Simple Suturing Techniques

16
CHAPTER
Techniques
SimpleSuturing
and KnotTying
PETERB. ODLANDandCRAIGS. MURAKAMI
-f tt" skill and art of suturingdate back thousandsof
I yearsto the Smith Papyrus.tAlthough techniques
and materialshave changed,the fundamentalreasons
for usingsutureshavenot. In cutaneoussurgery,sutures
should be used for gentle closureof wounds until the
tissuesre-establishtheir inherent tensilestrength.This
shouldbe done in a way that promotesa functionaland
aestheticoutcome while minimizing the risks of both
acute and late complications.The old adage"approximation without strangulation" clearly statesthe most
important point about proper suturingtechnique.
Suturing is defined as the "surgical uniting of two
surfacesby meansof stitches."2Suturingis an incredibly
simple concept,yet correct applicationrequiresa high
levelof concentration,attentionto detail,and discipline.
An understandingof basicwound healing,the natureof
suturematerials,and generalprinciplesregardingexcision and closure of wounds are all very important to
obtaining a satisfactoryoutcome. Failure to recognize
theseimportant conceptswill yield surgicalresultsthat
are less than adequate, thereby frustrating both the
surgeonand the patient and making the entire experienceunsatisfyingand unrewarding.
BasicTermsand Concepts
MATERIALSAND INSTRUMENTS
The sutureneedle3most commonlyusedin cutaneous
surgerycan be subdividedinto severalparts. The tip is
a fine, delicatepoint used to penetratetissuesurfaces.
The swageis where the needleis clampedto the suture
material;this representsthe broadestpoint of the entire
suture. The remaining portion, where the needle is
graspedwith instruments,is the body. The basicinstru178
mentsusedin cutaneoussuturingincludea needledriver
(holder),tissueforceps,and skin hooks.
The standardneedleholder has a ratchet-typelocking
mechanismthat stabilizesthe needle securely in the
jaws. When a needleis in the jaws, one shouldavoid
locking beyond the first snap. Locking the needle beyond this position causesflattening of the needle and
"denting" the opposing surfacesof the jaws of the
instrument.This frequently results in slippageof fine
suturematerialsduring subsequentuse.
Tissueforcepswith fine teeth allow for gentlehandling
and stabilizationof the tissuesbeing sutured and for
graspingthe emergingneedletip during suturing.However, if they are not used carefully and gently, trauma
to the wound edge may occur and compromisewound
healing. Alternatively, a skin hook can be used to
stabilizetissueand, in skilled hands,is lesstraumaticto
soft tissuethan forceps.
The needleholder shouldbe graspedwith the thumb
and ring finger in the loops of the instrument(Fig. 161.4). The tip of the first finger is extendedand restson
the arms of the instrumentat or near the hinge, while
the middle finger flexesgently to securethe baseof the
loop (Fig. I6-'J.8, C). None of the fingersare inserted
past the first knuckle to allow maximum dexterity and
rotation. Some surgeonschooseto "palm" the needle
holder and avoid placingfingersin the loops altogether
(Fig. 16-1D). Both techniquescan be learnedand used
effectively,althoughit is normal to feel awkwardwhen
usingeither techniqueinitially. A great deal of practice
is necessarybefore one becomesfacile in the use of
thesetechniques.Forcepsshouldbe held somewhatlike
a pencil, but this may vary dependingon the particular
use.
A skin hook can be effectively held between the
AND KNOTTYING
SIMPLESUTURINGTECHNIQUES
at
theinstrument
B, Supporting
theinstrument.
