedure is appropriate for many office settings, as well as for urgent care and emergency department practice environments. Diagnosis of a skin abscess is the first step . . . .

No potential conflict of interest relevant to this article was reported.

References

References

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   Meislin HW, Lerner SA, Graves MH, et al. Cutaneous abscesses: anaerobic and aerobic bacteriology and outpatient management. Ann Intern Med 1977;87:145-149
   Web of Science | Medline
2. 2
   Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970;1:1077-1080
   CrossRef | Web of Science | Medline
3. 3
   Llera JL, Levy RC, Staneck JL. Cutaneous abscesses: natural history and management in an outpatient facility. J Emerg Med 1984;1:489-493
   CrossRef | Medline
4. 4
   Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985;14:15-19
   CrossRef | Web of Science | Medline
5. 5
   Hankin A, Everett WW. Are antibiotics necessary after incision and drainage of a cutaneous abscess? Ann Emerg Med 2007;50:49-51
   CrossRef | Web of Science | Medline
6. 6
   Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and drainage in the emergency department -- part I. J Emerg Med 1985;3:227-232
   CrossRef | Medline
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   Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Acad Emerg Med 2005;12:601-606
   CrossRef | Web of Science | Medline
8. 8
   Fine BC, Sheckman PR, Bartlett JC. Incision and drainage of soft-tissue abscesses and bacteremia. Ann Intern Med 1985;103:645-645
   Web of Science | Medline
9. 9
   Burney RE. Incision and drainage procedures: soft tissue abscesses in the emergency service. Emerg Med Clin North Am 1986;4:527-542
   Medline
10. 10
    Frazee BW, Lynn J, Charlebois ED, Lambert L, Lowery D, Perdreau-Remington F. High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections. Ann Emerg Med 2005;45:311-320
    CrossRef | Web of Science | Medline
11. 11
    Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006;355:666-674
    Full Text | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1
   C. Liu, A. Bayer, S. E. Cosgrove, R. S. Daum, S. K. Fridkin, R. J. Gorwitz, S. L. Kaplan, A. W. Karchmer, D. P. Levine, B. E. Murray, M. J. Rybak, D. A. Talan, H. F. Chambers. (2011) Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clinical Infectious Diseases 52:3, e18-e55
   CrossRef
2. 2
   Edina Avdic, Sara E Cosgrove. (2008) Management and control strategies for community-associated methicillin-resistant Staphylococcus aureus. Expert Opinion on Pharmacotherapy 9:9, 1463-1479
   CrossRef

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Suturing and Wound Closure: How to Achieve Optimal Healing

Suturing and Wound Closure: How to Achieve Optimal Healing

• Volume 47 - Issue 12 - December 2007
• 345 reads
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Authors: 

