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24 3 Sutures and Suturing
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two or three cutting edges. Hence, they are referred to as cutting needles. They
cut tissue to ease their entry and passage. Cutting needles have either a triangular
or a spatulate (flat) cutting profile. The former, as its name suggests, has three
cutting surfaces, one always cutting inwards or outwards. The spatulate needle
only has only two, cutting to either side. Spatulate needles are the more useful
in oculoplastic surgery as the needle is less likely to inadvertently cut into or out
of the delicate lid tissues. The one non-cutting needle is the ‘round bodied’ or
‘taper point’ needle which has only a sharp point and lacks a cutting edge. Its
sharp point enables tissue penetration, and the tapered body stretches the opening
to allow the needle and suture to pass. Its passage causes minimal tissue damage.
It is the least likely to cut out of delicate tissues. The downside is that taper point
needles require more force to penetrate tissues. This is not an issue in lid surgery.
3.2.7 Needle Shape (Fig. 3.2)
Curved needles are the more useful for lid surgery. They allow shorter tissue bites
to be taken. They come in different radii of curvature and arc of curve (1/4, 3/8 or
½ circle). The 8 mm, tightly curved ½ circle needles are especially suited to tarsal
plate suturing.
1/2 3/8 1/4
abc
Fig. 3.2 Curved suture needle arc. a Half circle needles are best for eyelid suturing. c Quarter
circle needles are suited to suturing extraocular muscle to sclera
3.3 Suturing Techniques 25
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3.3 Suturing Techniques
3.3.1 Interrupted v Continuous (Fig. 3.3)
Interrupted sutures are knotted individually and are independent of each other
(Fig. 3.3a and b). They take slightly longer to place but if one fails this does
not affect the remaining sutures. Individual sutures can be removed selectively
as necessary e.g., for a suture abscess, without weakening the remainder of the
wound.
Continuous sutures only have a knot at either end. Fewer knots make them
faster to insert. However, when one bite cuts out the suture loosens along the
whole length of the suture line. Figure 3.3c, d and e illustrate how to bury the
knots of a continuous suture (only useful for absorbable sutures).
a
c
b
d
e
Fig. 3.3 Interrupted versus continuous suturing. a Place the first interrupted suture centrally to
align the closure. b Add sufficient additional sutures to close the defect. c Start a continuous
absorbable suture with a buried knot. d To finish, externalize a deep loop to tie a self-burying knot.
e Only bury absorbable suture knots
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3.3.2 Suture Bite Spacing (Fig. 3.4)
As a rule of thumb, sutures (or suture bites for a continuous suture) should be
spaced the same distance apart as span of the suture (Fig. 3.4a). The longer the
suture span the fewer sutures are needed to close the wound (Fig. 3.4b). This is
because their closing force is spread over a wider segment of the wound edge. In
thin skin use a short suture span by placing the bites close to the wound edges
to prevent the edges from rolling (in or out) and space the bites closely to reduce
gaping between them (Fig. 3.4c).
3.3.3 Suture Spaghetti
In a restricted space, such as the eyelid, pre-place all adjacent sutures before tying
any. Doing so allows you see the wound edges clearly before they are obscured
by the first stitch tied. You can evert the edges for clear visualization without fear
of loosening or of pulling out a previously tied suture. Clip each pair of suture
ends together with an aneurysm clip before placing the next one. This simplifies
the subsequent tying of the correct pairs of ends together and avoids a suture
spaghetti.
Fig. 3.4 Suture bite spacing.
a Inter suture spacing should
equal the suture span X. b In
thick skin place the sutures
further from the edge and
spaced further apart than in
thin skin. The longer the bite,
the more widely the suture’s
force is spread along the
wound (shaded sector). c Too
long a span encourages in
rolling of thin skin edges
a
x
x
X/2
b
c
3.3 Suturing Techniques 27
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3.3.4 Simple v Mattress (Fig. 3.5)
Mattress suturing is designed to evert epithelial surfaces to improve wound adhesion (as epithelial surfaces do not heal together when apposed). It also discourages
inclusion cyst formation (caused when surface epithelium gets buried). An additional benefit is to cause the wound edges to pout, making allowance for inward
scar contraction during healing (Fig. 3.6a). This discourages unsightly, depressed
scars from forming (Fig. 3.6b).
a
b
Fig. 3.5 Simple versus mattress suture. a A simple suture causes flat edge approximation. b A
horizontal mattress suture causes wound edge eversion (pouting)
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a
b
c
d
Fig. 3.6 Scar depression. Because of healing scar contraction, a vertical mattress pouting closure
(a) results in a flat scar (b). Simple suture flat closure (c) results in a depressed scar (d)
3.3.5 Horizontal v Vertical Mattress (Fig. 3.7)
In terms of suture line eversion there is little to choose between horizontal
(Fig. 3.7a) and vertical mattress (Fig. 3.7b) configurations. Use horizontal mattress sutures in thin skin and vertical in thick skin (such as in the forehead). Do
not insert the suture bites too far from the skin edges or the edges will separate as
you tighten the suture (Fig. 3.7c).