theneedleholder.A, Fingering
for grasping
Figure16-1.Technique
the instrument'
view).D, Palming
theiulcrum(vertical
the insirument-at
C,-supporting
thumb and the first finger'a"Choking" up on the handle
nearerto the hook wif allow for more accuratehandling
of the instrumentbY the surgeon'
PLACEMENTAND
NEEDLEAND INSTRUMENT
ORIENTATION
The needlemust be placedin the needledriver at the
end of the jawswith properorientation.This will achieve
optimum utilization-of the instrument' Correct placement of the needletoward the end of the jaws allows
for greateraccuracyand precisionin suturing' Further-ori, b""uusethe iurface areaat the end of the jaws is
smaller,there is lesschanceof crushingthe needleand
flatteningits curve. Orientationin the verticalaxis (tilt)
and aloig the longitudinal axis of the needle driver
(twist) m*ustbe exict (Fig. 16-2). Failure to properlyo.ienf the needlewill preventeffectiveadvancementof
the needlethrough tisiue' Positioningthe needlein the
jaws of the need6 driver ideally is done with a forceps'
179
view)'
thefulcrum(oblique
At first it may be a frustratingtechnique,but mastering
it will minimize the risk of needle sticks and with
experiencewill actually reduce operating^time' Most
suigeonsplace the needleholder one halfl's to three
fouithsuoi th" way from the tip to the swageon the
body of the needle.Placementcloserto the tip-may
limii advancementof the needlethrough the full thicknessof the skin being sutured, while placementcloser
to the swagefrequentlyresultsin bendingof the needle'
If a needle is unnecessarilybent severaltimes, it becomesweakenedto the point where it may break'
SUTURINGSTEPS
Proper wound closurerequires precisesuture plagement io re-establishthe original anatomicconfiguration
of the variousskin components(Fig. 16-3). The needle
should alwayspenetratethe surfaceperpendicularlyto
obtain ideal-woundedgeapproximationwith mild eversion (Fig. 16-4A). The needletip is the sharpestpoint'
180
BASICSURGICALCONCEPTSAND PROCEDURES
Figure 16-2. Placementot the needlein the needleholder.A, Correctplacementat the proximalllat portionof the needlebody. 8, The needle
is orientedperpendicularly
to the holder.C, Incorrectplacementat the roundedhub or swaged portionof the needle.D, The needle can oe
misplacedin the needleholderby a tiltingor twistingmovement.
Figure 16-3. Cutaneous
woundanatomy.A, Epidermal
layer.B,
Papillarydermallayer.C, Reticulardermallayer.D, Undermining
plane.E, Subcutaneous
fat layer.
A
AND KNOTTYING
SIMPLESUTURINGTECHNIQUES
It t
ttr
181
-ttl
semicircular
superficiar,
throughtissue.B, lncorrect
passage
withsquareor frask-shaped
.r6_4.Needre
A, correcttechnique
penetration.
Figure
throughtissue.
passage
The
backwardretractionof the needle into the tissue'
of initial
with
Its effectivenessin overcomingthe resistance
driver'
needle
the
with
grasped
be
should
tano"n"tiution is reducedif the ;eedle is introduced
"""af"
paii to the tilt and twist of the needleat
.rlr"
larger
be
will
wound
uaaition, a superficial
I;;;;["-i;
"ti""tion
itte jaws. By rotating the needledriver in the
o.rpenetration tfrc iip
will
;;;;;";;i"bl;
1iig. ro-441' rhe point
"i
,urn.'ur. as the n""dl", the rest of the needle
beforeapplymaterial
;;dd ;; t""t"[v s?lectedvery-caiefully
suture
attached
the
and
tissue
the
ttorn
jaws
*it( ttt" needle' Selectionof this point
t"g;;;
"."in"
ihe needlemust be repositionedin the
;iiii;il;;.
used
being
technique
suturing
the
J""o"'ndson the type of
penetrating
for
punctures oi-iri" n""Ore driver in preparation
;;Aih" soacingbetweensutures'Unnecessary
For
correct
edge'
wound
opposing
tissue O""p tittu" of the
and will resultin excessive
;;;;il";t.;d"esirable
horizontii alignment of the wound edges'
initial
the
applied'
is
pressure
;;;;..,il-in"iluting
at precisely
""rtl..i-""0
the needlemustpenetrateIhe oppos.ing.side
r e s i s t a n c e t o p e n e t r a t i o n w i l l r e s u l t i n a t e m p o r a r y;i;;;;
it
emerged.(Fig'
wtricrr
d$in is ttte side from
o.fthis
surdlor"rrion of the surfaceof the skin' The depth
iO-Sat. A iompleted knot should provide a level
of the
d e o r e s s i o n d e p e n d s o n t h e a n a t o m i c a r e a , t h e l a x l t yf;;i;h
ol
amount.of
small
;
iy*it"tri",
.eversion
iir. and tip designof the needlebeing
ilJ:,'id, ;J[t"
it" sidesof the wound should be well aligned^
suddenly
resistance
the
p,"s'ut",
Wittt increasing
i.J""J""t iissuedoesnot developat the end of
^i""i.i*
r"'ii",
suddenness "AnLt.
