detailed suturing technique from very basics to advanced level with each step in detail with reasoning and indication of suturing and contraindication nd their reason reference from best books

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Suturing: From Basics to Advanced — Complete Reference Guide

Sources: Fitzpatrick's Dermatology (8th Ed.) • Roberts & Hedges' Clinical Procedures in Emergency Medicine (7th Ed.) • Tintinalli's Emergency Medicine • Pfenninger & Fowler's Procedures for Primary Care (3rd Ed.) • Fischer's Mastery of Surgery (8th Ed.) • Bailey & Love's Short Practice of Surgery (28th Ed.) • Pye's Surgical Handicraft (22nd Ed.)

PART 1: FUNDAMENTALS - Anatomy of Wound Healing

Before placing a single suture, you must understand what you are trying to recreate.

Skin layers relevant to suturing:

Epidermis (outermost, no tensile strength)
Dermis (provides tensile strength; key layer for deep sutures)
Subcutaneous (fat + loose connective tissue; prone to dead space)
Deep fascia / muscle

Phases of wound healing relevant to suture timing:

Hemostasis (0-minutes): Platelet plug, vasoconstriction
Inflammation (0-72 hours): Tissue swells - relevant to suture tension
Proliferative (day 3 - week 3): Collagen synthesis; scar has only 5-10% of original strength at 2 weeks
Remodeling (weeks to months): Scar reaches ~80% original strength by ~6 weeks

This explains why sutures must maintain tension through weeks 1-3, and why deep absorbable sutures are chosen with specific tensile half-lives.

PART 2: INDICATIONS FOR SUTURING

When to Suture (Primary Closure)

Indication	Reasoning
Clean laceration < 6 hours old	Contamination is minimal; bacterial load still manageable
Incised wounds (surgical or traumatic)	Sharp edges approximate well
Wounds under tension that won't approximate spontaneously	Prevent dehiscence and wide scarring
Wounds in cosmetically important areas (face, hands)	Precise edge alignment reduces scarring
Wounds over joints (dynamic stress)	Requires secure closure to withstand movement
Deep wounds with dead space	Dead space harbors seroma/hematoma formation - must be obliterated
Wounds needing hemostasis	Sutures compress vessels

The 6-hour rule: As stated in Pye's Surgical Handicraft - "A reasonable estimate of the period during which a wound can be safely closed is 6 hours. Beyond this time contamination increases steadily." This applies primarily to contaminated traumatic wounds; clean surgical wounds are not subject to this restriction.

Wounds That Can Heal Without Sutures

Simple lacerations < 2 cm on the hand/finger with well-approximated edges
Small superficial abrasions
Puncture wounds (suturing may trap bacteria)

PART 3: CONTRAINDICATIONS TO SUTURING (PRIMARY CLOSURE)

Absolute Contraindications

Contraindication	Reason
Frank wound infection / abscess	Suturing traps bacteria; accelerates spread; risks necrotizing infection
Heavily contaminated wounds (soil, feces, bite wounds in most locations)	Anaerobic organisms (Clostridium, Bacteroides), aerobic contamination - suturing creates ideal anaerobic environment
Animal/human bite wounds (most locations)	Human bites are the most infection-prone; animal bites carry Pasteurella, Capnocytophaga - primary closure dramatically raises infection risk (exception: face bites may be primarily closed due to superior blood supply)
Devitalized tissue at edges	Dead tissue acts as culture medium; must debride first
Puncture wounds	Cannot be adequately irrigated; closure traps anaerobes
Wounds > 12-24 hours old in most body sites	Bacterial colonization is irreversible at this point

Relative Contraindications

Contraindication	Reason
Immunocompromised patient	Impaired healing and defense - consider delayed primary closure
Poorly controlled diabetes	Impaired angiogenesis and neutrophil function; higher dehiscence risk
Heavy contamination with foreign material	Must thoroughly debride/irrigate first; proceed only if all foreign material removed
Patients on anticoagulants	Higher hematoma risk under sutured wound; not absolute
Keloid-prone patients	Suture material increases foreign body reaction; minimize sutures, use skin tapes where possible

As Roberts & Hedges states: "With patients at risk of keloid formation, it makes logical sense to relieve tension and minimize the amount of foreign material introduced into the wound by using skin tapes or tissue adhesives, instead of sutures."

PART 4: INSTRUMENTS AND EQUIPMENT

The Suture Tray - What You Need and Why

1. Needle Holder

Holds the needle during passage through tissue
Key principle: The needle holder should be placed on the proximal 1/3 of the needle body, NOT at the swage (weak point) and NOT at the tip
The wrist pronation/supination motion follows the curve of the needle - this is critical (rotating the wrist to drive the needle in an arc rather than pushing it straight)

2. Tissue Forceps (Pickups)

Used to gently stabilize wound edges
Never crush the dermis - use toothed forceps (Adson's) for skin; teeth allow grip without crushing
Crushing the dermis with non-toothed forceps destroys capillaries and promotes necrosis

3. Scissors

Iris scissors: for cutting suture and fine dissection
Suture scissors: blunt-ended for cutting near tissue

4. Retractors, wound hooks - for exposure in deeper wounds

PART 5: SUTURE MATERIALS - Selection and Reasoning

Absorbable vs. Non-absorbable

Property	Absorbable	Non-absorbable
Definition	Loses >50% tensile strength within 60 days	Retains strength >60 days
Primary use	Deep dermal, subcutaneous, fascial layers	External epidermal closure; tendons
Elimination	Hydrolysis (synthetic) or enzymatic digestion (natural)	Must be removed; foreign body reaction if buried
Examples	Vicryl (polyglactin), Monocryl (poliglecaprone 25), PDS (polydioxanone), plain/chromic catgut	Nylon, Prolene (polypropylene), Ethibond (polyester), silk

Reasoning for layer-specific choices:

Deep sutures must be absorbable: non-absorbable sutures buried in vascularized tissue cause chronic foreign body reaction, fibroblast proliferation, and sinus formation
Scar has only 5-10% of original tensile strength at 2 weeks, so sutures must outlast this critical period
Slowly absorbable monofilament (PDS, Maxon) retains >50% strength at 6 weeks - ideal for fascia closure
Fast absorbable sutures (Vicryl Rapide) should NOT be used for fascial closure - risk of dehiscence before healing is adequate

Monofilament vs. Multifilament (Braided)

Property	Monofilament	Multifilament (Braided)
Friction/tissue drag	Low (slides easily)	Higher
Memory (recoil tendency)	High	Low
Knot security	Lower (needs more throws)	Higher (fewer throws)
Tissue reactivity	Low	Higher (capillary wicking)
Infection risk	Low	Higher (harbors bacteria in interstices)
Examples	Nylon, Prolene, Monocryl, PDS	Vicryl, Ethibond, Silk

Key rule: Monofilament needs 4 firm square throws for knot security; braided needs 3 (Pfenninger & Fowler).

