Types of suturing and where they are used
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suture techniques indications interrupted continuous mattress subcuticular surgical manual
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Types of suturing techniques and common uses
| Technique | Main use | Key point |
|---|---|---|
| Simple interrupted | Most traumatic lacerations, irregular wounds, contaminated wounds | Each stitch is independent. If one fails, the rest remain intact. Good for precise edge alignment. |
| Continuous running | Long, straight, low-tension wounds such as surgical incisions | Fast and uses less material, but failure of the suture can compromise a larger section of closure. |
| Running locked / continuous locking | Scalp wounds and wounds needing better hemostasis | The locking loops help control bleeding, but excessive tightening may impair blood supply. |
| Vertical mattress | Wounds under moderate tension, skin-edge eversion, areas prone to inversion | Useful for deeper wounds and thick skin, such as the back, palms, soles, or posterior neck. It everts wound edges well. |
| Horizontal mattress | High-tension wounds, fragile skin, or where tension must be spread over a wider area | Often used on the scalp, palms, soles, and friable skin. Remove early or use bolsters to avoid pressure necrosis. |
| Deep dermal, buried interrupted | Deep wounds with dead space or tension | Absorbable stitches placed beneath the skin reduce tension on the surface and eliminate dead space. |
| Subcuticular / intradermal running | Clean, straight surgical incisions with good edge approximation, especially cosmetic areas | A buried absorbable running stitch gives a fine cosmetic result and avoids removal. Common in face, trunk, and elective operative wounds. |
| Buried vertical mattress | Deep dermal closure under tension, especially cosmetic surgery | Provides tension relief and edge eversion without external stitch marks. |
| Figure-of-eight | Focal bleeding points, small deep defects, fascial approximation | Strong local compression. Often used for hemostasis or to secure tissue at a specific point. |
| Cruciate / X stitch | Hemostasis and closure of small round defects | A variation of interrupted suturing that crosses in an X pattern. |
| Purse-string | Closure of circular openings, such as stoma sites, drain sites, or around the appendix stump in selected operations | Tightening the circular stitch narrows or closes the opening. |
| Retention sutures | Selected abdominal wounds at very high risk of dehiscence | Large, tension-relieving sutures placed through several tissue layers. Used selectively because of discomfort and tissue injury risk. |
Choosing the technique
- Contaminated or irregular laceration: simple interrupted sutures, because individual stitches can be removed if infection develops.
- Long clean incision: continuous running or subcuticular closure.
- Wound under tension: deep dermal sutures plus vertical or horizontal mattress sutures as needed.
- Cosmetically important area: fine simple interrupted or subcuticular sutures, with careful eversion and minimal tension.
- Bleeding wound edge or scalp laceration: running locked suture or figure-of-eight stitch where appropriate.
- Circular defect or stoma/drain opening: purse-string suture.
Suture material by location
- Absorbable sutures are commonly used in the dermis, subcutaneous tissue, fascia, mucosa, and intradermal closure. Examples: polyglactin (Vicryl), poliglecaprone (Monocryl), polydioxanone (PDS).
- Nonabsorbable sutures are commonly used for external skin closure and tendon repair, where longer-lasting strength is needed. Examples: nylon and polypropylene.
Tintinalli's Emergency Medicine, pp. 614-620.
General principles are to use the smallest suture that provides enough strength, close deeper layers to reduce skin tension, and approximate rather than strangulate the tissue. Textbook of Family Medicine, p. 748.
Explain suture selection by wound location
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suture selection wound location face scalp trunk extremities hands feet laceration repair
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https://www.aafp.org/afp/2017/0515/p628
Suture selection by wound location is based mainly on skin thickness, wound tension, cosmetic importance, contamination, and whether suture removal is practical.