"-"J.
."ut"t, and needlepinetration occurs'The
iine anA causevertical or horizontal malitt"
to inex;-thtt penetrationmay be somewhatstal-tling
(Fie.
16-58). To accomplishthis' the opposwithoeriencedsurgeonsunh rnuy result in a reflexive
"fit"t""t
is g"nitv stabilizedwith forcepsor skin
i#;;;;;;Ji"
-#"k
For this reason,stabilizingthe
iitJ
il;;;i;f
into the deep tissue' Resistance
f* pen"etrati'on
"""ar".
on the patientor withthe tu:,g"-?:-t
ttuna
wasencounteredat the surface
than
less
*ifi n"*riffv be
"""if"-ari"i"!
ttuni rnuybe helpful' After initial penetratlon'
.oootir"
and advancementof the
introduction
hfter
til".
oeptn .f^in""
direct
tlie needleshould be driven to the appropnate
n""Of" into the tissuehorizontally, rotation will
skin'
i"i ttt" o".ticular stitchbeingused'The next movement ;i;;lb
of
the
surface
the
needle through
*itrt the ieedle driver being rotated
the
from
ir"^"',;iil;;"""'
"i1n"
equidistant
is
t"hat
point
a
at
This should be
r6ng axis' ihis advancesthe curvedneedlein
side'
the.opposite
the defect ;;;"d edgewhen comparedwith
"t.t"Jii.
u-tto.irontutplane ,o that the -tipemerges.in
almost all suturing
to
apply
steps
basic
fery
Th;"
gently
O"ti*d depth' The tip of the needleis then
and the
orientation
iuiure
in
t".ttniqu"t. irlodifications
"iitt"
graspedwith fine forceps or stabilizedwith
desired
of
;;;;;;iy
variety
a
produce
can
used
;6" ;i material
difficult'
u .f.in ttoot."ttt" tutt"t may be slightlymore
effects.
needle' the
il"*"""i,-uv placingthe hook,deepto th,e
point
the
at
gently
up
pulling
by
;;;ei".an ue ttuuiliZed
from the tissue' Rotating the hook
ii"-"tg".
;;;;
needle SimpleSuturingTechniques
mav provideevenmore stabilityby capturingthe
arc of the hook'
end of the semicir'cular
mi;?5;;;;ing
*iit;
The most important basic principles in suturlng
the jays 9l tfe
from
released
be
ti.j"or" ihould
approusing
times'
all
at
clude gentletranamg of tissue
itself' If the
n""at" driver without moving the needle
alwavsburyTgdermal.or
passed
has
needle
il;"t";i;;-"ntuti6n,. and.
u**nt of tissuethrough which the
a wound that is under
closing
when
sutures
tissue subcutaneous
;^ffi;, then securingt'heneedleor surrounding
will prevent tension.T
*iiit F"i."p. or a skinirook is importantand
182
BASICSURGICALCONCEPTSAND PROCEDURES
IF::!fi;,1iil,:ff,.':
i
:;hii[ \i;;7i:::.'d:;'X::,'
Figure 16-5, Alignmentof woundedges.A, Verticalmalalignment.
B, Horizontal
malalignment.