Suture Size (USP Scale)

Inversely proportional to diameter: 2-0 is thicker than 4-0
Tensile strength is directly related to diameter
Face: 5-0 or 6-0 (minimal scar marks, precision)
Scalp: 3-0 or 4-0 (high vascularity, under tension)
Trunk: 3-0 or 4-0
Extremities: 3-0 to 5-0
Deep dermal: 3-0 or 4-0 Vicryl/Monocryl
Fascia: 0 or 1-0 PDS or Maxon

PART 6: NEEDLE SELECTION

Needle Anatomy

Every surgical needle has three parts:

Swage (where suture attaches): weakest point - never clamp here
Body: held by needle holder
Point: cutting or tapered

Needle Types

Type	Cross-section at tip	Use	Reasoning
Reverse cutting	Triangle with edge on OUTSIDE of curve	Skin, fascia, tough tissue	Outer edge cuts away from wound edge - less likely to tear tissue toward wound
Conventional cutting	Triangle with edge on INSIDE of curve	Skin (especially face)	More precise placement; cutting edge faces the wound edge
Taper point	Round, no cutting edges	Intestine, vessel, peritoneum	Separates rather than cuts tissue fibers - less trauma to fragile structures
Blunt	Round, blunt tip	Liver, kidney, friable tissue	Dissects without cutting

Needle Curvature

3/8 circle: most common; used for most skin sutures
1/2 circle: deeper wounds with limited access
The curvature determines the arc of wrist movement needed - the needle holder wrist motion must follow the needle's curve exactly

PART 7: PRE-SUTURING PREPARATION

Step 1 - Patient Positioning

Place the patient and wound at elbow height
Clinician should be seated or standing comfortably at one end of the long axis of the wound
Adequate lighting is non-negotiable

Step 2 - Wound Assessment

Before touching the wound, assess:

Depth (does it enter a body cavity?)
Contamination (when? how? what?)
Structures at risk (nerves, vessels, tendons, ducts)
Tissue viability at edges
Tension when edges are approximated

Step 3 - Anesthesia

Local infiltration (1% or 2% lidocaine ± epinephrine)
Epinephrine reduces bleeding and prolongs anesthesia; historically avoided in digits/nose/ear/penis but current evidence supports its cautious use in digits with normal vascular exam
Allow at least 5-10 minutes for epinephrine effect
Warning: Epinephrine provides temporary vasoconstriction - increased bleeding may occur once it is metabolized post-procedure

Step 4 - Irrigation and Debridement

Copious irrigation with normal saline under pressure (minimum 200-500 mL for traumatic wounds)
Remove all foreign material and devitalized tissue
This is the most important infection-prevention step

Step 5 - Skin Preparation

Povidone-iodine or chlorhexidine to surrounding skin
Sterile draping
For facial wounds: leave landmarks visible; use a clear drape or leave undroped with wide cleansing
Hair management: tuck into draping or scrub hat

Step 6 - Assess Tension

Approximate wound edges manually before suturing
If wound edges don't come together easily: undermining is required
Decide on layered vs. single-layer closure

PART 8: FUNDAMENTAL TECHNIQUE - BEFORE ANY STITCH

Undermining

When: Any wound under significant static tension where edges don't approximate without force.

Technique:

Use a #15 scalpel blade held parallel to the skin surface, OR spread scissors in the correct tissue plane
Undermine at a distance from each wound edge approximately equal to the width of the wound gap
The correct plane is at the junction of dermis and subcutaneous fat (for skin undermining), or in the subcutaneous fat layer
This creates a flap that can be lifted and advanced toward the wound

Why it works: "The force required to reapproximate the edges of a wound correlates with the subsequent width of the scar" (Roberts & Hedges). Undermining reduces tension by recruiting adjacent mobile tissue.

Hazard: Can damage cutaneous nerves and reduce blood supply to the flap. Reserve for non-contaminated wounds.

Wound Edge Eversion - The Golden Principle

"An ideal wound closure consists of meticulous wound edge approximation and eversion. As wound contraction normally occurs during healing, wound edge eversion at the time of closure promotes the development of a flat, smooth, cosmetically-appropriate scar." (Fitzpatrick's)

A slightly everted wound edge, when it contracts during remodeling, flattens to a level surface
An inverted edge contracts to a depressed, pitted scar
Eversion is achieved by angling the needle away from the wound edge on entry (so the bite is wider deep than at the surface - the "bottle-shaped" stitch)

PART 9: STEP-BY-STEP SUTURING TECHNIQUES

TECHNIQUE 1: Simple Interrupted Suture

Indication: Standard workhorse; any wound requiring precise edge alignment; high-tension areas; areas where partial suture removal may be needed.

Step-by-step:

Load the needle: Clamp the needle holder at the proximal 1/3 of the needle body. Verify the needle is perpendicular to the needle holder jaws.
Enter the skin: Place the needle 2-3 mm from the wound edge, perpendicular to the skin surface. Reasoning: Entry at 90° combined with wrist rotation drives the needle in an arc, carrying more subcutaneous tissue than surface tissue - this creates eversion.
Drive through with wrist rotation: As the needle enters, pronate then supinate the wrist following the needle's own curve. Do NOT push the needle straight - let the curve do the work.
Cross the wound base: The needle tip exits in the wound base or on the contralateral wound edge. The stitch must be wider at the base than at the surface (bottle-shaped or flask-shaped).
Exit the contralateral side: Exit the skin the same 2-3 mm from the wound edge as entry. Exit at the same depth as entry to ensure level wound edges.
Pull suture through: Leave a 2-3 cm tail on the entry side.
Tie the knot (Instrument Tie - preferred):
- Hold the long strand (needle end) 8 cm from exit point
- Wrap the long strand clockwise once around the closed needle holder tip (single twist = square knot first throw)
- Grasp the short tail with the needle holder tip
- Pull short end toward you, long end away from you - this brings the first throw square to the skin
- Tension: edges should just touch, not bunch
- Reverse direction for the second throw (counterclockwise wrap) - locks the knot
- Add 2-3 more square throws for security (total 4 for monofilament, 3 for braided)
Cut the tails: Leave 3-4 mm tails for knot security.
Spacing: Place subsequent sutures to close gaps without overcrowding. Too few sutures = gaping between stitches. Too many = increased foreign material, tissue ischemia between puncture sites, higher infection risk.

