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Basic suturing techniques

_ It is very important to learn how to do suturing before graduation, and it's a requirement in fifth year .._ We should know the common surgical instruments and there is second quiz from beginning of the next week .._ Basically we will talk about wound healing, the scar, and the next lectures we will talk about principles of wound healing .._ So the goal of the closure ( why you close the wound by suturing ) is to >> obtain the fine line scar that maintain both the form and appearance of the tissue, especially when we talk about facial legion in general .._ it is important to let your patient know that any time there is an incision, there is going to be a scar, of course we talk here about scar and incision, if its in facial area or we considered about esthetic purposes ..However, if we talk basically what is the purposes of suturing >> it is one of the method to achieve hemostasis, control and enhance bleeding process .._ So whenever you approximate the wound edges >> its means that you are enhancing the bleeding process .._ For the preparation you need to plan/design the incision and the type of the closure, whenever you plan the incision, we are taking about surgical incision, because you have two types of the scars or incisions :: one of them is surgical scars/incision ( you plan to do them before surgical in the operation, so you may have incision from trauma that already the patient came to your clinic having wound, so we are taking about plant or prepare incision ..In fifth year we will take about how to deal with wounds due to trauma or accidents, every type have different way to deal with.._ whenever you want to do an incision, all surgical instruments need to be ready and you should know how to use it and its function .._ what is the meaning of time out ?? that you need to link the instruments to the specific patient to the specific procedure .._ What is mayo tray ?? It is surgical tray where you place your instruments .._ Everything need to be prepared before you start your preparation, you prepare the tray and blade, everything need to be organized .._ scrub, glove and grip you should do this whenever you do an incision, in the oral cavity there is no complete sterilization, we should minimize the load of bacteria ( disinfection ) but if we talk about incision that will apply to the face, you should have sterilization .._ If you work in the skin, you should prepare the skin with pethidine to the outside, but if we have major preparation in the oral cavity we do scrubbing to the facial area and we do irrigation intra orally .._ we scrub the wound with iodine, the scrub should be in specific direction, in – out direction, the area that you clean you do not go back to it ( not bring the bacteria back to it ) as the concept of scrub to our hand from up – down ..

Instruments: 1 ) Adison forceps .. 2 ) scissors .. 3 ) suture strips ..

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Adison forceps:_ It is tooth forceps .._ The difference between tooth forceps and non-tooth forceps from the application is the tooth forceps used to grasp the tissue gently not to cause trauma to the tissue and not to leave scar in the skin, but we are in the oral cavity not really interested in the scar because the nature structure of the mucosa in the oral cavity differs about structure in the other area of the skin, so the scar is minimal and if happen it is not that esthetic problem .._ so you use the Adison forceps to grasp the flap firming .._ used for firmly grasping the tissues while the needle is passed, it helps u to have a good handling to the tissues , and reflects if u have a professional behavior ..

Hemostat and Needle holder:_ Which is similar to the needle holder ( its important to differentiate between them ), the needle holder is Criss Cross   Serrated Tips , you hold the needle and close it to start the suturing .._ you can use scissors or blade to cut the suture sharply, be carful because a lot of instruments we use get dull by the time so we should change them, so the Scissors very important to be sharp in order to cut after u have completed knotting , some students use the blade instead of scissor , this is wrong coz easily u can traumatize tissues which is very common ._ It is very important to know how to use needle holder in the right way ..

_ Most of the blade that we use in the oral cavity is type 15 and in the skin type 10 .._ suture removal scissors and bandage scissors that we are rarely to use them in the oral cavity, but we use them for example when there is bandage on the head or bandage that cover the facial area, you can gently use the bandage scissors to not cause damage to the facial area and it is more used in orthopedic uses around the arm and leg, but we are rarely to use it ..

_ the doctor told us that we are going to take two lectures about the general anesthesia and sedation ..

