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150 Appendix A
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Table A-3. Common Suture Techniques
2,7,9
Simple interrupted • Most commonly used technique
• Versatile and easy
• More time-consuming than other techniques
• Used for linear or irregular traumatic and postoperative wounds
• Effective for deep wounds
• Consists of individual strands of material
• Approximation remains with breakage of a single strand
• Produces eversion of wound edges
Horizontal mattress • Used for gaping and high-tension wounds
• Effective for calloused areas of skin (soles of feet, palms)
• Tension is spread among all wound edges
• Compresses wound edges for hemostasis
• Produces eversion of wound edges
• Reduces risk of necrosis
Vertical mattress • Produces better eversion of wound edges than other techniques
• Used for thick or thin skin
• Provides secure grasp of tissue and good approximation
• Used for wounds under tension
• Increases risk of hatch mark scars
Running continuous • Used for long, linear, low-tension wounds
• Allows for more rapid closure than other techniques
• Produces even distribution of tension along wound
• Failure in any part of suture will comprise the entire suture
outcomes. See Table A-2 for suture size guidelines based on body region. However, smaller diameter
sutures may need to be placed closer together to close the wound.
Suture needles insert the suture material through the tissue. Suture needles have 3 parts: the eye,
body, and point.
manufactured into the eye.
curved body is available in different lengths. A curved needle with a 3/8 circle is most commonly
used for skin closure.
3 cutting edges and are available in standard or reverse cutting designs.
tough tissues such as skin.
tissues to insert the suture and are used with tissues that do not resist needle penetration, including
subcutaneous fat and fascia.
The suture technique is used to mechanically approximate the tissue edges and close the wound
in various patterns. Clinicians can determine the most effective technique for closure based on the
wound type, length, and location; amount of skin tension; and clinician skill, experience, and comfort with the technique. Table A-3 lists common suture techniques available to clinicians. See Table
A-4 for the single interrupted suture technique, perhaps the most commonly used for closure. The
sequence of suture placement varies among clinicians. Initial suture placement can begin over the
middle section of the wound and then alternate on each side toward the wound ends. Initial suture
placement can also begin approximately one-third from the wound edge on one side and then
6
The suture material attaches to the eye; most needles are swaged, with the suture
7
The body of a suture needle can be straight or curved. The circle of the
6,8
The needle point is commonly a cutting or tapered tip. Cutting needles have
8
Tapered needles are round and taper to a point. Tapered needles separate
7
8
These needles penetrate
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Table A-4. Simple Interrupted Suture on a Wound Model
• The needle holder is typically held with the dominant hand. Forceps are held in the
nondominant hand.
• Load the needle holder by grasping the suture needle one-third from the needle eye with
the tip of the needle holder (Figure A-1A).
Figure A-1A
• Gently evert (lift) the wound edge with forceps, place the needle perpendicular (90 degrees)
to the skin, and pierce the skin with the needle (Figure A-1B).
Figure A-1B
• Supinate the wrist and pass the needle through the skin (Figure A-1C). The needle should
travel perpendicular to the subcutaneous tissues.
Figure A-1C
continued
152 Appendix A
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Table A-4. Simple Interrupted Suture on a Wound Model
• Gently evert the skin on the opposing wound edge with forceps and continue to supinate
the wrist to push the needle through the skin (Figure A-1D). Release the skin and grasp the
suture needle with forceps.
Figure A-1D
• Pull the suture through both wound edges and leave 2 to 3 cm of the suture material
exposed (Figure A-1E). The stitch should be as wide as it is deep.
Figure A-1E
(continued)
• Hold the needle holder in the dominant hand and the long end of the suture between the
nondominant thumb and second finger (Figure A-1F).
Figure A-1F
continued
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Table A-4. Simple Interrupted Suture on a Wound Model
• Loop the long end of the suture around the tip of the needle holder twice in a clockwise
direction (Figure A-1G).
Figure A-1G
• Grasp the exposed, short end of the suture with the needle holder (Figure A-1H).
Figure A-1H
(continued)
• Pull the short end of the suture through the loops on the needle holder by moving the
hands in opposite directions with enough tension to close the wound and secure the throw
(Figure A-1I).
Figure A-1I
continued
154 Appendix A
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Table A-4. Simple Interrupted Suture on a Wound Model
• Release the suture from the needle holder and continue to hold the long end of the suture
with the nondominant thumb and finger.
• Loop the long end of the suture around the needle holder once in a counterclockwise
motion (Figure A-1J).
Figure A-1J
• Grasp the short end of the suture with the needle holder and then pull the hands in
opposite directions to secure the second throw (Figure A-1K).
Figure A-1K
(continued)
• Continue with 2 to 3 additional individual loop throws in the clockwise/counterclockwise
pattern.
•
Following the throws, cut the suture with scissors, leaving 3 to 4 mm tails (Figure A-1L).
• Continue with the procedure until wound closure is complete.
• At completion of the technique, use the needle holder to pull each knot to one side of the
wound, away from the laceration or incision.
Figure A-1L
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Table A-5. Suture Removal Time
Body Region Days
Scalp 6-8
Face/lips 3-5
Trunk 7-10a
Extremities 7-10a
Hands 7-10a
Feet 7-14a
a
Ten to 14 days with lacerations and incisions over joints or in areas of high skin tension.
continue with placement one-third from the opposite edge. Sutures continue in this alternate pattern
until wound closure. Sutures are typically spaced 2 to 4 mm apart.
