Once adequate debridement has been accomplished and hemostasis secured, you are ready to close. Using a small skin hook or a fine-toothed forceps for retraction of the skin margins and a plastic needle holder, close the deeper tissues in layers. I usually bury the knots in fat and muscle, especially in the face and neck. It is important to grab the needle in the middle and rotate your wrist as you are approximating the tissue to avoid bending the needle. Also, do not grab the needle near the point, for obvious reasons, as you pass it from one side of the wound to the other. It is usually easier to pass the needle through one margin at a time. One can cradle the needle with a skin hook after going through one side, before grabbing it again to secure the opposite side. Attempt to obtain the same depth of bite on each side as well as the same distance from the level of the external skin. It is necessary to cross your hands as the knots are laid down, to obtain a flat square not. If you are having difficulty keeping the margins together use a surgeon’s knot or a granny knot and square the second knot. Two square knots or a surgeon’s or granny knot and one square not are adequate. The ends of the sutures should be cut at the not when using buried nylon and usually this is best managed by touch rather than by sight. Slide one blade of the curved tenotomy scissors down the suture and or and until you feel the knot and then divide both in set the not. When using intradermal sutures (nylon), if the Indians are left more than a small fraction of a millimeter long they may protrude later, even though the knot is buried.

Closing the skin requires special attention. As noted previously, it is the layer of interrupted clear nylon placed intradermally that is the key to narrow scars. Using the small skin hook or fine-toothed forceps to divert the wound margin, insert the needle about one or 1.5 mm below the skin margin and bring it out just below the surface. Reverse the maneuver on the opposite side. As you tie a square not, cross your hands with each throw and orient the ends of the suture parallel to the wound. On the face, neck, scalp and external aspects of the years, skin sutures usually are desirable. If the approximation of the margins by the intradermal closure leaves no gaps, external skin sutures in the face and neck are not needed. The latter situation is the exception rather than the rule. Repair of wounds of the lip and ear are described in the chapter on special situations.

When suturing in any area, avoid contact of the suture with the skin as much as possible.

Keep a neat Mayo. Placing instruments and sponges in the same general area on the Mayo after you use them will make it easier to locate them.

Taking smaller suture bites at the extremities of elliptical or Chris at eight defects will provide a smoother surface contour. When closing the external skin with a running suture and the direction you are passing the needle becomes awkward, do a horizontal mattress suture to change the pattern. Avoid using a locking running suture because it constricts blood supply.

The selection of a suture involves three decisions: the type of suture (e.g. silk, nylon, catgut etc.), it’s size and the type of needle. 60 years ago, silk and catgut were the gold standard. Today, there are a multitude of sutures available. In all situations, you want the suture to be strong enough to do the job and easy to handle, with minimal package memory and good nodding characteristics. Also, most of the time minimal tissue reactivity is desirable and in many locations non--absorbability is important. These days I prefer nylon in most areas for the external skin, intradermally and in fat. Nylon is stronger per unit size is easy to work with is essentially nonreactive and also non--absorbable. The disadvantage of using buried nylon and it should be clear nylon, intradermally is that not infrequently a suture will become exposed exposure of nylon rarely results in inflammation and usually is manifested by a palpable splinter-light projection. Most of the time the offending suture can be easily removed with magnification, needle nosed forceps and suture removal scissors. Occasionally local anesthesia is required.

There is no question in my mind that clear intradermal nylon placed in an interrupted fashion provides the least conspicuous scars. The drawback of dealing with exposed sutures is a nuisance but the end result is worth it. As noted previously, the old teaching of diverting skin sutures during closure to narrow scars is nonproductive because there is no collagen present when the skin sutures are removed. Intradermal closures are not indicated in the hands and feet. I prefer six-0 black nylon for external skin closure in the face and neck and five all-black nylon for skin closure in the scalp. 5-0 clear nylon is used to approximate the fat muscle and intradermally in the face and neck.

Below is a table indicating my preferences for type of suture, suture size and needles for various areas.

Avoid using external skin sutures in the trunk and extremities except for the hands and feet. The scarring from external skin sutures almost always is more conspicuous than the scar from the wound.