Common mistake - tied too tight: Suture marks form even after 24 hours if sutures are too tight. "If sutures are tied too tightly, blood supply to the wound may be compromised, increasing the chance of infection" (Roberts & Hedges). The sign is blanched (pale) skin between the loop and the wound edge.

TECHNIQUE 2: Buried Dermal Suture (Deep Interrupted)

Indication: Any wound requiring layered closure; obliterates dead space; removes tension from epidermal sutures; improves eversion. This is the most structurally important suture in wound closure.

Step-by-step (inverted/buried technique):

Enter the needle at the base of the wound on one side, driving from deep to superficial
Exit at the dermal-epidermal junction on the same side
Re-enter the needle on the contralateral side at the dermal-epidermal junction, driving from superficial to deep
Exit at the base of the wound, level with the first entry point
Pull both ends upward - the suture forms a heart-shaped or "U" configuration in the dermis
Tie the knot at the base of the wound, so the knot is buried deep - this prevents knot protrusion through the healing epidermis and reduces reaction
The knot must be buried because if left superficial it will eventually extrude

Key principle: "Eversion of the wound edges is best achieved by placing sutures in the deep dermis and subcutis in a heart-shaped configuration, where the initial entry point and the final exit point are deepest relative to the skin surface" (Fitzpatrick's).

TECHNIQUE 3: Horizontal Mattress Suture

Indication: High-tension wounds; hemostasis; eversion in areas where simple interrupted fails to evert; volar hand/finger skin (where swelling is anticipated); bridging sutures while deep sutures are placed.

Step-by-step:

Enter the skin 4-6 mm from wound edge, cross the wound, exit the same 4-6 mm from the opposite edge (as in a simple interrupted stitch)
Do NOT tie yet
Move 4-6 mm along the wound edge (parallel), re-enter the skin on the same side you exited, cross back through the wound, and exit on the original side
You now have two parallel bites crossing the wound
Tie the knot on the original entry side

Why it works: The wide bite span distributes tension over a large area of skin; no punctures close to the wound edge preserve circulation to the edges.

Advantage for swollen tissues: "Horizontal mattress sutures are useful on the volar surfaces of hands and fingers, because these delicate skin areas may swell but the skin edges are not easily cut due to the placement of the skin punctures far from the wound" (Tintinalli's).

Hazard: Requires skill to achieve eversion without strangulation; bolsters (foam strips) can be placed under the suture loops to prevent skin necrosis.

TECHNIQUE 4: Vertical Mattress Suture

Indication: Maximum eversion; wounds where simple interrupted inverts; redundant skin; areas of minimal subcutaneous fat where buried sutures are difficult.

Step-by-step:

Place a wide (far-far) bite: enter 6-8 mm from wound edge, pass deeply through the wound base, exit 6-8 mm from the opposite edge
Reverse direction: re-enter the skin 1-2 mm from the wound edge on the same side you just exited, make a SHALLOW bite just under the dermis, exit 1-2 mm from the wound edge on the original side
Tie the knot on the original side
The resulting stitch has both a deep (far-far) component and a superficial (near-near) component

Why it works: The near-near component pulls the superficial dermis and epidermis upward, ensuring eversion even in thin or redundant skin where simple stitches would invert.

TECHNIQUE 5: Simple Continuous Running Suture

Indication: Long wounds under moderate tension; faster than interrupted for lengthy closures; fascial closure.

Step-by-step:

Place and tie an anchoring simple interrupted suture at one end of the wound, but cut only the short tail - the long strand continues as the running suture
Advance along the wound at 45° to the wound edge with each pass, crossing the wound at equal intervals (typically every 3-5 mm)
Re-enter on the opposite side each time at the same distance from the wound edge
Maintain even tension throughout - pull consistently with each pass
At the far end, leave the last loop without tightening - this loop serves as the "free tail"
Tie the working end (with needle) to this loop using an instrument tie

Key principle - suture length to wound length (SL:WL) ratio: Fischer's Mastery of Surgery states this has a critical cut-off to prevent wound dehiscence. A "small bite technique" with bites of 5 mm at 5 mm intervals and an SL:WL ratio of 4:1 is recommended for fascial closure. The original SL:WL of 4:1 is achieved with small bites at close intervals rather than large bites spaced far apart.

Disadvantage: If the suture breaks anywhere, the entire suture line loses tension. Therefore not ideal for high-tension or compromised wound closures.

TECHNIQUE 6: Continuous Locked Running Suture

Indication: High-tension wounds; fascial closure; where the suture line must not loosen.

Same as continuous running, PLUS: After each needle pass and before the next entry, pass the needle through the loop of the previous throw. This "locks" each throw, preventing the entire suture from loosening if one segment is cut or disrupted.

Disadvantage: Slightly slower; can impair circulation if locked too tightly.

TECHNIQUE 7: Subcuticular (Intradermal) Running Suture

Indication: Cosmetically critical wounds (face, elective surgery); areas where suture mark removal timing is important; best cosmetic outcome with no visible puncture marks.

Step-by-step:

Place a buried anchoring stitch at one apex of the wound
Enter the needle horizontally into the dermis just inside the wound edge, parallel to the skin surface - do NOT break through the epidermis
Exit the needle within the dermis, then re-enter on the opposite side at the same depth, taking a small horizontal dermal bite
Advance along the wound alternating sides, with each bite offset slightly so entry and exit points are not directly opposed
At the far end, exit the skin 1-2 cm from the wound end; secure by tying to itself or taping the tails to the skin with steri-strips
For long wounds, create "relief loops" every 4-5 cm by looping the suture out through the skin and back - these facilitate removal

Removal: Pull the suture in the direction of the long axis of the wound; for long sutures, cut at reliefs and remove in segments.

Key: "Place each successive bite 1-2 mm behind the exit point on the opposite side so that when the wound is closed, the entrance and exit points on either side are not directly apposed" (Roberts & Hedges). This prevents puckering.

TECHNIQUE 8: Half-Buried (Corner) Suture

Indication: Wound corners and flap tips; any triangular or V-shaped flap tip that needs to be secured without compromising its blood supply.

