The Importance of Good Suture Techniques
Frequently, when people get cosmetic, reconstructive, or plastic surgery they are only thinking about the actual surgery. However, in reality, the aesthetic results of the surgery are just as linked to the sutures as they are to the surgery itself. Since we take aesthetics so seriously at TSLMS, and the skills that our members need to keep people looking their absolute best, we do not want anyone in our industry to forget about the importance of good suture techniques.
What Is A Suture
We acknowledge that it is highly unlikely that anyone amongst our membership, or any of our SCALE Music City attendees, do not know what a suture is. However, it is important, we believe, to refresh this basic knowledge just as we refresh our suturing skills periodically.
According to Mirriam-Webster, a suture is either a noun: “1a: a strand of fiber used to sew parts of the living body also : a stitch made with a suture; b: the act or process of sewing with sutures; 2a: a uniting of parts; b: the seam or seem like line along which two things or parts are sewed or united; 3a: the line of union in an immovable articulation (as between the bones of the skull)also : such an articulation; or b: a furrow at the junction of adjacent bodily parts especially : a line of dehiscence (as on a fruit).” It can also be a verb: “sutured; suturing\ ˈsü-chə-riŋ , ˈsüch-riŋ \” or transitive verb: “to unite, close, or secure with sutures suturing a wound.”
In other words, in our world, sutures are what are used to close the wound that the surgeon makes.
What Is A Good Suture Technique
In our book this is anything that effectively and cleanly closed the wound in a way that leaves little to no visible, or unintentional, scarring. Stanford University’s Stanford Medical, has a fantastic guide to a 4-step microsurgery suturing process, complete with video. Breaking down suturing into 4 steps is useful in that it helps us to stay organized and intentional so we can think about the suture every single time. In brief, they describe this process as follows:
- Step 1: Picking up the Needle. At first, grasping the needle is difficult because it will have a tendency to want to jump around. What can oftentimes help is to get hold of the thread with the left-hand forceps at a point 2 to 3 cm away from the needle…. You should hold the needle just behind its midpoint (If you hold it too near the tip, it will point downward. If you hold it too near the thread end, it will point upward.).
- Step 2: Passing the Needle Through. The needle should pass through the tissue at a perpendicular. Place the tip of the left-hand forceps on the underside of the tissue at the point where the needle will enter, and gently push the edge upward. With the right hand, bring the needle into contact with the tissue, and press downward. These movements create eversion. Pass the needle through. Do not grab the tissue with your left hand forceps since it will damage the intima….The needle must pass through the other side at a perpendicular, too. NOTE: When operating on a vessel, the STAY sutures should be placed in 2 passes, while all other sutures are placed in 1 pass.
- Step 3: Pulling the Suture Through. Use the tip of the right-hand needle driver as a guiding pulley when pulling the needle through. Keep the suture parallel to the direction of the entry-exit line. Leave about a 3-mm tail.
- Step 4: Tying the Knot. First, pick up thread with left hand forceps. Then Grab suture about 1 cm from the incision site with left hand. Make sure the part that you are going to tie with comes out from the side of the forceps that is toward you. Next, make a loop. Turn the suture into a loop around the tip of the needle holder, close to the short end tail. Then, pick up the short end and complete the knot… Make sure the knots are squared… Now cut the short end of the suture first, and discard it. Then hold on to the long suture and cut it close to the knot. Pull on the long thread, and the needle will come into view, and you’re ready for your next stitch.
This guide was specifically designed by the University to teach techniques that require the hand and eye of an aesthetic practitioner. It is useful for those who are working in emergency medicine and closing any wound as well because everyone who ever closes a wound should aim to do so in a way that minimizes scarring and is effective.
One of the best pieces of literature on this topic was published by the Journal of Korean Medical Science, “Overview of Surgical Scar Prevention and Management,’ and republished by the US National Institutes of Health. In the article, they point out that suture technique is critical, but it is just the icing on the cake, so to speak. The incision is what will guide the healing that the suture allows. This means the cut is even more critical than the suture, but even a good cut will be ruined if the suture is off. This needs to be followed up with post-surgical wound care and scar management:
In scar prevention, the single most important modifiable factor is wound tension during the proliferative and remodeling phases, and this is determined by the choice of incision design. Traditional incisions most often follow relaxed skin tension lines, but no such lines exist in high surface tension areas. If such incisions are unavoidable, the patient must be informed of this ahead of time. The management of a surgical incision does not end when the sutures are removed. Surgical scar care should be continued for one year. Patient participation is paramount in obtaining the optimal outcome. Postoperative visits should screen for signs of scar hypertrophy and has a dual purpose of continued patient education and reinforcement of proper care.
Good surgeons have a good eye, a steady hand, and a technique that involves management of the scar, as well as the expectations of their clients from pre to post surgery. We are here to help all surgeons be better!