Dr. Joel Aronowitz - Plastic Surgeon's SUTURE TECHNIQUES (Running, Simple Cuticular, Vertical Mattress and Simple Buried)
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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “We're going to do a little demonstration just to show some suture techniques. Here's an incision. Okay, let's demonstrate a simple buried suture. So we're going to go from deep to superficial, come out just under the surface of the skin here, and then we're going to enter the skin superficial and come out deep on the opposite side.
So now we're going to tie our knot on the deep side so it will be buried, and the rabbit when we tie this will be deep and not poking out.
And we put down two throws, then one throw, then one throw so that each one is square. And with Vikral or a braided suture, we can easily get away with four throws very securely because that's going to hold the knot well. But with a monofilament, it's got to be four solid square throws and in a critical area, even five or six.
So there's our simple buried suture. And now I'm going to demonstrate a simple cuticular, not subcuticular but cuticular. So I'm going to go superficial to deep, deep to superficial, and you want to come back far enough so that it spreads the tension out, and you want to make sure when you place your that you don't strangle the tissue. So this would be strangling the tissue would be excessively tight, and this is everted, the skin margins. So that's no good. We don't want the skin margins inverted. We would like them everted or at least just barely together so that they can epithelialize across.
So Proline is a monofilament suture. I'm going to demonstrate just a couple of simple suture techniques. First is a simple cuticular suture. So I'm going to penetrate the skin at a right angle about three-eighths of an inch back from the margin.
And if you're talking about the scalp where we want to have the tension spread evenly, then I'm going to go from deep to superficial, come straight up so it's a nice square bite. So when I encircle this tissue with my knot, I've got the tissue underneath coming together, and I'm not just getting the very surface of the skin.
So now I've got a square double throw. Now I'm going to bring the second throw down square, and notice that's not super tight. That's just tight enough to approximate, but not so tight as to strangle the tissue. And with a monofilament suture, four square throws are going to be necessary.
So simple skin stitch. Next, I want to show you a vertical mattress. So a vertical mattress, I'm going to come back a little bit further from the margin. Again, I want to go in squarely. Then I want to come in, grab a generous amount of tissue subcutaneously. So I'm not just getting the edge like this.
I want to get that subcutaneous tissue. So it's bringing it all together underneath. I'm going to come up straight again. Now this is the vertical mattress part. I'm going to go far, far, near, near. So that's near number one, and this will be near number two.
And when I say near, it's usually about what I've shown there, about two, maybe three millimeters. And when you tie that knot, you want to be careful to not tie it too tightly again. So I'm going to bring that down square. Just enough tension to bring the skin margins together without blanching it, because that's going to basically strangle the tissue that's encom And four knots there. So we have a simple stitch and a vertical mattress. And now I'm going to demonstrate a running suture and a running locking suture.
Okay, so now I want to demonstrate a running suture.
And what we're going to do is just place a simple cutaneous suture. And we're going to tie the end here and two throws, one throw, one throw, a total of four throws minimum for a monofilament, because the monofilament is not going to hold the knot as well as a braided stitch.
So now when we're running, we can either advance on the outside, which gives you a baseball-looking stitch, or we can advance on the inside, which gives you straight stitches. So I'm going to show you this example where we're going to advance on the outside. So that means I'm going to go straight across here.
And then with each suture, I'm going to be careful to advance the same amount on each side and with each stitch. And if I can do it in one bite like this, I will, but if I can't, I'm just going to do it in two bites so that I have a nice result.
Remember, people, your patients are not going to see the inside work that you do. They're only going to see the outside and judge your work by that. So that's going to be a running simple stitch. And again, attention to the tension. If you pull this super tight, it is going to eventually distribute the tension evenly, but you can end up with a large area of marginal incisional necrosis there from over tightening. So there's no reason to do that. We want to just tighten enough to bring the skin margins together. Now, from this point, I'm going to demonstrate a locking stitch. So we're going to go in and we're going to come out.
And now I'm going to lock this. So a locking suture, you're going to use for hemostasis.
And the problem that you can get with locking sutures, and the reason you shouldn't use them too much is because they can easily cause marginal necrosis of your incision. So that's a locking stitch. And it's a perfectly acceptable stitch to use. But you, again, you want to use it only when you need to.
And you don't want to over tighten because, again, we're going to cause necrosis of the skin margin and additional scarring along the suture track. OK, let's just take a moment to appreciate the anatomy of the skin and the subcue because that's what we're working on when we're closing incisions. So the white layer is the dermis, and the deeper layer of the dermis is the reticular dermis.
