Closing Incisions
General
- Always start AWAY from yourself if possible
- Do corners and then middle first
- If long incision, use markers
- If incision is small or difficult to see, can consider not tying until the end and just snapping your stitches
Buried knots
| Bite 1: DEEP to SUPERFICIAL (on your side) | Bite 2: SUPERFICIAL to DEEP (on opposite side) |
 |  |
- When tying: sinch "sideways" on the second tie
Non-buried knots
- Everything is opposite from buried
- bite 1 on opposite side: superficial to deep
- bite 2 on your side: deep to superficial
- when tying: sinch "up" with your post
Skin
DOG EARRING
- definition: when you advance UNEQUALLY along each side with your bites, you end up with extra incision on one side at the end
- How to prevent: advance equally
- How to correct:
- bit closer to edge of incision on site dog-earring, bite farther away from incision on side that is not dog-earring (TBA)
- may have to cut out some stitches to release some tension (TBA)
APPROXIMATING VERTICALLY MISALIGNED SKIN
- bite deeper in the lower side (BITE LOW on the LOW side)
- bite superficially in the higher side (BITE HIGH on the HIGH side)
STAPLES
- use Addy's to bring each side together vertically before every staple
- Staples 5-7.5 mm apart
Knots
GENERAL PRINCIPLES OF KNOTS
- Always tie your first two knots in same direction, then alternate every knot therafter
Q: HOW MANY KNOTS SHOULD I TIE?
A:
monofilament = ≥ 6 ties (easier to spontaneously unwind so need more)
poly-filament (braided) = 4 ties
Common sutures we use and their filament structure
| Suture | Type |
| Maxon | monofilament |
| Vicryl | polyfilament |
| Monocryl | monofilament |
| Nylons | monofilament |
Q: WHAT LENGTH OF TAIL?
A:
In the body (i.e. under skin), you want the minimum amount of foreign material so shorter is always better. But you also don't want to cut so close that you compromise the knot and make it start unwinding.
On skin (outside the body), just keep a long tail (~1cm), it doesn't hurt.
Layer By Layer Guides
SPINE
| LAYER | BURIED KNOT? | Suture to ask for | Technique | Ideal pickup | Comments / Tips |
| Muscle | NO | NON-absorbable (prolenes) or Absorbable (Maxon) | Simple interrupted +/- superimposed running +/ - figure of 8 +/- V-lock (braided locking stitch)
| Rat tooth gerald | Often close muscle in same bite as fascia; technically closing muscle not strictly necessary. |
| Fascia | NO | Rat tooth gerald |
| ||
| +/- Fat or Scarpa | + / - depends on distance from skin | Rat tooth gerald or Addison w/ teeth | technically "useless" for closure but in really fat people, can close dead space where a seroma/infection may otherwise form | ||
| Deep dermal | YES | 3-0 or 2-0 vicryl (polysorb) or maxon/prolene also sometimes used | Simple interrupted | Addison |
|
| Skin | N/A
| Absorbable (monocryl or biosyn) Non-absorbable (nylon)
| Absorbable
Non-absorbable (nylon)
Other Subcuticular V-lock or stratafix | Addison |
|
CRANIAL
| LAYER | KNOT | Suture to ask for | Technique | Ideal pickup | Comments / Tips |
| Bone | pterional crani - anterior/superior occipital: superio-medial | ||||
| Dura | |||||
| Galea | |||||
| Skin |
CHEST (batteries)
| LAYER | KNOT | # Ties in KNOT | Tail Length | Suture to ask for | Technique | Ideal pickup | Comments / Tips |
| +/- Fat | |||||||
| Deep dermal | |||||||
| Skin |