Step-by-step:

Enter the skin on the non-flap side of the wound, 2-3 mm from the edge
Pass into the dermis of the flap tip - do not puncture the epidermis of the flap tip
Pass through the base of the flap tip in the dermal plane
Exit back through the non-flap side of the wound, matching the entry level
Tie the knot on the non-flap side

Why: The flap tip has compromised vascularity. Puncturing it with a suture needle can destroy the limited blood supply entering through the dermis. The half-buried technique holds the tip in position without interrupting dermal perfusion.

PART 10: KNOT TYING - THE INSTRUMENT TIE

The instrument tie is preferred for all office/skin procedures because it is economical, precise, and reduces needle-stick risk compared to hand ties.

Square Knot (Standard)

First throw: Wrap the long strand (needle end) clockwise once around needle holder tip
Grasp short tail with needle holder, pull short end toward you / long end away from you - lay the throw down to the tissue level, with just enough tension to approximate edges
Second throw: Wrap the long strand counterclockwise once around needle holder tip - this reverses direction and locks the square
Pull down, tighten without disturbing the first throw
Additional throws: 2 more for monofilament (total 4), 1 more for braided (total 3)
Leave 3-4 mm tails

Surgeon's Knot

First throw: double wrap around needle holder (clockwise twice)
Second throw: single wrap counterclockwise
More secure initially because the double loop generates greater friction before the second throw locks it
Useful when you need the first throw to hold while dealing with tissue tension

Common Knot Errors

Error	Consequence
Granny knot (both throws same direction)	Slips and unravels
Half hitches only	No security
Tied too tight	Ischemia, suture marks
Tied too loose	Gap; heals by secondary intention, wider scar
Too few throws (monofilament)	Knot slips at tension
Tails too short	Knot unravels

"Sutures must bring wound edges into apposition but not place excessive force on tissues - 'approximate but don't strangulate'" (Pfenninger & Fowler).

PART 11: LAYERED CLOSURE - The Logical Approach

Most wounds requiring formal repair need more than one layer. The layered approach is systematic:

Layer	Suture Choice	Reasoning
Deep fascia/muscle	0 or 1-0 slowly absorbable monofilament (PDS)	Fascia takes >1 year to fully heal; needs prolonged support
Subcutaneous fat	3-0 or 4-0 Vicryl or Monocryl	Obliterates dead space; reduces tension transferred to skin
Deep dermis	3-0 or 4-0 Vicryl or Monocryl (buried, inverted)	Carries the tension; provides eversion; critical layer
Epidermis	4-0 to 6-0 nylon or Prolene	Precision alignment; removed before scar marks form

"Any 'dead space' within a wound may accumulate fluid or blood, creating conditions for infection and delayed healing" (Roberts & Hedges). Every layer of dead space must be obliterated.

PART 12: SUTURE REMOVAL TIMING

Location	Timing	Reasoning
Face / Eyelids	5-7 days	Rich blood supply, low tension; minimize track marks
Neck	7 days
Scalp	7-14 days	Moderate tension
Trunk	10-14 days	Higher tension
Extremities	10-14 days	Dynamic tension with movement
Lower legs	Up to 21 days	Poorest vascularity; highest dehiscence risk
Over joints	14+ days	Dynamic stress; premature removal risks dehiscence

Technique for removal: Always pull the suture toward the wound line (not away from it) to avoid disrupting the healing scar. After removal, support with steri-strips for several additional days in high-tension areas.

PART 13: POSTOPERATIVE CARE

Pressure dressing: Apply immediately; leave intact 24-48 hours to minimize hematoma formation
Wound care: Clean with mild soap and water once to twice daily; reapply petrolatum jelly (preferred over antibiotic ointments due to allergy risk) and a non-adherent dressing
Activity restriction: Verbal and written instructions for wound protection
Infection signs to watch for:

Streptococcus: Expanding erythema within 24-48 hours
Staphylococcus: Erythema + purulent drainage at 2-5 days

PART 14: COMPLICATIONS AND PREVENTION

Complication	Cause	Prevention
Wound infection	Contamination, technique failure	Thorough irrigation, aseptic technique, debridement
Hematoma	Incomplete hemostasis	Meticulous hemostasis before closure, pressure dressing
Dehiscence	Excessive tension, premature removal, infection	Layered closure, correct suture selection, timing
Suture track marks (railroad tracks)	Sutures too tight, left too long, re-epithelialization around stitch	Proper tension, timely removal
Hypertrophic scar / keloid	Tension, genetic predisposition	Minimize tension, avoid keloid-prone sites if possible
Contact dermatitis	Antibiotic ointments (neomycin, bacitracin)	Use petrolatum instead
Suture sinus/extrusion	Buried non-absorbable suture; superficial knot burial	Use absorbable sutures deep; bury knots below dermal-epidermal junction

PART 15: ADVANCED CONSIDERATIONS

The Small Bite Technique for Abdominal Fascia

From Fischer's Mastery of Surgery (8th Ed.): Meta-analyses show the suture length to wound length (SL:WL) ratio has a critical cut-off for preventing wound dehiscence and incisional hernia. The 4:1 SL:WL ratio is achieved with bites of 5 mm at 5 mm intervals with a slowly absorbable monofilament (PDS, Maxon). Large bites at wide intervals use less suture length per wound length, falling below this ratio.

Barbed Suture Technology

Sutures with barbs cut into the material allow self-anchoring without knots. This eliminates the weakest point (the knot) from the suture line. Drawbacks include reduced tensile strength from the barb cuts and limited data on hernia rates for fascial closure.

Delayed Primary Closure

Indication: Contaminated wounds that cannot be safely closed primarily. The wound is left open, packed with saline-soaked gauze, and closed at 3-5 days after contamination is controlled. Infection rates are lower than primary closure of contaminated wounds. Skin grafting may ultimately be needed.

Bridging Sutures

Horizontal mattress sutures placed temporarily while deep sutures are being placed. They temporarily approximate wound edges under high tension, making placement of buried sutures technically easier. Once deep sutures are placed, bridging sutures may be removed or left for a few days.