SIMPLEINTERRUPTED
SUTURE
The simpleinterruptedsutureis undoubtedly
the most
commonlyused suturingtechniquebecauseof its versatility and relative ease of use. The technique for
employingthis stitch to evert the wound edge requires
that the needle enter the skin at a 90-degreeangle8
approximately1 to 2 mm from the woundedge.lAfter
penetration,the needleshouldbe redirectedto proceed
in a slightly oblique fashionawayfrom the wound edge
to the desireddepth and then acrossto the other side
of the wound, where its courseshould follow a mirror
imageof the first side.This canbe facilitatedby grasping
the deep tissuewith forceps,then passingthe needle
through the skin.eEither of these techniquesshould
createa loop that encirclesa broaderbaseof tissueat
its depth than at the surfaceso that the outline of the
suturepathwaylooks somewhatlike a flask (Fig. 166,4).Lversionof the woundedgesis a resultof a greater
amountof tissuebeingpushedtogetherdeeply,causing
the surfaceto be displaced(Fig. 16-68). Eversion is
desirable,becausewoundscontractas they heal. The
verticalcomponentof this contracturemay result in a
depressedscar at the suture line if the edgesare not
ro-12
initiallyeverted.T'
t\Y
;fii
.'l.t
i.7
a t
B
Figure 16-6, Wound closure using simple interruptedsuturesin conjunctionwith buried suture (nearlyreapproximatedwound) (A). B, Final
appearanceof the approximatedwound.
AND KNOTTYING
SIMPLESUTURINGTECHNIQUES
In someanatomicareas,inversionof the wound edges
through
may be desirable.When this is the case,passage
the tissueis just the oppositeof the eversionstitch,
with the sutuie pathwayincircling more tissuesuperficially than at the depth." This is accomplishedby
penetrating the skin perpendicutarly,as always, and
ihen direciing the needle-obliquelytoward the wound
edse. Exitine"the tissuethrough the other side of the
detectis agai-ndone in a mirror-imagefashion'It should
also be n6ted that the suture loop must be placed in
sucha way that it is wider than it is deep'
The advantagesof the simple interrupted stitch are
multiple and includethe following:
1. It is usefulfor makinggrossor minute adjustments
to ihe wound edgesfor profer alignmentand tension'7
2. It is easyto Perform'
3. It allowi expressionof serum or blood from betweensutures.13
4. It is usefulfor approximatingboth large and small
amountsof tissue.
5. It is helpful as a tacking stitch for flaps or large
irregularwounds.T
6] It trasgreatersecuritythan a running stitch'14
If the basicrequirementsof suturing.areobservedand
Dracticed.it is unlikelythat a simpleinterruptedstitch
iuill .uut" any problems.However,if placedincorrectly
these suturescan causewound inor inappropria^tely,
version,which in-the vast majority of casesis undesiraolthis stitchis "railroad
ble. The principaldisadvantage
This can be avoidedby
scarring.
track," oi ctoti-hut"h,
removing sutures before 7 days or by using a mo.re
advancedsuturingtechniquesuchas a running.subcuticular techniqu". Aso, comparedwith the.runningstitch,
this sutureis a time-consumingway to closea wound'7
183
BURIEDABSORBABLESUTURE
There are essentiallythree variations of buried absorbablesuturesthat are used in surgery of the skin:
and der(Fig. 16-7A), dermal-subdermal,'
subcutaneous
mal (Fig. I6-i Bl. Buried suturesare primarily-used.to
close'ariydead spacethat may have been producedby
to reapproximatethe-woundedges,
the surgicalexcisi,on,
wound dehiscence.Buried sutures
prevent
to
help
and
are especiilly important to use if a wound has been
closedunder significanttension' In this situation cutaneous surgeonJtry to prevent epithelializationof the
Suturetraiks by rernovingthe nonabsorbableepidermal
stitcheswithin 7 to 10 days. However, this removal
occursat a time when the wound has developedvery
little tensilestrength(Fig. 16-8) and is highly susceptible^
to separation.ttBy using buried sutures,.especia-lly^if
their tomposition givesthem a relatively long h.alf-life,
wiil be maintainedevenif the epidermal
woundint^egrity
sutures arJ remoued. The buried sutures are usually
oriented vertically but can also be oriented horizontally.1,7,8,11'13'tu Placementof buried suturesgenerally
followsadequateunderminingand hemostasis.The type
of buried suture used dependson the thicknessof the
defect, the tension on the wound, and the amount of
A relativelybroad excursionof the needle
deadspace.l?
is required to passthe suture through enough fibrous
septaeto maintain security' Small "bites" often tear
tissueas they are beingtightthioueh the subcutaneous
ened.-It should always be kept in mind that it is
particularly easy to strangulate subcutaneoustissue'
There is no significantadvantageto burying the knot
for this stitch (seeFig. 1'6-7A).