All always have the scrub nurse or technician show you the suture package before they open it. The amount of suture wasted daily in the emergency room and OR is significant because this rule is violated and one is given the incorrect suture.

Avoid silk for ligatures and use catgut instead. Rarely a patient will be allergic to silk and all the buried silk will extrude.

And crossing every “T” in the situation referenced will lead only to frustration and pent up anger. Early in my career I tried to do my very best work on everyone. Gradually dawned on me that in some circumstances either time limitations or the patient’s lifestyle made this approach impractical. Drunk drivers, drug addicts, etc., need to be adequately cared for but, in my opinion, do not deserve your best efforts. I felt a great sense of liberation and shedding of guilt when this epiphany occurred to me.

Most surgeons are familiar with the old cliché that “the enemy of good is better.” Shakespeare noted in King Lear that “striving to better, we oft mar what’s well.” Surgery, in a way, is like trimming a hedge. One needs to know when to quit. Obviously acquiring this judgment comes easier with experience. Sometimes there is a fine line between the possible benefits of further effort and the inherent risks and attempting subtle improvements.

In closing defects of the anterior aspect of the knee and posterior aspect of the elbow, the intradermal nylon searchers should be placed more deeply than usual. Such placement will decrease the risk of suture exposure as the scar stretch and then with time.

When repairing wounds where there has been extensive fragmentation of the tissue planes from blunt force, approximating all the layers below the dermis in a single suture usually is preferable to attempting to do a layered closure.

If it will be inconvenient or impossible for the patient to return for suture removal, or to go to another facility for same, do a meticulous intradermal closure and placed a few 6=0 plain chronic sutures externally, if necessary.

The less space there is to place an intradermal suture the more it is necessary to choke down on the needle-- that is, grab it closer to the tip.

Occasionally a running suture is used in the external skin closure but avoid and interlocking one.

Stair stepping of the margins of the ala rim, I led or air wounds has been advised by some but in general should be avoided. Often the pattern of the wound is such that it essentially mimics a stair step configuration. Even if it doesn’t, it is rare for contour abnormalities to ensue. Stair stepping about the nostril may lead to a significantly smaller opening.

When using a skin hook about the face, it is important at all times to keep in your mind’s eye the location of the sharp end of the instrument to avoid damaging and eye.

I routinely where a patient’s down when working in the emergency room or trauma bay. This is not for stability purposes but to protect my clothes. Not wearing a tie in these areas also is a good practice.

Work close to the wound you are repairing. Track down the tail end of the suture with your nondominant hand on both interrupted and running sutures so you are working close to the tissue and not a foot or so away.

In repairing wounds of the medial aspect of the eyelids it is not necessary to repair a single divided canaliculus. Frank McDowell pointed out years ago that the punctum and canaliculus constitute such a delicate vacuum cleaner type apparatus that it usually will not function satisfactorily following repair even if one can demonstrate the duct is open. It is quite rare for both canaliculi to be divided. I have never encountered a problem from not repairing a single divided canaliculus. The important step in medial eyelid repair is to get the eyelid against the globe. The first stitch, a 5-0 clear nylon on a P-3 in the medial canceled tendon is the most important one. It will approximate the lid against the globe satisfactorily if properly placed. The rest of the repair then is easy. See the chapter on special situations for more on this subject.

Gluing wound margins together will close and seal them but will not lead to a narrow scar.

If the wound parallels the natural skin wrinkles, fewer intradermal sutures are needed. An intradermal suture is different from a subdermal or subcutaneous suture. A subcutaneous or subdermal suture the notes that the closure is below the skin but these terms are not so precise as the term intradermal which obviously denotes that the suture is in the dermis.

I do not employ steri-strips. Every wound tends to drain a certain amount of serosanguinous fluid and this can accumulate under the steri-strips and cause maceration. Besides, I see no value in further supporting the wound margins if they have been well approximated. If they haven’t been, the strips provide no useful long-term function.

As we begin practice, we all tend to follow the routines and paradigms taught by our mentors. As time passes, more expeditious and productive regimens may become apparent and we switch to the latter. Many approaches and techniques pass the test of time and almost every surgeons experience. Other paradigms are like fashions in clothing, they tend to wax and wane or appear once and fade into the sunset.