Rule: use the smallest diameter suture that will reliably support the wound. A higher number of zeros means a finer suture: 6-0 is finer than 4-0.
| Wound location | Typical skin suture | Preferred material / approach | Why |
|---|---|---|---|
| Face | 5-0 or 6-0 | Nylon or polypropylene, simple interrupted. Fine absorbable suture may be appropriate when return for removal is unlikely. | Thin skin and high cosmetic priority. Use fine sutures and remove early. |
| Eyelid | 6-0, sometimes 7-0 | Fine nonabsorbable monofilament or rapidly absorbable suture by an experienced clinician | Very delicate tissue. Complex lid-margin, canalicular, or deep injuries need specialist repair. |
| Scalp | 3-0 or 4-0 | Nylon, polypropylene, staples, or hair-apposition technique for suitable simple wounds | Thick, vascular skin and hair conceal scars. Larger caliber provides strength; staples are often fast. |
| Neck | 4-0 or 5-0 | Monofilament simple interrupted; layered absorbable closure if deep | Moderate cosmetic importance. Carefully assess for deep structural injury before closure. |
| Trunk | 3-0 or 4-0 | Nylon or polypropylene for skin; absorbable deep dermal sutures if gaping/deep | Usually thicker skin and moderate tension. Use a layered repair to eliminate dead space. |
| Back | 3-0 or 4-0 | Strong monofilament, often with deep absorbable dermal sutures | Thick skin and relatively high tension. Sutures generally stay longer. |
| Upper extremity | 4-0 or 5-0 | Nylon or polypropylene | Moderate skin thickness. Choose 4-0 for greater tension, 5-0 for finer areas. |
| Over a major joint | 3-0 or 4-0 | Strong nonabsorbable monofilament plus deep absorbable tension-relieving sutures when needed | Repeated movement creates high dynamic tension. Assess for tendon, joint capsule, and nerve injury. |
| Hand and fingers | Usually 5-0 | Nylon or polypropylene, simple interrupted | Fine tissue and functional importance. Avoid tight closure that compromises circulation. Explore for tendon, nerve, and vascular injury when relevant. |
| Leg | 4-0, sometimes 3-0 in high-tension skin | Nonabsorbable monofilament; consider deep absorbable layer | Healing can be slower and tension higher, particularly below the knee. |
| Foot | 4-0 or 5-0 | Nonabsorbable monofilament | High mechanical stress; inspect carefully for foreign bodies and deeper structural injury. |
| Palm and sole | 3-0 or 4-0 | Strong nonabsorbable monofilament | Very thick, high-tension skin. Larger sutures and longer retention are usually needed. |
| Oral mucosa, tongue, lip mucosa | 3-0 or 4-0 | Absorbable, such as polyglactin or chromic gut | Avoids the need for removal. Repair is most important for gaping, bleeding, deep, functionally important, or cosmetically important wounds. |
| Genital mucosa | 3-0 or 4-0 | Absorbable | Moist mucosa and difficult follow-up make absorbable material preferable. |
Tintinalli's Emergency Medicine lists a practical guide: scalp 3-0 or 4-0, face 6-0, trunk 4-0, extremities 4-0, and digits 5-0. Tintinalli's Emergency Medicine, p. 316.
Layer-based selection
Location alone is not enough. A deep or gaping wound generally needs a layered closure:
- Deep dermis / subcutaneous tissue: absorbable 3-0, 4-0, or 5-0, depending on thickness and tension. Examples include polyglactin and poliglecaprone.
- Skin surface: usually nonabsorbable monofilament such as nylon or polypropylene, particularly where removal is feasible.
- Cosmetic linear incision: a buried dermal layer plus an absorbable running subcuticular stitch can minimize surface marks.
- Contaminated wound: simple interrupted skin sutures are often preferred over a fully buried continuous closure because individual sutures can be removed if infection occurs.
Approximate removal times
These are general ranges and should be adjusted for tension, healing, age, diabetes, vascular disease, infection, and use of deep sutures:
| Location | Remove external sutures |
|---|---|
| Face | 3-5 days |
| Scalp | 7-10 days |
| Neck | about 7 days |
| Arms / upper trunk | 7-10 days |
| Trunk / legs | 10-14 days |
| Hands / feet | 10-14 days |
| Palms / soles | 14-21 days |
Early removal on the face reduces visible cross-hatching. If support is still needed, Steri-Strips can reinforce the wound after removal. The AAFP laceration guide gives similar location-based size and removal recommendations. Roberts notes that early removal must be balanced against dehiscence risk, especially in wounds under tension. Roberts and Hedges’ Clinical Procedures in Emergency, p. 34.21.
This is a guide for uncomplicated cutaneous wounds, not a substitute for assessment of wounds involving the eyelid margin, vermilion border, tendons, nerves, vessels, joints, bites, heavily contaminated injuries, or wounds with impaired blood supply.
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