Running Combined Simple and Vertical Mattress Suture: A Rapid Skin-Everting Stitch

BACKGROUND: Vertical mattress sutures are used in skin surgery to produce eversion of the wound edges, which produces a better, cosmetically acceptable scar. The disadvantages of this closure include the risk of wound hypereversion if tied too tightly, longer time to perform the stitch, and difficulties with grasping the externalized loops during suture removal. OBJECTIVE: To examine and discuss the new modification of running vertical mattress sutures, which can overcome the disadvantages. METHODS: Running combined simple and vertical mattress suture techniques are presented in a series of schematic diagrams that follow. RESULTS: The running combined simple and vertical mattress is easier and quicker to close the wound than the classic interrupted or running vertical mattress suture. Whereas the mattress suture everts the wound edges, the simple suture coapts the sides, preventing undue inversion or hypereversion of the wound. Suture removal is less uncomfortable for the patient and is performed faster by the medical staff owing to a reduction in the number of externalized loops by half compared with the classic vertical mattress stitch. CONCLUSION: Alternation of the vertical mattress and simple running suture saves the surgeon's time without lessening the advantages of good wound eversion and hence the formation of a less apparent, cosmetically more appealing scar after wound contraction.     

Locking Horizontal Mattress Suture

The horizontal mattress suture is useful in wounds in which there is a need for wound edge compression to provide hemostasis, closure is under moderate tension, or edge eversion is important. Its primary disadvantage is difficult suture removal and precise wound edge apposition. We describe a locking horizontal mattress technique that facilitates suture removal and provides more control over wound edge placement while providing hemostasis, tensile strength, and eversion.     

Enhanced Cosmetic Outcome with Running Horizontal Mattress Sutures

BACKGROUND: Cutaneous sutures should provide good wound eversion, firm closure, and cosmetically elegant results. Simple running sutures are commonly employed in cutaneous surgery but may not always be effective in achieving wound eversion. OBJECTIVE: We compared the cosmetic results of simple running nonabsorbable sutures with running horizontal mattress sutures in primary closures of facial defects. METHODS: Fifty-five patients with facial Mohs surgery defects appropriate for primary multilayer repair were randomized into one of two arms. Either the superior or the inferior half of the wound was closed with a running horizontal mattress suture. The other half of the wound was closed with a traditional simple running suture. At 1 week, 6 weeks, and 6 months, the cosmetically superior half of the wound, if any, was blindly determined by the investigators. RESULTS: The running horizontal mattress suture was significantly more cosmetically pleasing than the simple running suture. Forty-seven patients completed the study. At the 6-month follow-up, 25 patients did better with the horizontal suture and 5 did worse, and with 17 patients, there was no clinically perceptible difference. The 6-week scores predicted the outcome at 6 months, but the 1-week scores did not. CONCLUSIONS: In primary closures of the face, the running horizontal mattress suture is a cosmetically elegant alternative to a traditional running cutaneous suture. The final scar appears smoother and flatter than those produced by traditional simple running sutures.     

Modification of Laurence��s stitch for skin closure

Laurence’s stitch has previously been described for surgical wound closure. The technique describes a continuous horizontal mattress using an absorbable suture material, with the knot buried at each end of the wound. We have modified this stitch by leaving the knot outside the skin and beyond the ends of the wound. We feel that this improves Laurence’s stitch by avoiding any possibility of a surgical knot abscess and allowing a slightly faster wound closure but still providing the benefits associated with a continuous horizontal mattress.     

Laurence’s stitch: continuous horizontal mattress suture for skin closure

Various techniques have been described for closure of surgical wounds. These include, subcuticular technique, interrupted vertical mattress, clips, etc. We report a technique of continuous horizontal mattress for skin closure using absorbable suture material. This technique is quick and easy to master, avoid gaping of wound, good cosmesis and is suitable for all wound sizes.     

