Running Subcuticular Suturing

For those of you just here for a nuts and bolts review of the technique, here you go:

For those of you who prefer lengthy discourse and want to know why this technique is relevant to them, read on.

Running subcuticular sutures are considered to be the “holy grail” of suturing techniques by many.  That is to say, when done correctly, they give the best cosmetic outcome.  Hand in hand with that, they are certainly the most technically challenging and time consuming of suturing techniques.  While they are common practice in the OR and second nature for surgeons, it is all but an abandoned technique for emergency practitioners.  Most attending docs I talk to about this technique say, “Oh yeah…I remember learning to do that in medical school,” and it astounds me how many senior emergency medicine residents whom I have worked with have difficulty with this technique.

It’s true–this is not a technique we will employ all that often in the ED.  For one, a wound needs to be non-contaminated, with straight, even wound edges and low tension to even be a candidate for this type of closure. Basically, a surgical incision (which  is why surgeons use it).  But consider some of the techniques we have explored on this website.  With judicious wound excision, an ugly macerated lac can become a clean lac with straight edges.  A high tension wound can become low tension using the technique of undermining and layered closure with deep dermals.  In other words, you can prep your wound to be a candidate for this type of closure.

Even so, some may make the argument that in the era of tissue adhesives, the use of running subcuticular suturing for wound closure is not necessary.  It’s true, all studies I have reviewed directly comparing subcuticular closure to tissue adhesive show either equivalence of the techniques or superiority of tissue adhesive (based upon patient satisfaction and comfort).  Mind you, all studies looking at this topic have occurred in the operative wound closure setting, not in dealing with traumatic lacerations.  I would contend this: based on the latest Cochrane review data on tissue adhesive use, tissue adhesive has a number needed to harm of 40 (in other words, for every 40 lacerations you think will hold with glue, one will dehisce).  I believe there are a subset of wounds that really will do better with well placed subcuticular sutures than with tissue adhesive.  How do you determine which wound will benefit? Think about the last time you saw a lac and thought, “well, maybe dermabond will hold this together…maybe…” and consider using this technique instead.

5 thoughts on “Running Subcuticular Suturing”

  1. The method of placing the first deep dermal suture is incorrect. For the knot to be buried, one has to start deep and then go superficial, not the other way around. For example, see: (correct) http://www.youtube.com/watch?v=Vq7upcvzgUc and (incorrect) http://www.youtube.com/watch?v=RTwVyyH90-E

    • Thanks for the comment, and for making the catch! I agree with you that a deep dermal is best tied deep–>superficial then superficial–> deep to reduce risk of stitch abscess formation. This is also demonstrated in my deep dermal suture placement video.
      I disagree slightly that it is totally incorrect to tie it the other way. If one enters superficially just below the epidermal layer, and cuts right at the knot at completion of the tie, it’s not likely to bulge from the wound (as suggested in your video link) or be noticed by the patient, and I know many colleagues who prefer this way for ease of handling.
      Thanks again so much for your observation. When I have a chance to revise the video in the future, I will demonstrate as you’ve suggested.

  2. Thanks for the quick reply. My compliments on your educational website.

    Starting deep then superficial, followed by superficial to deep on the opposite wound edge positions the knot deeper in the wound and thereby reduces the chance of the knot causing irritation during the healing process (i.e. ‘suture spitting’). Since the epidermal layer is quite thin (depending on body area and patient) it well worth taking the extra effort to avoid this from happening.

    If you do decide to revise the video in the future I would recommend switching to a resorbable monofilament suture (or mention that these are generally used with this technique). Perhaps a second video could demonstrate the use of non-resorbable monofilament subcuticular sutures (pull-out type fixed with Steri-Strips or tied with loops) in, for example, small low-tension facial lacerations.

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