Techniques of suturing: general principles, placement of specific types of sutures, alternative methods of wound closure (2023)

simple interrupted seam

The most common and versatile suture material in skin surgery is the simple button suture.[43]This suture is placed by inserting the needle perpendicular to the epidermis, through the epidermis and through the full thickness of the dermis, and exiting perpendicular to the epidermis on the opposite side of the wound. The two sides of the stitch should be placed symmetrically in depth and width.

In general, the suture should be bottle-shaped, meaning that the stitch is wider at its base (dermal side) than at its surface (epidermal side). If the suture includes more tissue volume at the base than at the apex, the resulting compression at the base will push the tissue upward and encourage deflection of the wound edges (see image below). This maneuver reduces the chance of scarring if the wound subsides during healing.

Simple intermittent suture placement. The image below right shows a bottle pinch that maximizes deflection.

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In general, tissue bites should be placed evenly so that the edges of the wound meet flush. This minimizes the possibility of uneven (ie offset) wound edge heights. However, the size of the bite taken on either side of the wound can be deliberately varied by varying the distance of the needle insertion point from the wound edge, the distance of the needle exit point from the wound edge, and the depth of the wound. bite taken

Using different sized needle bites on each side of the wound can correct a pre-existing asymmetry in the thickness or height of the margins. The edges of the wound can be closed with small stitches. Large bites can be used to reduce wound stress. Correct tension is important to ensure accurate approach to the wound and avoid tissue strangulation. (See image below.)

Broken seam line.

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Simple continuous stitching

A continuous single (continuous) stitch is essentially an uninterrupted series of discontinuous stitches. The seam starts with a simple interrupted stitch that is tied off but not cut. A series of single sutures are applied sequentially without tying or cutting the suture after each pass. Seams should be evenly spaced and tension should be evenly distributed along the seam line.

(Video) Deep Wound Closures | The Cadaver-Based Suturing Course

The seam line is finished by tying a knot at the end of the seam line after the last pass. The knot is tied between the trailing edge of the suture where it exits the wound and the loop of the last suture placed. (See image below.)

Continuous seam line.

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Perform a locked seam

A single running seam can be locked or left unlocked. The first knot of a snap running stitch is tied like a traditional running stitch and can be locked by passing the needle through the loop in front of each stitch (see image below). This stitch is also known as the baseball stitch because of the finished appearance of the continuous closed stitch line.

Perform a locked seam.

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Vertical layer seam

A vertical layer seam is a variation of a simple interrupted seam. It consists of a single interrupted stitch placed across the width and depth of the wound edge and a second, more superficial interrupted stitch placed closer to the wound edge and in the opposite direction (see image below). The width of the stitch should increase according to the tension in the wound, i.e. H. the greater the tension, the wider the stitch.

(Video) Simple interrupted suture (wound suturing) - OSCE Guide

Vertical layer seam.

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Semi-buried vertical mattress seam

A semi-buried vertical mattress suture is a modification of a vertical mattress suture that eliminates two of the four entry points, thereby reducing scarring. Placement is the same as for the vertical mattress suture except that the needle penetrates the skin on one side of the wound to the level of the deep dermis and deeply punctures the skin on the left side of the wound. opposite side without coming off the skin, crosses back to the original side and finally comes off the skin. The entry and exit points are thus on one side of the wound.

pulley seam

A pulley seam is a modification of a vertical layer seam. A vertical layer stitch is made, the knot is left untied and the stitch is passed and pulled through the outer loop on the other side of the incision (see image below). At this point the knot is tied. This new loop acts like a pulley and relieves the other threads.

Pulley seam, type 1.

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Modified vertical layer long-short-short-long seams

Another stitch that performs the same function as a pulley stitch is a modified vertical seam in the very near-near-far mattress seam. The first loop is placed approximately 4-6 mm from the contralateral side of the wound and approximately 2 mm from the proximal side of the wound. The suture crosses the suture line and reenters the skin on the original side 2 mm from the edge of the wound on the proximal side. The loop is completed and the suture exits the skin on the opposite side 4-6 mm from the edge of the wound (see image below). This creates a pulley effect.

Modify very close to the vertical seam of the layer, creating a pulley effect.