D. BRADY PREGERSON, MD

Although many lacerations are treated in the emergency department, primary care clinicians still see their share of such wounds. Most lacerations are incurred on the face and head (as a result of falls or altercations) or on the hand or lower arm (caused by tools, broken glass, or other sharp objects).
Here I review the basic principles of wound closure and discuss the pros and cons of various suturing techniques. I also offer tips on pre-closure anesthesia.
CONTROL OF BLEEDING
Hemostasis is critical to thorough wound exploration. Bleeding may have been controlled by the time you see the patient; however, if this is not the case—or if bleeding recurs—direct pressure applied for 10 minutes is the safest and usually the most effective way to achieve hemostasis.
For life-threatening or arterial bleeding, an arterial pressure cuff can be very effective, at least temporarily. Alternatively, a blood pressure cuff can be inflated to 30 mm Hg above the patient's systolic blood pressure and then clamped with a hemostat. A blood pressure cuff is safer than a tourniquet. However, to avoid limb ischemia, do not leave either type of cuff in place for more than 2 hours.
If electrocautery or tying off of small arteries is needed, consult with a surgeon. Nerves are often found in close proximity to arteries and can be inadvertently damaged during attempts at hemostasis.
PRE-CLOSURE ANESTHESIA
Local injection. Anesthesia in adults is most often accomplished through either local injection or nerve blocks using lidocaine(, bupivacaine(, or both. Bupivacaine has the advantage of inducing anesthesia that lasts 4 to 8 hours, which can provide the patient longer relief from discomfort. However, bupivacaine often does not work well in finger blocks and is not recommended in the lips.
Epinephrine is sometimes added to lidocaine or bupivacaine to help control bleeding. Avoid the use of epinephrine( in areas of compromised circulation, such as flaps and partially devitalized tissue. However, the traditional injunction against using epinephrine in the nose and digits has recently been called into question, and its benefits probably outweigh its risks if there is no compromise in circulation and if small amounts are used.
For large lacerations, the maximum dose of lidocaine is 4.5 mg/kg, or 7 mg/kg of lidocaine combined with epinephrine; the maximum dose of bupivacaine is only 2 mg/kg. For a 70-kg adult, this translates to about 30 mL of 1% lidocaine, 50 mL of 1% lidocaine with epinephrine, or 50 mL of 0.25% bupivacaine. Be sure to use a shield when you inject.
There are several ways to diminish the discomfort of anesthetic injection. Use of a small-gauge needle and a slow rate of injection can help tremendously. Decreasing the acidity of the local agent by buffering it with sodium bicarbonate( may also lessen pain. Most sources recommend 1 part buffer to 9 parts anesthetic.
Topical anesthetics. These can be highly effective, especially in well-vascularized areas such as the face.
Currently, LET (lidocaine-epinephrine-tetracaine) is the preferred topical agent; it avoids the potential toxicity and other issues associated with the older TAC (tetracaine-adrenaline-cocaine). LET is most effective in the face (in about 85% of cases), but it is also effective in 45% of extremity lacerations. In addition, it is more effective in larger lacerations than in smaller ones.
For adequate anesthesia, allow LET to sit for at least 20 minutes before proceeding to wound irrigation and exploration—although contact times of 30 to 60 minutes produce even better results. The development of skin blanching (caused by the epinephrine) is a fairly reliable indication that the treated area is numb. Strategies to maximize the effectiveness of topical anesthesia are listed in the Box.
IRRIGATION, EXPLORATION, AND DEBRIDEMENT
Irrigation. Copious irrigation is most important in contaminated wounds and those more than 3 hours old, in which bacterial counts may be higher. Do not irrigate puncture wounds; irrigation may just push dirt in deeper. Wounds longer than 1 cm are usually large enough to allow adequate irrigation.
A variety of wound irrigation products are available. I prefer a large amount of tap water followed by a small amount of sterile saline. Studies show good results with tap water, although one theoretical disadvantage to its use is that because it is hypotonic, it might damage tissue. Always use appropriate splash precautions.
Exploration. Adequate wound exploration is a critical step in laceration management. Poor or incomplete exploration increases the risk of a bad outcome. Be sure to explore the wound in a bloodless field through the full range of motion to its base. Even when imaging results appear normal, look or gently probe with a metal instrument for small foreign bodies that may not show up on an x-ray film; radiographs miss up to 40% of glass foreign bodies smaller than 0.5 mm.

