Running Cutaneous Suture

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
Email

Send Email

Recipient(s) will receive an email with a link to 'Running Cutaneous Suture' and will have access to the topic for 7 days.

Subject: Running Cutaneous Suture

(Optional message may have a maximum of 1000 characters.)

×


Introduction

The running (continuous) cutaneous suture provides a rapid and convenient means of wound closure. This technique is similar to simple interrupted sutures, except that the suture material is not cut and tied with each succeeding suture placement. The suture evenly distributes tension along the length of a wound, thereby preventing damage to the skin edges from excessive tightness of individual sutures. Because suture material is not consumed in creating repetitive knots and cutting ends, this technique can provide cost savings in limiting the use of suture material. This suture method is used primarily in wounds that are well approximated, not under much tension, have a low risk of infection, or require rapid closure. 
The running cutaneous suture may not provide much skin edge eversion and is generally avoided in cosmetically important areas such as the face. Another disadvantage of a running cutaneous suture is that if the suture thread breaks, the entire wound may dehisce. In addition, this suture may achieve less accurate edge approximation compared with interrupted sutures, final adjustments cannot be made once it is placed, and it can only be removed in its entirety from the skin. A continuous suture does not permit selective removal of sutures in response to healing. Interestingly, the strength of wound closure and the likelihood of dehiscence are equivalent with both interrupted and running sutures. Because the entire suture is removed at one time, slightly longer times before removal are recommended. 
The running locked suture is a variation of the simple running suture technique. Before beginning each new throw, the needle is looped under the previous external segment of suture crossing the wound. The locked loops counteract some tension on the skin edges, and so this technique may help prevent inversion even in wounds closed under tension. However, the pressure exerted by the external loops may cause focal necrosis. Because this method may produce inferior cosmetic outcomes, it is not commonly used. 

Equipment

  • The basic skin-suturing instruments used are listed in Appendix G.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation recommendations appear in Appendix E.

Indications

  • Emergency triage situations that do not allow time for interrupted closure

  • Closure of long wounds in less cosmetically important (nonfacial) areas

  • Shallow wounds with loose skin nearby, such as the scrotum or dorsum of the hand

  • To secure a split- or full-thickness skin graft

Contraindications (Relative)

  • Widely separated wound edges that are better approximated with tension-reducing sutures

  • Severe bleeding disorders

  • Extreme illness that would make wound healing difficult

  • Cellulitis in the tissues to be incised

  • Conditions that may interfere with wound healing (collagen vascular diseases, smoking, renal insufficiency, diabetes mellitus, nutritional status, obesity, chemotherapeutic agents, and corticosteroids)

  • Disorders of collagen synthesis that affect wound healing such as Ehlers-Danlos syndrome and Marfan syndrome

  • Concurrent medications that may increase the likelihood of intraoperative bleeding (aspirin, other nonsteroidal anti-inflammatory drugs, warfarin)

  • Uncooperative patient

  • Patients with a propensity to pick at wounds or sutures

The Procedure

Step 1

The closure begins with placement of a simple interrupted suture at one end of the wound. The free end is cut, but the long end (with the needle attached) is not cut. 

Step 2

Reverse the suture needle, move down the incision one suture length, and make another pass across the wound. 
  • PITFALL: Many providers immediately start making diagonal passes across the top of the incision at this point, but this allows the knot to migrate across the incision, loosening the sutures.

Step 3

Multiple passes are made straight across the wound, moving down the wound edge about 4 to 5 mm to initiate each pass, with the suture thread at a 60-degree angle to the wound. 

Step 4

The suture thread beneath the wound is perpendicular to the long axis of the wound. At the far end of the wound, the suture is tied by looping the suture over the needle driver and reaching back to grasp the final loop across the wound. 
  • Pearl: Make sure the sutures are evenly spaced and the tension is distributed along the suture line.

  • PITFALL: Do not tie the suture too tightly. The wound edges will bunch up if the final knot is too tight.

Complications

  • Bleeding

  • Infection

  • Scar formation

  • Crosshatch scarring, especially when the suture is pulled too tightly

  • Uneven wound edges

  • Puckering of the wound

  • Wound dehiscence if the suture thread breaks

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. Sometimes it is necessary to sedate the patient to repair the laceration (see Pediatric Sedation). The maximum recommended dose of lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Instruct the patient to gently wash an area that has been stitched after 1 day but not to put the wound into standing water for 2 to 3 days. Have the patient dry the area well after washing and use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. Have them cover the wound with a nonocclusive dressing for 2 to 3 days. A simple adhesive bandage (Band-Aid) will suffice for many small lacerations. The dressing should be left in place for at least 48 hours, after which time most wounds can be opened to air. Scalp wounds can be left open if small, but large head wounds can be wrapped circumferentially with rolled gauze. 
Most uncontaminated wounds do not need to be seen by a provider until suture removal, unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 2 to 3 days. Give discharge instructions to the patient regarding signs of wound infection. 

Coding Information and Supply Sources

All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives with or without adhesive strips on the skin surface. If a layered closure is required, use alternate codes: intermediate closure codes 12031 to 12057 or complex repair codes 13100 to 13160. 
Add together the lengths of wounds in the same classification and anatomic sites. Use separate codes for repairs from different anatomic sites. Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing or when appreciable amounts of devitalized or contaminated tissue are removed. 

Bibliography

Adams B, Anwar J, Wrone DA, et al. Techniques for cutaneous sutured closures: variants and indications. Semin Cutan Med Surg.  2003;22(4):306–316. [View Abstract]
Bennett RG. Fundamentals of Cutaneous Surgery . St. Louis: Mosby;  1988:464–465.
Boutros S, Weinfeld AB, Friedman JD. Continuous versus interrupted suturing of traumatic lacerations: a time, cost, and complication rate comparison. J Trauma .  2000;48:495–497. [View Abstract]
Brown JS. Minor Surgery: A Text and Atlas . 3rd ed. London: Chapman & Hall;  1997:70–96.
Lammers RL, Trott AL. Methods of wound closure. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine . 3rd ed. Philadelphia: WB Saunders;  1998:560–598.
Moy RL. Suturing techniques. In: Usatine RP, Moy RL, Tobnick EL, eds. Skin Surgery: A Practical Guide. St. Louis: Mosby;  1998:88–100.
Moy RL, Lee A, Zalka A. Commonly used suturing techniques in skin surgery. Am Fam Physician .  1991;44:1625–1634. [View Abstract]
Stasko T. Advanced suturing techniques and layered closures. In: Wheeland RG, ed. Philadelphia: WB Saunders; 1994:304–317.
Stegman SJ, Tromovitch TA, Glogau RG. Basics of Dermatologic Surgery . Chicago: Year Book Medical Publishing;  1984:45–48.
Swanson NA. Atlas of Cutaneous Surgery . Boston: Little, Brown;  1987:42–45.
Wong NL. Review of continuous sutures in dermatologic surgery. J Dermatol Surg Oncol.  1993;19: 923–931. [View Abstract]
Zuber TJ. Basic Soft-Tissue Surgery . Kansas City: American Academy of Family Physicians;  1998: 58–69.
Zukin DD, Simon RR. Emergency wound care: principles and practice. Rockville, MD: Aspen, 1987:51–54.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
×