Basic Knot typing : _ you should do sketch, so you need to bind the knots .._ there is types :1 ) surgical knot ..2 ) non-surgical knot .. _ the doctor told us to see suture techniques on videos or YouTube that will help us .._ there is a lot of people who hold the cord after using needle holder and knot it with his fingers, which is correct but it is more professional.._ it is important to know how to do surgical knots ( which is the most important knot ) .. _ what is the difference between the surgical knot and others knot ?? The surgical knot is tight / محكمة, the first knot close the two edges to other and the second twist is invert/contrary the first that it will be firm .. Therefore, the surgical knot must not separated .._ So the first twist will be clock wise and the second twist will be anti-clockwise ..

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_ there is a role in the oral cavity that we hold the mobile tissue to other side and insert the needle and then insert to the other side, there should be short arm of the cord and long arm of the cord, then with needle holder we open the holder and hold the short arm of the cord then we make knot ( the first twist is clock wise and the second twist is clockwise, then another twist clockwise, and the final twist will be anti-clockwise to stabilize the previous knot ) .._ Anyone who want to learn the suturing techniques can go to the doctor and ask here, she will help him .._ before closure for any wound it should be clean, especially the wound after the trauma because its dirty .._ never suture any wound without asking about time ( when this wound happen ), although in the facial area there is a good and excellent blood supply ( so I do not be a frayed from necrosis ), but if a patient come in the second day of the accident >> here we have to stop .. so after 24 hours definitely necrosis happen .. The wound should be irrigated and debrided .. Used atraumatic techniques.. _ when there is wound you have to made alignment with the relax skin tension line with angle of the incision that is important in esthetic cases by consideration vascularity of the area, which is important .._ We are not supposed to do closure to wound in the facial area but may in any time patient with facial area came to the hospital, so you should know how to do suturing .._ we should close the dead space under the incision, especially in the neck surgery, for example if there is tumor in the neck so we clean the nodes and there is layers, these layers should suture layer by layer not to form dead space .. _ So, close in layers when there is a lot of layers involvement, not to have dead space .. _ It is very important the alignment of edges, especially the face, otherwise there will be bad scar .._ Careful choice for access of incision, its very important when you do incision in the face, it should be with the tension line.._ if there is wound in the forehead; it should be suture horizontally not vertically .._ So for deep/inner layer the cord should be resorb able, but in outer layer we use non-absorbable..

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_ sometimes the edges does not bind to each other ( the wound not close ), whenever you do suturing it must in the relaxed state with no tension ( because if there is tension the edges will be separated ), So we need to do under-mining which means goring tissues from the adjacent area as you open the tissues, we bring the hemostat and you enter it exactly under the layer that you want and you open the tissue such as they are giving !! _ and this is called in the oral cavity scouring , sometimes when I need to close the wound, there is no tissues, and I cannot close it under tension because it will open, so I enter the hemostat in the underling layer and open it or I bring the blade ( from the inner aspect from the side of the periosteum ) I do incomplete incision with light strikes to an extent ( but we cannot do this when there is big deficiency in the tissue, we do this when maximum I need to increase the extent 0.5 cm from each side, but when I need more tissue in that time I plane for graft and if it's not enough I plane for flaps, this we can do in major surgery ) .. _ you never close the wound when there is bleeding, because if there is bleeding and I do stretching, sketching and suturing, this will result in hematoma and wound separation, and formation of hematoma will result in infection, so first I will control the bleeding then I do suturing .. _ We go with the tension line to choose the suitable area for the suture .. _ ( From the internet ) The edges of the wound should pull together easily; if not, undermining needs to be done. Undermining means cutting the fibrous septea that connect the skin to the underlying fascia, and generally, this is accomplished by using the scalpel to cut the septea just beneath the dermis as shown here. Undermining has the advantage of freeing the wound edges and decreasing tension on the wound, which allows for faster wound healing and lessens the chance of scar spreading and keloid formation. The disadvantage of undermining is that it cuts blood vessels and nerves, and thereby slows wound healing and creates an area of anesthesia that generally is temporary. One rule of thumb is that one should undermine about the same radius as the maximum width of the wound .. 