Also look for partial tendon injuries that might be missed on strength testing. Tendons run surprisingly close to the surface on the dorsum of the hand and fingers (Figure 1). Any tendon involvement requires antibiotic prophylaxis, specialty consultation, and follow-up.
Debridement. Debridement of devitalized tissue is critical to minimizing the risk of infection. Devitalized tissue can usually be identified by its dusky appearance and lack of or limited connection to the subcutaneous blood supply. However, avoid the temptation to "straighten up" wound margins when tissue is viable. Jagged wound edges aid in proper closure and minimize scarring. Unnecessary debridement increases wound tension and often leads to a wider and more noticeable scar.
STRATEGIES TO MINIMIZE INFECTION RISK
The overall rate of infection in wounds of any kind is about 3%. Factors that lower this risk include adequate debridement and irrigation, and the use of tape or staples rather than suture. "Loose" closure has been shown not to diminish risk. Factors that increase the risk of infection include comorbidities, such as heart, liver, or kidney disease and diabetes; use of epinephrine; edema; delayed presentation; crush injuries; and foreign bodies.
Consider skin closure strips for smaller wounds that are contaminated or in a location where the risk of infection is higher (eg, intra-oral wounds). Lacerations that are smaller than 1 cm often heal well without formal closure or when managed with skin closure strips alone.
Delaying—or skipping—primary closure. Closing a wound too soon may increase infection risk in certain settings. In some cases, primary closure is contraindicated. For example, puncture wounds and animal bites to the hands or feet should almost never be closed, mainly because of the increased risk of infection in such wounds.
When wounds are more than 8 hours old, the risks and benefits of primary closure must be carefully weighed. Primary closure can be considered:

• If the wound is clean.
• If it is on the head or face.
• If it can be properly irrigated.

However, delaying primary closure in wounds more than 8 hours olddecreases the risk of infection and may be the wisest course:

• If the wound is dirty.
• If it is on an extremity or the torso.
• If it is too small to irrigate properly.
• If it has devitalized tissue.

Also consider delaying primary closure for:

• Infected or heavily contaminated wounds.
• Bite wounds.
• Wounds that are more than 8 to 12 hours old (older than 24 hours for wounds on the head or face).

When primary closure is delayed, the wound is still anesthetized, explored, cleaned, and debrided as for initial primary closure. It is then packed open and re- checked in 36 to 48 hours and again after 3 to 5 days. If the wound does not appear infected at the time of the second check, it can then be sutured. Cosmetic results are similar to those achieved with early primary closure, but the risk of infection is much lower.
Antibiotic prophylaxis. In lacerations, the use of antibiotic prophylaxis is somewhat controversial. However, there is evidence to support prophylactic antibiotic use in the following settings:

• Open fractures.
• Tendon injuries.
• Animal bites to the extremities.
• Presence of lymphedema.
• Presence of a heart murmur.

You may also want to consider antibiotics in other wounds with high-risk features, especially if several of these features are present.
Tetanus booster. With clean lacerations, administer a tetanus booster if it has been more than 10 years since the last vaccination—with high-risk wounds, if it has been more than 5 years.
PREPARATION OF THE SKIN
Topical antiseptics such as povidone-iodine may be used on intact skin, but they should be kept out of the wound, or at least washed out if they do get in. Also make sure that hair is kept out of the wound: either trim the hair or use a topical antibiotic ointment to mat it down. If you trim a patient's hair, use scissors or electrical clippers; razors increase the risk of infection. (Most texts suggest avoiding shaving eyebrows because these may not grow back.) Follow preparation of the skin with a sterile prep and drape.
SELECTION OF SUTURE
Each type of suture has advantages and disadvantages. Thinner suture leaves smaller holes in the skin and is appropriate for the face, areas of cosmetic concern, and areas of low tension where strength to resist breaking is not an issue. Thicker suture is stronger and is appropriate for the extremities and areas of higher wound tension, such as near joints. Many clinicians prefer to use 6.0 or sometimes 5.0 on the face, and 4.0 in most other areas. On the sole of the foot or in areas with high tension where there is a risk of breakage, 3.0 suture can be used.
Absorbable suture is appropriate for buried stitches and for patients who may not be able to return for suture removal. Also consider using absorbable suture in uncooperative patients, such as young children, especially if conscious sedation is required to place the stitches.
Many clinicians prefer the feel of nylon to that of polypropylene; nylon also has better workability and knot security. However, polypropylene has better strength and tissue reactivity; it also may be the better choice when stitches must be placed in dark eyebrows or other areas where its blue color may help make the stitches more visible, facilitating their removal. Other features of some of the more popular types of suture are compared in the Table.
STITCHING BASICS