The dermal-subdeimalstitcht6is passedfirst through
the deep side of one of the undermined edgesof the
defect io that the suture pathway is through a small
and shallow
dermal-subdermal
buriedsutures(A) andmoresuperficial
woundclosedwith deepsubcutaneous
Fioure16-7. Full-thickness
possible
in
tissue'
as
deeply
as
buried
always
O"i*i .rtrr"" fa- flot" thattheseknotsare
184
BASICSURGICALCONCEPTSAND PROCEDURES
bR
f.r! 100
Fq
F
zr-\
5R
F
F
F
rh
it)
z
dro
(t)
----<t+
z
h
6utura
F
F
a
wouod
tensil,.
Btrengtb
rrl
. ' !
a
z
/
F
(t)
F
u
40
0
60
Figure 16-8. Wound tensile
strengthcomparedwith suture
tensilestrength.
DAYS AFTBR SUTITRING
amount of both subcutaneous
and dermal tissue.If the
dermis is thick, it is unnecessary
to bury the knot. This
suture is necessarilyvertically oriented. As the name
implies, the dermal stitch is placed exclusivelywithin
the dermis. For relatively thin skin, the wound edge is
reflectedto exposethe underminedsurfaceof the dermis. The needlepenetratesthis surface2 to 5 mm away
from the wound edge and is directedobliquely toward
the edge and the surfacesuchthat the epidermaledges
will be everted. With few exceptions,the knot should
by passbe buried (Fig. 16-78), which is accomplished
ing the stitch from deep to superficialand then from
superficial to deep. Occasionallya fine, horizontally
oriented, absorbabledermal suturecan be placed.The
utility of such a stitch to relieve tensionat the surface
must be balancedagainstthe risk of suture abscessor
tattooing.
A multilayereddeepclosureis requiredin the caseof
a full-thicknesswound. First the deep fascialand muscular tissues are approximated with buried sutures.
tissueand
Then, in a layeredfashion,the subcutaneous
superficiallayersof the dermisare closed.If a significant
amount of tension is anticipated,a dermal-subdermal
suture should be used, but if there is no tension, a
dermal stitch shouldbe used.
Buried suturesare very usefulfor relievingtensionin
wounds, closing dead space, and ensuringproper realignmentof anatomiclayers.There are very compelling
reasonsto use buried stitchesin nearlyall full-thickness
cutaneoussurgery; noted exceptionsare wounds that
are without tension and some selectedprocedureson
thin-skinnedareasof the body suchas the eyelids.The
tensilestrengthof a wound at the time of sutureremoval
is less than 5Vo of what it ultimately will be. Without
deepsuturereinforcement,the risk of wounddehiscence
after sutureremovalis great. In addition,ideallyplaced
deep sutures will apposethe skin edgesso well that
fewer skin stitcheswill be required, yielding a better
cosmeticresult.l
Althoush there are both theoretical and real disadvantages
Io using deep sutures,the benefitsgenerally
outweighthem. The potentialpitfallsof buried sutures
include possible strangulationand necrosisof tissue,
promotion of infection, and prolongedinflammationas
the resultof the presenceof foreignmaterial.lT
Difficulties encounteredin placement of buried sutures often result from the small working area. Ideally,
the first stitch is olacedin the exact middle of the two
sidesof the wound. This is possiblein most instances
by havingan assistant
gently,physicallycoaptthe edges
of the wound as the first two throws of a knot are
secured.When tensionon the wound is great, an alternative techniqueis to begin the deep closureat one of
the apicesof the wound. However,there is a potential
problem in this situation:by the time the oppositeapex
is reached, the sides may have become unequal in
length,requiringa redundanttissuerepair.l'7,8,1r'13'16
Knots
There are many knot configurationsused to approximate soft tissues.In selectingsuture material and knot
types,it must be rememberedthat the ultimate goal of
suturing is to provide adequateapproximation of the
tissueswith the least amount of trauma and inflammation. Thus, the surgeonselectsa suturematerialwith an
appropriatetissuehalf-life and knots that will be secure
long enough to keep the wound approximated until
adequateintrinsictensilestrengthhas been established.
