Running Continuous Suture in Dermatologic Surgery | Instructional Tutorial

The deep dermal stitch is a surgical technique used to relieve tension on wounds before closing the superficial skin layer, involving alternating bites from deep to superficial on each side of the wound to bury the knot within the tissue, and always requires absorbable sutures since they cannot be removed later.

Deep tension relief sutures (similar to inverted sutures but in the deep dermis) are used to reduce tension on wound edges before superficial closure. This technique is particularly important in plastic surgery to prevent visible scarring. By relieving tension in the deep dermis, subsequent superficial sutures (like intradermal or simple sutures) can be placed more easily without causing tissue strangulation or visible marks.

This video demonstrates multiple suturing techniques for closing cutaneous wounds, including simple interrupted suture (most common technique), simple buried suture (for deep dermal closure), vertical mattress suture (for tension reduction in swollen or high-risk wounds), horizontal mattress suture (faster than two simple sutures), half-buried suture (for plastic surgery to avoid disrupting blood supply), simple running suture (continuous closure), simple running locking suture (for tension control in areas like scalp), subcuticular running suture (cosmetic closure with no external material), curved wound closure (compensating for unequal lengths), Y-shape suture (complex geometric closure), and dog ear correction (marking desired scar location and repositioning tissue).

The simple buried suture is used for deeper tissue approximation before skin closure. The technique requires starting deep within the tissue and exiting superficially without buttonholing the skin, then doing the opposite on the other side (superficial to deep). Both suture ends must exit from the same side of the loop to allow proper knot burial. Perform an instrument tie while pulling the suture along the length of the wound, which helps bring skin edges together and distributes tension away from the skin surface. This technique takes tension off the skin, allowing for better approximation during subsequent skin closure.

The simple buried suture is a fundamental surgical technique where the suture is placed deep within the tissue and exits through the dermis without buttonholing the skin; the technique involves passing the needle from deep to superficial on one side and superficial to deep on the opposite side, ensuring both ends exit on the same side of the loop, followed by an instrument tie pulled along the wound length to relieve skin tension and allow proper skin edge approximation.

Proper post-operative wound care involves using sterilized instruments for suture removal, where non-absorbable sutures (like ethicon) are typically removed completely while absorbable sutures may remain under the skin without causing issues; wound healing depends on the patient's immune system strength, nutrition, rest, medication adherence, and proper wound care, with complete healing typically taking 6 months to 1 year, and complications like pus, swelling, or prolonged pain may occur due to infections, poor healing conditions, or weight gain affecting the surgical site.

This segment covers post-suturing care and wound management. Sutures should be removed between days 7-12, with day 10 being optimal. Timing depends on patient healing capacity, immune function, and wound characteristics. Diabetic patients may require longer suture retention. Sutures are removed using a suture removal tool by grasping one end, lifting the suture, cutting with scissors, and pulling out completely. After suturing, the wound is cleaned again and dressed with antibiotic cream if available. Bandages are applied using a circular technique for coverage, secure but not too tight to restrict circulation.

Sutures must be removed only when the wound has healed sufficiently, with timing varying by body location: face/head (4 days), neck (7 days), arm/trunk (7-10 days), extremities (12-14 days), and joints (10-14 days); removal should only occur when wound edges are firmly attached and there are no signs of infection, as premature removal can cause wound reopening and infection.

Proper post-operative wound care includes keeping the incision clean and limiting movements involving the incision to promote better healing. Surface sutures should be removed at appropriate times - facial sutures typically at 5-7 days post-op, while scalp sutures usually require 7-14 days. The wound should remain covered with ointment transitioning to scar gel. Moist wounds heal better than dry wounds because they allow epithelial cell migration to occur more directly. When incisions dry out and scab over, the underlying dermis becomes desiccated and partially necrotic, impairing healing and leaving worse scars.