There are many ways to suture a wound. Most emergency department physicians use primarily interrupted stitches (Figure 2), while most surgeons use primarily running stitches. I prefer running stitches; their main advantage is that they save time. They also distribute tension more evenly and thus can minimize tissue strangulation. In a clean linear wound, a single long running stitch may be all that is needed.
If there is tension on a wound or if it has irregular areas, interrupted stitches may be required. Some clinicians also prefer to use interrupted stitches in infection-prone wounds: if the wound becomes infected in just one area, some of the stitches can be removed while others are left.

Figure 3

Figure 4

Figure 5

With running stitches, the first stitch and tie are the same as for a simple interrupted stitch. I generally start at one edge of the wound, although I may start in the center if there is tension. With a linear wound, I stretch the wound (to avoid translational errors) as I begin my first stitch (Figure 3). If there is tension on the wound, I "lock" the stitch after the first throw by pulling both sides of the suture to one side. This holds the first throw tight and helps prevent a loose first knot. I then cut the short end and continue suturing with the long end, making sure that the second stitch is close to the first. Each stitch should run perpendicular to the wound below the surface, leaving the visible portions of suture at a slight angle to the wound (Figure 4). The final 2 stitches, like the first 2, should also be close together. Tie the final knot using a "bite" of suture that is a loop rather than a single loose end (Figure 5). Because suturing done with running stitches relies on a single knot at each end, I make sure that my knots have at least 5 throws each.
STITCHES FOR SPECIAL SETTINGS
Other, less frequently used suturing techniques include:

• Vertical mattress stitch.
• Horizontal mattress stitch.
• Interlocking stitch.
• Subcuticular stitch.
• Buried stitches.

Mattress stitches. The vertical mattress stitch might be described as 2 stitches in 1. It is useful in settings in which you do not want to place a deep stitch because of tension on a wound.
A horizontal mattress stitch is basically 2 stitches side by side. However, in a regular interrupted stitch the suture material crosses above the wound, while in a horizontal mattress stitch, it does not (Figure 6). Use of the mattress stitch helps maintain wound eversion and may decrease suture time by halving the number of knots that need to be tied. Wound inversion may be a problem in skin that has minimal or loose supportive tissue, such as that of the back of the hand (where the horizontal mattress stitch is likely to work well).

A variation of the horizontal mattress stitch is a good choice for the pointed tip of a skin flap. Start on the non-flap area, then run the stitch sideways through the tip of the flap. Finally, finish as you would with a regular horizontal mattress stitch. This technique helps to minimize tissue strangulation in an area with compromised circulation.
Buried stitches. These can be helpful in wounds under tension and when there is potential dead space that needs to be closed. Buried stitches can also improve cosmetic results by minimizing wound tension at the epidermal level and decreasing hematoma formation. However, buried stitches are probably overused. They can increase infection risk, and they can work their way out to the surface weeks after the wound has healed. Newer, antibiotic-impregnated absorbable suture may reduce the risk of infection. Avoid sewing through adipose tissue; this causes strangulation and increases infection risk. When deep stitches are used, make sure the patient is aware of their presence.
Subcuticular stitches. Continuous subcuticular or running dermal sutures are frequently used by surgeons in conjunction with skin closure strips to obviate the need for suture removal. Subcuticular stitches are technically more difficult than other types. The stitches are placed parallel to the skin surface at the dermal-epidermal junction; backtrack slightly with each stitch to ensure correct positioning. Skin closure strips may be used on the surface to improve apposition.
Subcuticular stitches are a good choice for patients who are prone to keloid formation. However, avoid the use of absorbable suture in such patients; it may provoke more tissue reaction than nylon or polypropylene.
If non-absorbable suture is used, make sure that both ends exit the skin, and stitch so that the suture surfaces every 3 cm (this allows it to be easily cut into segments and thus facilitates removal). When absorbable suture is used, the entire closure may remain buried.
SAFE SUTURING

