Subcuticular suture

David Salim med. student, Christoffer Bing Madsen med. student, Magnus Avnstorp MD.

Application

Used for epidermal approximation for wounds under minimal to no tension. It is almost never used solitary in absence of deep dermal suture, since its advantage is to fine-tune epidermal approximation. It does not recruit any strength from the dermis.

Suture material choice

Depending on the chosen technique variation, this technique may be used with either absorbable or non-absorbable suture. If nonabsorbable  monofilament If absorbable  non-braided monofilament Usually 5-0, 6-0 is used in this technique, since its limited to fine-tuning epidermal approximation.

Step by step guide

1) The needle is inserted at the far right corner o the wound, parallel to the incision line, beginning approximately 2-5 mm from the apex. The needle is passed from this point, which is lateral to the incision apex, directly through the epidermis, exiting into the interior o the wound just medial to the apex. Note that this first pass may be needed depending on the technique used or finishing the closure, as addressed in detail below.

2) With the tail o the suture material resting lateral to the incision apex and outside the wound, the wound edge is gently reflected back and the needle is inserted into the dermis on the ar edge o the wound with a trajectory running parallel to the incision line. The needle, and there ore the suture, should pass through the dermis at a uniform depth. Bite size is dependent on needle size, though in order to minimize the risk o necrosis it may be prudent to restrict the size o each bite. The needle should exit the dermis at a point equidistant from the cut edge from where it entered.

3) The needle is then grasped with the surgical pickups and simultaneously released by the hand holding the needle driver. As the needle is reed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to repeat the above step on the contralateral edge of the incised wound edge.

4) A small amount of suture material is pulled through, the skin on the contralateral wound edge is resected back, and the needle is inserted into the dermis on the contralateral side o the incised wound edge and the same movement is repeated. The needle should enter slightly proximal (relative to the wound apex where the suture line began) to the exit point, thus introducing a small degree of backtracking to the snake-like follow of the suture material. This will help reduce the risk of tissue bunching.

5) The same technique is repeated on the contralateral side until the end o the wound is reached. At this point, the needle is inserted from the interior of the wound in line with the incision line and exits just lateral to the apex of the wound.