Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Stitches, Sutures, and Staples, Oh My! For the rest of the Mangled Mondays series, [click here].
First off, this title is a misnomer. That’s because sutures is the medical word for both stitches and the act of stitching.
The concept of sutures and staples for wound closure is a very simple one: in order for skin to properly heal, the edges of the skin must be held together. With shallow cuts, the tension of the underlying tissue, known as the fascia, may be enough to keep skin together for good healing, but for deeper cuts, this isn’t the case.
Sutures and staples help by making it easy for the skin to start to glom together.
Types of Closures
Traditional sutures themselves are an art form. Humans have been stitching themselves together with horsehair for ages, and “gut” stitches made from cat intestines were popular at one time. Today sutures are typically made from nylon, which must be removed, or dissolvable materials such as Vicryl.
Suture material is rated by size, from 5 (largest, used to stitch tendons together) to 10-0 (smallest, used for eye surgeries).
Muscles are typically sewn with a 4-0 dissolvable suture (such as Vicryl). Some body elements, such as abdominal walls and deep tissues, may have non-absorbable sutures used which will eventually simply become part of the area.
A rough guide for suture size:
10-0: Opththalmic (eye) surgery
7-0: Vascular (blood vessel) repair; facial plastic surgery
4-0: Skin with little tension over it, muscle tissue
2-0: Skin with a lot of tension over it (joints)
2: Deeper muscles (thigh, back), abdominal wall
Absorbable Suture Types:
Vicryl, Monocryl, Chromic
Non-Absorbable Suture Types:
Silk, Nylon, Prolene
The vast majority of wounds will get nylon sutures, with a few exceptions. Sutures placed in the mouth or in deep tissue are typically dissolvable, and eye sutures are almost always thin silk.
Absorbable sutures will typically dissolve over 2–4 weeks, depending on the suture type; however, their structural integrity reduces as the body dissolves them. This means that if the suture is going to fail, it will likely be about a week before the estimated dissolution date.
Interrupted, Purse String, or Running?
Sutures can be applied as individual stitches (known as simple interrupted sutures) or as running (continuous) sutures, which are faster to put in but more likely to fail.
Imagine a simple linear cut that requires six stitches to close. If the sutures are interrupted, if one portion of that suture fails, the other five remain intact. With a running stitch, if one of the stitches breaks, the entire suture job is at risk of coming apart. Thus, simple interrupted sutures are the most common.
Purse-string sutures are a type which endeavors to close a round hole with sutures or to stitch a tube into place. These are often used with small puncture wounds or to hold in place a chest tube or drainage tube.
Suture needles are usually curved, almost semicircular needles, which make it easier to come back out through the skin during the sewing.
If the provider putting in sutures is able to use it, lidocaine will numb the affected area and make it easier to clean the wound and close it. Characters may feel nothing, or may feel some pressure – but usually not pain – as the suture is placed.
If no lidocaine is available (or used), the receiving character will feel every insertion and exit of the needle. The sensation has been described as pinching. It’s a bit like getting a piercing… if the piercing happened over and over again in the same area that already hurts.
Healthcare providers, and indeed those trained in first aid, are often known to put in their own stitches. It’s painful, but it’s definitely doable, so long as both hands can reach the site that requires stitching.
Liquid sutures, in the form of cyanoacrylate (CA) glue, have been used as a wound closure off and on since the 1940s when the glues were first developed. In fact, superglue was developed as a medical product before it was commercially used as an adhesive. While there are many brand names and even generic liquid sutures available, the most common is called Dermabond, and providers may refer to all liquid suture by this name even if they’re using a different brand.
Many forms of CA glue can cause problems, but the glue was used in spray form in Vietnam to stanch severe bleeding, and was FDA approved in 1998 as wound closure material under the name Dermabond. It’s since become a favorite of quite a few ER physicians.
CA glues are typically used for smaller wounds, and Dermabond is marketed to replace any suture requiring 5-0 or smaller thread. The wounds seal very well, and the glue forms a hard, water-resistant cover on the outside of the wound. The wound can then be washed normally. Because the CA glue will come off as the skin eventually sheds, there is no need to remove these sutures.
This makes a liquid suture an ideal tool in austere and remote environments where medical help isn’t available, though it’s worth noting that suturing is one of the lowest-tech and most portable forms of first aid available.
When liquid sutures are applied, the wound is prepped in the typical way and held together, then the adhesive is applied. The character has to be careful to let the glue air-dry, because CA glue is notorious for adhering to anything, and may embed cloth in the wound.
One thing to know is that the typical hardware-store CA glues have a tendency to irritate and burn, due to an exothermic reaction with natural tissues, but will work for your characters in a pinch; the medical-specific forms of CA glue do not have this drawback. Various products are available over-the-counter as of this writing, including Liquid Skin, Liquid Stitch, and Vet Bond.
One benefit of liquid sutures is that they are extremely easy to apply, making them an excellent choice for field closure of a wound for characters who lack access to someone who’s skilled in suture placement.
Staples have become a common wound closure tool, especially in the emergency department. They’re ideal for closing scalp wounds: they go in more quickly than sutures, don’t require the head to be shaved, and are easy to remove.
When the staples go in they’ll feel like pressure; when the staples come out they’ll feel like pressure and then relief. Staples must be removed with a special tool to avoid bending them during removal and thus damaging skin.
Staples and sutures are almost always placed under local anesthesia. This is usually a solution of 1% lidocaine (or lidocaine with epinephrine), which is injected under the skin with a very small needle about 2 minutes prior to any skin procedure.
In some cases an anesthetic cream, such as EMLA (lidocaine + prilocaine) or LET (lidocaine + epinephrine + tetracaine), is used about 40 minutes prior to wound repair and left to anesthetize the skin. This is particularly common in pediatric care. LET is safe to apply into the meat of the wound with a swab; EMLA is not, and is applied to the surrounding skin.
Circular Wound? Enlarge It.
Typically, circular wounds like gunshot wounds (in cases where no major underlying damage has occurred) or shallow stab wounds can be sutured closed. However, oftentimes the provider closing the wound will actually cut the skin surrounding the wound.
The goal is to make a circle behave like a line. Circular closures tend to do poorly, while laceration closures do well; thus, a scalpel will be used to make two 1–2cm incisions in opposite directions from the wound. The wound will then be closed as described above.
Larger wounds, particularly deep wounds with missing flesh, will be discussed in the next section.
Scalp Wounds and the HAT Trick
The Hair Apposition Technique, or HAT trick, is one additional method of closing a wound over a hairy area such as the scalp. Hairs on each side of the wound are rolled, then twisted together to hold the wound closed; a drop of liquid suture is used to hold the makeshift suture in place. This is repeated multiple times as a suture would be.
This technique is especially valuable in the austere environment. Because the glue can be applied to the hair and not the wound, commercially-available superglues can be used rather than medical-grade liquid suture.
That about wraps up this post!
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.
The book will be out 10/23, just in time for NaNoWriMo!