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Needles:_ We should use the appropriate needle with appropriate gauge, as we talk there is inverse relationship between gauge and the diameter, if the number of the needle large the diameter will be small.._ In the oral cavity, we usually use 30 or 40 needles .. _ In the face, we use 60 or 50 needles or more, because it is esthetic area where the needle should be very thin .. _ In the abdominal or lower limb surgery, we use 10 or 20 needle.._ In the micro-vascular surgery, we use 90 or 100 needle that used under the microscope .._ the needle may be strait or curved needles ..

Curvature of the needle :

We have : ►3/8 circle►5/8 circle►½ circle►¼ circle►Straight we do not use itWe use : ½ circle and 3/8 circle_ In the oral cavity it's important to hold the needle, usually one third or one-half depending on the application area that will help me to get good bite/good handle.._ the cross section of the needle is very important >> it may be:1 ) round, blunt and atraumatic needle ..2 ) triangular, pointed and traumatic needle ..

_ conventional cutting use in the oral cavity .._ reverse cutting used for skin surface usually .. For skin its important where the taper is in upper area, in the surface, or in the bottom, ( this is not important )..

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_ in the suture the needle should enter the tissue perpendicular and out the tissue perpendicular .._ it's important to bind/connect the two edges as everted edges, there is other type which is edge-to-edge but everted edges is the best, because it gives the best outcome and better healing because we will close the two epithelium edges without any soft tissues, but if we cannot do everted we can do edge to edge .._ We should take good bite from both sites of tissues not at the periphery of the edges not to tear the tissue .._ You should know how much of the distance you have to leave between the knots, and the knot should not place at the area of incision .._ The tie should not be in the line of the incision, because at the end infection may occur ( sinus tract infection, in the area that the needle enter or going out ).._ inverting suture not used, because it will form scar .._ if there is soft tissue involvement it will compromise healing, such as when we do implant we put the titanium exactly on the bone and this will lead to excellent Osseo integration, if soft tissue enter between the implant and the bone, it will compromise the healing in very bad way ..

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The most suture technique we use is simple interrupted suture, and it is very important to know how to do it and it is the most common suture to be used for laceration, closure, biopsies and lesion removal..

Simple interrupted suture:_ most common suture to be used most common suture to be used .._ used to close the deep wound .._ give the best esthetic outcome and the most easy to do ..

continuous suture:_ can be used but it has problem that if one side of the cord split the whole suture will destroyed and the wound will open ..

Continuous locked suture:_ enter with the needle with both edges ( normal suture ) and before I do the next sketch, I enter with the needle from the beginning, so the suture will be firm and good tight ..

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♦Mattress sutures: the tie is located buccaly not over the incision line; the needle enters 4 times ( facial linguallingualbuccal ) then tie it tightly.

A- Horizontal mattress suture : _advantages: tightly locked, hard to open, it’s the best suture that give control to the edges and give firm and tight result .._ I enter and go out from the area then I suture (place the knot) at one side, so the edge is sealed, for example if sometimes oroantral communication happen when you extract upper 6 or upper 7 and you open the sinus, in this case you should close the wound tightly ( so here the mattress suture is indicated )..

B- Vertical mattress: on the same line of horizontal mattress, used in cleft palate cases ..

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Subcuticular suture:_ used when there is big distance the in abdomen or in the neck, such in total thyroidectomy surgery ( remove the thyroid ) they open the neck transversely from one side to the other side, if they suture it by simple interrupted suture this will be time consuming so they do Subcuticular suture .._ her there is one end and the other end, you enter with the needle under the skin whereas there is no knots and you take bite of tissue from one site and other bite from another site where you grasp the subcutaneous tissue then you get out from the other site ( bring the two edges together with no cord on the surface of the skin ) .. Then we cower it by adhesive, then after week or 10 days we remove the knots by hold the cord and take it out ..

داخلية بتكون الخياطة .. يعني

_ Elliptical incision if you have lesion and you need to remove it, you do around it ellipse, it is best incision that you suture it with no scaring ..

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_ Modified ellipse, which is not very important ..

The most important in this lecture is table that the doctor will ask us about it, the suture material with its types and classification ( absorbable or non-absorbable )..