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(Video) Suture Techniques Course Video

Horizontal layer seam

A horizontal mattress suture is placed in the skin 5 mm to 1 cm from the edge of the wound. The suture is taken deep into the dermis on the opposite side of the suture line and exits the skin equidistant from the edge of the wound (essentially a simple interrupted deep stitch). The needle re-enters the skin on the same side of the suture line, 5 mm to 1 cm lateral to the exit point. The tip is inserted deep into the opposite side of the wound, where it emerges from the skin. then the knot is tied (see image below).

Horizontal layer seam.

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Sutura horizontal semi-interrada

A semi-buried horizontal suture (also known as a barbed suture or three-point corner stitch) is started on the side of the wound where the flap will be attached. The suture is passed through the dermis at the edge of the wound to the dermis at the edge of the flap. The needle is passed laterally flush with the skin with the edge of the flap, exiting the edge of the flap and reentering the skin to which the flap is to be attached. The needle is oriented vertically and emerges from the skin. then the knot is tied (see image below).

Semi-buried horizontal seam (point stitch, three-stitch corner stitch).

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Dermo-hypodermal vision

A dermal-subcutaneous suture is placed by inserting the needle parallel to the epidermis at the junction of the skin and subcutaneous tissue. The needle curves upwards and exits through the papillary dermis, again parallel to the epidermis. The needle is inserted parallel to the epidermis into the papillary dermis at the opposite end of the wound, bent down through the reticular dermis, and exits through the base of the wound at the dermis-subcutaneous tissue interface and parallel to the epidermis.

The knot is tied at the base of the wound to minimize the possibility of tissue reaction and extrusion of the knot. If the suture is placed more superficially in the dermis, 2-4 mm from the edge of the wound, deflection is enhanced.


Buried horizontal mattress seam

A buried horizontal layer stitch is a purse string stitch. The suture should be placed in the mid to deep part of the dermis to avoid tearing the skin. If the suture is tied too tightly, it can strangle the surrounding tissue.

Run horizontal layer seams

A simple suture is placed and the knot is tied but not cut. A continuous series of horizontal layer stitches is made, with the final loop tied at the free end of the stitch.[44]

running subcutaneous sutures

A running subcutaneous suture is a buried form of a running horizontal layer suture. Placement is by horizontal sutures along the papillary dermis on alternate sides of the wound (see image below). No suture marks are visible and the suture can stay in place for several weeks.

Hypodermic stitch. The skin surface remains intact along the suture line.

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running subcutaneous suture

A continuous subcutaneous suture begins with a simple interrupted subcutaneous suture that is tied but not cut. The suture is wrapped through the subcutaneous tissue and passed successively from opposite sides of the wound. The knot is tied at the opposite end of the wound by connecting the long end of the suture to the loop of the last suture placed.

Running hypodermic corset flexion stitch

Before inserting the needle, forceps are used to forcefully pull at least 1–2 cm of tissue to ensure tissue tightness.[19]With orthosis, at least 1-2 centimeters of fatty tissue and fascia are created in each bite. After ligation of the first bite, bites are made continuously along the entire length of the defect on opposite sides of the wound. The free end is pulled tight to shrink the defect and then the suture is tied.

Variations in edge (corner) stitch material.

Modified semi-buried horizontal layer seam

A modified semi-buried horizontal layer suture places an additional vertical layer suture superficial to the semi-buried horizontal layer suture. A small skin forceps is used instead of forceps to avoid injuring the flap.[9]

deep stitch

A deep lace stitch is essentially a fully hidden form of triangle stitch. The suture is placed in the deep dermis of the edge of the wound to which the flap is to be attached, passed through the dermis of the edge of the flap, and inserted into the deep dermis of the opposite edge of the wound.[8]


What are the 6 types of suturing techniques? ›

Some of them are:
  • Continuous sutures. This technique involves a series of stitches that use a single strand of suture material. ...
  • Interrupted sutures. This suture technique uses several strands of suture material to close the wound. ...
  • Deep sutures. ...
  • Buried sutures. ...
  • Purse-string sutures. ...
  • Subcutaneous sutures.
Apr 6, 2018

What are the 4 methods of wound closure? ›

Wounds can be closed primarily in the emergency department (ED) by the placement of sutures, surgical staples, skin closure tapes, and adhesives.

