CHAPTER 16

Simple Suturing Techniquesand Knot TyingPETER B. ODLAND and CRAIG S. MURAKAMI

-f tt" skill and art of suturing date back thousands ofI years to the Smith Papyrus.t Although techniques

and materials have changed, the fundamental reasonsfor using sutures have not. In cutaneous surgery, suturesshould be used for gentle closure of wounds until thetissues re-establish their inherent tensile strength. Thisshould be done in a way that promotes a functional andaesthetic outcome while minimizing the risks of bothacute and late complications. The old adage "approxi-mation without strangulation" clearly states the mostimportant point about proper suturing technique.

Suturing is defined as the "surgical uniting of twosurfaces by means of stitches."2 Suturing is an incrediblysimple concept, yet correct application requires a highlevel of concentration, attention to detail, and discipline.An understanding of basic wound healing, the nature ofsuture materials, and general principles regarding exci-sion and closure of wounds are all very important toobtaining a satisfactory outcome. Failure to recognizethese important concepts will yield surgical results thatare less than adequate, thereby frustrating both thesurgeon and the patient and making the entire experi-ence unsatisfying and unrewarding.

ments used in cutaneous suturing include a needle driver(holder), tissue forceps, and skin hooks.

The standard needle holder has a ratchet-type lockingmechanism that stabilizes the needle securely in thejaws. When a needle is in the jaws, one should avoidlocking beyond the first snap. Locking the needle be-yond this position causes flattening of the needle and"denting" the opposing surfaces of the jaws of theinstrument. This frequently results in slippage of finesuture materials during subsequent use.

Tissue forceps with fine teeth allow for gentle handlingand stabilization of the tissues being sutured and forgrasping the emerging needle tip during suturing. How-ever, if they are not used carefully and gently, traumato the wound edge may occur and compromise woundhealing. Alternatively, a skin hook can be used tostabilize tissue and, in skilled hands, is less traumatic tosoft tissue than forceps.

The needle holder should be grasped with the thumband ring finger in the loops of the instrument (Fig. 16-1.4). The tip of the first finger is extended and rests onthe arms of the instrument at or near the hinge, whilethe middle finger flexes gently to secure the base of theloop (Fig. I6-'J.8, C). None of the fingers are insertedpast the first knuckle to allow maximum dexterity androtation. Some surgeons choose to "palm" the needleholder and avoid placing fingers in the loops altogether(Fig. 16-1D). Both techniques can be learned and usedeffectively, although it is normal to feel awkward whenusing either technique initially. A great deal of practiceis necessary before one becomes facile in the use ofthese techniques. Forceps should be held somewhat likea pencil, but this may vary depending on the particularuse.

A skin hook can be effectively held between the

Basic Terms and ConceptsMATERIALS AND INSTRUMENTS

The suture needle3 most commonly used in cutaneoussurgery can be subdivided into several parts. The tip isa fine, delicate point used to penetrate tissue surfaces.The swage is where the needle is clamped to the suturematerial; this represents the broadest point of the entiresuture. The remaining portion, where the needle isgrasped with instruments, is the body. The basic instru-

178

SIMPLE SUTURING TECHNIQUES AND KNOT TYING 179

Figure 16-1. Technique for grasping the needle holder. A, Fingering the instrument. B, Supporting the instrument at the fulcrum (oblique view)'

C,-supporting the insirument-at the iulcrum (vertical view). D, Palming the instrument'

thumb and the first finger'a "Choking" up on the handlenearer to the hook wif allow for more accurate handlingof the instrument bY the surgeon'

NEEDLE AND INSTRUMENT PLACEMENT ANDORIENTATION

The needle must be placed in the needle driver at theend of the jaws with proper orientation. This will achieveoptimum utilization- of the instrument' Correct place-ment of the needle toward the end of the jaws allowsfor greater accuracy and precision in suturing' Further--ori, b""uuse the iurface area at the end of the jaws is

smaller, there is less chance of crushing the needle andflattening its curve. Orientation in the vertical axis (tilt)

and aloig the longitudinal axis of the needle driver(twist) m*ust be exict (Fig. 16-2). Failure to properly-o.ienf the needle will prevent effective advancement of

the needle through tisiue' Positioning the needle in thejaws of the need6 driver ideally is done with a forceps'

