Once the circumstances of the patient's injury have been considered and the patient examined with particular emphasis on the wound(s), anesthesia can be administered locally. The wound is then irrigated and debrided followed by primary closure.

ADHESIVE STRIPS
Adhesive skin strips alone might be useful for skin approximation or in combination with sutures. However, certain areas are not amenable to this technique of skin closure because of potential motion such as around the fingers or mouth and in hair-bearing areas including the beard. It should be remembered that children may not leave this type of closure alone but may disturb the adhesive strips with the resultant reopening on the wound. When these adhesive strips are utilized, an additional dressing over the site is recommended.

SUTURE SELECTION
In general, sutures can be divided into absorbable and non-absorbable, monofilament and braided types.

Absorbable sutures are degraded by the body's enzymatic pathways. Such sutures include catgut, both chromic and plain, and those derived from polyglycolic acid whose trade names include Vicryl^TM, Dexon^TM, PDS^TM. These sutures are most often used below the surface of the skin to provide support to the skin closure. They can also be used in areas where suture removal might jeopardize the repair such as with small children who might not easily cooperate with suture removal.

Non-absorbable sutures are permanent and would need to be removed when placed through the skin. These include nylon and polypropylene, silk and cotton.

Monofilament sutures cause less reaction than do braided sutures but require more ties to assure an adequate maintenance of the knot compared to braided suture.

Braided suture, on the other hand, usually incites a greater inflammatory response but requires fewer ties to maintain the knot integrity. These include silk, cotton, Mersilene^TM.

The strength of the sutures varies according to their size, which can be determined by a uniformly applied number. For example, a 6-0 suture is more delicate and has less strength than a 4-0 suture.

The needles associated with the suture come in two configurations: A tapered point or a cutting tip. Generally, we utilize cutting edge needles for skin closure as well as the underlying soft tissue.

SIMPLE INTERRUPTED EVERTING STITCH
This is the most commonly utilized stitch, which includes the dermis in the needle bite. The correct technique tends to evert the wound edges when placed equally distant from the wound margin. (Figure 1) shows the correct and incorrect way to complete this stitch.

MATTRESS SUTURE
The suture can be placed in a vertical format or in a horizontal format. Tension can be taken off the wound edges when using the horizontal technique, but it may lead to tissue ischemia if tied too tightly. (Figure 2) shows these two variations of the mattress suture.

CONTINUOUS STITCH
A Continuous stitch is easily placed since knots are only placed at the beginning and ending of the suture line. When placed incorrectly and too tightly the skin margins can become ischemic. On the other hand, tension is more evenly distributed along the entire wound with this suture technique.

CONTINUOUS BURIED PULL-OUT STITCH
This technique is most useful for linear wounds. The suture can remain in place for a long period of time without fear of having suture marks or cross-hatching on the skin surface from sutures being left in place too long. (Figure 3)

TECHNICAL POINTERS
By approximating known landmarks of the injured tissues, definitive closure will be made easier. Approximate the tissues carefully without too much tension since the tissues will swell as they become edematous. A long, narrow flap should not be placed under tension. This closure can be achieved with a V-Y technique as seen in (Figure 4).

NUMBER OF STITCHES
Use as many stitches as necessary to approximate the wound edges. Every stitch becomes a foreign body and becomes the source of an additional wound. Use what is required and no more.

BURIED STITCHES
These are additional foreign bodies in the wound but are indicated when there is a potential for a large dead space in the subcutaneous space. Buried absorbable sutures are also useful to repair divided muscle or fascia. Buried stitches also take tension off the wound edges when utilized in the dermis.

SPECIAL SITUATIONS

a. Full thickness lip wounds

These wounds should be closed in layers after complete irrigation and debridement has occurred. Be sure all foreign material is removed including fragments of teeth or other materials.

b. Ear Lacerations

Debride devitalized fragments of cartilage. Approximate edges carefully and close the skin on both surfaces. Sutures may be placed in the cartilage but are often not necessary as long as stability is maintained.

c. Eyebrows

Do not shave these structures since hair may not grow back completely. Line up the wound carefully so that the anatomy is restored.

d. Nostril base

Align the edges of the region carefully to avoid the development of a notch.

e. Eyelid lacerations

Be certain to repair this tissue in layers and avoid knots irritating the cornea or conjunctiva.

f. Tongue

Small lacerations can be left open. However, lacerations along the margin of the tongue should be repaired with absorbable sutures.

g. Leg wounds

These sutures should be left in place longer than in other regions. For this reason, a buried pull-out stitch might be indicated to avoid suture marks on the skin surface.

STITCH REMOVAL
Patients should be advised to return for a wound check should there be unexpected swelling, erythema, or drainage. A stitch may need to be removed so that adequate drainage can be assured if there is a collection beneath the skin surface.

The stitches are left in place varying times depending on their location. Healing is usually rapid in the head and neck region and slowest in the distal lower extremities. Usually, sutures may be removed from the face on the fourth or fifth day after repair, from the trunk on the seventh or eighth day and from the leg on the ninth or tenth day.

Patients who have compromised healing (poor nutrition, diabetes, on steriod medication, etc.) require their stitches to remain for longer time periods.