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skin can be pulled more tightly than elsewhere. Firm, but not strangulating,
apposition of the wound will also help with hemostasis.
To ensure proper alignment, the first suture may be placed at the midpoint of
the wound, with subsequent sutures then placed in a bisecting fashion lateral to
the midpoint. Use of noncrushing forceps to hold tissue should be encouraged
because this allows the operator to precisely pass the needle through the desired
points alongside the wound edge. However, forceps use should be kept to a
minimum during the repair to avoid tissue damage.
Skin wounds can generally be repaired using interrupted sutures. To place a
simple interrupted suture, the needle is held pointing down toward the skin and
the wrist is pronated as the needle enters the skin at a 90-degree angle. The needle
tip will then move farther away from the wound margin and penetrate deeply.
Thus, more tissue is at the depth of the wound, and this causes the wound to
evert. Sutures should be placed about 2 mm apart and 2 mm from the wound edge
on delicate areas such as the face. More sutures placed closer together decrease
wound tension and leave a less noticeable scar. Larger bites should be used for
body parts where cosmesis is less important.

FIGURE 110.3 A: The buried subcutaneous suture. B: The horizontal dermal stitch.

Use an instrument tie to secure the suture ( Fig. 110.4 ). The knots should
ideally be placed on one side of the wound. Knots placed directly over the wound
increase inflammation and scar formation. On the first throw, the provider should
wrap the needle holder twice to create a surgeon’s knot and then wrap subsequent