At first it may be a frustrating technique, but masteringit will minimize the risk of needle sticks and withexperience will actually reduce operating^time' Mostsuigeons place the needle holder one halfl 's to threefouithsu oi th" way from the tip to the swage on thebody of the needle. Placement closer to the tip-maylimii advancement of the needle through the full thick-ness of the skin being sutured, while placement closerto the swage frequently results in bending of the needle'If a needle is unnecessarily bent several times, it be-comes weakened to the point where it may break'

SUTURING STEPS

Proper wound closure requires precise suture plage-ment io re-establish the original anatomic configurationof the various skin components (Fig. 16-3). The needleshould always penetrate the surface perpendicularly toobtain ideal-wound edge approximation with mild ever-sion (Fig. 16-4A). The needle tip is the sharpest point'

180 BASIC SURGICAL CONCEPTS AND PROCEDURES

Figure 16-2. Placement ot the needle in the needle holder. A, Correct placement at the proximal llat portion of the needle body. 8, The needleis oriented perpendicularly to the holder. C, Incorrect placement at the rounded hub or swaged portion of the needle. D, The needle can oemisplaced in the needle holder by a tilting or twisting movement.

Figure 16-3. Cutaneous wound anatomy. A, Epidermal layer. B,Papillary dermal layer. C, Reticular dermal layer. D, Underminingplane. E, Subcutaneous fat layer.

A

181SIMPLE SUTURING TECHNIQUES AND KNOT TYING

Figure .r6_4. Needre penetration. A, correct technique with square or frask-shaped passage through tissue. B, lncorrect superficiar, semicircular

passage through tissue.

It t

- t t lt t r

Its effectiveness in overcoming the resistance of initial

o"n"tiution is reduced if the ;eedle is introduced tan-

I;;;;["-i; uaaition, a superficial wound will be larger

;;;;;";;i"bl; 1iig. ro-441' rhe point o.r penetration

;;dd ;; t""t"[v s?lected very-caiefully before apply-

t"g;;; *it( ttt" needle' Selection of this point

J""o"'nds on the type of suturing technique being used

;;Aih" soacing between sutures' Unnecessary punctures

;;;;il";t.;d"esirable and will result in excessive tissue

;;;;..,il-in"iluting pressure is applied' the initial

r e s i s t a n c e t o p e n e t r a t i o n w i l l r e s u l t i n a t e m p o r a r ydlor"rrion of the surface of the skin' The depth o.f this

deoress iondependsontheanatomicarea, the lax l tyo lilJ:,'id, ;J[t" iir. and tip design of the needle being

"-"J. Wittt increasing p,"s'ut", the resistance suddenly

."ut"t, and needle pinetration occurs' The suddenness

;-thtt penetration may be somewhat stal-tling to inex-

oerienced surgeons unh rnuy result in a reflexive with-

il;;;i;f iitJ """ar".

For this reason, stabilizing the

"""if"-ari"i"! ttuna on the patient or withthe tu:,g"-?:-t

.oootir" ttuni rnuy be helpful' After initial penetratlon'

tlie needle should be driven to the appropnate oeptn

i"i ttt" o".ticular stitch being used' The next movement

ir"^"',;iil;;"""' *itrt the ieedle driver being rotated

"t.t"Jii. r6ng axis' ihis advances the curved needle in

u-tto.irontut plane ,o that the -tip emerges.in the defect

"iitt" O"ti*d depth' The tip of the needle is then gently

;;;;;;iy grasped with fine forceps or stabilized with

u .f.in ttoot."ttt" tutt"t may be slightly more difficult'

il"*"""i,-uv placing the hook,deep to th,e needle' the

;;;ei".an ue ttuuiliZed by pulling up gently at the point

;;;; ii"-"tg". from the tissue' Rotating the hook

mav provide even more stability by capturing the needle

i;?5;;;;ing end of the semicir'cular arc of the hook'*iit; ti.j"or" ihould be released from the jays 9l tfe

