sensation or pain when a sharp object is gently applied
to the skin.
Administering local anesthesia is similar except
you are anesthetizing nerves immediately adjacent to
where you will be working instead of nerve trunks.
There are two generally accepted methods of
infiltrating the anesthesia. One is through the skin
surrounding the margin of the wound and the other is
through the wound into the surrounding tissue. In
either case, sufficient quantities must be infiltrated to
effect anesthesia approximately ½ inch around the
wound, taking care not to inject into a vein or artery.
CAUTION: The maximum recommended
amount of Xylocaine to be used is 50 cc for a
1% solution or the equivalent.
General Principles of Wound Suturing
Wounds are closed either primarily or secondarily.
A primary closure takes place within a short time of
when the wound occurs, and it requires minimal
cleaning and preparation. A secondary closure, on the
other hand, occurs when there is a delay of the closure
for up to several days after the wound's occurrence. A
secondary closure requires a more complex procedure.
Wounds 6 to 14 hours old may be closed primarily if
they are not grossly contaminated and are meticulously
cleaned. Wounds 14 to 24 hours old should not be
closed primarily. When reddening and edema of the
wound margins, discharge of pus, persistent fever, or
toxemia are present, do not close the wound.
Do not use a primary closure for a large, gaping,
soft-tissue wound. This type of wound will require
warm dressings and irrigations, along with aseptic care
for 3 to 7 days to clear up the wound. Then a secondary
wound closure may be performed.
The steps to perform a delayed wound closure are
1. Debride the wound area and convert circular
wounds to elliptical ones before suturing.
Circular wounds cannot be closed with
satisfactory cosmetic results.
2. Try to convert a jagged laceration to one with
smooth edges before suturing it. Make sure that
not too much skin is trimmed off; that would
make the wound difficult to approximate.
3. Use the correct technique for placing sutures.
The needle holder is applied at approximately
one-quarter of the distance from the blunt end of
the needle. Suturing with a curved needle is
done toward the person doing the suturing.
Insert the needle into the skin at a 90 angle, and
sweep it through in an arclike motion, following
the general arc of the needle.
4. Carefully avoid bruising the skin edges being
sutured. Use Adson forceps and very lightly
grasp the skin edges. It is improper to use
dressing forceps while suturing. Since there are
no teeth on the grasping edges of the dressing
forceps, the force required to hold the skin
firmly may be enough to cause necrosis.
5. Do not put sutures in too tightly. Gentle approxi-
mation of the skin is all that is necessary. Remember
that postoperative edema will occur in and about the
wound, making sutures tighter. Figure 4-33
illustrates proper wound-closure techniques.
6. If there is a significant chance that the sutured
wound may become infected (e.g., bites,
delayed closure, gross contamination), place an
iodoform (anti-infective) in the wound. Or
place a small rubber drain in the wound, and
remove the drain in 48 hours.
7. When suturing, the best cosmetic effect is
obtained by using numerous interrupted simple
sutures placed 1/8 inch apart. Where cosmetic
result is not a consideration, sutures may be
slightly farther apart. Generally, the distance of
the needle bite from the wound edges should be
equal to the distance between sutures.
8. When subcutaneous sutures are needed, it is
proper to use 4-0 chromic catgut.
9. When deciding the type of material to use on
skin, use the finest diameter that will satis-
factorily hold the tissues. Table 4-4 provides
guidance as to the best suture to use in selected
10. When cutting sutures, subcutaneous catgut
should have a 1/16-inch tail. Silk skin sutures
should be cut as short as is practical for removal on
the face and lip. Elsewhere, skin sutures may have
longer tails for convenience. A tail over ¼ inch is
unnecessary, however, and tends to collect
11. The following general rules can be used in
deciding when to remove sutures:
a. Face: As a general rule, 4 or 5 days. Better
cosmetic results are obtained by removing
every other suture and any suture with