Secrets to great suture techniques

Tension can build in the operating room and at the surgical site when an incision is tough to close. Fortunately, there have been talented surgeons over the decades that have developed some quick tension relieving techniques to help you close tough wounds. To help relieve tension there are a variety of plasty techniques that can be employed to relieve tension.  Many are familiar with how to perform these common techniques but there are some nuances to consider when it’s time to suture.  

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It’s a great time to discuss the top tension relieving procedures and how to suture them closed

The Perennial Subcutaneous Suture 

Placing a subcutaneous layer has a host of benefits including providing hemostasis, closing dead space and, perhaps most importantly, to relieve tension.  The subcutaneous layer is mainly composed of adipose tissue. Nerve fibers, blood vessels, and hair follicles are located here. Although this layer may not be the principal holding layer, sutures placed in the subcutaneous layer are vital for proper healing. Regardless of the level of surgical experience, most are relatively familiar with the technique to how to oppose subcutaneous tissue. However there are nuances to the closure of the subcutaneous tissue that can be helpful

More than one layer.  Be comfortable with closing the subcutaneous tissue in multiple layers. In situations where the wound contains excessive adipose tissues, close the deepest layer of fat first. The second layer of subcutaneous closure can include the fat layer just deep to the dermis. Those two layers of subcutaneous closure can help to relieve tension adjacent to the skin.  Fat doesn't really have the best holding power so if you find yourself pulling through the fat, the recommendation would be to take larger bites with a slightly larger suture.  Additionally, tacking (or quilting) is an important step that can relieve tension over regions with minimal skin motion..  Tacking or a quilting suture pattern was described first in 1998 in humans as a way to prevent seroma formation. WIth this suture pattern, pass the suture through the rectus sheath on every second or third bite what you doing is anchoring the subcutaneous tissue to the abdominal wall. This technique may help decrease seroma formation and postoperative pain. 

The V to Y PLASTY

The suffix plasty originates from the Greek word plastos meaning, ‘formed, moulded.”  Like an artist, the skin can be molded or released to help you relieve tension from your closure. One of the most effective plasties, and my personal favorite, is a V to Y PLASTY.  Although it is effective at mitigating tension on wound closure it only provides a small amount of relaxation to the skin. If there is excessive kin tension, other tension relieving techniques should be employed (i.e. undermining etc) prior to closure of this technique.. A V-shaped incision is made in the skin adjacent to a wound. The apex or point of the ‘V’ should be facing away from the wound. The primary surgical site is closed first then this followed by closure of the V. 

The V incision that was performed can now be closed but there are some important nuances to consider. Begin the suture pattern by placing sutures on alternate ends at the top of the Y. This will help distribute tension more evenly. At this stage, it can be helpful to incorporate a tension relieving suture pattern like a far-near-near-far suture pattern while closing the arms of the Y. Once tension rises at the level of the V, then the stem of the Y can be closed side-to side to close the stem of the Y. 

Tension Suture

When the tension on a wound requires a more assertive approach to tension relief that a skin plasty tensioning suture can be employed. Harness the power of the skin’s natural biology via the phenomenon of mechanical creep. .This phenomenon is defined as the elongation of skin with a constant load over time beyond its intrinsic extensibility. This unique characteristic of skin is exploited in other ways as well including during intraoperative tissue expansion, skin-stretching devices, and skin retraction with undermining. When constant, low-grade, tension is gradually applied to skin over 2 to 4 days, collagen and elastic fibers straighten, elongate, and become parallel which lengthens the skin.1,2 Once the skin elongates, less force is required to maintain the collagen fibers in their new stretched position because the skin’s elastic fibers lose their natural recoil (ie, stress relaxation).1,2  Tensioning sutures also have the advantage of being able to hold dressing in place.

Select a suture that is slightly larger than you would select normally for added strength. In most cases, this means selecting 0 instead of 2-0, or 1 over 0 monofilament suture material on a cutting needle. Start 3cm from skin edge and main perpendicularity to the wound. Take several bites in a simple continuous suture pattern maintaining this same distance from the wound edge with each bite.  The suture is either placed loosely so that a wound dressing can be inserted under the tensioning sutures or it can be lightly tighten to the level of the skin.  Both ends are then tied.  Then the surgeon pulls on the suture loops in the middle of the wound, gathering the excess suture in the middle of the wound in order to bring the skin edges closer in apposition. The excess suture is held in place with a reusable fishing split shot sinker or spring clasp (see below)  This process may need to be repeated multiple times for longer wounds.

References::

1. Pavletic MM. Use of an external skin-stretching device for wound closure in dogs and cats. J Am Vet Med Assoc. 2000;217(3):350-354.

2. Tsioli V, Papazoglou LG, Papioannou N. The use of skin stretching devices and their application to small animal cases. Aust Vet Practit. 2009;39:112-119.