Suture removal technique: use scissors and gauze, clean the wound area with alcohol, use forceps to hold the suture, cut the suture on the side away from the wound (cut both strands), and pull the suture through the skin. Cutting on the wrong side can cause the suture to retract into the wound, introducing bacteria. Wound dressing application: use a square gauze pad with a central hole, position the hole over the wound, extend at least 0.5cm beyond the wound edges, and secure properly. If the wound is wet or bleeding, use gauze to absorb moisture. Apply a bandage over the dressing, extending at least 1cm beyond the wound edges, applied horizontally (not lengthwise) to prevent constriction. Post-suturing care includes: documenting the procedure in the patient's medical record, disposing of contaminated materials properly, and returning reusable equipment for sterilization. Patient instructions include: keeping the wound dry and clean, avoiding getting the wound wet, changing the dressing as needed, monitoring for signs of infection, and returning to the healthcare provider if infection is suspected. Nutrition: consume protein-rich foods (meat, eggs) to promote wound healing. Medication: take prescribed antibiotics as directed. Follow-up: return for suture removal (typically 7 days after suturing). Tetanus vaccination should be administered if not up to date.

Tummy tuck wound healing involves multiple potential complications. Wound separation (dehiscence) occurs when top sutures separate because they carry less stress than deeper stitches holding the abdomen together—treatment involves simple cleaning and natural healing. Infections range from superficial cellulitis (treatable with antibiotics) to deep wound infections requiring surgical drainage and packing. Spitting stitch syndrome involves minor infections around individual stitches, treatable by removing the stitch. Numbness and hyperesthesia (nerve hypersensitivity) are common nerve-related side effects treatable with touch therapy using multiple stimuli. These complications, while uncomfortable, typically resolve without long-term consequences.

Evisceration is a surgical emergency where abdominal contents protrude through an open wound, while dehiscence refers to wound edge separation. The mnemonic 'DEHISCENCE' helps remember signs: D (dehiscence), E (evisceration), H (herniation), I (infection), S (separation), C (compromise), E (exposure), N (necrosis), C (complication), E (emergency). Immediate management includes covering with sterile moist saline dressing and applying an abdominal binder. For cast complications, itching is common and managed with powder, but cold cast with inability to move indicates compartment syndrome requiring immediate surgical intervention. Fiberglass casts dry in 24-48 hours while plaster casts may take up to 72 hours.

Suture dehiscence in dermatological surgery primarily results from premature suture removal (not a fixed 7-day rule but varies by location: 7 days for eyelids, 12 days for face, 15+ days for trunk/members), improper suture technique (failing to traverse the entire skin thickness perpendicularly, placing sutures too far from wound edges, or tying knots too loosely), excessive hemostasis causing tissue necrosis, infection, or suturing under excessive tension; management involves assessing wound healing before removal, avoiding premature extraction during infection, and performing resuturing with spaced sutures to allow drainage when dehiscence occurs.

Surgical site infection occurs within 30 days (90 days with prosthetics), caused by endogenous flora. Risk factors include age >60, immunosuppression, obesity, diabetes, malnutrition, smoking, and previous radiation. Procedures are classified by infection risk: clean (1-5%), clean-contaminated (5-10%), contaminated (up to 20%), infected. Depth classification (superficial, deep, organ-space) guides treatment. Superficial infections present with local signs without systemic symptoms; treatment involves drainage and debridement without routine antibiotics unless cellulitis or prosthetics are present. Deep infections present with systemic symptoms and require debridement plus antibiotics. Organ-space infections involve intracavitary organs and require comprehensive management. Wound dehiscence is separation of sutured tissues, classified as superficial (skin/subcutaneous) or deep (muscle/aponeurosis). Primary cause is surgical site infection; other factors include technical errors, hematoma, increased intra-abdominal pressure, obesity, corticosteroids, malnutrition, neoplasia, radiation, and chronic diseases. Evisceration is protrusion of viscera through the incision, representing the most severe form. Prevention involves optimizing patient factors (glycemic control, smoking cessation, nutrition) and proper surgical technique with layered closure using continuous suture 1 cm from edges with 1 cm spacing. Management depends on defect size: small dehiscences may be managed conservatively, while large defects require surgical revision.

The speaker describes a serious surgical complication where the incision from his appendectomy has completely reopened (dehiscence), returning to the state it was in immediately after the original surgery. The wound has become infected with necrotic (sputtering) tissue, which was partially removed, treated, and drainage tampons were inserted. This demonstrates how surgical wounds can become severely compromised, requiring immediate medical intervention to prevent further complications.