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