For millennia, surgical and traumatic wounds have been closed with sutures and similar materials, yet it was only with the introduction of local anesthesia 130 years ago that surgeons were able to move from focusing on the most rapid suture placement technique to the most effective. From William Halsted’s promotion of the buried suture technique in the late nineteenth century to contemporary articles on the subtleties of suture placement and tissue handling, a paradigm shift has taken place, with an increasing appreciation that not only are there multiple available approaches for any single suture placement, but that this choice may impact outcomes.

Shifting tension as deep as possible in the surgical wound is the key principle of suture placement, and, indeed, adhering to this approach leads directly to improved patient outcomes, both functionally and aesthetically. Tension across the superficial dermis leads to increased scarring; shifting this tension to the deep dermis or even the fascia, and suturing in a fashion that keeps the tension deep permits wounds to heal with the subtlest of scars.

The surgical literature is rife with myriad techniques with flashy names and multiletter acronyms. While sexy and catchy technique names and acronyms are sometimes appealing, they do little to describe a technique or place it within the larger context of other fundamental and well-established approaches. Moreover, this tendency increases the risk that previously described approaches could simply be shined off, dressed up, and renamed as ostensibly novel approaches—something that only serves to increase confusion for the novice and expert alike, since developing a common language is an important step in improving techniques—and therefore outcomes. When possible, Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair utilizes descriptive names for suture techniques so that the nature of the technique is, at least somewhat, described by its name. Furthermore, when possible, techniques are explained in the context of the existing literature; for example, the “running looped suture” does not tell the reader what the technique entails, but referring to it as a “running locking horizontal mattress suture” suddenly allows the reader to understand the fundamental approach, even in the absence of a multipage description.

In the interest of consistency and developing a meaningful and translatable nomenclature, some liberty has been taken in (re)naming techniques so that they make intuitive sense. Therefore, for example, what was described in the literature as the “modified tip stitch” is referred to as the “modified vertical mattress tip stitch,” and what was originally named as the “vertical mattress tip stitch,” is instead referred to as the “hybrid mattress tip stitch.” Once the reader has an understanding of the techniques on which these approaches are based, the value of the slight shift in nomenclature should become obvious. This shift in terminology is not meant as a slight to those who have named techniques in the past, but rather as an aid to those becoming increasingly familiar with myriad suture technique variations.

Throughout the text, certain terms are used regularly. As there is significant regional variability in training and terminology, it may be worthwhile to clarify some terms. Each “bite” refers to a pass of the needle through tissue; thus a simple interrupted suture could be performed by taking a single large bite (assuming the needle is sufficiently large), starting by entering the skin on one wound edge and ending by exiting the skin on the contralateral wound edge, but it may also be closed with two separate bites, with the transition between the two bites consisting of the needle’s exit and subsequent reloading and reentry between the incised wound edges. Similarly, each “throw” refers to a single half knot, formed by the loop of the suture material around the needle driver in the case of an instrument tie.