Surgeons have a variety of materials to choose from when closing a wound or an incision, as well as a number of suturing techniques, such as interrupted sutures and vertical and horizontal mattress suturing. However, one technique offering some of the best cosmetic outcomes without track marks is subcuticular suturing.
Subcuticular Suturing Do’s and Don’ts
To be performed correctly, subcuticular suturing requires a wound to be non-contaminated with straight, even edges in the dermis layer of skin, which is common for incisions but often not the case with wounds. That’s why it’s commonly used in the operating room, but very rarely employed in the emergency room. It can also be time-consuming, and in the ER, every second counts.
Subcuticular sutures should almost never be used unless there is already a deep dermal suture in place, as its strength lies in its ability to fine-tune epidermal approximation. It should also only be employed on incisions or wounds that experience very little or no tension, otherwise it becomes much less effective. Finally, because subcuticular suturing is an intradermal technique, and the suture does not gather strength in the epidermis, it should not be used on atrophic skin or on a thin dermis (for example, the eyelids, the thinnest skin on the body).
Choosing Subcuticular Suturing Material
As always, choosing the thinnest suture possible (taking into consideration the location of the wound or incision) is ideal. Since the subcuticular suture should not be holding tension, a 5-0 or 6-0 suture should be selected. Surgeons may choose to use absorbable or nonabsorbable sutures, however, because there will likely be a large amount of absorbable material left behind from the deep dermal suture, surgeons may choose to use a removable material. If absorbable sutures are chosen, a nonbraided monofilament suture may be best to minimize the risk of infection and foreign body reaction.
Subcuticular Suturing Technique
Subcuticular suturing can be a challenge to learn as many surgeons have their own variations on the technique. While there are many professional journals online trying to explain the subcuticular suturing technique, we actually found these six easy-to-understand steps from a first-year OB/BYN surgeon to be one of the best.
- Step 1: Throw your anchor knot. Start to the right or left of the apex, and take a bite in and out through the dermis (deep to superficial). Pull the suture through and tie it down with a one-handed or instrument tie.
- Step 2: Take a deep to superficial bite at the apex, exiting just below the epidermis. This is your target exit depth for the remainder of the suture. Pull this through, and it will “dunk” or subvert the first knot.
- Step 3: Begin taking horizontal bites. Using your tissue forceps, turn one side of the wound up and expose the dermal/epidermal junction. Be sure you are working in a plane parallel with the skin. You should begin each bite exactly opposite where you exited with the previous bite. Continue taking bites in this fashion until you’re near the opposite apex.
- Step 4: When you take your last horizontal bite, leave some slack in the suture, pull the distal material through, and “sinch” down making this your new loop. This is the most difficult part to explain without actually seeing it done, but there’s only one way to do this part correctly without pulling the needle through.
- Step 5: Use this new loop as a tail to tie with and throw down 3 or 4 knots. Alternatively, you can repeat this “sinching” process 3 times and then pass the needle/needle driver through the last loop.
- Step 6: Take one final bite, underneath the knot, in line with the longitudinal axis of the wound, exiting distal to the apex. Pull the suture taught and cut directly on the skin, allowing the tail to retract slightly once cut.
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The BandGrip Alternative
While subcuticular suturing offers good best cosmetic outcomes, it can be time-consuming and in emergency situations, a wound usually doesn’t lend itself to this method. One solution that works for both planned surgical procedures and ER situations in BandGrip Micro-Anchor Skin Closures. These applications offer a less invasive alternative to suturing by gently gripping the wound edges to pull incisions closed without placing excessive tension on the skin.
BandGrip can be applied by any healthcare professional and can be removed by the patient when healing is completed. Since the micro-anchor hooks don’t penetrate the skin deeply enough to reach nerve endings, BandGrip is not only painless to apply and remove, but it also greatly reduces the risk of infection.
In addition, BandGrip’s smooth, waterproof surface also supports increased ambulation and even allows the patient to take a shower 24 hours after application. Studies have shown that wounds closed using BandGrip feature better cosmetic outcomes, with far less scarring than similar wounds closed using tradition techniques.
To learn more about how BandGrip’s revolutionary micro-anchor technology works, check out our latest video or request a sample for a first-hand look.