That's the thicker layer. The papillary dermis, I don't know how much of this you can see, but that's the part of the dermis that is undulating up and down with little papillae. And if you look very carefully, you can see the hair follicles going all the way through the dermis, and the bulb of the hair follicles actually at the bottom of the dermis in the subcutaneous fat right in here.
So here's subcutaneous fat, and you can see there's septi within the fat that separate the lobules of fat. And if you look very carefully, you can see the hair follicles going all the way through the dermis, and the bulb of the hair follicles is actually at the bottom of that dermis in the subcutaneous fat right in here.
So here's subcutaneous fat, and you can see there are septi within the fat that separate the lobules of fat. And if we go even further, we'll see there's actually a septal layer right here. This white dense layer, even in a kind of an obese tummy, the layers are evident. And those same layers are present in the scalp and throughout the rest of the body. So when we're suturing, it's a good idea to pay attention to those layers.
When you're holding the tissue, if you crush like this, it's not really helping the tissue. It's causing a crush injury to the blood supply, which is this dermal subdermal plexus. So delicate tissue handling should be part of our routine in sewing. I'm going to place a deep vicryl suture here for the closure. And you see, I've come out about two millimeters below the surface of the skin.
And when I go back in the other side, when I'm sewing this back together, then I want to go in this layer so that when the edges come together, like in this specimen, they come together perfectly like this. And they're not overriding with one side higher than the other or with the edges inverted because it's going to be very hard for it to heal.
So when we do finish, the edges should be just very nicely together. They should be aligned perfectly and held with the minimum tension.”
And what we're going to do is just place a simple cutaneous suture. And we're going to tie the end here and two throws, one throw, one throw, a total of four throws minimum for a monofilament, because the monofilament is not going to hold the knot as well as a braided stitch.
So now when we're running, we can either advance on the outside, which gives you a baseball-looking stitch, or we can advance on the inside, which gives you straight stitches. So I'm going to show you this example where we're going to advance on the outside. So that means I'm going to go straight across here.
And then with each suture, I'm going to be careful to advance the same amount on each side and with each stitch. And if I can do it in one bite like this, I will, but if I can't, I'm just going to do it in two bites so that I have a nice result.
Remember, people, your patients are not going to see the inside work that you do. They're only going to see the outside and judge your work by that. So that's going to be a running simple stitch. And again, attention to the tension. If you pull this super tight, it is going to eventually distribute the tension evenly, but you can end up with a large area of marginal incisional necrosis there from over tightening. So there's no reason to do that. We want to just tighten enough to bring the skin margins together. Now, from this point, I'm going to demonstrate a locking stitch. So we're going to go in and we're going to come out.
And now I'm going to lock this. So a locking suture, you're going to use for hemostasis.
And the problem that you can get with locking sutures, and the reason you shouldn't use them too much is because they can easily cause marginal necrosis of your incision. So that's a locking stitch. And it's a perfectly acceptable stitch to use. But you, again, you want to use it only when you need to.
And you don't want to over tighten because, again, we're going to cause necrosis of the skin margin and additional scarring along the suture track. OK, let's just take a moment to appreciate the anatomy of the skin and the subcue because that's what we're working on when we're closing incisions. So the white layer is the dermis, and the deeper layer of the dermis is the reticular dermis.
That's the thicker layer. The papillary dermis, I don't know how much of this you can see, but that's the part of the dermis that is undulating up and down with little papillae. And if you look very carefully, you can see the hair follicles going all the way through the dermis, and the bulb of the hair follicles actually at the bottom of the dermis in the subcutaneous fat right in here.
So here's subcutaneous fat, and you can see there's septi within the fat that separate the lobules of fat. And if you look very carefully, you can see the hair follicles going all the way through the dermis, and the bulb of the hair follicles is actually at the bottom of that dermis in the subcutaneous fat right in here.
So here's subcutaneous fat, and you can see there are septi within the fat that separate the lobules of fat. And if we go even further, we'll see there's actually a septal layer right here. This white dense layer, even in a kind of an obese tummy, the layers are evident. And those same layers are present in the scalp and throughout the rest of the body. So when we're suturing, it's a good idea to pay attention to those layers.
When you're holding the tissue, if you crush like this, it's not really helping the tissue. It's causing a crush injury to the blood supply, which is this dermal subdermal plexus. So delicate tissue handling should be part of our routine in sewing. I'm going to place a deep vicryl suture here for the closure. And you see, I've come out about two millimeters below the surface of the skin.
And when I go back in the other side, when I'm sewing this back together, then I want to go in this layer so that when the edges come together, like in this specimen, they come together perfectly like this. And they're not overriding with one side higher than the other or with the edges inverted because it's going to be very hard for it to heal.
So when we do finish, the edges should be just very nicely together. They should be aligned perfectly and held with the minimum tension.”
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