The double loop mattress suture

An interrupted stitch type with favorable tissue characteristics will reduce local wound complications. We describe a novel high‐strength, low‐tension repair for the interrupted closure of skin, cartilage, and muscle, the double loop mattress stitch, and compare it experimentally with other interrupted closure methods. The performance of the double loop mattress technique in porcine cartilage and skeletal muscle is compared with the simple, mattress, and loop mattress interrupted sutures in both a novel porcine loading chamber and mechanical model. Wound apposition is assessed by electron microscopy. The performance of the double loop mattress in vivo was confirmed using a series of 805 pediatric laparotomies/laparoscopies. The double loop mattress suture is 3.5 times stronger than the loop mattress in muscle and 1.6 times stronger in cartilage (p ≤ 0.001). Additionally, the double loop mattress reduces tissue tension by 66% compared with just 53% for the loop mattress (p ≤ 0.001). Wound gapping is equal, and wound eversion appears significantly improved (p ≤ 0.001) compared with the loop mattress in vitro. In vivo, the double loop mattress performs as well as the loop mattress and significantly better than the mattress stitch in assessments of wound eversion and dehiscence. There were no episodes of stitch extrusion in our series of patients. The mechanical advantage of its intrinsic pulley arrangement gives the double loop mattress its favorable properties. Wound dehiscence is reduced because this stitch type is stronger and exerts less tension on the tissue than the mattress stitch. We advocate the use of this novel stitch wherever a high‐strength, low‐tension repair is required. These properties will enhance wound repair, and its application will be useful to surgeons of all disciplines.     

A novel technique in securing the subcuticular suture—“Loop & Lock” technique

There are various ways to secure a buried subcuticular suture, but most techniques present problems with excess knot material buried within the wound, a steep learning curve in mastering the technique or limited resistance to pull-through. A novel technique to secure a buried subcuticular suture is described in this report. This technique is simple to master and can secure excellent approximation of the wound with good eversion. Resistance to pull through is observed in clinical applications in repairs of surgical wounds on trunks and limbs. We present the experience of one author (GSR) on about 1,000 patients.     

Comparative study of leg wound skin closure in coronary artery bypass graft operations.

A prospective randomised study of four different methods of leg wound skin closure after removal of the long saphenous vein was carried out in 113 patients undergoing coronary artery bypass grafting. These methods were: (1) continuous nylon vertical mattress suture (27 patients); (2) continuous subcuticular absorbable (Dexon) suture (29 patients); (3) metal skin staples (Autosuture) (27 patients); and (4) adhesive sutureless skin closure ("Op-site") (30 patients). All wounds were examined by two independent observers at five, 10, and 45 days after operation. At five days, inflammation, extent of oedema, discharge, and infection were assessed. At 10 days attention was paid to the state of wound healing and at 45 days to the final cosmetic appearance. The use of continuous subcuticular suture resulted in significantly less discharge than did the use of metal staples, nylon vertical mattress suture, or Op-site. The incidence of established wound infection was 4.5% overall, with no infection in the wounds closed with Dexon. Assessment of the healing process showed subcuticular Dexon to be more effective than metal staples or vertical mattress nylon suture. The final cosmetic result showed continuous subcuticular suture to be superior to nylon vertical mattress suture and skin staples but as effective as Op-site sutureless skin closure.     

The effect of suture pattern and tension on cutaneous blood flow as assessed by laser Doppler flowmetry in a pig model

OBJECTIVE: To determine the effects of various suture patterns on cutaneous blood flow (CBF) at the wound edge as increasing tension is applied through the suture. METHODS: Four different suture patterns commonly used for wound closure (simple, vertical mattress, horizontal mattress, and Allgower-Donati) were placed individually after a full-thickness incision was made in an anesthetized pig. A laser Doppler flowmeter (LDF) was placed on the skin edge after the suture was passed. Baseline CBF was recorded. Increasing tension was applied to the wound edge via the suture through a tensionometer in 0.5-lb (0.23-kg) increments from 0 to 2.5 lb (1.13 kg). CBF was then recorded as a function of tension for each suture pattern. RESULTS: The Allgower-Donati suture pattern affected CBF significantly less than the other three suture patterns did for all tensions from 0.5 to 2.0 lb (0-0.9 kg; P < 0.05). There were no significant differences between vertical mattress, horizontal mattress, and simple suture patterns. CONCLUSIONS: The Allgower-Donati suture pattern had the least effect on CBF with increasing tension in this model. Further study is warranted on the benefits of this suture pattern because it may decrease wound complications in traumatized tissues.     