n""at" driver without moving the needle itself' If the

u**nt of tissue through which the needle has passed

;^ffi;, then securing t'he needle or surrounding tissue

*iiit F"i."p. or a skinirook is important and will prevent

backward retraction of the needle into the tissue' The

"""af" should be grasped with the needle driver' with

.rlr" "ti""tion

paii to the tilt and twist of the needle at

tfrc iip "i

itte jaws. By rotating the needle driver in the

,urn.'ur. as the n""dl", the rest of the needle will

"."in" ttorn the tissue and the attached suture material

;iiii;il;;. ihe needle must be repositioned in the jaws

oi-iri" n""Ore driver in preparation for penetrating the

O""p tittu" of the opposing wound edge' For correct

""rtl..i-""0 horizontii alignment of the wound edges'

the needle must penetrate Ihe oppos.ing.side at precisely

;i;;;; d$in is ttte side from wtricrr it emerged.(Fig'

iO-Sat. A iompleted knot should provide a level sur-

f;;i;h ; iy*it"tri", small amount.of .eversion of the

"AnLt. it" sides of the wound should be well aligned^

r"'ii", i.J""J""t iissue does not develop at the end of

itt" ^i""i.i*

iine anA cause vertical or horizontal mal-

"fit"t""t (Fie. 16-58). To accomplish this' the oppos-

i#;;;;;;Ji" is g"nitv stabilized with forceps or skin-#"k f* pen"etrati'on into the deep tissue' Resistance

*ifi n"*riffv be less than was encountered at the surface

.f^in"" til". hfter introduction and advancement of the

n""Of" into the tissue horizontally, rotation will direct

;i;;lb "i1n"

needle through the surface of the skin'

This should be at a point t"hat is equidistant from the

;;;"d edge when compared with the.opposite side'

Th;" fery basic steps apply to almost all suturing

t".ttniqu"t. irlodifications in iuiure orientation and the

;6" ;i material used can produce a variety of desired

effects.

Simple Suturing Techniques

The most important basic principles in suturlng m-

clude gentle tranamg of tissue at all times' using appro-

il;"t";i;;-"ntuti6n,. and. alwavs buryTg dermal .orsubcutaneous sutures when closing a wound that is under

tension.T

182

SIMPLE INTERRUPTED SUTUREThe simple interrupted suture is undoubtedly the most

commonly used suturing technique because of its ver-satility and relative ease of use. The technique foremploying this stitch to evert the wound edge requiresthat the needle enter the skin at a 90-degree angle8approximately 1 to 2 mm from the wound edge.l Afterpenetration, the needle should be redirected to proceedin a slightly oblique fashion away from the wound edgeto the desired depth and then across to the other sideof the wound, where its course should follow a mirrorimage of the first side. This can be facilitated by grasping

BASIC SURGICAL CONCEPTS AND PROCEDURES

Figure 16-5, Al ignment of wound edges. A, Vert ical malal ignment. B, Horizontal malal ignment.

the deep tissue with forceps, then passing the needlethrough the skin.e Either of these techniques shouldcreate a loop that encircles a broader base of tissue atits depth than at the surface so that the outline of thesuture pathway looks somewhat like a flask (Fig. 16-6,4). Lversion of the wound edges is a result of a greateramount of tissue being pushed together deeply, causingthe surface to be displaced (Fig. 16-68). Eversion isdesirable, because wounds contract as they heal. Thevertical component of this contracture may result in adepressed scar at the suture line if the edges are notinitially everted.T' ro-12

t\Y

Figure 16-6, Wound closure using simple interrupted sutures in conjunction with buried suture (nearly reapproximated wound) (A). B, Finalappearance of the approximated wound.

B

IF::!fi;,1iil,:ff,.': i:;hii[ \i;;7i:: :.'d:;'X::,'

i.7a t

.'l.t;fii

SIMPLE SUTURING TECHNIQUES AND KNOT TYING 183

In some anatomic areas, inversion of the wound edges

may be desirable. When this is the case, passage through

the tissue is just the opposite of the eversion stitch,with the sutuie pathway incircling more tissue superfi-cially than at the depth." This is accomplished bypenetrating the skin perpendicutarly, as always, and

ihen direciing the needle-obliquely toward the wound

edse. Exitine" the tissue through the other side of the

detect is agai-n done in a mirror-image fashion' It shouldalso be n6ted that the suture loop must be placed in

such a way that it is wider than it is deep'The advantages of the simple interrupted stitch are

multiple and include the following:

