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Suturing
Table of Contents
  • Placing the Scar
  • Skin closure
  • Clips
  • Tapes
  • Suture Materials
  • Instruments
  • Excising lesions
  • Scar problems
  • Dressings
  • Removal of Sutures
    • Most of us at some time or other will need to suture a wound. This may be due to an accident or one that we create while removing a lesion. It is important to do it well. Here are some guidelines to keep in mind.

    Placing the Scar

    i. Use of natural lines - the scar should be placed in the line of a wrinkle or at least parallel to it, so it will look like another wrinkle.

    ii.Consider the direction of the scar, run it parallel to an expression line

    iii.Place the scar where it will not be seen, e.g. inside the hairline

    Skin closure

    There are many types available and they differ in composition.

    Nonabsorbable: nylon, polypropylene,

    Absorbable: catgut, polyglycolic acid, polyglyconate.

    There are a large number of different needle sizes and types. For skin you must use a cutting needle and 19 or 24mm diameter is a good choice.

    Clips

    These are becoming more acceptance but are really only useful for large incisions and when time is an important consideration. They are generally too expensive in general practice.

    Tapes

    These are made in various width and colours. My preference is for 1/4 inch flesh toned type. These can be cut in half length so as to make them easier to handle and more cost effective. These are the least conspicuous and are easy to apply. Anything smaller or wider is less accurate. Often a few strips of tape will hold the epithelium together provided that the deeper tissues are not under tension.

    Suture materials

    Silk

    - NOT recommended as it causes too much tissue reaction.

    Nylon

    This should be the main material used and the sizes of 4/0 or 3/0 are ideal. The reason for the finer sutures is that they will break before you can apply too much tension to the wound edges.

    Polypropylene

    (Surgilene, Prolene) Best for subcuticular and continuous type suturing. These are the easiest to pull out.

    Polyglycolic Acid (Dexon II)

    Synthetic absorbable for deeper layers. Absorbed by hydrolysis and in general not recommended in the skin. Commonly used in children as a subcuticular suture. The newer Dexon II is also easier to tie than its predecessor. Catgut - dissolves in an unpredictable time frame, excites tissue reaction during its destruction.

    Instruments

    Forceps

    - toothed fine Adsonís

    Needle holder

    - use a small one for fine sutures

    Scissors

    - for cutting sutures as well as for dissecting tissues

    Scalpel blade

    - No.15 or No.10 Handle for scalpel

    Anaesthetic

    Xylocaine with Adrenaline 1:100,000 is a good safe general purpose agent but must be careful in cases where cardiac problems exist and must not use it on fingers, toes. In children EMLA cream for ONE hour over the area will stop the pain but this time delay is not always practical.

    Excising lesions

    General considerations apply and those related to the particular pathology. Must have an adequate margin of excision for a BCC, SCC. Removal of the lesion is the first priority and the ability to close the defect is only the secondary consideration. Send all specimens for pathological examination. This will confirm your diagnosis and determine the margins of clearance. The wound should be closed in layers.

    Scar problems

    Hypertrophic

    - red raised scar that will eventually subside, confined to the area of injury

    Keloid

    - red raised scar, exceeds the boundaries of the injury, progressive. It takes many years to subside.

    Dressings

    Light and absorbent material should be used. The other function of dressings is to splint the part to give it a rest and allow oedema to be absorbed.

    Removal of Sutures

    On the face about 5-7 days is enough. Scalp, back or limbs minimum of 10 days is advisable. It is also good practice to splint the scar with adhesive-strips or sticky tape for a further week. This will give a better cosmetic result.

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