Comparison of various methods and materials for treatment of skin laceration by a 3-dimensional measuring technique in a pig experiment

BACKGROUND: The ability to obtain an objective comparison of scar formations by reproducible and quantitatively measurable results have posed a longstanding problem. This was especially troublesome when conclusions were to be drawn about the materials and methods applied. Two-dimensional methods (photography) gave no plastic impression about the spatial coherences in an examined scar. However, a quantifiable and reproducible recording of volumes and a 3-dimesional visualization of scars should provide the basis of any evaluation of methods and materials. METHODS: The OPTOCAT 3-dimensional scanning technique that was used was provided by the Breuckmann GmbH Company (Meersburg, Germany), and it permits a 3-dimensional, contact-free recording of data. The experiment animal was the Goettinger minipig. A total of 10 animals were used to examine the process of wound healing and scar development in full skin incisions. Every animal was incised 20 times with a 10-cm long and 20 times with a 2-cm long wound. In our investigation, comparable suture materials (skin adhesive, absorbing and nonabsorbing suture materials) of the companies Braun (Histaocryl, Monosyn, Safil, Premilene) and Ethicon (Dermabond, Monocryl, Vicryl, Prolene) as well as various suture techniques were used (continuous, mattress suture, and over-and-over/interrupted suture; each once with and once without an intracutaneous suture). In the course of the trial, numerous images of all wounds-a total 1200-were taken. Thanks to the 3-dimensional software, the resulting scar volumes of lacerations, which received different wound management, were quantifiably recorded, compared, and evaluated. RESULTS: In total, dehiscence occurred in 2.5% of all treated wounds. The greatest share (15%) fell to wounds treated with Histoacryl skin adhesive. In the end, skin adhesive, mattress, and interrupted suture all delivered similar results. An additional intracutaneous suture had, with an increasing wound length, a positive effect on the intention/wound healing, especially in connection with the application of skin adhesive. Except the combination of continuous absorbable suture and intracutaneous suture, the scar volume dwindled over time and adapted to the surrounding skin level. Continuous sutures were, by comparison, more inclined to an increased scarring (absorbable suture > nonabsorbable suture). It did not escape our notice that in case of small wounds, all various suturing materials and methods led to almost identical results. With respect to scarring, no significant difference regarding the suturing material was proven. CONCLUSIONS: If possible, the wound closure, treated with common suturing techniques and especially with skin adhesive, should be enhanced by an intracutaneous suture with an increasing length of the wound. Under certain circumstances, skin adhesive is an adequate substitute for common suturing materials and methods. The final decision about the method and material is as much closely related to the length and localization of the wound as to time exposure, efficiency, and the comfort of the patient. SUMMARY: For objective comparison of intention and scarring, a scanning technique was used that permits a quantifiable, contact-free, single-session recording of volume differences. For this purpose, various suture materials and methods were used. Altogether, it could be shown that, if possible, wound closure treated with common suturing techniques, and especially with skin adhesive, should be enhanced by an intracutaneous suture with an increase in wound length. At the same time and under certain circumstances, skin adhesive poses an adequate substitute for the common suturing materials and methods. In the end, however, the final decision about the choice of method and material should be made depending on the localization and expanse of the wound as well as on the comfort of the patient (eg, absorbable suture/nonabsorbable suture), the time of exposure (eg, skin adhesive vs suture), and the economic efficiency (eg, producer of suture material).     

Wide spread scars, hypertrophic scars, and keloids

Patients with a wide scar may complain of having a "keloid," yet have a hypertrophic or a wide spread scar. The plastic surgeon should make the appropriate clinical diagnosis, because therapy varies depending on the condition present. A wide spread scar is best treated with excision and closure. A buried dermal flap may help to prevent recurrence, which is nevertheless likely to some degree. A hypertrophic scar can be distinguished from a keloid on clinical grounds. Although both may be red, nodular, and itchy, the keloid overgrows the original wound boundary and is much more likely to recur after surgical excision. Nonsurgical treatment of hypertrophic scars and keloids is similar, using repeated intralesional injections of Kenalog 40 mg per cc and sustained pressure on the lesion when possible. Surgical treatment differs for hypertrophic scars or keloids. Scar excision and closure, and selective Z-plasty, may be used in hypertrophic scars. In keloids, aggressive surgery is usually avoided, unless the lesion has a narrow pedicle. Surgery of keloids should be accompanied by intra- and postoperative Kenalog-40 injections, and on occasion by sustained pressure. Very large keloids may be resistant to medical management, and too aggressive for surgery owing to a high likelihood of recurrence. These difficult lesions serve as the impetus for continued biochemical and tissue culture research, seeking a biochemical means of control keloids.     