1. It is useful for making gross or minute adjustmentsto ihe wound edges for profer alignment and tension'7

2. It is easy to Perform'3. It allowi expression of serum or blood from be-

tween sutures.134. It is useful for approximating both large and small

amounts of tissue.5. It is helpful as a tacking stitch for flaps or large

irregular wounds.T6] It tras greater security than a running stitch'14

If the basic requirements of suturing.are observed and

Dracticed. it is unlikely that a simple interrupted stitchiuill .uut" any problems. However, if placed incorrectlyor inappropria^tely, these sutures can cause wound in-

version, which in-the vast majority of cases is undesira-ble. The principal disadvantage olthis stitch is "railroadtrack," oi ctoti-hut"h, scarring. This can be avoided by

removing sutures before 7 days or by using a mo.re

advanced suturing technique such as a running. subcutic-ular techniqu". Aso, compared with the. running stitch,this suture is a time-consuming way to close a wound'7

BURIED ABSORBABLE SUTURE

There are essentially three variations of buried ab-sorbable sutures that are used in surgery of the skin:subcutaneous (Fig. 16-7A), dermal-subdermal,' and der-mal (Fig. I6-i Bl. Buried sutures are primarily- used.toclose'ariy dead space that may have been produced bythe surgical excisi,on, to reapproximate the-wound edges,and to help prevent wound dehiscence. Buried suturesare especiilly important to use if a wound has beenclosed under significant tension' In this situation cuta-neous surgeonJtry to prevent epithelialization of theSuture traiks by rernoving the nonabsorbable epidermalstitches within 7 to 10 days. However, this removaloccurs at a time when the wound has developed verylittle tensile strength (Fig. 16-8) and is highly susceptible^to separation.tt By using buried sutures,. especia-lly^iftheir tomposition gives them a relatively long h.alf-life,wound int^egrity wiil be maintained even if the epidermalsutures arJ remoued. The buried sutures are usuallyoriented vertically but can also be oriented horizon-tally.1, 7, 8, 11' 13' tu Placement of buried sutures generallyfollows adequate undermining and hemostasis. The typeof buried suture used depends on the thickness of thedefect, the tension on the wound, and the amount ofdead space.l? A relatively broad excursion of the needleis required to pass the suture through enough fibrousseptae to maintain security' Small "bites" often tearthioueh the subcutaneous tissue as they are being tight-ened.- It should always be kept in mind that it isparticularly easy to strangulate subcutaneous tissue'There is no significant advantage to burying the knotfor this stitch (see Fig. 1'6-7A).

The dermal-subdeimal stitcht6 is passed first throughthe deep side of one of the undermined edges of thedefect io that the suture pathway is through a small

Fioure 16-7. Full-thickness wound closed with deep subcutaneous buried sutures (A) and more superficial dermal-subdermal and shallow

O"i*i .rtrr"" fa- flot" that these knots are always buried as deeply as possible in tissue'

184 BASIC SURGICAL CONCEPTS AND PROCEDURES

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bRf.r! 100FqF

zr-\Fit)

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(t) u40 60

DAYS AFTBR SUTITRING

amount of both subcutaneous and dermal tissue. If thedermis is thick, it is unnecessary to bury the knot. Thissuture is necessarily vertically oriented. As the nameimplies, the dermal stitch is placed exclusively withinthe dermis. For relatively thin skin, the wound edge isreflected to expose the undermined surface of the der-mis. The needle penetrates this surface 2 to 5 mm awayfrom the wound edge and is directed obliquely towardthe edge and the surface such that the epidermal edgeswill be everted. With few exceptions, the knot shouldbe buried (Fig. 16-78), which is accomplished by pass-ing the stitch from deep to superficial and then fromsuperficial to deep. Occasionally a fine, horizontallyoriented, absorbable dermal suture can be placed. Theutility of such a stitch to relieve tension at the surfacemust be balanced against the risk of suture abscess ortattooing.

A multilayered deep closure is required in the case ofa full-thickness wound. First the deep fascial and mus-cular tissues are approximated with buried sutures.Then, in a layered fashion, the subcutaneous tissue andsuperficial layers of the dermis are closed. If a significantamount of tension is anticipated, a dermal-subdermalsuture should be used, but if there is no tension, adermal stitch should be used.

