The document describes various suture techniques including simple interrupted sutures, which are the gold standard, subcuticular sutures which avoid external knots, half-buried horizontal mattress sutures which keep knots on one side, continuous over-and-over sutures which can be placed rapidly but are less precise than interrupted sutures, skin staples which are a timesaving alternative to sutures, skin tapes and adhesives which can be used in low tension areas, and Z-plasties which help prevent or limit scarring and contractures. It also outlines indications, contraindications and potential complications of Z-plasty techniques.

1. Suture techniques

3. Simple Interrupted
Suture.
• Gold standard
• most commonly employed suture
• Sutures are usually placed
approximately 5 to 7 mm apart and
to 2 mm from the skin edge

6. Subcuticular
suture
 obviates the need for external skin
sutures
 circumvents the possibility of suture
marks in the skin.
 Absorbable or nonabsorbable suture
can be used, with the latter to be
removed at 1 to 2 weeks after
suturing

7. Half-Buried
Horizontal Mattress
Suture
 used when it is desirable to have
the knots on one side of the suture
line with no suture marks on the
other side.
 For example, when insetting the
areola in breast reduction

8. Continuous Over-
and-Over Suture
 known as running simple sutures,
 can be placed rapidly but depend
on the wound edges being more or
less approximated beforehand.
 not nearly as precise as interrupted
sutures
 Can also be placed in a locking
fashion to provide hemostasis by
compression of wound edges.
 They are especially useful in scalp
closures

9. Skin Staples
 useful as a timesaver
 Grasping the wound edges with
forceps to evert the tissue is helpful
when placing the staples to prevent
inverted skin edges.
 Staples must be removed early to
prevent skin marks and are ideal for
the hair-bearing scalp

10. Skin Tapes.
.

11. Skin Adhesives
in areas where there is no tension
on the closure, or where strength
of closure has been provided by
a layer of buried dermal sutures.
Adhesives, by themselves,
however, do not evert the wound
edges.
Eversion must be provided by
deeper sutures.

12. Z-PLASTY

13.  1856, Denonvilliers first described the Z-plasty technique as a surgical
treatment for lower lid ectropion.
 The first reference to this technique in American literature was in 1913, by
McCurdy, as treatment for contracture at the oral commissure.
 Limberg, in 1929, provided a more detailed geometric description

14. indications
 Limiting/preventing contracture of linear scars, especially when they cross
the border of a facial aesthetic unit (eg, vermillion border) or when scars
cross a concave surface (eg, the medial canthus)
 Changing scar length (eg, scar contracture of lip, eyelid, or neck)
 Changing scar vector (eg, repositioning a scar across the nasolabial fold)
 Repositioning malposed tissues (useful for "trapdoor" or "pin-cushion"
defects)

15.  Effacing web/release contracture (similar to first listed use)
 Closing cutaneous defects (eg, large oval defects, pharyngocutaneous
fistulae)
 Correcting stenosis (eg, tracheostoma, nares, external auditory canal) using
single or multiple Z-plasties [3]
 Transposing healthy tissue to close a fistula (eg, tracheostoma closure after
irradiation)

16. contraindications
 health risks that affect vascular supply to the skin (eg, atherosclerotic heart
disease, diabetes, smoking, collagen vascular disease, prior irradiation,
anticoagulation).
 A history of poor wound healing, hypertrophic scarring, or keloid
formation is a relative contraindication to Z-plasty

30. complications
 Hematoma
 Dehiscence
 Trap door
 Flap necrosis
 infection

31. Reconstructive
ladder

32. FREE TISSUE TRANSFER
REGIONAL TISSUE TRANSFER
LOCAL TISSUE TRANSFER
SKIN GRAFT
DIRECT TISSUE CLOSURE
ALLOW WOUND TO HEAL BY SECONDARY INTENTION