What are the principles of proper suture technique? ›

Proper suture technique should incorporate three major principles, including proper distribution of tension to the deeper layers, atraumatic handling of tissues, and eversion of wound margins.

What is the suture technique for wound closure? ›

Sutures can be placed intradermally in either a simple or running fashion. Place the needle horizontally in the dermis, 1-2 mm from the wound edge. Do not pass the needle through the skin surface. The knot is buried in the simple suture, and the technique allows for minimization of tension on the wound edge.

What are the different types of suture methods? ›

Sutures are basically of two types: Absorbable: It loses the tensile strength in 60 days. It is generally preferred for a buried type of suturing and does not require removal. Nonabsorbable: The tensile strength lasts for more than 60 days.

What are the 3 types of sutures? ›

Suture material
  • Nylon: Nylon creates a type of natural monofilament suture.
  • Polypropylene (Prolene): This material creates a monofilament suture.
  • Silk: Silk sutures are typically braided and made naturally.
  • Polyester: This form is synthetic and braided.

What are the 5 methods of wound classification? ›

The Centers for Disease Control and Prevention created a surgical wound classification system (SWC: I, clean; II, clean/contaminated; III, contaminated; and IV, dirty) to preemptively identify patients at risk of surgical site infection (SSI).

What are the five 5 basic principles of the management of a wound or laceration? ›

The basic principles for the management of a wound or laceration are:
  • Haemostasis.
  • Cleaning the wound.
  • Analgesia.
  • Skin closure.
  • Dressing and follow-up advice.

What are the different types of wound closure? ›

There are two major types of wound closure: primary and secondary. In primary closure, the skin is closed at the end of the surgery, whereas in the secondary closure the wound is left open at the end of surgery and heals by granulation and contraction.

What is proper suture placement? ›

To ensure proper apposition of the wound without excess tissue on one side (also called a "dog ear"), the clinician places the first stitch at the midline of the wound. The next two stitches go on each side of the first stitch, midway between the center stitch and the wound corners.

What is the rule of 3 in suturing? ›

Silverstein's “Rule of Three's” for suturing is just what I needed. Place the thread 3mm from any adjacent suture. Always tie with 3 throws. ( First is a double surgeon's knot, and number 2 & 3 are singles).

What is the best suture technique for skin? ›

Vertical mattress sutures have the advantage of good wound eversion and closure of dead space. Running continuous sutures can be quickly placed and divide tension equally along the skin edge.

What is the alternative to stitches? ›

Skin staples are an alternative to stitches, which can be applied in an emergency department or urgent care setting. They basically work in the same way as stitches, only they're stronger and can be good for areas where the skin is thicker — such as the scalp. They can also be used to treat very long cuts.

What is the best alternative to stitches? ›

Skin adhesive is an alternative that can be as effective as stitches when used on the appropriate wound. Usually, that means a small wound; not very deep or wide; not “dirty” or prone to infection; and not on highly mobile parts, such as joints.

What is a 3 layer suture closure? ›

In this case, a “three-layer” closure is needed: first, the underlying dermis and subcutaneous tissues must be approximated; then, the epidermis is closed; finally, the intra-oral mucosal layer is closed.

What is the most common type of suturing? ›

The most common suture technique used for wound closure is the simple subcutaneous suture technique. This technique is performed in order to release the tension from the surface of the wound, thus easing the healing of the skin.

What are the most used suture types? ›

In general, surgeons typically use either polypropylene or polydioxanone sutures for fascia, depending on how strong the repair needs to be. Polypropylene is also very common in cardiovascular surgery. Deep dermis closure is with either polyglycolic acid or poliglecaprone 25 sutures.

What is the difference between sutures and stitches? ›

Although sutures and stitches are often referred to as one and the same, they are actually two different things. Sutures are the threads or strands used to close a wound. “Stitches” refers to the actual process of closing the wound.

What are the 4 main sutures? ›

There are four major sutures that connect the bones of the cranium together: the frontal or coronal, the sagittal, the lambdoid, and the squamous.

What are the three types of sutures and describe how they differ? ›

Monofilament, Multifilament and Barb Sutures

Braided sutures provide better knot security whereas monofilament sutures provide better passage through tissues. In general, Monofilament sutures elicit lower tissue reaction compared to braided sutures.

