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throws a single time. The first and second throws should be snug enough to
approximate the wound edges, but not so tight that tissue is strangulated. All
subsequent knots are squared to maintain the closure. Four or five throws are
usually required to keep the knot from unraveling. A “loop knot” is effective in
apposing the wound edge with minimal tension. This involves placing a surgeon’s
knot, using the instrument tie, followed by a loop. The surgeon’s knot will “give”
slightly should edema develop subsequently. The loop knot allows easier, painless
removal of sutures because it creates a free space between the suture and the skin
( Fig. 110.5 ).
Running or continuous sutures can be applied rapidly to close large, straight
wounds or multiple wounds. With this technique, the suture is not cut and tied
with each stitch. The first suture is placed at one end of the wound and a knot is
tied, cutting only the end of thread not attached to the needle. The next loop is
placed a few millimeters away and continuous loops of equal bites are made to
close the wound. On the final loop, because the suture is not completely pulled
through, a small loop remains on the opposite side of the wound. Now, the knot
can be tied using the preceding loop of suture ( Fig. 110.6 ). This type of stitch is
more likely to leave suture marks if not removed in 5 days. Apposition of the
edges and eversion are more difficult to achieve with running sutures, and the
entire suture line can unravel if the suture breaks anywhere along the repair.
However, the technique gives the advantage of having equal tension on the
wound edges.

FIGURE 110.4 Simple interrupted skin suture secured with instrument tie.