The document provides guidance on suturing techniques. It recommends everting the skin edges when suturing to achieve better dermal apposition, improved healing, and a finer scar. A triangular suture passage with the base located deeply is suggested to evert the wound edges, while an inverted triangular shape tends to invert them. Dermal sutures are recommended first to reduce tension before cutaneous sutures. Adjusting where the knot lies can help flatten steps between uneven wound edges. The document also reviews appropriate suture materials for different areas, recommending absorbable sutures that elicit minimal tissue reaction for the face and longer-absorbing sutures for prone areas like the back.

2. GPs
Suturing workshop

3. Suturing
• The skin edges should always be everted when
suturing is complete.
• This results in:
• Better dermal apposition
• Improved healing
• A finer final scar.

4. Cutaneous suture
• The aim of this suture is to accurately appose
and evert the skin edges.

5. Cutaneous suture
• The following may be helpful in achieving this.
• When viewed in a cross-section, the suture
passage should be triangular-shaped
– with its base located deeply as this will evert the
wound edges.
– A triangular-shaped suture passage with the base
located superficially tends to invert the wound
edges.

7. Trust the needle

8. If in doubt mattress

9. If in doubt mattress

10. Dermal suture
• Most wounds are closed by first opposing the
skin edges with a dermal suture.
• This reduces the tension on the subsequent
cutaneous suture and helps to limit
• stretching of the wound.
• Use either monocryl (face) or pds

11. Dermal suture
• The dermal suture should enter the deep reticular
dermis on the incised edge of the wound.
• It should then pass superficially into the papillary
dermis.
• The knot should be tied deeply to prevent
subsequent exposure of the suture.
• This method of suture placement produces good
apposition and eversion of the skin edges.

21. Cheat stitch
• This combination dermal and interrupted
suture is helpful with wounds under tension
• Especially when you are happy to leave the
suture in for 2 weeks and stitch marks not a
great concern
– Backs, legs, arms

29. Fudging!
• If one of the wound edges lies lower than the
other, the suture should be passed through
the cut edge of the skin low on that side (‘low-
on-the-low’).

30. Fudging!
• If one of the wound edges lies higher than the
other, the suture should be passed through
the dermis high on that side (‘high-on-the-
high’)
• Passing the suture in this way acts to flatten
out any vertical step between the wound
edges and ensures that the sides are on a level
plane.

31. • Fine adjustments can be made by changing
the side on which the knot lies
– the knot will tend to raise the side on which it lies

35. Subcuticular/Intradermal
• The suture passes through the dermis, not
under the skin.
• Should always be there to approximate the
epithelium with no tension
• The hard work is done by the deep dermals

36. Another cheat stitch
• Useful for long wounds where you want to
save time but still get everted skin edges
• Combination of “over and over” and
horizontal mattress

38. What suture when?

39. Vicryl
• Vicryl is a braided synthetic
suture
• It loses its strength by 21
days and is absorbed by 90
days.
• Its braided nature may
make it more prone to
bacterial colonization than
monofilament alternatives.
• It may provoke a significant
inflammatory reaction
• Don’t use as a dermal
suture in the face.

40. PDS
• PDS is a monofilament
synthetic suture composed
of polydioxone.
• It is absorbed more slowly
than either vicryl, monocryl
or dexon.
• It loses its strength by 3
months and is absorbed by
6 months.
• It is primarily used as a
dermal suture in areas
prone to developing
stretched scars.

41. Monocryl
• Monocryl is a
monofilament synthetic
suture composed of
poliglecaprone 25.
• It has similar absorption
characteristics to vicryl.
• Its monofilament
composition may make
it less prone to bacterial
colonization.

42. What suture when?
• Sutures that retain their strength for a
significant amount of time, such as a
PDS, should be used in areas prone to scar
stretching, such as the back, legs torso.
• Sutures that elicit a minimal tissue
reaction, such as monocryl, should be used in
the face.

43. Face
• Kids • Adults
– 6.0 fastgut with – Nylon or prolene
dermabond glue to • Skin
waterproof • 5.0 or 6.0
– Steristrips on top of – Monocryl
wound • Dermal
• 5.0
– Remove sutures day 5 or
6
– No later as may leave
stitch marks

45. Scalp
• Kids • Adults
– Vicrylrapide/vicryl – Staples or any suture
– monocryl different colour to
patients hair

46. Rest of body
• Kids • Adults
– Same as adults – Depends on extent of
wound and depth
• Usually dermal
pds/monocryl
• Interrupted
nylon/prolene