Advanced Suturing Techniques Bucky Boaz, ARNP-C Subcutaneous Stitch Deeper wounds or wounds under tension. Inverted knot. Begin at bottom of wound edge and come up. Go straight across incision and down. Running Stitch Indicated for low risk repairs. Tie knot at one end, do not cut until repair complete. Faster technique. Plastic surgery quality. Running Locked Stitch Modified running stitch. Used to prevent slippage of loops as running stitch continues. Allows for continuing stitch along irregular laceration. Vertical Mattress Stitch Promotes eversion of the skin. Tension or very thick skin. Enter wound on one side, pierce other side twice, and exit on side entered. Horizontal Mattress Stitch Needle is introduced in normal fashion. Second bite is placed ВЅ cm adjacent to exit site. Brought back next to original insertion. Tie knot. Intracuticular running suture Used to close linear wounds that are not under much tension. Yields an excellent cosmetic result. The ends of the suture do not need to be tied. Taping under slight tension will preserve approximation. Three-point or half-buried mattress suture Closure of the acute corner of a laceration without impairing blood flow to the tip. Three-point or half-buried mattress suture Needle is inserted into nonflap portion of the wound at the mid-dermis level; and then at the same level, the suture is passed transversely through the tip and returned on the opposite side of the wound paralleling the point of entrance. Three-point or half-buried mattress suture The suture is tied, drawing the tip snugly into place in good opposition. This same approach can be utilized in closing a stellate 4- or 5-point laceration, drawing the tips together in a purse-string fashion. Parallel Lacerations The horizontal technique is used to cross all lacerations Wound tapes can be used if low tension If island in middle is wide enough, interrupted sutures can be used Special Anatomic Sites Extramarginal Lid Lacerations Upper lid lacerations are usually closed with simple interrupted Intramarginal lid lacerations are best left to plastics Eyebrow lacerations Most eyebrow lacerations can be closed without tissue debridement If devitalized, excise tissue parallel to hair shaft Ear 72-hr window to drain perichondral hematoma Simple noncartilaginous lacerations are closed with interrupted or running sutures Lacerations involving cartilage Lip Must approximate vermilion border Through and through lacerations involve orbicularis oris muscle Repair muscle first Then, vermillion border Then, rest Questions?