Atlas of Primary Care Procedures, 1st Edition

Dermatology

14

Simple, Interrupted Skin Suture Placement

The simple, interrupted skin suture has been one of the most commonly employed wound closure techniques in the last century. The simple suture can be used alone or in conjunction with deep sutures to provide optimal wound healing and cosmesis. Properly placed interrupted skin sutures incorporate symmetric amounts of tissue from each wound edge, evert the skin edges, and provide wound edge opposition without tissue strangulation. Interrupted skin sutures allow precise adjustments between stitches. Proper timing for suture removal allows for adequate healing (i.e., strength to the developing scar) and minimizes the development of suture marks (i.e., railroad or Frankenstein marks.) Interrupted skin sutures also permit removal of selected stitches (e.g., every other stitch) to individualize the time sutures are present.

Wound edge eversion is an important goal when placing interrupted skin sutures. Healing wounds have a natural tendency to become inverted with the retraction that occurs within scars. Indented or inverted scars can cast a shadow on adjacent surfaces, and the shadow magnifies the appearance of the scar. Everted wounds are created so that the final scar is flat and not inverted. Eversion is accomplished by incorporating a greater amount of deep tissue in the needle path, which pushes together the deep tissue, causing upward lift to the wound edges.

The simple, interrupted skin suture is used in a variety of clinical settings. The technique is used for superficial wounds when single-layer closure is indicated. Suture placement permits functional movement of an area after closure and is especially valuable over the dorsum of the fingers. Although simple sutures can be used to close wide surgical wounds, the distribution of tension to approximate the skin edges may be better handled with vertical or horizontal mattress skin sutures or by placement of deeply buried subcuticular sutures.

Nonabsorbable suture materials such as nylon generally are selected for interrupted suture placement. Smaller-caliber sutures (5-0 and 6-0) tend to produce less skin marking and scarring than larger-caliber sutures (3-0 and 4-0). Placement of tightly clustered sutures close to the wound edge distributes the skin edge tension better than placement of widely spaced sutures placed back from the wound edge. Suggested suture removal times are listed in Appendix C.

Wound adhesives are an alternate means for wound closure. Some practitioners believe that wound edge eversion is superior with suture closure, but adhesives

P.110

can produce good cosmetic results for wounds with closely approximated edges. Wound adhesives are costly (more than $40 for single applications) and probably will not eliminate the need for simple interrupted closures.

INDICATIONS

• Superficial wounds that can be closed in a single layer
• Eversion of wound edges after approximation with mattress or buried sutures
• Marking of skin for correct anatomic approximation (e.g., vermilion border)
• Closure of wounds over areas of movement such as flexor creases or on the dorsum of the fingers

RELATIVE CONTRAINDICATIONS

• Closure of defects on breast tissue (use a running intracutaneous suture closure)
• Widely separated wound edges that are better approximated with deeply buried sutures
• Presence of cellulitis, bacteremia, or other active infection
• Uncooperative patient

P.111

PROCEDURE

A retracted scar on a vertical surface, such as the face, produces a shadow that magnifies the appearance of the scar (Figure 1A). Wound edges should be everted at closure (Figure 1B) so that subsequent scar retraction will produce a final scar that is flat (Figure 1C).

The poorly performed, “scooped” passage of a suture needle across both wound edges (Figure 2A) will fail to create proper closure. The stitch should be deeper than it is wide. The needle should enter the skin vertically (Figure 2B) and exit the skin vertically.

P.112

Symmetric amounts of tissue from each wound edge should be included in the passage of the suture. Uneven bites of tissue in the distance from the edge or the depth of passage (Figure 3A) produce a closure with uneven edges (Figure 3B). The resulting scar will cast a shadow and be cosmetically inferior.

PITFALL: Forcefully pushing or twisting the needle when passing it through the tissue will cause the body of the needle to bend or break. Follow the curve of the needle; do not apply twisting or torquing forces to the needle. Regrasp (remount) the needle in the center of the wound rather than force a small needle through both wound edges. If the needle bends, remove it, and open another suture pack. Broken needle tips can result in hours of frustrating searching to find the broken piece.