Buried sutures are very useful for relieving tension inwounds, closing dead space, and ensuring proper re-alignment of anatomic layers. There are very compellingreasons to use buried stitches in nearly all full-thicknesscutaneous surgery; noted exceptions are wounds thatare without tension and some selected procedures onthin-skinned areas of the body such as the eyelids. Thetensile strength of a wound at the time of suture removalis less than 5Vo of what it ultimately will be. Withoutdeep suture reinforcement, the risk of wound dehiscenceafter suture removal is great. In addition, ideally placeddeep sutures will appose the skin edges so well thatfewer skin stitches will be required, yielding a bettercosmetic result.l

0Figure 16-8. Wound tensilestrength compared with suturetensile strength.

Althoush there are both theoretical and real disad-vantages Io using deep sutures, the benefits generallyoutweigh them. The potential pitfalls of buried suturesinclude possible strangulation and necrosis of tissue,promotion of infection, and prolonged inflammation asthe result of the presence of foreign material.lT

Difficulties encountered in placement of buried su-tures often result from the small working area. Ideally,the first stitch is olaced in the exact middle of the twosides of the wound. This is possible in most instancesby having an assistant gently, physically coapt the edgesof the wound as the first two throws of a knot aresecured. When tension on the wound is great, an alter-native technique is to begin the deep closure at one ofthe apices of the wound. However, there is a potentialproblem in this situation: by the time the opposite apexis reached, the sides may have become unequal inlength, requiring a redundant tissue repair.l ' 7,8, 1r' 13' 16

KnotsThere are many knot configurations used to approxi-

mate soft tissues. In selecting suture material and knottypes, it must be remembered that the ultimate goal ofsuturing is to provide adequate approximation of thetissues with the least amount of trauma and inflamma-tion. Thus, the surgeon selects a suture material with anappropriate tissue half-life and knots that will be securelong enough to keep the wound approximated untiladequate intrinsic tensile strength has been established.The larger the suture diameter and knot volume, thegreater the risk of tissue inflammation and infection.18On the other hand, choosing suture or knots that aretoo weak for a giyen wound will result in wound dehis-cence and surgical complications. Studies have shownthat the security of a knot is related to the surfacecoefficient of frictionie'20 and the stiffness of the suturematerial.

SIMPLE SUTURING TECHNIQUES AND KNOT TYING

Figure 16-10. Surgeon's knot.

if this becomes necessary, tension on the wound may besufficient fo warrant use of other measures to reducethe tension.

INSTRUMENT TIE

Closure of soft tissue defects in cutaneous surgery isusually accomplished using an instrument tying tech-nique. The two-handed tie technique that is often seenin i general surgical practice is rarely used for soft tissuesurgery of the skin. Instrument tying is-quick, effective,

"as"y tb perform, and suture sparing (Fig. 16-11). To

uss the instrument technique to tie a square knot or asurgeon's knot, the needle is first passed through .thetissire. This task is completed when the suture is pulledthrough the wound until 2 to 3 cm of tail suture remains'Leaving a longer tail results in cumbersome -aggravationand uniecessaiy suture wastage. Starting with the needleholder between the two strands of suture, the holder isrotated clockwise around the suture, the short end ofthe suture is clamped, and the knot is placed flat acrossthe wound by crossing the hands. The second throw isbegun by again placing the needle holder between thetw6 strands, but this time the holder is rotated counter-clockwise around the suture and the throw placed flatby crossing the hands in the reverse direction' Theneedle holder always rotates around the suture; thesuture does not rotate around the needle holder, as thistechnique is cumbersome, time consumin€, and distractsattention from the tail of the suture. When the secondthrow is placed, it is important to be especially carefulnot to ovbrtighten the knot and strangulate the wound'Some surgeons prefer to place a second double throwto stabilizl the knot (Fig. 16-12). Poor technique willlead to pressure necrosis and prominent suture marks'

185

Figure 16-9. Square knot.