Figure 7

Figure 8

Figure 9

Always consider your own safety and comfort when you close lacerations. Use proper lighting and positioning: elevate the bed or examination table until the wound is at about the level of your elbow. Use protective goggles when injecting anesthesia. Avoid grabbing the needle with your hand; use a needle driver and regular-tip forceps to handle the needle instead. You can actually complete the entire repair without ever touching the needle with your hand (Figures 7, 8, and 9).
AFTERCARE, FOLLOW-UP, AND SUTURE REMOVAL
Once the repair is finished, I have the patient put light pressure on the wound with 1 finger for 10 minutes. This minimizes the amount of blood that oozes from the wound (oozing blood can slow healing by separating wound edges). The pressure also minimizes seepage of blood through the needle holes, which can later make suture removal more painful. In addition, a clean outer appearance looks better and may increase patient satisfaction.
After 10 minutes of light pressure, place a sterile dressing, along with a splint to prevent added wound tension when appropriate. Instruct the patient to keep the wound clean and dry (except for antibiotic ointment) for the first 48 hours to allow adequate time for an epithelial layer to form. After that, the patient may shower, and antibiotic ointment is no longer recommended for most wounds.
Wounds are usually checked within 48 hours. In high-risk wounds, a 48-hour check is obligatory.
Suture removal. The appropriate timing of suture removal depends on the location and depth of the wound, wound tension, patient age, and comorbidities. I find the following breakdown of time to suture removal useful (with allowances made for special considerations):

• After 4 to 5 days: facial wounds.
• After 15 days: extremity lacerations, wounds with tension.
• After 10 days: all other wounds.

Consider leaving sutures in for additional time in patients in whom healing may be delayed, such as elderly persons, those with compromised immune systems, and smokers. Leaving stitches in a few extra days prevents wound dehiscence from early removal, and except in facial lacerations—in which a delay in suture removal could cause "cross-track" scarring from the sutures—it has few disadvantages.
Minimizing scarring. Patients frequently ask whether they will have a scar. The appropriate answer is that all lacerations leave some form of scar, but that scarring can be minimized by appropriate sun protection. Initially, this may involve bandages and hats or clothing. Once the wound is healed, counsel patients to use sunscreen daily for at least 6 months and preferably up to a year. Advise patients in whose wounds the tension was initially great enough to hold the edges more than 5 mm apart that with time their scar is likely to widen. Also, warn patients with lacerations from blunt trauma or crush mechanisms that they have a higher risk of noticeable scarring.

References

1. www.ERPocketBooks.com.
2. Pregerson DB. Quick Essentials Emergency Medicine. 2nd ed. Available at: www.ERPocketBooks.com. 2006.

Suturing Techniques

Overview

As a method for closing cutaneous wounds, the technique of suturing is thousands of years old. Although suture materials and aspects of the technique have changed, the goals remain the same: closing dead space, supporting and strengthening wounds until healing increases their tensile strength, approximating skin edges for an aesthetically pleasing and functional result, and minimizing the risks of bleeding and infection.
Proper suturing technique is needed to ensure good results in dermatologic surgery. The postoperative appearance of a beautifully designed closure or flap can be compromised if an incorrect suture technique is chosen or if the execution is poor. Conversely, meticulous suturing technique cannot fully compensate for improper surgical technique. Poor incision placement with respect to relaxed skin tension lines, excessive removal of tissue, or inadequate undermining may limit the surgeon's options in wound closure and suture placement. Gentle handling of the tissue is also important to optimize wound healing.
The choice of suture technique depends on the type and anatomic location of the wound, the thickness of the skin, the degree of tension, and the desired cosmetic result. The proper placement of sutures enhances the precise approximation of the wound edges, which helps minimize and redistribute skin tension. Wound eversion is essential to maximize the likelihood of good epidermal approximation. Eversion is desirable to minimize the risk of scar depression secondary to tissue contraction during healing. Usually, inversion is not desirable, and it probably does not decrease the risk of hypertrophic scarring in an individual with a propensity for hypertrophic scars. The elimination of dead space, the restoration of natural anatomic contours, and the minimization of suture marks are also important to optimize the cosmetic and functional results.
In this article, the suture techniques used in cutaneous surgery are reviewed. The techniques of suture placement for each type of stitch are described, the rationale for choosing one suture technique over another are reviewed, and the advantages and disadvantages of each suture technique are discussed. Frequently, more than one suture technique is needed for optimal closure of a wound. After reading this article, the reader should have an understanding of how and why particular sutures are chosen and an appreciation of the basic methods of placing each type of suture.^{[1, 2]}

