By Carey Alexander Clark, III, MD

The following technique was developed from my attempt to decrease surgical closure time, hasten the suture removal process, and create a better experience for my patients during their first post op visit.

Choosing an efficient way to close larger volar and dorsal wrist wounds was my challenge. The dermis is very thin and often there is no subcutaneous fat. Absorbable subcutaneous sutures can create small thickened areas along the suture line that can be both tender and cosmetically displeasing. Occasionally the subcutaneous suture can “spit” generating additional clinic visits and patient concern. So with that in mind I frequently close the skin with a single layer suture. I have settled upon a running horizontal mattress using a 5-0 nylon. I tried prolene but it did not perform as well. A subcuticular suture doesn’t get any bite and adding steristrips can cause blisters from swelling. Individual mattress sutures are used once or twice if proximal to a drain for protection during drain removal however after that I have found the running horizontal mattress suture to be fast, strong, and provide an aesthetically pleasing scar.

This, however, created a problem with suture removal. My MA is instructed to cut the knot and grab the suture every few throws, to pull it out , and to cut the suture along the way. It is hard separating the skin from the suture. The 5-0 is so small and the throws are every few millimeters. My MA ends up having to dig the suture away from the skin. Even when I would throw a simple loop across the suture line it was still a painful experience. The process took far too much time in clinic. Rooms needed to be filled and I would stick my head in to check on my MA only to find both MA and patient often holding their breath while removing sutures, no matter what kind of scissors we tried. Not good.

My personal solution was to add “whiskers” to the closure. At regular intervals upon closure I will incorporate a piece of suture (Figure 1).

I often use undyed 2-0 absorbable suture, but I am not sure that it really matters. Now, when the patient returns for suture removal, my MA has something to use. The MA will cut the end knot, grasp both sides of the suture “whisker” and gently pull the nylon out, cutting it after advancing. I have found this to save both my patient and MA a lot of time and anxiety creating a better first post-op visit experience.