How to Sew Like a Pro

Written by Clay Smith

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Suturing of facial lacerations by novice physicians resulted in less cosmetically favorable repair than experienced physicians.

Why does this matter?
Lacerations are our bread and butter.  We need to be wound care experts.  Cosmetic outcome is very important to our patients.  Since experts had better outcomes, what can we learn from them?  Here are some tips to sew like a pro.

Sew like a pro
In this retrospective review of 66 facial lacerations, 22 repaired by novices (n=6 doctors) and 44 by experts (n=6 doctors), cosmetic outcome was measured at 5-10 days after suture removal using the Stony Brook Scar Evaluation Scale (SBSES; 0=worst scar, 5=best scar).  Novices had a lower (worse) median score of 3.  Experts had a median score of 5 (best) despite the wounds being longer and more complex than those closed by the novices.  There were several issues with this study. It was not clear if the scar evaluators were blinded to who did the repair, which would be critical in avoiding bias.  Also, the number of lacerations included was small, number of total physicians was small, and it was single-center.  Finally, long-term cosmetic outcome was not assessed.  Here were the take home tips for the best scar.

  1. Proper wound tension - Sutures 2-3mm from the edge are best. Wide bites make hatch marks. Wound edema makes for loose sutures later.  Tight sutures cause wound edge ischemia.  Wound tension is the most important determinant of scarring.
  2. Match layers - Match each wound layer precisely and close layers separately.
  3. Evert edges - Eversion of epidermal wound edges creates a smooth scar rather than dimpling in and making a shadow.
  4. Atraumatic handling - Wound edges must be handled very gently and crushing avoided.
  5. Trim/debride as needed - Devitalized, jagged, or contaminated wounds need debridement or trimming.  This technique was used twice as often by the experts compared to the novices.

Source
What are the key elements in suture education? Comparison of cosmetic appearances after facial lacerations repaired by junior residents and experts.  Am J Emerg Med. 2018 Jul 24. pii: S0735-6757(18)30624-7. doi: 10.1016/j.ajem.2018.07.044. [Epub ahead of print]
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Reviewed by Thomas Davis

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