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 (see image below). 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 (see image below). 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 (see first image below). Alternatively, the needle holder may be held in the palm to increase dexterity (see second image below). 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^[3]

  • 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 (see image below). Knot tying.

Next Section: Indications

Indications

• Simple interrupted sutures

  • 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.
• Simple running sutures

  • 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

  • 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.
• Vertical mattress sutures

  • 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

  • The half-buried vertical mattress is used in cosmetically important areas such as the face.
• Pulley sutures

  • 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

  • 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

  • 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.
• Half-buried horizontal sutures or tip stitches or 3-point corner stitches

  • 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. The corner stitch may provide increased blood flow to flap tips, lowering the risk of necrosis and improving aesthetic outcomes.^[4] However, in larger flaps with greater tension, this technique has been reported to position the flap tip deeper than the surrounding tissue, often resulting in a depressed scar.^{[5, 6]}
• 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

  • 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

  • The buried horizontal mattress suture is used to eliminate dead space, reduce the size of a defect, or reduce tension across wounds.^[7]
• Running horizontal mattress sutures

  • 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. While slightly more time consuming, this technique appears to result in smoother and flatter scars as compared to simple running sutures.^[8]
• Running subcuticular sutures

  • 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.^[9] 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

  • 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.
• Running subcutaneous corset plication stitches^[10]

  • The corset plication technique is used in wounds wider than 4 cm that are under excess tension. This suture creates natural eversion and better wound edge approximation. Placement of this stitch eases subsequent placement of intradermal sutures, as wound diameter and tension are reduced significantly. Strength of the suture relies on inclusion of the septations from the fascial layer beneath the subcutaneous tissue. If tissue ruptured postoperatively, tension would be distributed more broadly. Potential problems include suture breakage and wound distortion.^[10]
• Modified half-buried horizontal mattress sutures^[6]

  • The modified corner stitch allows for equal eversion of the flap tip edges and improved aesthetic outcomes. While it may increase risk of necrosis if tied too tightly, the incidence of flap tip necrosis was found to be comparable with that of the traditional corner stitch.^[6]
• Deep tip stitch^[5]

  • This stitch is used for M-plasty, W-plasty flaps, and V-Y closures to increase wound eversion. It provides longer-term support to the flap than the traditional corner stitch and improves alignment of the tip with the sides of closure. This technique also avoids surface sutures, decreasing the risk of track marks. Flap tip necrosis and complications were comparable to that of standard sutures.^[5]

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Equipment

• Needle
• Needle holder
• Suture material

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Technique

• Simple interrupted sutures

  • The most commonly used and versatile suture in cutaneous surgery is the simple interrupted suture.^[11] 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 (see image below). 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. The image below shows a line of interrupted sutures. Line of interrupted sutures.
• Simple running sutures

  • 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. The image below shows a running suture line. Running suture line.
• Running locked sutures

  • 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 (see image below) because of the final appearance of the running locked suture line. Running locked suture.
• Vertical mattress sutures

  • 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 (see image below). Vertical mattress suture.
• Half-buried vertical mattress sutures

  • 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.
• Pulley sutures

  • 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 (see image below). Pulley stitch, type 1.
• Far-near near-far modified vertical mattress sutures