SQUARE KNOT

The most common knot used is the square knot' In

optimal circumstances this knot will provide 80 to 90Vooi the tensile strength of an intact suture' When exam-

inins a square knot, it can be seen that each strandbesi;s and ends on the same side of the knot (Fig' 16-

9)."Because of its symmetric design, it tends to tightenand remain secure when tension is applied equally toboth strands. However, this is somewhat dependent on

the type of suture material being used'. Some suturemateiials are too slippery and will not hold with a simplesquare knot. Suturei are often coated with silicone or*u* to allow easier passage through the^so.ft tissues, butthis decreases the holding capacity of the knot'21 Inaddition, suture material becomes more slippery when

covered with blood and serum. If the knot is not placedflat or if the tension on each strand is uneven, the squareknot twists into a half-hitch knot' which slides and is

extremely unstable.22 For this reason' the square \nol t'

usually reinforced with an additional throw, and withslippery materials such as monofilament nylon, two to

three extra throws may be necessary.

SURGEON'S KNOT

Many surgeons prefer the surgeon's knot, which is a

double throw tottoweO by a single throw in parallel, asin the square knot (Fig. 16-10). L-ike the square knot,the surg'eon's knot is usually reinforced with an addi-tional tfrrow. The initial double throw provides increasedfriction to hold the 'fuound together until the secondthrow can be placed. This is especially helpful in closingwounds that are under mild tension. A triple throw canalso be placed to provide even more tension' However,

186 BASIC SURGICAL CONCEPTS AND PROCEDURES

Figure 16-11. Instrument knot-tying technique. A, Needle is regrasped after first passing through tissue. 8, Initiating the surgeon's knot. C,First wrap of suture is made around needle holder. D, Initiating the second wrap. E Completing the second wrap. 4 Preparing to make thefirst (forehand) throw. G, Completing the first throw. (Courtesy ot Dr. T. McCulloch.)

SIMPLE SUTURING TECHNIQUES AND KNOT ryING

Figure 16-12. Double surgeon's knot

oDtimal results are to be obtained. If there is no tenston

on the epithelial margins, one may use surface-support-ing tape strips or a knot technique that is.tension free'Tfre Straith^loop, one such knot, is a double throwfollowed by a small 4 to 5-mm gap an{ secured with a

,quur. knot. The advantages of this knot are that itpi"u"ntt postoperative edema from strangulating the

ivound around the suture, it prevents overtightening the

second throw, and it makbs suture removal easier'

Simply cutting the base of the loop allows atraumaticrembvat of fine suture. If the wound is free of tension,itr" rutg"on can also use an interlocking slip knot'5. .

Once"the cutaneous knots are placed, they should be

moved to one side or the othei and not left directlyover the wound. This prevents the tails of the suturefrom becoming imbedded in the wound and allows easieru.".ir and reilroval'26 The knot should also be placed

away from structures that might become.irritated -(e'g',ifr" 6y"t and nose) and away-from the edges of a flap'z'

SUMMARY

A variety of wound healing studies2s'-2e have shownthe importince of using meticulous technique in per-

forming simple knot tying for wound closure' Despite

Itt" ffiur"nt simplicity oithe technique, knowledge of

187

Figure 16-11 Continued H, Initiating the second (glackhand) throw' /' Grasping the free end

bo-mpieting the second tnrow ot a su-rgeon's knot. (Courtesy of Dr' T. Mc6ulloch')

Instrument tying is easy and. quick if the.surgeon con-

centrates on conservlng motion and eliminating extra-

neous maneuvers. As with most other surgical proce-

Jui"t, suturing should be a smooth flow of progressive

rt"pt'tft"t pro"ceed in an accurate, logical, and rapid

manner.if tit" needle holder is not alternately rotated in a

ctoct*it" and then a counterclockwise direction, ai nrunnv" knot is created. This type of knot slips. more

tfiun tfi. square knot and is therefore less desirable'

Simple plac'ement of additional throws will help secure

tttit't not, but it is preferable to develop a consistent

tying i".finique that results in predictably more reliable

and secure square knots.If the han^ds are not alternately crossed with each

thiow, a sliding knot is created (Fig' 1.6-13)' lo1 thick*unat under'tension, such as scalp defects, this knot

allows the suture to slide and tighten, much like a lasso

Oo". utorrna a post' To secure this knot, two or three

additional throws must be placed, depending on the

rutut" being used.23' 24 This increases the overall volume

oi ttr" knot"and increases the risk of inflammation and

inJ".tion when this knot is used subcutaneously'18'23In cutaneous soft tissue surgery' the subcutaneous

rut*" U"utt the majority of the tension'. There should

be minimal or zero teniion on the epithelial edges if

of the suture to complete the second throw. J,

1 8 8 BASIC SURGICAL CONCEPTS AND PROCEDURES

Figure 16*13. Two different typesot sliding knots.

suture materials, needles, and different types and usesof various knots3o is vital to a good outcome in all cases.