What are the 7 types of wounds? ›

Nearly everyone will experience an open wound at some point in their lives, but the level of severity will range significantly depending on the type:
  • Penetrating wounds. Puncture wounds. Surgical wounds and incisions. Thermal, chemical or electric burns. Bites and stings. ...
  • Blunt force trauma. Abrasions. Lacerations. Skin tears.

What are the 4 wound types? ›

  • Class 1 wounds are considered to be clean. They are uninfected, no inflammation is present, and are primarily closed. ...
  • Class 2 wounds are considered to be clean-contaminated. ...
  • Class 3 wounds are considered to be contaminated. ...
  • Class 4 wounds are considered to be dirty-infected.
Apr 24, 2023

What are 8 key principles for wound management? ›

  • Hemostasis. ...
  • Wound Classification. ...
  • Assessment/Modification of Risk Factors. ...
  • Infection Prevention and Control. ...
  • Wound Cleansing, Debridement, and Dressing. ...
  • Tissue Perfusion and Moisture Control in Wound Environment. ...
  • Appropriate and Adequate Analgesia. ...
  • Skin Closure.

What are the three R's of wound healing? ›

Tissue engineering in wound repair: the three "R"s--repair, replace, regenerate.

What are the 4 phases of wound healing? ›

Wound healing is classically divided into 4 stages: (A) hemostasis, (B) inflammation, (C) proliferation, and (D) remodeling. Each stage is characterized by key molecular and cellular events and is coordinated by a host of secreted factors that are recognized and released by the cells of the wounding response.

What are the six common types of open wound? ›

Open wound types include abrasions, excoriation, skin tears, avulsions, lacerations and punctures, according to our Skin and Wound Management course workbook. Traumatic open wounds involve a disruption in the integrity of the skin and underlying tissues caused by mechanical forces.

What is the 4 1 suture rule? ›

This has also been observed that the length of abdominal incision increases up to 30% in postoperative period. Therefore, 4:1 suture to wound length ratio will allow adequate bites and would also avoid cutting through the fascial sheath.

Why is it important to use the correct suture technique? ›

Proper placement of sutures enhances the precise approximation of the wound edges, which helps minimize and redistribute skin tension. Wound eversion is essential to maximize the likelihood of good epidermal approximation.

What are the 4 ideal suture material characteristics? ›

In addition to high tensile strength and low tissue reactivity, ideal features of a suture material include sterility, uniform thickness, flexibility for simple handling, and the ability to retain knot security, as well as low inflammatory response to promote healing.

What is the golden rule for suturing? ›

Traumatic lacerations are often sought to be sutured within six hours which is characterized as the "golden period". However, this rule is based on an animal experiment conducted by Paul Leopold Friedrich in 1898.

What are the layers of suturing? ›

WOUND ANATOMY — The epidermis, dermis, and subcutaneous layer are the tissue layers of concern during skin laceration repair: The epidermis and dermis are tightly adhered and clinically indistinguishable; together, they constitute the skin (figure 1).

How many types of suture patterns are there? ›

Sutures may be placed in two main types of patterns Surgery: suture patterns - basic patterns : Interrupted. Continuous.

What suture techniques are used to reduce scarring? ›

Zigzag suturing is also good for long suture wounds because it effectively disrupts the tension on the resulting scar. As a result, zigzag suturing is an effective approach for releasing linear scar contractures. Another major benefit of Z-plasties is that segmented scars mature faster than long linear scars.

What is the best suture for wound infection? ›

As a monofilament suture, polydioxanone causes minimal tissue reaction. It is useful in contaminated wounds or wounds in locations at greater risk for infection. Polydioxanone is also useful as a buried suture in wounds that require prolonged dermal support.

What is the most common knot used in suturing? ›

The square knot, or surgeon's knot, is traditionally preferred. The knot should be tightened sufficiently to approximate the wound edges without constricting the tissue and impeding blood flow.

How do you heal without stitches? ›

Cover the area with an adhesive bandage or gauze pad if the area is on the hands or feet, or if it's likely to drain onto clothing. Change the dressing and reapply the antiseptic ointment at least every day and whenever it gets wet or dirty. Check the area each day and keep it clean and dry.

