Atlas of Primary Care Procedures, 1st Edition

Dermatology

15

Running Cutaneous and Intracutaneous Sutures

The running (continuous) cutaneous suture provides a rapid and convenient means for wound closure. This technique is similar to simple interrupted sutures, except that the suture material is not cut and tied with each succeeding suture placement. The suture evenly distributes tension along the length of a wound, thereby preventing damage to the skin edges from excessive tightness in individual sutures. Because suture material is not consumed in creating repetitive knots and cutting ends, this technique can provide cost savings in limiting the use of suture material. This suture method is used primarily in wounds that are well approximated and that are not under much tension.

The running cutaneous suture may not provide much skin edge eversion and is generally avoided in cosmetically important areas such as the face. One disadvantage of a running cutaneous suture is that, if the suture thread breaks, the entire wound may dehisce. A continuous suture does not permit selective removal of sutures in response to healing. Because the entire suture is removed at one time, slightly longer times to removal are recommended (see Appendix C).

The running intracutaneous (intradermal) suture is an elegant but technically difficult and time-consuming technique for wound closure. This suture is placed when skin suture marks must be avoided. Certain body locations such as the neck and breast favor the placement of running intracutaneous sutures. This suture also is indicated when closing erythematous forehead skin or facial skin with extensive sebaceous gland activity, which can develop prominent suture marks. This technique is best applied to shallow wounds or to wounds with the edges narrowed by placement of deeply buried sutures.

The running intracutaneous suture is placed within the dermis using a horizontal looping action. Although an absorbable suture may be used in children, nonabsorbable suture generally is chosen. Intradermal sutures remain in place for 2 to 4 weeks; a slippery suture material such as polypropylene (Prolene) is often selected to facilitate suture removal. Because long sutures can be difficult to extract after several weeks, placement of extracutaneous loops of suture in the center of a long suture can aid in removal.

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INDICATIONS

Running Cutaneous Suture

  • Closure of long wounds in less cosmetically important (nonfacial) areas
  • Closure of wounds where speed of closure is important (e.g., in the emergency department)
  • Shallow wounds with loose skin nearby, such as the scrotum or dorsum of the hand

Running Intracutaneous Suture

  • Closure of wounds on highly vascular, ruddy, or plethoric skin
  • Closure of wounds on skin subject to increased motion, such as the neck
  • Closure of breast wounds or surgical sites that are subject to expansion and suture marks
  • Closure of cosmetically sensitive areas where suture marks must be avoided, such as the head and neck

RELATIVE CONTRAINDICATIONS

  • Uncooperative patient
  • Unreliable patient (i.e., unlikely to provide necessary postoperative care for a running suture)
  • Wounds best closed by other methods
  • Widely separated wounds that close under significant tension
  • Presence of cellulitis, bacteremia, or active infection

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PROCEDURE

The closure begins with placement of a simple interrupted suture at one end of the wound. The free end is cut, but the long end (with the needle attached) is not cut (Figure 1A). Multiple loops are made straight across the wound, moving down the wound edge about 4 to 5 mm to initiate each pass, with the suture thread at a 60-degree angle to the wound (Figure 1B). The suture thread beneath the wound is perpendicular to the long axis of the wound. At the far end of the wound, the suture is tied by looping suture over the needle driver and reaching back to grasp the final loop across the wound (Figure 1C).

 

(1) The running cutaneous suture.

PITFALL: Do not tie the suture too tightly. The wound edges will bunch up if the final knot is too tight.

Some practitioners prefer not to have the suture angled across the top of the wound. An alternate technique causes the suture thread to appear perpendicular to the wound above the skin surface. Angle the needle beneath the wound to exit the skin 4 to 5 mm down the wound edge (Figure 2A). The final result appears in Figure 2B.

 

(2) Instead of angling the suture across the wound, some prefer to angle the needle beneath the wound to exit the skin 4 to 5 mm down the wound edge.

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The most commonly employed method to initiate this suture is to percutaneously enter the wound 1 cm from the end of the wound (Figure 3A). A hemostat can be placed on the free end of the suture to prevent it from slipping into the wound (Figure 3B). A horizontal, intracutaneous loop is created on each side of the wound (Figure 3C). The suture comes straight across the wound with each successive pass and does not pass back to the prior exit site of the last loop on that side of the wound (Figure 3D). The suture then exits the wound with a percutaneous pass 1 cm from the end of the wound (Figure 3E).

 

(3) The running intradermal suture.

PITFALL: Smaller loops create much less bunching of the skin edges. Even experiences physicians may observe some edge bunching, and placement of a few simple, interrupted sutures may be needed to refine the skin edge.

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After cutting the needle free, the free ends of suture are secured with tape at the ends of the wound (Figure 4A). Alternately, a knot can be tied by reaching back onto the thread (Figure 4B). This knot tying frequently causes excess pull and bunching of the skin edges, and it is discouraged because of its technical difficulty.

 

(4) After the needle has been cut free, the ends of the suture are secured with tape at the ends of the wound.

To facilitate suture removal, an extracutaneous loop may be placed in long suture lines. The extracutaneous loop is cut, creating two smaller threads that are easier to extract than one long thread.

 

(5) Placement of an extracutaneous loop.

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CODING INFORMATION

Use the codes listed in Chapter 12 for fusiform excision and in Chapter 14 for simple, interrupted skin sutures.

INSTRUMENT AND MATERIALS ORDERING

The basic skin-suturing instruments used are listed in Appendix A. Suggested suture removal times are listed in Appendix C. A suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation recommendations appear in Appendix H. Skin preparation recommendations appear in Appendix H.

BIBLIOGRAPHY

Bennett RG. Fundamentals of cutaneous surgery. St. Louis: Mosby, 1988:464–465.

Boutros S, Weinfeld AB, Friedman JD. Continuous versus interrupted suturing of traumatic lacerations: a time, cost, and complication rate comparison. J Trauma 2000;48:495–497.

Brown JS. Minor surgery a text and atlas, 3rd ed. London: Chapman & Hall, 1997:70–96.

Lammers RL, Trott AL. Methods of wound closure. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine, 3rd ed. Philadelphia: WB Saunders, 1998:560–598.

Moy RL, Lee A, Zalka A. Commonly used suturing techniques in skin surgery. Am Fam Physician 1991;44:1625–1634.

Moy RL. Suturing techniques. In: Usatine RP, Moy RL, Tobnick EL, Siegel DM, eds. Skin surgery: a practical guide. St. Louis: Mosby, 1998:88–100.

Stasko T. Advanced suturing techniques and layered closures. In: Wheeland RG, ed. Philadelphia: WB Saunders, 1994:304–317.

Stegman SJ, Tromovitch TA, Glogau RG. Basics of dermatologic surgery. Chicago: Year Book Medical Publishing, 1984:45–48.

Swanson NA. Atlas of cutaneous surgery. Boston: Little, Brown, 1987:42–45.

Wong NL. Review of continuous sutures in dermatologic surgery. J Dermatol Surg Oncol 1993; 19:923–931.

Zuber TJ. Basic soft-tissue surgery. The AAFP illustrated manuals and videotapes of soft-tissue surgery techniques. Kansas City: American Academy of Family Physicians, 1998:58–69.

Zukin DD, Simon RR. Emergency wound care: principles and practice. Rockville, MD: Aspen Publishers, 1987:51–54.



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