skin can be pulled more tightly than elsewhere Firm, but not strangulating, apposition of the wound will also help with hemostasis To ensure proper alignment, the first suture may be placed at the midpoint of the wound, with subsequent sutures then placed in a bisecting fashion lateral to the midpoint Use of noncrushing forceps to hold tissue should be encouraged because this allows the operator to precisely pass the needle through the desired points alongside the wound edge However, forceps use should be kept to a minimum during the repair to avoid tissue damage Skin wounds can generally be repaired using interrupted sutures To place a simple interrupted suture, the needle is held pointing down toward the skin and the wrist is pronated as the needle enters the skin at a 90-degree angle The needle tip will then move farther away from the wound margin and penetrate deeply Thus, more tissue is at the depth of the wound, and this causes the wound to evert Sutures should be placed about mm apart and mm from the wound edge on delicate areas such as the face More sutures placed closer together decrease wound tension and leave a less noticeable scar Larger bites should be used for body parts where cosmesis is less important FIGURE 110.3 A: The buried subcutaneous suture B: The horizontal dermal stitch Use an instrument tie to secure the suture ( Fig 110.4 ) The knots should ideally be placed on one side of the wound Knots placed directly over the wound increase inflammation and scar formation On the first throw, the provider should wrap the needle holder twice to create a surgeon’s knot and then wrap subsequent throws a single time The first and second throws should be snug enough to approximate the wound edges, but not so tight that tissue is strangulated All subsequent knots are squared to maintain the closure Four or five throws are usually required to keep the knot from unraveling A “loop knot” is effective in apposing the wound edge with minimal tension This involves placing a surgeon’s knot, using the instrument tie, followed by a loop The surgeon’s knot will “give” slightly should edema develop subsequently The loop knot allows easier, painless removal of sutures because it creates a free space between the suture and the skin ( Fig 110.5 ) Running or continuous sutures can be applied rapidly to close large, straight wounds or multiple wounds With this technique, the suture is not cut and tied with each stitch The first suture is placed at one end of the wound and a knot is tied, cutting only the end of thread not attached to the needle The next loop is placed a few millimeters away and continuous loops of equal bites are made to close the wound On the final loop, because the suture is not completely pulled through, a small loop remains on the opposite side of the wound Now, the knot can be tied using the preceding loop of suture ( Fig 110.6 ) This type of stitch is more likely to leave suture marks if not removed in days Apposition of the edges and eversion are more difficult to achieve with running sutures, and the entire suture line can unravel if the suture breaks anywhere along the repair However, the technique gives the advantage of having equal tension on the wound edges FIGURE 110.4 Simple interrupted skin suture secured with instrument tie FIGURE 110.5 Placement of a “loop knot” in conjunction with simple sutures of the skin using an eversion technique A: The needle enters the skin at a right angle in a way that allows somewhat less skin and more subcutaneous tissue to be caught in the passage of the needle The needle should incorporate the same amount of skin and subcutaneous tissue on each side The ideal suture material for placing a “loop knot” is 4-0 nylon One can also use 5-0 nylon B: The first knot should be a surgeon’s knot drawn down gently to barely coapt the skin edges C: The second tie should be placed to produce a square knot but should be drawn to produce an approximate 2- to 3-mm loop D: The third tie should be placed to produce a square knot This third tie can be secured tightly against the second tie, preserving the loop and allowing for some spontaneous loosening of the surgeon’s knot as later edema develops FIGURE 110.6 Continuous skin sutures A: The simple continuous running stitch B: The continuous interlocking skin stitch C: The running lateral mattress stitch or continuous halfburied horizontal mattress stitch FIGURE 110.7 A–E: The vertical mattress suture After initially placing a simple interrupted stitch with a somewhat larger bite, make a backhand pass across the wound, taking small, superficial bites When the knot is tied, the edges of the laceration should evert slightly (From Grisham J Wound care In: Dieckmann RA, Fiser DH, Selbst SM, eds Illustrated Textbook of Pediatric Emergency & Critical Care Procedures St Louis, MO: Mosby; 1997:676, reprinted with permission.) The vertical mattress stitch is useful for deep wounds in which it may be difficult to tie a simple, deep, interrupted suture It reduces tension on the wound and may close dead space within the wound It essentially combines a deep and superficial stitch in one suture The needle is placed deep within the wound (about mm from the wound edge) and brought out to the opposite skin surface It is then brought across the epidermis to approximate the epidermal edges ( Fig 110.7 ) This stitch takes more time to accomplish and produces more cross marks, but it provides excellent, exaggerated wound eversion and apposition of the wound edge Too tight of a knot can pucker the wound The horizontal mattress stitch reinforces the subcutaneous tissue and effectively relieves tension from the wound edges It does not provide woundedge approximation as well as the vertical mattress stitch The needle is passed ½ ... (From Grisham J Wound care In: Dieckmann RA, Fiser DH, Selbst SM, eds Illustrated Textbook of Pediatric Emergency & Critical Care Procedures St Louis, MO: Mosby; 1997:676, reprinted with permission.)