  • 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 (see image below). Far-near near-far pulley stitch.
• Horizontal mattress suture

  • 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 (see image below). Horizontal mattress suture.
• Half-buried horizontal sutures or tip stitches or 3-point corner stitches

  • 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 (see image below). Tip stitch.
• Dermal-subdermal sutures

  • 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.
• Buried horizontal mattress suture

  • 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.
• Running horizontal mattress sutures

  • 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.^[12]
• Running subcuticular sutures

  • 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 (see image below). Subcuticular stitch. The skin surface remains intact along the length of the suture line.
• Running subcutaneous sutures

  • 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.
• Running subcutaneous corset plication stitches^[10]

  • Before inserting the needle, forceps are used to pull firmly on at least 1-2 cm of tissue to ensure tissue strength. The corset plication includes at least 1-2 cm of adipose tissue and fascia within each bite. After the first bite is tied, bites are taken on opposite sides of the wound in a running fashion along the defect. The free end is pulled firmly reducing the size of the defect, and the suture is then tied.

Variations of tip (corner) sutures

• Modified half-buried horizontal mattress sutures^[6]

  • This stitch places an additional vertical mattress suture superficial to the half-buried horizontal mattress suture. A small skin hook instead of forceps is used to avoid trauma of the flap.
• Deep tip stitch^[5]

  • The deep tip stitch is essentially a full-buried form of the 3-corner stitch. The suture is placed into the deep dermis of the wound edge to which the flap is to be attached, passed through the dermis of the flap tip, and inserted into the deep dermis of the opposite wound edge.

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.

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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. Because they have a tendency to fall off, they are used mainly in low-tension wounds and rarely 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^{[13, 14, 15]}

  • Superglues that contain acrylates may be applied to superficial wounds to block pinpoint skin hemorrhages and to precisely coapt wound edges. Because of their bacteriostatic effects and easy application, they have gained increasing popularity.^[16] They have demonstrated either cosmetic equivalence or superiority to traditional sutures in various procedures, including sutureless closure of pediatric day surgeries, saphenous vein harvesting for coronary artery bypass, and blepharoplasty.^{[17] [18, 19]} The most commonly used adhesive, 2-octyl cyanoacrylate (Dermabond), has also been used as a skin bolster for suturing thin, atrophic skin.^[20] Advantages of these topical adhesives include rapid wound closure, painless application, reduced risk of needle sticks, no suture marks, and no removal. Disadvantages include increased cost and less tensile strength (compared to sutures).
  • The use of tissue adhesives in dermatologic surgery is still evolving. It appears that using high viscosity 2-octyl cyanoacrylate in the repair of linear wounds after Mohs micrographic surgery results in cosmetic outcomes equivalent to those of epidermal sutures.^[21]
  • 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.^[22] 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.^[23]
• 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.^[24]
  • Barbed sutures have also been used in minimally invasive procedures to lift ptotic face and neck tissue.^[25] In a recent study, average patient satisfaction 11.5 months after a thread lift was 6.9/10.^[25] By 3 months postprocedure, the skin of the neck and jawline relaxed and the final results became apparent. Overall, the barbed suture lift was determined to provide sustained improvement in facial laxity.^[25] However, painful dysesthesias and suture migration distant to insertion site have been reported.^{[26, 27]} Although the long-term efficacy of barbed suspension sutures remains unclear, they may allow for a minimally invasive facial lift with few adverse effects.^[28]
• Novel punch biopsy closure^[29]

  • Placing sutures lateral to a punch biopsy causes the defect to taper, allowing for a more linear closure and improved cosmetic outcomes. A simple interrupted stitch is placed 1-3 mm lateral to a wound edge, a second stitch is placed 1-3 mm lateral to the opposite wound edge, and a final stitch is placed at the center of the wound. Sites greater than 4 mm may require additional interrupted stitches. Disadvantages include extended procedure time and increased risk of suture marks.