Quick Reference: Suture Type by Clinical Scenario

Scenario	Technique	Material
Simple face laceration	Subcuticular or simple interrupted	5-0 nylon or Prolene
Scalp laceration	Simple interrupted	3-0 nylon + 3-0 Vicryl deep
Hand/finger volar surface	Horizontal mattress	4-0 nylon
Wound with significant tension	Buried dermal + simple interrupted epidermal	3-0 Vicryl deep + 4-0 nylon
Long abdominal incision fascia	Continuous small-bite	PDS 1-0 or 0
Flap/triangular corner	Half-buried mattress	5-0 nylon
Maximum eversion needed	Vertical mattress	4-0 nylon
Elective surgical excision	Layered: buried + subcuticular	4-0 Vicryl + 4-0 Monocryl

References:

Fitzpatrick's Dermatology, 9th Ed., Chapters on Cutaneous Surgery - suture materials, techniques, and complications
Roberts & Hedges' Clinical Procedures in Emergency Medicine, 7th Ed. - Chapter 35: Wound Closure Techniques
Tintinalli's Emergency Medicine, 9th Ed. - Chapter 41: Wound Management
Pfenninger & Fowler's Procedures for Primary Care, 3rd Ed. - Chapter 25: Knot Tying and Suturing Techniques
Fischer's Mastery of Surgery, 8th Ed. - Chapter on Abdominal Wall Closure
Bailey & Love's Short Practice of Surgery, 28th Ed. - Wound Closure
Pye's Surgical Handicraft, 22nd Ed. - Wound Closure

Generate a PDF reference card for quick bedside suture selection and timing

Reading File

Running Command

ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace not found"

Running Command

mkdir -p /home/daytona/workspace/suture-refcard && python3 -c "import reportlab; print('reportlab ok')" && python3 -c "from reportlab.lib.pagesizes import A4; print('A4 ok')"

Writing File

~/suture-refcard/build_card.py

#!/usr/bin/env python3
"""
Suture Quick-Reference Card — PDF generator
Two A4 pages, landscape, colour-coded, bedside-ready
"""

from reportlab.lib.pagesizes import A4, landscape
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.platypus import (
    SimpleDocTemplate, Table, TableStyle, Paragraph,
    Spacer, HRFlowable, KeepTogether
)
from reportlab.platypus import PageBreak

# ── Colour palette ──────────────────────────────────────────────────────────
NAVY    = colors.HexColor("#0D3B66")
TEAL    = colors.HexColor("#0A7E8C")
AMBER   = colors.HexColor("#E07B00")
RED     = colors.HexColor("#C0392B")
GREEN   = colors.HexColor("#1A7A4A")
LGRAY   = colors.HexColor("#F4F6F8")
MGRAY   = colors.HexColor("#BDC3C7")
WHITE   = colors.white
BLACK   = colors.black
LBLUE   = colors.HexColor("#D6EAF8")
LGREEN  = colors.HexColor("#D5F5E3")
LORANGE = colors.HexColor("#FEF9E7")
LRED    = colors.HexColor("#FADBD8")

W, H = landscape(A4)      # 297 x 210 mm  →  841 x 595 pt
MARGIN = 10 * mm

# ── Style helpers ────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def sty(name, parent="Normal", **kw):
    return ParagraphStyle(name, parent=base[parent], **kw)

HDR1  = sty("hdr1", fontSize=14, textColor=WHITE,
            fontName="Helvetica-Bold", alignment=TA_CENTER, leading=16)
HDR2  = sty("hdr2", fontSize=9,  textColor=WHITE,
            fontName="Helvetica-Bold", alignment=TA_CENTER, leading=11)
CELL  = sty("cell", fontSize=7.5, fontName="Helvetica", leading=9,
            alignment=TA_LEFT, textColor=BLACK)
CELLB = sty("cellb", fontSize=7.5, fontName="Helvetica-Bold", leading=9,
            alignment=TA_LEFT, textColor=NAVY)
CELLIC= sty("cellic", fontSize=7, fontName="Helvetica-Oblique", leading=9,
            alignment=TA_LEFT, textColor=colors.HexColor("#555555"))
WARN  = sty("warn", fontSize=7.5, fontName="Helvetica-Bold", leading=9,
            alignment=TA_LEFT, textColor=RED)
FOOT  = sty("foot", fontSize=6, fontName="Helvetica-Oblique",
            alignment=TA_CENTER, textColor=colors.HexColor("#777777"), leading=8)
SECTITLE = sty("sectitle", fontSize=8.5, fontName="Helvetica-Bold",
               textColor=NAVY, leading=10)

def P(txt, style=CELL): return Paragraph(txt, style)
def PB(txt): return P(txt, CELLB)
def PI(txt): return P(txt, CELLIC)
def PW(txt): return P(txt, WARN)

# ══════════════════════════════════════════════════════════════════════════════
# PAGE 1  –  SELECTION, MATERIAL, NEEDLE, KNOTS
# ══════════════════════════════════════════════════════════════════════════════

# ── Section 1: Technique by clinical scenario ────────────────────────────────
SCEN_DATA = [
    [PB("Clinical Scenario"), PB("Technique"), PB("Material (Deep)"), PB("Material (Skin)"), PB("Size (Skin)")],
    [P("Simple face laceration"),    P("Subcuticular or\nSimple interrupted"), P("Buried dermal\n(Monocryl/Vicryl)"), P("Nylon / Prolene"),       P("5-0 or 6-0")],
    [P("Scalp laceration"),          P("Simple interrupted\n(layered)"),         P("Vicryl"),                          P("Nylon"),                  P("3-0 / 4-0")],
    [P("Trunk / back"),              P("Layered closure"),                        P("Vicryl 3-0"),                      P("Nylon / Prolene"),         P("3-0 / 4-0")],
    [P("Extremity laceration"),      P("Simple interrupted"),                     P("Vicryl 3-0"),                      P("Nylon"),                   P("3-0 / 4-0")],
    [P("Volar hand / fingers\n(swelling expected)"), P("Horizontal mattress"), P("—"),                               P("Nylon"),                  P("4-0")],
    [P("High-tension wound"),        P("Buried dermal +\nSimple interrupted"),   P("Vicryl / Monocryl 3-0"),           P("Nylon / Prolene"),         P("3-0 / 4-0")],
    [P("Flap / triangular corner"),  P("Half-buried (corner)\nsuture"),          P("—"),                               P("Nylon"),                  P("5-0")],
    [P("Maximum eversion needed"),   P("Vertical mattress"),                      P("—"),                               P("Nylon"),                  P("4-0")],
    [P("Elective excision (cosmetic)"), P("Layered: buried +\nSubcuticular"),   P("Vicryl 4-0"),                      P("Monocryl (subcuticular)"), P("4-0")],
    [P("Long abdominal fascia"),     P("Continuous small-bite\n(SL:WL = 4:1)"), P("PDS / Maxon 0 or 1-0"),            P("Nylon (skin)"),            P("3-0")],
]

