Key Practice Points
Most lacerations can be closed with one or two simple techniques. However, some wounds and lacerations are more complicated and require advanced repair techniques to close.
Long, straight lacerations can take a long time to close. Techniques to save time include running sutures, staples, and wound adhesives.
The corner, or flap stitch, is an important suture technique for the surgeon to master to preserve the blood supply of the tip of the flaps or corners in an irregular wound.
Injured fat in a laceration or in the underside of a flap has no value and can act as substrate for bacterial growth. Injured fat should be débrided before closing the wound with sutures.
When closing a curving laceration, a “dog-ear” defect can be created. The “dog-ear” technique can repair that defect and can improve the cosmesis of the wound.
Most lacerations and wounds are straightforward and can be closed with the basic techniques described in Chapter 10 . Some wounds are more complicated, however, and present with a variety of technical challenges. This chapter describes some of the more complicated wound problems that can be encountered in a wound care setting. Techniques for “solving” these “puzzles” are suggested.
Running Suture Closure
Lacerations, usually caused by simple shearing forces, can be quite long and time consuming to close. Lacerations often are caused by slash wounds from a knife or a piece of glass. The continuous “over-and-over” (running) suture technique can be used when a shortage of time is a factor. Wounds longer than 5 cm can be considered for this technique. The time saved is beneficial to the person repairing the wound, because he or she can return quickly to other emergency-department duties. There are drawbacks to this technique. If one loop of the suture breaks or is imperfectly positioned, the whole process has to be repeated. Wound edge eversion can be difficult to control with this technique. Continuous sutures are reserved for straight lacerations in healthy, viable skin that would not collapse in with suturing. If this technique is applied to curved lacerations, it can create a “purse-string” effect that bunches up the wound. Another technique that can be used for long, straight lacerations is wound stapling (see Chapter 14 ).
Technique for Continuous Over-and-Over (Running) Suture
The technique for continuous over-and-over suturing is shown in Figure 11-1 A. The closure is started with the standard technique of a percutaneous interrupted suture, but the suture is not cut after the initial knot is tied (see Fig. 11-1 A). The needle is used to make repeated bites, starting at the original knot and making each new bite through the skin at a 45-degree angle to the wound direction ( Fig.11-1B through 11-1 F). The cross stays of suture, on the surface of the skin, are at a 90-degree angle to the wound direction. The final bite is made at a 90-degree angle to the wound direction to bring the suture out next to the previous bite exit ( Fig.11-1 G). The final bite is left in a loose loop. The loop acts as a free end of suture for knot tying. The first throw of the final knot is made by looping the suture end held in the hand around the needle holder, then by grasping the free loop ( Fig. 11-1 H). The first throw is snugged down to skin level ( Fig. 11-1 I). The knot is completed in the standard instrument-tie manner with several more throws at skin level ( Fig. 11-1J and 11-1 K).
Beveled (Skived) Wounds
A common problem in layer matching is the beveled-edge, or “skived,” laceration. Beveled edges are created when the striking angle of the wounding object is not perpendicular, but the angle and force are not acute enough to create a true flap deformity.
Technique for Closure of a Beveled Edge
A common misconception about the repair of a beveled-edge wound is that a larger bite is taken from the thin edge of the laceration rather than from the bigger edge. The opposite technique is the solution to proper layer matching. The technique for closing a beveled laceration is shown in Figure 11-2 . By taking unequal bites as shown, the edge is brought into correct apposition with the opposite edge. If sufficient tissue redundancy exists in the wound area, excision of the edges can equalize the wound so that simple sutures can close the wound.
Pull-Out Subcuticular Closure
A favorite technique of plastic surgeons is the pull-out subcuticular stitch using a nonabsorbable suture material, such as polypropylene (Prolene). This suture material is stiffer and stronger than nylon and allows for easier removal. A newer, nonabsorbable suture material, polybutester (Novafil), is also useful for this technique. The pull-out closure is limited to straight lacerations less than 4 cm long, because the suture would be too difficult to extract at removal time. Children have naturally higher skin tension, so this technique is thought by some clinicians to be superior for children because it prevents suture marks. Despite this fact, the pull-out subcuticular closure has no distinct advantage over percutaneous closure when final wound and scar appearance is compared. Another use for this technique is for closure of lacerations over which splinting materials or plaster will be placed. It also can be used in patients who are at risk for keloid formation to prevent keloid formation at the needle puncture sites.
Technique for Pull-Out Subcuticular Closure
Before placement of a pull-out subcuticular closure, the superficial fascia (subcutaneous tissue) has to be apposed adequately with absorbable suture to bring the dermis close to approximation. The actual closure is begun by passing the needle of 4-0 or 5-0 nylon or polypropylene 1 to 1.5 cm from the wound end through the dermis layer and bringing it out of the wound parallel to and through the plane of the dermis. Subsequent bites are made ( Fig. 11-3 ) parallel to the dermis at a depth of 2 to 3 mm into the dermis. Each bite should “mimic” the other with regard to bite size and dermal depth on each side of the wound until the “tail” is brought out at the opposite end of the wound. The beginning and final tail can be secured by wound tape. In the face, this suture can remain in place for 7 days. This technique often is used in conjunction with wound taping to match dermal and epidermal layers accurately. The suture is removed merely by pulling on one end with forceps or a needle holder and sliding the suture out of the dermal layer.
Subcuticular Running Closure
Surgeons often use a subcuticular running closure to close straight incisions. The subcuticular running closure can suffice to close the wound alone, or it can be supplemented with interrupted skin sutures. In wound care, this closure should be reserved for straight, clean lacerations with sharp, nondevitalized wound edges. It can be used to close wounds that have been excised or trimmed where the edges are left fresh and straight.
Technique for Subcuticular Running Suture
An absorbable suture material (e.g., Dexon, Vicryl, PDS, Maxon, or Monocryl) can be used. One strand is used, without interruption, for the entire laceration. As shown in Figure 11-4 , the suture is anchored at one end of the laceration. The plane chosen is either the dermis or just deep to the dermis in the superficial subcutaneous fascia. While maintaining this plane, “mirror image” bites are taken horizontally the full length of the wound. The final bite leaves a trailing loop of suture (see Fig.11-4 ) so that the knot can be fashioned for final closure. This technique commonly is supplemented with wound tapes, particularly if some degree of gapping of the edges remains.