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a
b
c
Fig. 3.7 Mattress sutures. a Horizontal mattress suture. b Vertical mattress sutures. c Horizontal
mattress suture induced wound edge separation as the bites are too far from the edge
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3.3.6 The Humble Horizontal Mattress (Fig. 3.8)
The horizontal mattress has three additional advantages over a simple suture:
1. The long surface loop pulls down against the skin, rather than towards the
wound edge. This makes a mattress suture less prone to cut out than a simple
suture (Fig. 3.8a).
2. The two bites act as a double pully during suture tightening, halving the suture
tension required to bring the wound edges together (Fig. 3.8b).
3. The downward pull of the first throw against the skin during knot tightening
significantly enhances friction. This prevents the first throw from slipping while
you tie the second knot throw (Fig. 3.8c).
These properties make the horizontal mattress suture particularly useful for directly
closing wounds under tension, as recommended in Chap. 14.
A buried horizontal mattress suture is very useful for suturing tarsal plate to
canthal tendon.
3.3.7 The ‘Magic Suture’ (Fig. 3.9)
The exotically named magic suture is nothing more than a strategically placed,
buried, subcutaneous, absorbable suture (Fig. 3.10). It should run subcutaneously
for 10 mm on either side of a facial wound. Within thin eyelid orbicularis a 5 mm
long bite is sufficient. Insert the suture from within the wound so that the knot
becomes deeply buried.
The magic in these sutures is twofold. Placing a single suture in this fashion magically transforms a defect’s geometry. The first stitch simulates the final
effect that the specific wound closure direction will have on the lid position. If
you judge the effect to be sub-optimal, remove and replace the suture in a more
favourable orientation. Secondly, because the muscle layer carries the overlying
skin, the suture almost closes the skin defect. This makes skin suturing easier by
reducing skin closure suture tension which, in turn, makes the resulting scar less
likely to stretch. For magic suture placement steps see Chap. 5.
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a
b
c
Fig. 3.8 Horizontal mattress suture advantages. a Mattress closure force is spread along the length
of the suture bite (low skin pressure) making it less likely to cut out than a simple suture whose
force is concentrated on a small area of skin the width of the suture gauge (high pressure). b The
horizontal mattress double pulley action makes pulling the wound edges together easy. c The knot
first double throw locks against the skin and doesn’t slip
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Fig. 3.9 Suture magic
ab
cd
Fig.3.10 The magic suture. a Take a long muscle bite (5−10 mm) starting deep in the wound.
b Take a similar bite on the far side starting close to the skin. c Lift and tighten the knot’s first
double throw until the wound closes. d Complete the knot ensuring it retracts deep into the wound
3.4 The Cotton Bud: An Aid to Suturing 33
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3.4 The Cotton Bud: An Aid to Suturing
Cotton buds (cotton tip applicators) are commonly used in eyelid surgery to swab
blood and to help localize bleeding points. When doing this, roll the cotton bud
over the surface to be cleaned rather than wiping as wiping may restart bleeding by
rubbing off clots that have already formed. Forwards and backward rolling across
a bleeding point helps to visualize the leaking vessel for accurate diathermy.
The friction between cotton bud and tissue is useful for tissue retraction, either
by gently pressing and pulling or by rolling the cotton bud between one’s fingers.
The friction is also useful for blunt dissection of tissue planes.
A novel use of the cotton bud is as an aid to suturing in which role it has five
functions:
1. To unroll thin skin to reveal the true wound edge before suture placement.
2. To aid needle penetration of lax skin by applying counter pressure under the
needle tip.
3. To pull the needle and suture through the tissues once the needle tip is
embedded in the bud.
4. To hold the needle for re-grasping with a needle holder in preparation for the
next suture bite.
5. As a needle tip protector to reduce the likelihood of tip damage or needle stick
injury.
The technique of using a cotton bud for suturing is easy to learn but requires a
little practice. Tightly wound cotton buds are better for use in suturing. Remember
that buds have a hard central core which you need to avoid with your needle tip
by entering the bud at a glancing angle.
3.4.1 Steps (Fig. 3.11)
1. Hold the bud against the surface or underneath the skin and slowly rotate it to
retract and unroll any in-turned skin revealing the true wound edges.
2. Use the bud to apply tissue counter pressure under the needle tip (Fig. 3.11a).
3. During needle penetration adjust the angle between the needle tip and the bud
so that the needle penetrates the soft cotton covering without hitting the hard
central core (Fig. 3.11b).
4. When the needle tip is embedded, rotate the bud to pull the remainder of the
curved needle through the tissues (Fig. 3.11c). Avoid doing this too vigorously
so as not to disengage the needle from the bud.
5. As soon as the whole needle is clear of the tissue apply slight counter rotation to
the bud and lift it up to pull the suture through (Fig. 3.11d). The counter rotation
prevents the suture drag from pulling the needle out of the bud prematurely.
6. Re-grasp the needle with the needle holder ready for the next suture bite and
disengage it from the bud.
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