scen_col = [55*mm, 45*mm, 48*mm, 42*mm, 22*mm]
SCEN_TABLE = Table(SCEN_DATA, colWidths=scen_col, repeatRows=1)
SCEN_TABLE.setStyle(TableStyle([
    # Header row
    ("BACKGROUND",   (0,0), (-1,0), NAVY),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7.5),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    # Zebra
    *[("BACKGROUND", (0,i), (-1,i), LGRAY if i % 2 == 0 else WHITE)
      for i in range(1, len(SCEN_DATA))],
    ("BACKGROUND",   (0,1), (-1,1), LGRAY),
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 3),
    ("BOTTOMPADDING",(0,0), (-1,-1), 3),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
]))

# ── Section 2: Suture material properties ───────────────────────────────────
MAT_DATA = [
    [PB("Suture"), PB("Type"), PB("Absorbable"), PB("Strength\nHalf-life"), PB("Knot\nSecurity"), PB("Tissue\nReaction"), PB("Best Use")],
    [P("Vicryl\n(polyglactin)"),        P("Braided"),      P("Yes"), P("~3-4 wk"),   P("Good"),      P("Low"),  P("Dermis, subcut")],
    [P("Monocryl\n(poliglecaprone 25)"),P("Mono"),         P("Yes"), P("~1-2 wk"),   P("Fair"),      P("Very low"), P("Subcuticular")],
    [P("PDS\n(polydioxanone)"),         P("Mono"),         P("Yes"), P("~6 wk"),     P("Fair"),      P("Low"),  P("Fascia, tendon")],
    [P("Maxon\n(polyglyconate)"),       P("Mono"),         P("Yes"), P("~6 wk"),     P("Fair"),      P("Low"),  P("Fascia")],
    [P("Plain catgut"),                 P("Twisted"),      P("Yes"), P("~3-5 days"), P("Poor"),      P("High"), P("Mucosa only")],
    [P("Chromic catgut"),               P("Twisted"),      P("Yes"), P("~10-14 days"),P("Poor"),     P("High"), P("Avoid if possible")],
    [P("Nylon\n(ethilon)"),             P("Mono"),         P("No"), P("Permanent*"), P("Poor\n(4 throws)"), P("Low"),  P("Skin (all sites)")],
    [P("Prolene\n(polypropylene)"),     P("Mono"),         P("No"), P("Permanent"),  P("Very poor\n(4+ throws)"), P("Lowest"), P("Skin, vessels")],
    [P("Ethibond\n(polyester)"),        P("Braided"),      P("No"), P("Permanent"),  P("Very good"), P("Low"),  P("Tendons, fascia")],
    [P("Silk"),                         P("Braided"),      P("No"), P("Degrades\n~1 yr"), P("Excellent"), P("High"), P("Ties, mucosa\n(avoid buried)")],
]

mat_col = [34*mm, 20*mm, 22*mm, 22*mm, 24*mm, 22*mm, 34*mm]
MAT_TABLE = Table(MAT_DATA, colWidths=mat_col, repeatRows=1)
MAT_TABLE.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0), TEAL),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    *[("BACKGROUND", (0,i), (-1,i), LGRAY if i % 2 == 0 else WHITE)
      for i in range(1, len(MAT_DATA))],
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 2.5),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("FONTSIZE",     (0,1), (-1,-1), 7),
]))

# ── Section 3: Size guide ────────────────────────────────────────────────────
SIZE_DATA = [
    [PB("Location"), PB("Deep"), PB("Skin")],
    [P("Eyelid"),      P("6-0 Vicryl"),    P("6-0 nylon")],
    [P("Face"),        P("4-0 Vicryl"),    P("5-0 / 6-0 nylon")],
    [P("Ear / Nose"),  P("4-0 Vicryl"),    P("5-0 nylon")],
    [P("Neck"),        P("4-0 Vicryl"),    P("4-0 / 5-0 nylon")],
    [P("Scalp"),       P("3-0 Vicryl"),    P("3-0 / 4-0 nylon")],
    [P("Trunk"),       P("3-0 Vicryl"),    P("3-0 / 4-0 nylon")],
    [P("Extremity"),   P("3-0 Vicryl"),    P("3-0 / 4-0 nylon")],
    [P("Hand (palm)"), P("4-0 Vicryl"),    P("4-0 nylon")],
    [P("Foot / sole"), P("3-0 Vicryl"),    P("3-0 nylon")],
    [P("Fascia"),      P("0 / 1-0 PDS"),   P("3-0 nylon")],
]

size_col = [32*mm, 32*mm, 34*mm]
SIZE_TABLE = Table(SIZE_DATA, colWidths=size_col, repeatRows=1)
SIZE_TABLE.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0), AMBER),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7.5),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    *[("BACKGROUND", (0,i), (-1,i), LGRAY if i % 2 == 0 else WHITE)
      for i in range(1, len(SIZE_DATA))],
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 2.5),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("FONTSIZE",     (0,1), (-1,-1), 7),
]))

# ── Section 4: Knot throws ───────────────────────────────────────────────────
KNOT_DATA = [
    [PB("Material"),         PB("Min. Throws"), PB("Tail length")],
    [P("Monofilament"),      P("4 square"),     P("3-4 mm")],
    [P("Braided / Vicryl"),  P("3 square"),     P("3-4 mm")],
    [P("Nylon"),             P("3 square"),     P("3-4 mm")],
    [P("Prolene"),           P("5-6 square"),   P("4-5 mm")],
    [P("Cut on knot\n(no tails)"), P("+1 extra throw"), P("—")],
]

knot_col = [34*mm, 28*mm, 28*mm]
KNOT_TABLE = Table(KNOT_DATA, colWidths=knot_col, repeatRows=1)
KNOT_TABLE.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0), GREEN),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7.5),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    *[("BACKGROUND", (0,i), (-1,i), LGREEN if i % 2 == 0 else WHITE)
      for i in range(1, len(KNOT_DATA))],
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 2.5),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("FONTSIZE",     (0,1), (-1,-1), 7),
]))

# ══════════════════════════════════════════════════════════════════════════════
# PAGE 2  –  TIMING, INDICATIONS, CONTRAINDICATIONS, COMPLICATIONS
# ══════════════════════════════════════════════════════════════════════════════