وباالمتحانات ورابعة بخامسة مهم وإنه الجدول حفظ على وشددت ركزت الدكتورةالشفوية واألسئلة ^_^ .. النهائية

_ Plain gut, chromic gut and Vicryl (Polyglactin) are absorbable materials .._ plain gut >> tensile strength is poor, retention is four days (that mean how much its stay in the tissue until absorption occur so this time is very important), also the type of filaments is collagen .._ Chromic gut >> the retention is 10 days and the type of filaments is collagen .._ Vicryl (Polyglactin acid) >> the retention is 2 -3 weeks, so you can use it in layers incision, in deeper layer in skin, that’s why I used absorbable suture, but for the surface of the skin we use non-absorbable suture and synthetic .. _ It is important to know the type of filaments .. _ surgical silk and nylon are non-absorbable .. _Nylon >> is monofilament, when I do the tie, I should wrap it 4 or 5 times, because the monofilament is slippery and the knot may separated .._ Silk >> wrap it 3 times which is enough, two wraps clockwise and one wrap anti-clockwise, low price, most common suture material that we use but the problem is tensile strength is poor and tissue reaction is high so you take it in the closest time .. _ Polyester, prolene suture and stainless steel suture .._ Stainless steel suture is very good suture material, monofilament, non-absorbable and it has the best tensile strength (important information) .._ the cost of them is important, the prolene is high and polyester is high .._ Prolene and polyester is synthetic and used for face to reduce the scar ( حكت

باالمتحان سؤال تجيبها راح ..( P: الدكتورة_ the cost of the silk is low .. _ you should care about patient and the wound does not infected, so you need to give anti-biotics and its important to cover the wound by adhesive material in the skin to not get wet to get good result but in the oral cavity we do not have to cover the wound

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.._ The materials that we use to reduce the scar ( anyone interested read about it ) ..

The next information is from the last year sheet and the table is from the internet ..Types of suture materials :

• Absorbable Vs. Non-absorbable• Monofilament Vs. Multifilament• Natural or Synthetic

1ש st classification 1ש -absorbable: Digested by body enzymes (tissue enzymes) or hydrolyzed by

tissue fluids. Can be natural or synthetic.

non-absorbable : cannot be digested by tissue enzymes, they are encapsulated or - 2 שwalled off and can be natural, synthetic, or metallic.

♣ 2 nd classification: 1- ♣Monofilament: the same suture made of single strandAdvantages: A-it resists harboring microorganism's coz its one strand, and always multiple strands gives site to Bacteria to be harbored in.B- It ties smoothly, but at the same time it is untangled easily so it's more slippery (e.g. nylon) so it needs to be knotted more times (for example 5 knots) than multi filament (3 knots for example)

♣2-multi filament: consist of several filaments twisted or braded together into a single strandمجدوله has good handling and tying characteristics.Disadvantage: harbors bacteria.

◙ Different suturing materials:

1-Surgical gut: natural• Monofilament and absorbable • Collagen derived • Plain: (not colored) / Chromic: means it has a die ( colored) which is some

kind of preservative in order to last longer, here u have to be careful : if u are making a facial suture u don’t use chromic coz the die will give you poor esthetics on the face.

2- Vicryl (Polyglactin) : it’s a synthetic and absorbable3- polydixanone : Synthetic, absorbable4- Collagen: natural monofilament and absorbable.5- Lynin   : natural, multi filament, non absorbable6- Surgical Silk  : non absorbable.7- Surgical Cotton  : natural multi filament and non absorbable8- Surgical steel  : natural multifilament and non-absorbable9- Nylon: synthetic, mono/multi filaments but mostly we see monofilaments,

non-absorbable, highly esthetic suture, so nylon+ polypropylene groups are

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mostly used in plastic surgeries, because of their smoothness, which makes perfect tissue handling upon suturing.

10- Polypropylene : synthetic, monofilament, non-absorbable.

◙Using non absorbable sutures is preferable , but in some situations when the patient has bleeding tendency , epilepsy and patients with special needs who can't be back to the hospital; we use absorbable sutures to avoid bleeding upon removing the suture.