P.113

The proper needle path to produce wound edge eversion is in the shape of a flask (Figure 4A). The nondominant hand is used to push down on both wound edges (Figure 4B), causing the tissue in the deep portion of the wound to move toward the center of the wound (Figure 4C). The needle enters the skin vertically and exits the skin vertically. When the nondominant hand relaxes, the tissue returns to its natural position. The suture path is flask shaped, and with tying, the suture produces eversion.

PITFALL: Pushing down on the wound edges with the fingers increases the risk for an inadvertent needlestick. Instruments can be used to push down on the wound edges. If the fingers are used, exert added care to minimize the risk of a needle injury.

P.114

An alternative method to produce a flask-shaped path is technically more difficult. As the needle enters the right wound edge, the nondominant hand grasps tissue beneath the wound edge using Adson forceps and pulls tissue to the center of the wound (Figure 5A). Before the needle passes through the opposite wound edge, the deep tissue is pulled to the center of the wound with a backhanded technique using Adson forceps (Figure 5B).

PITFALL: Avoid traumatizing the skin or deep tissue with the forceps. Traumatized tissue may necrose, creating excessive time to healing and inferior cosmetic results.

Antibiotic ointment is placed over the sutured wound, and a pressure dressing is applied.

P.115

CODING INFORMATION

All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives with or without adhesive strips on the skin surface. If a layered closure is required, use alternate codes: intermediate closure codes 12031–12057 or complex repair codes 13100–13160.

Add together the lengths of wounds in the same classification and anatomic sites. Débridement is considered a separate procedure only when gross contamination requires prolonged cleansing or when appreciable amounts of devitalized or contaminated tissue are removed.

Simple repair is included in the codes reported for benign and malignant lesion excision (see Chapter 12). The billing chart cites the following wound locations: scalp, neck, axillae, external genitalia, trunk, extremities, hands, and feet (SNAGTEHF) and face, ears, eyelids, nose, lips, and mucous membranes (FEENLMM).

P.116

INSTRUMENT AND MATERIALS ORDERING

Instruments for simple, interrupted, skin suture placement are found in Appendix A and can be ordered through local surgical supply houses. Suture materials can be ordered from Ethicon, Somerville, NJ (http://www.ethiconinc.com) and from Sherwood-Davis & Geck, which is now part of Kendall Healthcare (http://www.tyco.com). A suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation recommendations appear in Appendix H.

BIBLIOGRAPHY

Bennett RG. Fundamentals of cutaneous surgery. St. Louis: CV Mosby, 1988:384–394.

Brown JS. Minor surgery a text and atlas, 3rd ed. London: Chapman & Hall, 1997:70–96.

Ethicon wound closure manual. Somerville, NJ: Ethicon, 1994.

Lammers RL, Trott AT. Methods of wound closure. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine, 3rd ed. Philadelphia: WB Saunders, 1998:560–598.

McCarthy JG. Plastic surgery. Philadelphia: WB Saunders, 1990:1–68.

Moy RL, Lee A, Zalka A. Commonly used suturing techniques in skin surgery. Am Fam Physician 1991;44:1625–1634.

Moy RL. Suturing techniques. In: Usatine RP, Moy RL, Tobnick EL, Siegel DM, eds. St. Louis: Mosby, 1998:88–100.

Odland PB, Murakami CS. Simple suturing techniques and knot tying. In: Wheeland RG, ed. Cutaneous surgery. Philadelphia: WB Saunders, 1994:178–188.

Spicer TE. Techniques of facial lesion excision and closure. J Dermatol Surg Oncol 1982;8: 551–556.

Stegman SJ, Tromovitch TA, Glogau RG. Basics of dermatologic surgery. Chicago: Year Book Medical Publishers, 1984:41–42.

Swanson NA. Atlas of cutaneous surgery. Boston: Little, Brown, 1987:26–28.

Zitelli JA. TIPS for a better ellipse. J Am Acad Dermatol 1990;22:101–103.

Zuber TJ. Basic soft-tissue surgery. The AAFP illustrated manuals and videotapes of soft-tissue surgery techniques. Kansas City: American Academy of Family Physicians, 1998:34–38.