# ── Section 5: Suture removal timing ────────────────────────────────────────
TIMING_DATA = [
    [PB("Anatomic Site"), PB("Removal Timing"), PB("Key Reasoning")],
    [P("Eyelids"),         P("5-7 days"),   P("Excellent vascularity; early removal avoids track marks")],
    [P("Face"),            P("5-7 days"),   P("Rich blood supply; cosmetic priority")],
    [P("Ear"),             P("5-7 days"),   P("Limited tissue; early eversion critical")],
    [P("Neck"),            P("7 days"),     P("Low tension; good healing")],
    [P("Scalp"),           P("7-14 days"),  P("Moderate tension; higher dehiscence risk")],
    [P("Trunk / back"),    P("10-14 days"), P("Higher static tension")],
    [P("Upper extremity"), P("10-14 days"), P("Dynamic tension with movement")],
    [P("Lower extremity"), P("10-14 days"), P("Poor vascularity compared to face")],
    [P("Lower leg"),       P("Up to 21 days"), P("Worst vascularity; highest dehiscence risk")],
    [P("Over joints"),     P("14+ days"),   P("Dynamic tension; premature removal risks dehiscence")],
    [P("Palms / soles"),   P("14-21 days"), P("High mechanical stress; thicker skin")],
]

timing_col = [40*mm, 30*mm, 95*mm]
TIMING_TABLE = Table(TIMING_DATA, colWidths=timing_col, repeatRows=1)
TIMING_TABLE.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0), NAVY),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7.5),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    *[("BACKGROUND", (0,i), (-1,i), LBLUE if i % 2 == 0 else WHITE)
      for i in range(1, len(TIMING_DATA))],
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 2.5),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("FONTSIZE",     (0,1), (-1,-1), 7),
]))

# ── Section 6: Indications ───────────────────────────────────────────────────
IND_DATA = [
    [PB("Indication"),                          PB("Reason")],
    [P("Clean wound < 6 hrs old"),              P("Bacterial load still manageable; safe primary closure")],
    [P("Wound under tension"),                  P("Prevents dehiscence and wide scar formation")],
    [P("Cosmetically sensitive area"),          P("Precise edge approximation reduces scarring")],
    [P("Deep wound with dead space"),           P("Dead space harbors seroma/hematoma and infection")],
    [P("Active bleeding from laceration"),      P("Sutures provide mechanical hemostasis")],
    [P("Wound over a joint"),                   P("Dynamic stress requires secure closure")],
    [P("Wound with visible deep structures"),   P("Must cover tendons/vessels to prevent desiccation")],
]

ind_col = [75*mm, 100*mm]
IND_TABLE = Table(IND_DATA, colWidths=ind_col, repeatRows=1)
IND_TABLE.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0), GREEN),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7.5),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    *[("BACKGROUND", (0,i), (-1,i), LGREEN if i % 2 == 0 else WHITE)
      for i in range(1, len(IND_DATA))],
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 2.5),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("FONTSIZE",     (0,1), (-1,-1), 7),
]))

# ── Section 7: Contraindications ────────────────────────────────────────────
CON_DATA = [
    [PB("Contraindication"),                    PB("Severity"), PB("Reason")],
    [P("Frank wound infection / abscess"),       PW("ABSOLUTE"), P("Traps bacteria; accelerates spread")],
    [P("Heavily contaminated wound\n(soil, feces, devitalized tissue)"), PW("ABSOLUTE"), P("Anaerobic environment created; debride first")],
    [P("Human / animal bite (most sites)"),     PW("ABSOLUTE"), P("High infection risk (Pasteurella, Eikenella)\nException: face bites may close primarily")],
    [P("Puncture wounds"),                      PW("ABSOLUTE"), P("Cannot irrigate adequately; anaerobes trapped")],
    [P("Wound > 12-24 hrs old (most sites)"),  PW("ABSOLUTE"), P("Bacterial colonization irreversible")],
    [P("Immunocompromised patient"),             P("Relative"), P("Consider delayed primary closure")],
    [P("Poorly controlled diabetes"),            P("Relative"), P("Impaired healing and neutrophil function")],
    [P("Keloid-prone patient"),                  P("Relative"), P("Minimize sutures; prefer tapes/adhesives")],
    [P("Anticoagulated patient"),                P("Relative"), P("Higher hematoma risk; ensure hemostasis first")],
]

con_col = [72*mm, 25*mm, 78*mm]
CON_TABLE = Table(CON_DATA, colWidths=con_col, repeatRows=1)
CON_TABLE.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0), RED),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7.5),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    *[("BACKGROUND", (0,i), (-1,i), LRED if i % 2 == 0 else WHITE)
      for i in range(1, len(CON_DATA))],
    ("TEXTCOLOR",    (1,1), (1,5), RED),
    ("FONTNAME",     (1,1), (1,5), "Helvetica-Bold"),
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 2.5),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("FONTSIZE",     (0,1), (-1,-1), 7),
]))

# ── Section 8: Complications ─────────────────────────────────────────────────
COMP_DATA = [
    [PB("Complication"),       PB("Timing"),         PB("Prevention")],
    [P("Wound infection"),     P("2-5 days"),         P("Irrigate, debride, aseptic technique")],
    [P("Hematoma"),            P("0-24 hrs"),         P("Hemostasis before closure, pressure dressing")],
    [P("Wound dehiscence"),    P("Days-weeks"),       P("Layered closure; correct suture selection")],
    [P("Suture track marks"),  P("> 7-10 days skin"), P("Remove on time; correct tension at tying")],
    [P("Keloid / hypertrophic"), P("Weeks-months"),   P("Minimize tension; silicone sheets post-removal")],
    [P("Suture sinus"),        P("Weeks-months"),     P("Use absorbable sutures deep; bury knots properly")],
    [P("Contact dermatitis"),  P("3-5 days"),         P("Use petrolatum, not antibiotic ointment")],
]

comp_col = [47*mm, 33*mm, 95*mm]
COMP_TABLE = Table(COMP_DATA, colWidths=comp_col, repeatRows=1)
COMP_TABLE.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0), colors.HexColor("#5D4037")),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 7.5),
    ("ALIGN",        (0,0), (-1,0), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    *[("BACKGROUND", (0,i), (-1,i), LORANGE if i % 2 == 0 else WHITE)
      for i in range(1, len(COMP_DATA))],
    ("GRID",         (0,0), (-1,-1), 0.3, MGRAY),
    ("TOPPADDING",   (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 2.5),
    ("LEFTPADDING",  (0,0), (-1,-1), 3),
    ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("FONTSIZE",     (0,1), (-1,-1), 7),
]))