Load to failure of common meniscal repair techniques: Effects of suture technique and suture material

Success of meniscal repair with early or immediate motion depends on the ability of the suture fixation to withstand the loads applied. Vertical and horizontal mattress suture techniques were tested using 2-0 Ethibond, and 0-PDS and 1-PDS sutures (Ethicon, Somerville, NJ). Mulberry knot technique was tested with 0-PDS and 1-PDS sutures. Twenty menisci (60 sutures) were tested for each suture material. Sutures were placed 3 to 4 mm from the peripheral edge of the meniscus with double barreled cannulas for vertical and horizontal mattress techniques or a spinal needle for the mulberry knot technique, reproducing clinical techniques of meniscal repair. Mechanical testing of suture fixation was performed to failure at a rate of 10 mm/min on a MTS material testing system (MTS Systems Corp. Minneapolis, MN). Suture pullouts were reported as the load displacement to failure from the inner fragment only, because clinical failure would ensue should a suture pull through the inner fragment of a tear. Vertical mattress technique with 1-PDS suture had significantly greater load to failure than any other combination (P < .05). Analysis of variance showed that the vertical mattress technique had statistically superior pullout strength (P < .0001) compared with the horizontal mattress and mulberry knot techniques, which were statistically similar. There were significant differences (P < .0001) between suture types, with 1-PDS proving best compared with 0-PDS, which was stronger than 2-0 Ethibond. Selection of suture material had the greatest impact on vertical mattress load to failure and was not important to the strength of the other techniques.     

Intracutaneous butterfly suture – a horizontal buried interrupted suture for high tension

Background: Tension on surgical wound margins frequently results following the excision of skin lesions such as tumors, naevi or scars. This tension is commonly counteracted with buried, intracutaneous, interrupted sutures of absorbable or non-absorbable material anchored vertically in the corium. Method: A horizontal, buried, intracutaneous suture has now been developed which can be more firmly anchored in the corium. It adapts and everts wound margins nearly as broadly as two vertical sutures, particularly, when the wound edges are cut obliquely with a longer rim of epidermis. When finished, the suture has a butterfly shape, whence its name. It can also be laid as a double suture (double butterfly suture). In creating this sutures, the surgeon changes the customary direction of the needle holder from horizontal to vertical. Materials: Since 1985, this suture has been made with polydioxanon in more than 30000 skin lesion excisions with very good results. In most cases the resulting narrow and smoth scars were narrow and flat in the most cases. During the study, the following suture materials were tested prospectively in 1325 patients: polyglactin 910 (Vicryl^®) (n=390), polytrimethylcarbonate (Maxon^®) (n=95), poliglecaprone 25 (Monocryl^®) (n=175), and (PDS^®) (n=665). Results: The results were unsatisfactory in only 8% of procedures. Polyglactin 910 was accompanied by somewhat more inflammation and scar dehiscence, poliglecaprone 25 by a high rate of scar dehiscence. Polytrimethylcarbonate caused skin reactions in 23% and was discontinued. Suture perforation occurred in 9%. Polydioxanon yielded the best results (p-value of the difference <0.05). Conclusions: The butterfly suture has the advantages of withstanding tension better while everting wound margins and requiring fewer stitches for wound closure. However, it is important that the suture knot be deeply anchored beneath the corium.     

硅胶线牵张技术辅助头皮延伸术治疗瘢痕性脱发

目的探索应用一种硅胶线牵张技术增加头皮延伸术对头皮瘢痕性脱发的治疗效果。方法在局部浸润麻醉下,于头皮瘢痕区域内沿瘢痕长轴的中线切开瘢痕皮肤达帽状腱膜下,并向两侧潜行分离,范围不少于瘢痕的宽度。继之,将一直径3mm的硅胶线从切口的一端内面缝合固定于两侧的帽状腱膜上,并以连续水平褥式缝合法将之贯穿于整个切口的两侧。待达到切口的另一端后将之穿出皮面,辅以阻挡装置固定。1周后,以隔日1次的间隔期收紧此硅胶线,直至两侧正常头皮组织接近。然后行二次手术切除瘢痕组织,直接闭合两侧切口。结果1999年10月至2006年3月,共治疗12例,切除瘢痕的宽度为5~10.5cm;平均牵张期为26.4d。术后随访3个月,效果良好。结论该硅胶线牵张技术可以使头皮组织不断伸展,明显增加头皮延伸术的临床治疗效果。     