What kind of stitches don't get removed? ›

"Dissolvable stitches placed internally won't need to be removed," says Dr. Yaakovian. "They will break down and disappear on their own over time. As for permanent stitches placed on the outside of the skin, these are typically left in for about two weeks before being removed."

Can you stitch your own wound? ›

DIY Suturing Should Only Be Done in Real Emergencies

If you do it incorrectly, at worst you can cause a life-threatening infection or the wound to heal improperly; at best, you'll leave a terrible looking scar on the person.

What kind of stitches are used for wounds? ›

Two types of stitches are used to repair wounds: non-absorbable and absorbable. The type of injury that you have will determine what type of stitches you need. Non-absorbable stitches are good for skin wounds. These stitches are removed when the wound has healed, and generally have a cosmetically appealing result.

What are the three types of wound closures? ›

And with wound healing, there are three types of wound closure techniques to consider to achieve this — primary intention, secondary intention, and tertiary intention.

What is the normal closure of suture? ›

The average age of coronal suture closure is 24 years; however, numerous diseases and factors may cause the dysfunction of a suture. The most common dysfunction is early closure or abnormal closure of a suture or group of sutures of the skull. Premature ossification of the sutures is referred to as craniosynostosis.

What is the layered closure technique? ›

Layered closure is sequential closure of each fascial layer individually. The primary advantage of this method is that multiple suture strands exist, so that if a suture breaks, the incision is held intact by the remaining sutures. Mass closure is continuous fascial closure with a single suture.

What is the most difficult suturing technique? ›

Running subcuticular sutures are considered to be the “holy grail” of suturing techniques by many. That is to say, when done correctly, they give the best cosmetic outcome. Hand in hand with that, they are certainly the most technically challenging and time consuming of suturing techniques.

What is the most common suture technique for ER? ›

'Reverse' type sutures are the most commonly used in most Emergency Departments. This type of suture gives optimum control of the depth of suture to the operator.

What is the most common suturing? ›

In general, surgeons typically use either polypropylene or polydioxanone sutures for fascia, depending on how strong the repair needs to be. Polypropylene is also very common in cardiovascular surgery. Deep dermis closure is with either polyglycolic acid or poliglecaprone 25 sutures.

What is an alternative to suturing? ›

Adhesive Tape

Doctors use sticky strips of tape (such as Steri-Strips) to pull together the edges of minor skin wounds. Skin tape costs less than other types of materials used to close wounds.

What type of suture is most appropriate for performing closure of the skin? ›

Percutaneous closure — The simple interrupted suture is the most common method used to close most small, uncomplicated, traumatic skin lacerations [1,14,15]. For proper healing, the edges of the wound must be everted by each stitch.

What is the best suture to use? ›

Suture (brand names)SiteTensile strength
Polypropylene (Prolene, Synthalin, Unilene)AnyBest
Fast-absorbing gutFaceLow
Polyglactin (Vicryl Rapide)Scalp Skin laceration under cast or splintFair
Chromic gutScalp Fingertip and nailbed Laceration under cast or splintFair
9 more rows

Which suture is best? ›

Polyglactin Sutures

The Polyglactin Suture comprises a synthetic braid, which is good to repair lacerations on the face and hands and is the most preferred option for general soft tissue approximation. Like the Poliglecaprone suture, this suture too is used in of vascular anastomosis procedures.

Which type of suture should be used? ›

Optimal cosmetic results can be achieved by using the finest suture possible, depending on skin thickness and wound tension. In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face.

What are the strongest suture types? ›

Steel wire has exceptional tensile strength (it is by far the strongest suture material) and provides long-lasting security as it does not break down.

Which suture is most resistant to infection? ›

The monofilament sutures performed better than the multifilament sutures. Lubricating coatings had no effect on infectibility. Natural sutures performed poorly and should not be used in wounds that are potentially susceptible to infection.


1. Learn How to Perform Basic Suturing
(Surgical Teaching)
2. Basic Suturing Techniques
(EM CapeTown)
3. Basics of Sutures Part 1 | Learn the Different Sizes and Shapes of Suture Needles?
(Surgical Teaching)
5. LEARN TO SUTURE THE EASY WAY ! Surgical Technique - Interrupted Buccal Suturing - Dental - Medical
(Dr Stuart Orton-Jones)
6. Correct handling of suturing instruments
(MEDICINE in a Nutshell)


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