# ══════════════════════════════════════════════════════════════════════════════
# LAYOUT HELPERS
# ══════════════════════════════════════════════════════════════════════════════

def section_header(text, color):
    """Coloured bar acting as a section header."""
    t = Table([[Paragraph(text, HDR2)]], colWidths=[W - 2*MARGIN])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), color),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 6),
    ]))
    return t

def page_title(text):
    t = Table([[Paragraph(text, HDR1)]], colWidths=[W - 2*MARGIN])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), NAVY),
        ("TOPPADDING",   (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ]))
    return t

def two_col(left, right, lw=None, rw=None):
    """Side-by-side layout for two sub-tables."""
    lw = lw or (W - 2*MARGIN) * 0.56
    rw = rw or (W - 2*MARGIN) * 0.42
    wrapper = Table([[left, right]], colWidths=[lw, rw])
    wrapper.setStyle(TableStyle([
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 0),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ]))
    return wrapper

def three_col(a, b, c, aw, bw, cw):
    wrapper = Table([[a, b, c]], colWidths=[aw, bw, cw])
    wrapper.setStyle(TableStyle([
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 2),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ]))
    return wrapper

GAP = Spacer(1, 2*mm)

# ══════════════════════════════════════════════════════════════════════════════
# BUILD DOCUMENT
# ══════════════════════════════════════════════════════════════════════════════

OUT = "/home/daytona/workspace/suture-refcard/Suture_Reference_Card.pdf"
doc = SimpleDocTemplate(
    OUT,
    pagesize=landscape(A4),
    leftMargin=MARGIN, rightMargin=MARGIN,
    topMargin=8*mm, bottomMargin=8*mm,
)

story = []

# ── PAGE 1 ────────────────────────────────────────────────────────────────────
story.append(page_title("SUTURE QUICK-REFERENCE CARD  |  Page 1 of 2  —  Selection, Materials & Knots"))
story.append(GAP)

# Row 1: Scenario table (full width)
story.append(section_header("TECHNIQUE SELECTION BY CLINICAL SCENARIO", NAVY))
story.append(SCEN_TABLE)
story.append(GAP)

# Row 2: Material table (full width)
story.append(section_header("SUTURE MATERIAL PROPERTIES", TEAL))
story.append(MAT_TABLE)
story.append(GAP)

# Row 3: Size guide + Knot security side by side
size_block  = [section_header("SUTURE SIZE BY LOCATION", AMBER), SIZE_TABLE]
knot_block  = [section_header("KNOT SECURITY — MIN. THROWS", GREEN), KNOT_TABLE]

# Wrap each sub-list into a single-cell table
def vstack(items):
    rows = [[x] for x in items]
    t = Table(rows)
    t.setStyle(TableStyle([
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 0),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 1),
    ]))
    return t

story.append(two_col(vstack(size_block), vstack(knot_block),
                     lw=99*mm, rw=97*mm))

# Footnote
story.append(Spacer(1, 2*mm))
story.append(Paragraph(
    "* Nylon loses ~20% tensile strength per year in vivo — NOT truly permanent.  "
    "SL:WL = Suture Length : Wound Length ratio.  "
    "Deep = buried absorbable layer.  Skin = external non-absorbable layer.  "
    "References: Fitzpatrick's Dermatology 9e · Roberts & Hedges 7e · Tintinalli 9e · Fischer's Mastery of Surgery 8e · Pfenninger & Fowler 3e",
    FOOT))

story.append(PageBreak())

# ── PAGE 2 ────────────────────────────────────────────────────────────────────
story.append(page_title("SUTURE QUICK-REFERENCE CARD  |  Page 2 of 2  —  Timing, Indications, Contraindications & Complications"))
story.append(GAP)

# Timing (full width)
story.append(section_header("SUTURE REMOVAL TIMING BY ANATOMIC SITE", NAVY))
story.append(TIMING_TABLE)
story.append(GAP)

# Indications + Contraindications side by side
ind_block = [section_header("INDICATIONS FOR PRIMARY SUTURE CLOSURE", GREEN), IND_TABLE]
con_block = [section_header("CONTRAINDICATIONS TO PRIMARY CLOSURE", RED),     CON_TABLE]
story.append(two_col(vstack(ind_block), vstack(con_block),
                     lw=180*mm, rw=97*mm))
story.append(GAP)

# Complications (full width)
story.append(section_header("COMMON COMPLICATIONS & PREVENTION", colors.HexColor("#5D4037")))
story.append(COMP_TABLE)

# Footnote
story.append(Spacer(1, 2*mm))
story.append(Paragraph(
    "The 6-hour rule (Pye's Surgical Handicraft 22e): clean wounds may be safely closed up to 6 hrs after injury; this is a guide, not an absolute.  "
    "Face bites: exception to bite closure rule due to superior facial vascularity.  "
    "Delayed primary closure: close contaminated wounds at 3-5 days after contamination control.  "
    "Pull suture toward wound on removal (not away) to avoid disrupting healing scar (Roberts & Hedges 7e).",
    FOOT))

doc.build(story)
print("PDF generated:", OUT)

Running Command

cd /home/daytona/workspace/suture-refcard && python3 build_card.py 2>&1

Running Command

ls -lh /home/daytona/workspace/suture-refcard/Suture_Reference_Card.pdf

Your reference card is ready. Here's what's inside:

Suture Reference Card

PDF Document · PDF

2-page A4 landscape, colour-coded by section:

Page 1 - Selection, Materials & Knots

Section	Colour
Technique by clinical scenario (11 scenarios)	Navy
Suture material properties (11 materials, absorbable & non-absorbable)	Teal
Suture size by anatomic location	Amber
Knot security - minimum throws by material	Green

Page 2 - Timing, Indications, Contraindications & Complications

Section	Colour
Suture removal timing by site (with reasoning)	Navy
Indications for primary closure	Green
Contraindications (absolute vs. relative, bold red flags)	Red
Complications + prevention	Brown/orange

Each page has a footnote line with key rules (6-hour rule, SL:WL ratio, face bite exception, suture removal direction) and full textbook references. Print double-sided landscape on a single A4 sheet for a laminate-ready pocket card.

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