Sutures used in the closure of surgical incisions consist of needles and thread. Different suture materials are used according to different tissues and complications. The technique of using sutures also varies according to the complications, just as much as the differences in materials. In this article, we discuss the suture techniques that vary according to the type of surgical operations and incisions.

Simple Suture

This is the easiest way to close a wound. Each suture is independent of the others. The needle is inserted at a 90-degree angle from the edge of the incision. After the tip of the needle is removed, it is reinserted at the same depth on the opposite side. After holding the needle with a needle holder, the free thread is looped twice clockwise around the needle holder. This forms the first knot. The next knot is formed by looping counterclockwise, and the procedure continues alternating directions.

Vertical Mattress Suture

This type of suture is used when there is a lot of space within the wound (e.g., after removing cysts or tumors from under the skin) and when it is desired to bring the wound edges together better. The suture passes twice through the wound edges in the vertical plane, forming four suture holes. The goal here is to reduce wound tension. Otherwise, closing the wound under tension can lead to tears and result in hypertrophic or keloid scarring. The needle enters at a distant point on one side of the wound and exits at a distant point on the other side. The needle then turns 180 degrees and enters at a short distance from where it last exited and exits at a short distance on the opposite side. The knot is placed on the side where the needle entered and should not be too tight. Variants of the vertical mattress suture include the “half-buried vertical mattress suture,” where one side of the suture is buried in the wound (used in eyebrow stitches), and the “far-near vertical suture,” which involves one far and one near entry and exit point (used when more eversion of the wound edges is desired).

Horizontal Mattress Suture

Sometimes the wound edges can be very far apart. In this case, the wound is closed under too much tension. The horizontal mattress suture aims to reduce this tension by distributing it over a wider area.

Continuous Subcuticular Suture

This should be preferred in situations where there is no tension in closing the wound. The needle is inserted at the corner where the wound starts, and a knot is placed. Then, the needle is turned inside the wound edges with a needle holder (the needle entry and exit points are under the skin) and exited from one side. The process is continued by entering and exiting not directly opposite but one-third or one-fourth of the way back from the other side. Monofilament and non-reactive threads (such as polypropylene) should be used. This allows the thread to be pulled out from inside the wound. If the wound is very long, it should be exited every 2-3 cm to facilitate the removal of the suture.

Corner Suture

Especially in flap surgeries (e.g., M-plasty, rhomboid flap), there can sometimes be sharp corners. A special technique must be used to bring these corners together. The needle first enters the immobile corner, exits from the subcutaneous tissue, and passes through the subcuticular section of the movable corner in a “U” shape. Finally, it enters the subcutaneous tissue of the immobile corner and exits from the epidermis. When the knot is tied, the corner automatically joins the other. The knot should not be too tight, as it can cause necrosis at the tip.

Self-Removing Suture

This type of suture can be removed by the patient themselves. It is ideal for situations where a single suture is placed after a punch or small biopsy. Monofilament, non-absorbable threads (nylon or polypropylene) are more suitable. The patient can remove the suture by pulling the long end.

Subcutaneous Suture

When closing deep wounds, areas that can create spaces in the subcutaneous tissue should first be closed. Absorbable suture materials are used for this, and the knot remains hidden inside the wound. The suture starts at the bottom of the wound, exits without coming to the surface, and enters and exits at the same levels on the opposite side. The knot is buried at the bottom of the wound. The ends of the thread should be cut short so they do not protrude. There are also modifications of the subcutaneous suture, such as “horizontal,” “continuous,” and “pursestring.”

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