REFERENCES

1. Bennett RG: Fundamentals of Cutaneous Surgery. CV Mosby, StLouis, 1988, pp 382.

2. Stedman's Medical Dictionary. 23rd ed. Williams & Wilkins,Balt imore, 1976.

3. Trier WC: Considerations in the choice of surgical needles. SurgGynecol Obstet 149:84-94, 1979.

4. Pookin GL, Gibbs RC: Another look at the skin hook. J DermatolSuig Oncol 4:366-368, 1978.

5. White JH, Stern RU: A theoretical consideration of suturingtechnique. Ann Opthalmol 3:509, 1971'.

6. Holt GR, Holt JE: Suture materials and technique. Ear NoseThroat J 60:12,1981'.

7. Stegman SJ: Suturing techniques for dermatologic surgery. JDermatol Surg Oncol 4:63-68, 1978.

8. Jankauskas S, Cohen IK, Grabb W: Basic techniques of plasticsurgery. In: Smith J, Aston S (eds): Plastic Surgery. Little, Brown,Boston ,1991.

9. Dushoff IM: A stitch in time. Emerg Med l:16, 1973.10. Lober CW: Suturing techniques. In: Roenigk RK, Roenigk HH

Jr (eds): Dermatologic Surgery. Marcel Dekker, New York, 1989,pp 205-217.

11. McCarthy JG: Introduction to plastic surgery. In: McCarthy JG(ed): Plastic Surgery. WB Saunders, Philadelphia, 1990, pp 1-68.

L2. Zitelli JA: TIPS for a better ellipse. J Am Acad Dermatol 22:1'01'-103, 1990.

13. Chang W: Wound management. In: Chang W (ed): Fundamentalsof Plastic and Reconstructive Surgery. Williams & Wilkins, Bal-timore, 1980.

14. Stephenson KL: Suturing. Surg Clin North Am 57 :863-873, 1977 .

15. Odland PB, Whitaker DW: Wound dehiscence. In: Salasche SJ,Whitaker DW, Zitelli JA (eds): Complications in CutaneousSurgery. WB Saunders, Philadelphia. In press.

16. Albom MJ: Dermo-subdermal sutures for long, deep surgicalwounds. J Dermatol Surg Oncol 3:504-505, L977.

17. Milewski PJ, Thomson H: Is a fat stitch necessary? Br J Surg67:393-394, L980.

18. Elek SD, Conen PE: The virulence of Staphlyococcu.s pyogenesfor man: a study of the problems of wound infection. Br J ExpPathol 38:573, 1957.

19. Gupta BS: Effect of suture material and construction on frictionalproperties of sutures. Surg Gynecol Obstet 161:12-16, 1985.

20. Taylor FW: Surgical knots. Ann Surg 107:458-468, 1938.21. Becker J, Davidoff MR: The physical properties of suture mate-

rials as related to knot holding. S Afr J Surg 15:105-113, 1977.22. Flinn RM: Knotting in medicine and surgery. Practitioner

183:322-328, 1959.23. Trimbos JB, Brohim R, van Rijssel EJC: Factors relating to the

volume of surgical knots. Int J Gynecol Obstet 30:355-359, 1989.24. van Rijssel EJC, Brand D, Admiraal C, et al: Tissue reaction and

surgical knots: the effect of suture size, knot configuration, andknot volume. Obstet GynecolT4:64-68, L989.

25. van Rijssel EJC, Trimbos JB, Booster MH: Mechanical perform-ance of square knots and sliding knots in surgery: a comparativestudy. Am J Obstet Gyncol 162:93-97, 1990.

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