Meta-analysis of skin adhesives versus sutures in closure of laparoscopic port-site wounds

Objective  To analyze the effectiveness of skin adhesives and sutures in the closure of laparoscopic port-site wounds. Methods  Electronic databases were searched to find relevant randomized controlled trials and their data was analyzed to generate a summative outcome. Results  Seven trials on port-site wound closure after laparoscopic procedures encompassing 902 patients were retrieved from the electronic databases. Four randomized controlled trials on 404 patients qualified for the review according to inclusion criteria. In both fixed- and random-effects models, there was no difference between the two port-site wound closure techniques in terms of wound infection, wound dehiscence and, patient satisfaction. However, statistically tissue adhesives were quicker in port-site wound closure as compared with sutures. Conclusions  Based on this review, there is insufficient evidence that port-site wound closure technique by tissue adhesives is superior to traditional suture closure technique in terms of wound infection, wound dehiscence, and patient satisfaction. However, tissue adhesives are quicker in port-site wound closure. A multicentre randomized controlled trial is required in order to obtain stronger evidence.     

Laser assisted skin closure (LASC) by using a 815-nm diode-laser system accelerates and improves wound healing

BACKGROUND AND OBJECTIVE: This study aimed to evaluate a 815-nm diode-laser system to assist wound closure to accelerate and improve healing process. STUDY DESIGN/MATERIALS AND METHODS: A total of 25 male hairless rats (mutant OFA Sprague-Dawley rats, IFFA-CREDO, L'Arbresle, France) with four dorsal skin incisions were used for the study. For each wound, the good apposition of the edges was obtained with buried absorbable suture. In the laser group, the laser beam was applied spot by spot through a transparent adhesive dressing along two incisions with the following parameters: 1.5 W; 3 seconds; spot diameter, 2 mm; fluence, 145 J/cm(2). Both control wounds were closed with conventional suture techniques. The duration of the closure procedure was noted for each group. Clinical examination, histologic study, and measurement of tensile strength were performed at 3, 7, 15, and 21 days after surgery. Determination of activation of heat shock protein 70 (Hsp70) through immunocytochemistry was performed at days 1 and 7. RESULTS: LASC was 4 times faster to process than conventional suture: 1 minute 49 +/- 20.6 seconds vs. 7 minutes 26 +/- 62.2 seconds. In the laser group, healing was accelerated resulting in a more indiscernible scar than in the control groups. Histologic aspect was better with earlier continuous epidermis and dermis and a thinner resulting scar. Tensile strength was 30 to 58% greater than in control groups at 7 and 15 days (P < 0.001). Expression of Hsp70 was markedly induced in skin structures examined after laser exposure. CONCLUSIONS: This study shows the ability of the 815-nm diode-laser system to assist wound closure leading to an acceleration and an improvement of wound healing with indiscernible resulting scar. The mechanisms of this phenomenon are still unclear but further investigations are in progress to attempt to explain them.     

VADER (vacuum-assisted dermal recruitment): a new method of wound closure

Acute wounds which cannot be closed primarily are usually closed with a split skin graft. However a split skin graft has both functional (where tendons are exposed) and esthetic sequelae (contour deformity, different skin in color and texture). A novel technique is described which allows delayed primary closure of either fasciotomy wounds or full-thickness defects after harvest of a free or pedicle flap. The technique described combines the bootlace suture technique (which achieves wound closure by progressive suture tightening) with the VAC (vacuum-assisted closure) system (which reduces tissue edema, facilitating movement of tissue, and also reduces bacterial contamination of the wound). Twelve of 14 wounds (average width of wound after insertion and tightening of bootlace suture was 5 cm) were successfully closed after an average of 8 days (range, 4-23 days) in 11 patients (mean age, 45 years; range, 18-77 years) using this technique. Of the 2 patients where the technique was not successful, one patient was noncompliant and the other developed wound-edge necrosis. Other complications were self-limiting.The combined use of 2 methods of wound management facilitates delayed primary wound closure.     