The larger the suture diameter and knot volume, the
greater the risk of tissueinflammation and infection.18
On the other hand, choosingsuture or knots that are
too weak for a giyen wound will result in wound dehiscence and surgicalcomplications.Studieshave shown
that the security of a knot is related to the surface
coefficientof frictionie'20and the stiffnessof the suture
material.
AND KNOTTYING
SIMPLESUTURINGTECHNIQUES
185
Figure 16-9. Squareknot.
SQUAREKNOT
The most common knot used is the squareknot' In
this knot will provide 80 to 90Vo
optimal circumstances
oi the tensilestrengthof an intact suture'When examinins a squareknot, it can be seen that each strand
besi;s and endson the samesideof the knot (Fig' 169)."Becauseof its symmetricdesign,it tendsto tighten
and remain securewhen tension is applied equally to
both strands.However, this is somewhatdependenton
the type of suture material being used'.Some suture
mateiialsare too slipperyand will not hold with a simple
squareknot. Suturei are often coatedwith siliconeor
tissues,but
*u* to allow easierpassagethrough the^so.ft
knot'21In
the
of
capacity
holding
the
this decreases
addition, suture material becomesmore slipperywhen
coveredwith blood and serum.If the knot is not placed
flat or if the tensionon eachstrandis uneven,the square
knot twists into a half-hitch knot' which slidesand is
For this reason'the square\nol t'
extremelyunstable.22
usually reinforced with an additional throw, and with
slippery materialssuch as monofilamentnylon, two to
three extra throws may be necessary.
if this becomesnecessary,tensionon the wound may be
sufficientfo warrant use of other measuresto reduce
the tension.
TIE
INSTRUMENT
Closureof soft tissuedefectsin cutaneoussurgeryis
usually accomplishedusing an instrument tying technique. The two-handedtie techniquethat is often seen
in i generalsurgicalpracticeis rarely usedfor soft tissue
surgeryof the skin. Instrumenttying is-quick,effective,
tb perform, and suture sparing(Fig. 16-11). To
"as"y
uss the instrumenttechniqueto tie a squareknot or a
surgeon'sknot, the needle is first passedthrough.the
tissire.This task is completedwhen the sutureis pulled
throughthe wounduntil 2 to 3 cm of tail sutureremains'
Leavinga longertail resultsin cumbersome-aggravation
and uniecessaiysuturewastage.Startingwith the needle
holder betweenthe two strandsof suture, the holder is
rotated clockwisearound the suture, the short end of
the sutureis clamped,and the knot is placedflat across
the wound by crossingthe hands.The secondthrow is
begun by again placing the needle holder betweenthe
tw6 strands,but this time the holder is rotated counterclockwisearound the suture and the throw placed flat
SURGEON'SKNOT
by crossingthe hands in the reverse direction' The
needle holder always rotates around the suture; the
Many surgeonsprefer the surgeon'sknot, which is a
suturedoesnot rotate around the needleholder, as this
double throw tottoweOby a singlethrow in parallel, as
techniqueis cumbersome,time consumin€,and distracts
knot,
the
square
in the squareknot (Fig. 16-10).L-ike
attentionfrom the tail of the suture. When the second
addian
with
reinforced
the surg'eon'sknot is usually
is important to be especiallycareful
tional tfrrow.The initial doublethrow providesincreased throw is placed,it
knot and strangulatethe wound'
the
ovbrtighten
'fuound
to
not
together until the second
friction to hold the
prefer
to place a seconddouble throw
surgeons
Some
in
closing
helpful
throw can be placed.This is especially
(Fig.
