Closing the Gap: Deep Sutures

While many wounds are adequately repaired with simple interrupted sutures, not infrequently we are confronted with wounds that require more specialized suturing methods. One such method is deep sutures. Here to answer some questions regarding deep sutures is our wound management guru, and author of the book “Wounds and Lacerations: Emergency Care and Closures,” Dr. Alexander Trott. 

 DIAGRAM BY RILEY GROSSO, MD. THIS WORK IS LICENSED UNDER A  CREATIVE COMMONS ATTRIBUTION-NONCOMMERCIAL-SHAREALIKE 4.0 INTERNATIONAL LICENSE .

DIAGRAM BY RILEY GROSSO, MD. THIS WORK IS LICENSED UNDER A CREATIVE COMMONS ATTRIBUTION-NONCOMMERCIAL-SHAREALIKE 4.0 INTERNATIONAL LICENSE.


Deep Suture Management Q&A with Dr. Trott

When should I place deep sutures?

"Traditionally, deep subcuticular closure is reserved for deep lacerations where a superficial cuticular closure will not close the deep portion of the wound. It might leave behind an open space that can fill with blood or other wound exudate that is thought to increased the risk of infection or increased scar formation.

Deep closures are also used to reduce tension of the superficial, cuticular closure.

However, as is common in wound care, there is no definitive research, either bench or clinical, that can shed light on these techniques and their outcomes." - Trott

Are there any tricks of the trade that can improve wound healing when placing deep sutures?

"Effective, high pressure irrigation using a 20 cc syringe capped with a standard splash shield remains the most important step in cleaning deep wounds. Also, debriding contaminated or non-viable wound tissue is essential to minimize risk of infection.

To further decrease the incidence of wound infection when placing deep sutures, it is preferable to use monofilament, absorbable suture material such as Monocryl.  Braided suture material potentially has a higher risk of infection because of increased surface area of braiding.  Place as few deep sutures as needed to close the deep space or reduce wound tension.  In practice, I rarely use more than 3 deep closures per wound that does not need extensive repair. If the wound is deep, but not too deep, consider a vertical mattress which has both a deep and superficial configuration.

When in doubt, leave them out.  The body has remarkable healing powers without unnecessary interventions." - Trott


Reference

1. Trott AT. “Wounds and Lacerations: Emergency Care and Closure” Fourth Edition. 2012