4. Grundlagen chirurgischer Indikationen: Hilfen zur Entscheidungsfindung

Zusammenfassung Nach mehr als 1 500 Hautnähten von etwa 7 bis 30 cm Länge bei Operationen in jedem Lebensalter mit einem monofilen, synthetischen, resorbierbaren Poly-Dioxanon-Faden berichten wir über unsere guten Erfahrungen mit dieser Technik. Bei Kindern zur Erzielung einer kosmetisch sauberen Narbe, ohne die Fäden später entfernen zu müssen, halten wir das Material für besonders geeignet. Die Reißfestigkeit, Resorptionsrate und das reaktionsarme Verhalten in der Wunde ist so günstig, so daß wir keine Nachteile durch die Verwendung dieses resorbierbaren, synthetischen Fadens zur intracutanen Hautnaht gesehen haben. Insbesondere kommt es zu keiner Wundheilungsstörung: Im Gegenteil, durch die sichere und ungestörte Wundrand-Adaptation entsteht eine reizlose, feste und strichförmige Narbe. Der Zeitaufwand für die Ausführung der Naht ist sicher nicht gröBer als bei anderen Techniken.

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Intracutaneous skin suture with an absorbable monofile synthetic thread

Summary We report about our good experience with a monofile, synthetic, absorbable Polydioxanone thread used for skin suture in an intracutaneous technique, after we performed more than 1,500 sutures of 7 to 30 cm length in patients of any age. We consider the suture to be suitable for children to achieve a cosmetically fine scar without a subsequent necessity to pull out the thread. The breaking strength, the absorbtion rate and the loss of inflammatory reaction is so satisfactory that we could not see any disadvantage by using this absorbable, synthetic thread for skin closure. Especially there was no disturbance in wound healing. In contrast, because of the secure and undisturbed wound-edge adaption a non-irritant, firm, and hairline-like scar could be achieved. The time to carry out the suture is no longer than for other techniques.

     

The Rousso stitch: A new everting skin closure technique

The purpose of this article is to describe a new suturing technique that everts the skin and is a modification the horizontal mattress suture called the Rousso stitch. The technique is described step by step, along with reference pictures. The Rousso stitch technique was developed based on the well-documented theory behind everting the edges of thicker skin on closure of surgical incisions to allow for ideal coaptation and minimal scar formation. It is an easy technique to learn and appears to be a good time-saving option for the surgeon to use for the same applications of the typical horizontal mattress suture.     

Arthroscopic Rotator Cuff Repair Using a Triple-Loaded Suture Anchor and a Modified Mason-Allen Technique (Alex Stitch)

Surgical repair of the rotator cuff must have good resistance and should restore the tendon footprint. To attain this goal, a stitch with a strong biomechanical profile that avoids tissue strangulation should be used. We describe an arthroscopic suture technique undertaken to repair rotator cuff tears with a single triple-loaded suture anchor. The technique consists of a combination of a horizontal mattress and 2 vertical simple sutures that are positioned medial to the mattress suture. The suture anchor used is the 5-mm self-tapping ThRevo (Linvatec). This anchor is loaded with 3 sutures: 2 No. 2 nonabsorbable braided polyester sutures of different colors and a central high-strength No. 2 polyethylene suture. The shape of the anchor eyelet permits all 3 sutures to glide freely. A modified Mason-Allen technique (Alex stitch) that combines a horizontal side-to-side suture and 2 simples sutures as vertical loops is used. With use of the Spectrum suture passing device and shuttle relay system (Linvatec), both limbs of the centrally located polyethylene suture are passed through the cuff from bottom to top, approximately 1 cm from the tendon edge. This suture is not immediately tied. Next, with use of the same system, the other 2 sutures are placed medially and over the previous horizontal suture. Simple sutures are placed at an approximately 30° angle from the center of the anchor; 1 is placed anterior and the other posterior. The sutures are tied through the lateral portal. The mattress horizontal central stitch is always tied first, followed by the 2 vertical sutures. The horizontal mattress suture serves as a “rip stop stitch” and theoretically reduces the possibility of cutting out of the simple sutures.