16-12). Poor techniquewill
knot
the
to
stabilizl
can
throw
A
triple
tension.
mild
woundsthat are under
prominent suture marks'
and
necrosis
pressure
alsobe placedto provide even more tension'However, lead to
knot.
Figure16-10.Surgeon's
186
BASICSURGICALCONCEPTSAND PROCEDURES
knot.C,
A, Needleis regrasped
afterfirstpassingthroughtissue.8, Initiating
the surgeon's
technique.
Figure16-11. Instrument
knot-tying
the secondwrap.E Completing
to makethe
the secondwrap.4 Preparing
Firstwrapof sutureis madearoundneedleholder.D, Initiating
the firstthrow.(Courtesy
ot Dr.T. McCulloch.)
first(forehand)
throw.G, Completing
AND KNOTryING
SIMPLESUTURINGTECHNIQUES
187
the freeendof the sutureto completethe secondthrow.J,
throw'/' Grasping
the second(glackhand)
H, Initiating
Figure16-11 Continued
Mc6ulloch')
T.
Dr'
(Courtesy
of
knot.
thesecondtnrowot a su-rgeon's
bo-mpieting
Instrumenttying is easyand.quickif the.surgeonconcentrateson conservlngmotion and eliminatingextraneous maneuvers.As with most other surgicalproceJui"t, suturingshould be a smooth flow of progressive
rt"pt'tft"t pro"ceedin an accurate,logical, and rapid
manner.
if tit" needle holder is not alternatelyrotated in a
ctoct*it" and then a counterclockwisedirection, a
i nrunnv" knot is created.This type of knot slips.more
tfiun tfi. square knot and is therefore less desirable'
Simple plac'ementof additionalthrows will help secure
tttit't not, but it is preferable to develop a consistent
tying i".finique that resultsin predictablymore reliable
and securesquareknots.
If the han^dsare not alternately crossedwith each
thiow, a sliding knot is created(Fig' 1.6-13)'lo1 thick
*unat under'tension,such as scalpdefects,this knot
allowsthe sutureto slide and tighten, much like a lasso
Oo". utorrna a post' To securethis knot, two or three
additional throws must be placed, dependingon the
24
rutut" beingused.23' This increasesthe overallvolume
oi ttr" knot"and increasesthe risk of inflammationand
inJ".tion when this knot is usedsubcutaneously'18'23
In cutaneoussoft tissue surgery' the subcutaneous
rut*" U"utt the majority of the tension'.There should
be minimal or zero teniion on the epithelial edgesif
oDtimalresultsare to be obtained.If there is no tenston
on the epithelialmargins,one may use surface-supporting tape strips or a knot techniquethat is.tensionfree'
Tfre Straith^loop, one such knot, is a double throw
followed by a small 4 to 5-mm gap an{ securedwith a
,quur. knot. The advantagesof this knot are that it
pi"u"ntt postoperativeedema from strangulatingthe
ivoundaroundthe suture,it preventsovertighteningthe
second throw, and it makbs suture removal easier'
Simply cutting the base of the loop allows atraumatic
rembvatof fine suture. If the wound is free of tension,
itr" rutg"on can also use an interlockingslip knot'5. .
Once"thecutaneousknots are placed,they shouldbe
moved to one side or the othei and not left directly
over the wound. This preventsthe tails of the suture
from becomingimbeddedin the wound and allowseasier
u.".ir and reilroval'26The knot should also be placed
awayfrom structuresthat might become.irritated-(e'g',
ifr" 6y"t and nose)and away-fromthe edgesof a flap'z'
SUMMARY
have shown
A variety of wound healing studies2s'-2e
in pertechnique
meticulous
using
of
importince
the
Despite
forming simple knot tying for wound closure'
Itt" ffiur"nt simplicity oithe technique,knowledgeof
knot
surgeon's
Figure16-12.Double
188
BASICSURGICALCONCEPTSAND PROCEDURES
Figure16*13.Twodifferent
types
ot slidingknots.
suture materials,needles,and different types and uses
is vital to a good outcomein all cases.
of variousknots3o
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