After closure, irrigate the wound with normal saline and pat the area dry with sterile gauze.
Clinicians can immobilize wounds over joints to prevent excessive skin tension. Cover the wound
with a secondary dressing based on patient needs and activity. Numerous nonocclusive and occlusive dressings can be used with sutured wounds. An evidence-based review demonstrated no
findings to support the best nonocclusive or occlusive dressing for postoperative incisions healing
by primary intention (tissue approximation using sutures, staples, dermal adhesives, or a combination of these) to lower the rates of infection.
designs such as sterile gauze or nonadherent pads to protect the wound and sutures. The sutured
wound is often protected from showering and dressing changes for 24 to 48 hours. The authors of
an evidence-based review examining early showering (on or before day 2) and delayed showering
(after day 3) reported no differences in the rates of infection among postoperative incisions.11
Clinicians should monitor and reassess the patient and wound daily for intervention outcomes and
the development of adverse reactions.
Nonabsorbable sutures are removed based on the healing of the wound and the duration of
time in place (Table A-5). A suture removal kit or sterile suture scissors and tweezers or forceps are
needed for the technique. The clinician should use the clean technique for the procedure. If applicable, remove the secondary dressing from the wound. Gently scrub the laceration or incision site
with sterile gauze premoistened with a topical antiseptic. Irrigation or wet-to-moist debridement
with normal saline or potable tap water can be used to soften the dried crust adhered to the sutures
or wound site. Pat the wound dry with sterile gauze and remove the sutures (Table A-6). After suture
removal, wound closure strips can be applied to support the healing tissues.
sure strips should be considered with athletes and active patients involved in movements that may
produce high skin tension across the wound site.
10
Clinicians may select cost-effective nonocclusive
3
The use of wound clo-
156 Appendix A
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Table A-6. Suture Removal on a Wound Model
• Using tweezers or forceps, grasp the knot and gently lift the suture (Figure A-2A).
Figure A-2A
• Place the curved tip of the suture scissors under the suture close to the skin (Figure A-2B)
and cut (Figure A-2C).
Figure A-2B
Figure A-2C
continued
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Table A-6. Suture Removal on a Wound Model
• Slowly pull the suture out of the tissues with tweezers or forceps (Figure A-2D).
Figure A-2D
• Place each removed suture on gauze and count the total to ensure removal of all sutures.
(continued)
STAPLES
Stainless steel staples are an option for wound closure based on the patient’s assessment and
wound condition following cleansing and debridement. Staples are indicated for the closure of linear
lacerations and incisions on the scalp, trunk, and extremities
for suturing.
pain with pressure and potential poor cosmetic outcomes. Staples are preloaded and dispensed
through a stapler. Staples are available in 2 sizes based on their width, regular and wide. See Table
A-7 for the staple technique. Staple placement begins at one end of the wound and progresses toward
the other. Staples are generally placed 5 to 10 mm apart over the wound. Care of the patient and
wound following closure with staples mimics the guidelines used with sutures.
The removal of staples is performed with a skin staple remover tool. Remove staples in the
scalp at 7 days and trunk and extremity staples at 10 days. The clean technique is used for removal.
Remove the dressing if in place, gently scrub the wound site with sterile gauze premoistened with a
topical antiseptic, then pat dry the area, and remove the staples (Table A-8). Wound closure strips
can be applied after the removal of staples if warranted.
9
Staples are inappropriate for wounds on the hands, feet, and face because of increased
2
and wounds that are not conducive
Several options are available to clinicians for the closure of traumatic lacerations and incisions
and postoperative incisions. Two methods, sutures and staples, are more advanced closure techniques and may be regulated by state laws and practice acts. Clinicians should review applicable
regulations before using sutures and staples for wound closure. The techniques are presented to
align with educational standards and to serve as a resource for practicing clinicians involved in
wound closure. Wound closure with sutures and staples requires knowledge of anatomy, wound
healing, wound management interventions, and training and practice with the techniques.
SUMMARY
158 Appendix A
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Table A-7. Staple Technique on a Wound Model
• Approximate and evert the wound edges with forceps or the nondominant thumb and first
finger.
• A second clinician can assist with tissue approximation.
• Position the stapler upright (90 degrees) to the skin and over the center of the wound with
gentle pressure (Figure A-3A). The depth of staple placement in the skin is determined by
the amount of downward pressure applied to the stapler.
Figure A-3A
• Fully squeeze and then release the stapler handle or trigger to insert the staple in the skin.
• Lift the stapler from the wound and assess staple placement. The staple crossbar should be
slightly elevated above the wound and periwound tissue (Figure A-3B).
Figure A-3B
• Continue with the procedure until wound closure is complete.
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Table A-8. Staple Removal on a Wound Model
• Position the 2-pronged lower jaw of the remover tool under the staple (Figure A-4A).
Figure A-4A
• Squeeze the handle of the remover tool until closed (Figure A-4B), bending the middle
portion of the staple crossbar downward and the outer edges upward and lifting the staple
from the tissues (Figure A-4C).
Figure A-4B
Figure A-4C
continued
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