Deep Dermal Suture (OSCE)

Choice of suture 

 An absorbable suture should be used to allow the knot to be hidden below the skin

 Monocryl (3-0 or 4-0) or undyed Vicryl (3-0 or 4-0) are usually used 

 PDS may also be used where dermis is thick 

 Smaller suture such as Monocryl (5-0 or 6-0), or Vicryl or Rapide should be used as they allow rapid healing 

Equipment 

 Needle Holder: hold with dominant hand, place thumb and ring finger in handles 

 Toothed forceps: hold with non-dominant hand, like a pen ✍ 

 Scissors: to cut sutures, use index finger beneath blades for precision ✂ 

 Suture: material depends on wound and surgeon’s preference 

What sutures should I use? 

 Hands: Monofilament (4-0/5-0) for 10 to 14 days ✋ 

 Nailbed: Braided (6-0), absorbed 

 Limbs: Monofilament (3-0/4-0/5-0) for 10 to 14 days or absorbed 

 Scalp: Monofilament (3-0/4-0) for 7 to 10 days 

 Face/lip: Monofilament (6-0), for 3 to 5 days 

 Chest/abdomen/back: Monofilament (3-0/4-0), for 7 to 10 days 

Dermal Sutures preparation 

1. Sterilise skin with antiseptic solution 
2. Place drape around sterile field 
3. Wash hands ✋ 
4. Don gloves ✋ 
5. Wash wound 
6. Debride wound edges  
7. Load needle holder 

Deep dermal suture 

 Used to close large wounds to hide suture beneath skin 

1. Prepare dermal suture as described above ⬆ 
2. Use toothed forceps to carefully evert skin edge 
3. Turn wrist so palm faces downwards ⬇ 
4. Place suture deep in one side of wound 
5. Turn wrist so palm faces upwards, causing needle to move from deep in wound, nearer to surface, but not puncturing skin ⬆ 
6. Use needle holders to pull needle through the skin, then use the toothed forceps to pull the needle and thread, leaving sufficient thread inside the wound to tie the knot 
7. Push the needle through the skin on the opposite side of the wound 
8. Turn wrist so palm faces upwards, and the needle moves from the skin, deeper into the wound ⬆ 
9. Pull needle through 

Tie the knot: 

1. Pull suture through, leaving 3cm on the deep side of the wound 
2. Loop the suture around the needle holder twice, in the direction away from your body ➿ 
3. Hold the suture end with needle holder 
4. Lay the ends of the suture parallel to wound, forming the first knot 
5. Release suture from needle holder 
6. Loop the suture around the needle holder once, in the direction towards your body ➰ 
7. Hold the suture end with needle holder 
8. Lay the ends of the suture parallel to wound, in the opposite direction this time, forming the second knot  
9. Loop the suture around the needle holder once, in the direction away from your body ➰ 
10. Hold the suture end with needle holder 
11. Lay ends of suture parallel to wound, forming the last knot 
12. Trim the ends of the suture ✂ 

Useful tips: 

 Make sure the needle enters and exits the skin symmetrically on both sides of the wound so that the skin either side is at the same level 

 Place deep dermal sutures deep in dermis to prevent it protruding through the skin 

Completion 

1. Appropriately dispose of sharps 
2. Wash, dry and dress wound: 
3. Face wounds: steristrips and micropore tape or chloramphenicol 1% ointment 
4. Limb wounds: non-adhesive dressings or waterproof dressings for small wounds 
5. Torso wounds: non-adhesive dressings followed by Opsite/Mepore, or gauze and mefix for large wounds 
6. Review wounds 5-7 days later 
7. Remove non-absorbable sutures when appropriate 

Summary:

1. Use local anaesthetic prior to intervening 
2. Thoroughly wash wound and examine for internal damage 
3. Ensure patient is up to date with tetanus immunisation 
4. Administer antibiotics if wound is infected  
5. Perform x-rays if you suspect fracture or presence of foreign objects 
6. Debridement of wound edges 
7. Thicker skin requires larger sutures