{"id":292,"date":"2020-08-13T17:40:36","date_gmt":"2020-08-13T17:40:36","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=292"},"modified":"2020-08-13T17:40:36","modified_gmt":"2020-08-13T17:40:36","slug":"suturing","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/technical-skills\/suturing\/","title":{"rendered":"1.02 Suturing"},"content":{"rendered":"<p><iframe loading=\"lazy\" width=\"560\" height=\"315\" src=\"https:\/\/www.youtube.com\/embed\/TFwFMav_cpE\" frameborder=\"0\" allow=\"accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture\" allowfullscreen><\/iframe><\/p>\n<p>Duration 19:44<\/p>\n<input type='hidden' bg_collapse_expand='69e9dd61709596039212100' value='69e9dd61709596039212100'><input type='hidden' id='bg-show-more-text-69e9dd61709596039212100' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9dd61709596039212100' value='Hide Transcript'><button id='bg-showmore-action-69e9dd61709596039212100' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9dd61709596039212100' ><\/p>\n<p>00:06<br \/>\nhi welcome to the Duke suture skills<br \/>\n00:09<br \/>\ncourse my name is Michael Zen and on the<br \/>\n00:13<br \/>\ndirector of the human tissue lab here at<br \/>\n00:14<br \/>\nDuke this course will teach you the<br \/>\n00:17<br \/>\nbasics in suture technique we&#8217;ll review<br \/>\n00:20<br \/>\nsimple suture mattress suture running<br \/>\n00:24<br \/>\nsuture and some of the variations and<br \/>\n00:26<br \/>\nproper surgical technique it&#8217;s our goal<br \/>\n00:30<br \/>\nthat by teaching you proper technique<br \/>\n00:33<br \/>\nyou&#8217;ll be the best surgical resident or<br \/>\n00:35<br \/>\nsurgeon that you can be before we get<br \/>\n00:39<br \/>\nstarted I&#8217;d like to thank G in the<br \/>\n00:40<br \/>\noffice at Duke for their generous grant<br \/>\n00:42<br \/>\nthat made this video possible<br \/>\n00:52<br \/>\nbefore get started showing you different<br \/>\n00:55<br \/>\nsuture techniques I want to show you a<br \/>\n00:57<br \/>\nbasic instrument I this can be used with<br \/>\n00:59<br \/>\nany of the suture techniques that you&#8217;ll<br \/>\n01:01<br \/>\nlearn once the suture is placed you&#8217;ll<br \/>\n01:03<br \/>\nhave a short end and then a longer loop<br \/>\n01:06<br \/>\nend your needle driver should be placed<br \/>\n01:09<br \/>\ndirectly between the two and then we<br \/>\n01:12<br \/>\nwill do a surgeon&#8217;s knot you&#8217;ll wrap<br \/>\n01:14<br \/>\nthere&#8217;s a longer end twice around the<br \/>\n01:16<br \/>\nneedle driver grab the smaller end and<br \/>\n01:20<br \/>\npull it to the opposite side and what<br \/>\n01:23<br \/>\nwill happen when you pull it to the<br \/>\n01:24<br \/>\nopposite side it will square the knot<br \/>\n01:27<br \/>\nand you can see how square the knot sits<br \/>\n01:29<br \/>\ndown now because it&#8217;s a surgeon&#8217;s knot<br \/>\n01:31<br \/>\nit&#8217;ll sit unless you pull up on it so<br \/>\n01:35<br \/>\ndon&#8217;t pull up on it place the needle<br \/>\n01:37<br \/>\ndriver between the two the short end and<br \/>\n01:39<br \/>\nthe loop end now you&#8217;re going to loop it<br \/>\n01:41<br \/>\naround only once<br \/>\n01:42<br \/>\ngrab the short end and then bring it to<br \/>\n01:45<br \/>\nthe opposite side again squaring the<br \/>\n01:48<br \/>\nknot and don&#8217;t pull up on the suture<br \/>\n01:50<br \/>\nuntil you just get it down and then you<br \/>\n01:52<br \/>\ncan tighten it and now it&#8217;s locked in<br \/>\n01:54<br \/>\nplace I recommend at least three throws<br \/>\n01:56<br \/>\ninstrument between bring the small to<br \/>\n01:59<br \/>\nthe other side and done some suture<br \/>\n02:01<br \/>\nmaterial you may need four throws<br \/>\n02:03<br \/>\nsomething maybe like an absorbable<br \/>\n02:04<br \/>\nsuture but this is a very basic<br \/>\n02:07<br \/>\ntechnique it allows you to suture in a<br \/>\n02:10<br \/>\nsmall place so if multiple people are<br \/>\n02:12<br \/>\nworking and will do one more for you<br \/>\n02:14<br \/>\nright here you can suture notice I like<br \/>\n02:17<br \/>\nto keep this short and very short your<br \/>\n02:19<br \/>\ninstrument doesn&#8217;t move around very much<br \/>\n02:21<br \/>\nthen keep the needle driver between the<br \/>\n02:23<br \/>\ntwo grab the small end pull it to the<br \/>\n02:26<br \/>\nopposite side square and you&#8217;re not lock<br \/>\n02:29<br \/>\nit down with that surgeon&#8217;s knot don&#8217;t<br \/>\n02:31<br \/>\npull up on it now until you now grab<br \/>\n02:33<br \/>\nthis and then pull it through for the<br \/>\n02:35<br \/>\nsecond time and now it locks down needle<br \/>\n02:39<br \/>\ndriver between the two wrap once pull<br \/>\n02:42<br \/>\nthrough the opposite side and keep that<br \/>\n02:44<br \/>\nknot nice and square square nuts will<br \/>\n02:46<br \/>\nnot untie also will look cosmetically<br \/>\n02:49<br \/>\nmore appealing<br \/>\n02:57<br \/>\nthe first suture we&#8217;re going to teach<br \/>\n02:58<br \/>\nyou is the simple interrupted suture<br \/>\n03:01<br \/>\nthis is the most common suture that<br \/>\n03:03<br \/>\nyou&#8217;ll be using and wound closure just a<br \/>\n03:05<br \/>\nquick tip on handling a needle you&#8217;ll<br \/>\n03:07<br \/>\nnotice your needle has a flat portion in<br \/>\n03:09<br \/>\nthe middle this is where you grab the<br \/>\n03:10<br \/>\nneedle with your needle driver you don&#8217;t<br \/>\n03:13<br \/>\nwant to grab it at the end where the<br \/>\n03:14<br \/>\nsuture comes in or the swedge because<br \/>\n03:16<br \/>\nit&#8217;s round and you&#8217;ll be unstable never<br \/>\n03:19<br \/>\ngrab the needle at the tip because<br \/>\n03:21<br \/>\nyou&#8217;ll dull it a simple bike will want<br \/>\n03:24<br \/>\nto enter the skin at 90 degrees and<br \/>\n03:26<br \/>\nwe&#8217;ll go back a few millimeters from the<br \/>\n03:28<br \/>\nskin edge and take a nice bite<br \/>\n03:30<br \/>\nperpendicular to the skin and then on<br \/>\n03:32<br \/>\nthe opposite side the same and<br \/>\n03:34<br \/>\nexaggerate that 90 degrees if you take<br \/>\n03:36<br \/>\nit at 90 degrees the skin edges will<br \/>\n03:38<br \/>\nthen Evert and come together nicely here<br \/>\n03:41<br \/>\nwe&#8217;ll set up a instrument tie and you<br \/>\n03:45<br \/>\ncan see here again we do three throws<br \/>\n03:49<br \/>\nfor nylon and we&#8217;ll go ahead and clip<br \/>\n03:51<br \/>\nthis this is approximation without<br \/>\n03:55<br \/>\ntension you want to go back a couple<br \/>\n03:57<br \/>\nmillimeters for each bite if you go back<br \/>\n04:00<br \/>\ntoo far it&#8217;ll tend to invert the skin<br \/>\n04:03<br \/>\nand we want to avoid that<br \/>\n04:05<br \/>\nso here again exaggerate the 90 degrees<br \/>\n04:07<br \/>\non each side to make sure that we are<br \/>\n04:09<br \/>\nback the same distance on each side an a<br \/>\n04:13<br \/>\ninstrument tie we do a surgeon&#8217;s knot<br \/>\n04:15<br \/>\nfor the first we cross the suture over<br \/>\n04:18<br \/>\nlay it down nice and flat don&#8217;t pull up<br \/>\n04:20<br \/>\non it until we get the second suture<br \/>\n04:22<br \/>\ndown and tighten it and lock it in so<br \/>\n04:25<br \/>\nthis is the simple suture it&#8217;s something<br \/>\n04:28<br \/>\nthat you&#8217;ll need to practice a lot to<br \/>\n04:29<br \/>\nmaster<br \/>\n04:36<br \/>\nnext is a simple buried suture this will<br \/>\n04:39<br \/>\nbe the main suture you&#8217;ll use when<br \/>\n04:41<br \/>\nputting some deeper sutures in before<br \/>\n04:43<br \/>\nputting your skin suture in it&#8217;s<br \/>\n04:46<br \/>\nimportant to bury a suture that we start<br \/>\n04:48<br \/>\ndeep and go superficial and end up in<br \/>\n04:52<br \/>\nthe dermis without buttonholing the skin<br \/>\n04:54<br \/>\nand then on the opposite side we&#8217;re<br \/>\n04:56<br \/>\ngonna do the opposite we&#8217;re gonna go<br \/>\n04:58<br \/>\nsuperficial and then deep and if you<br \/>\n05:01<br \/>\nwant your not to bury it&#8217;s important<br \/>\n05:03<br \/>\nthat both ends are on the same side of<br \/>\n05:06<br \/>\nthe loop you see here&#8217;s my loop and<br \/>\n05:08<br \/>\nhere&#8217;s the suture coming out from the<br \/>\n05:10<br \/>\nsame side and as we tie this down we&#8217;ll<br \/>\n05:15<br \/>\ndo an instrument tie but we&#8217;ll pull it<br \/>\n05:16<br \/>\nalong the length of the wound and<br \/>\n05:18<br \/>\nthat&#8217;ll help the skin adjust to come<br \/>\n05:19<br \/>\ntogether and do a nice instrument tie<br \/>\n05:24<br \/>\nand what this does is it takes the<br \/>\n05:26<br \/>\ntension off the skin so that when you go<br \/>\n05:30<br \/>\nto do your skin closure you really can<br \/>\n05:31<br \/>\nwork on approximation you can see here<br \/>\n05:33<br \/>\nthat helps hold that together let&#8217;s go<br \/>\n05:36<br \/>\nahead and do one more you&#8217;re gonna go<br \/>\n05:40<br \/>\nfrom deep superficial without button<br \/>\n05:43<br \/>\nhauling the skin and then go from<br \/>\n05:46<br \/>\nsuperficial to deep make sure that<br \/>\n05:49<br \/>\nyou&#8217;re coming out on the same side of<br \/>\n05:50<br \/>\nthe loop<br \/>\n05:55<br \/>\nand we&#8217;ll do our instrument tie and<br \/>\n05:56<br \/>\nwe&#8217;ll pull it along the length of the<br \/>\n05:58<br \/>\nwounds so it&#8217;ll allow it to bury come<br \/>\n06:01<br \/>\nback to the other side and back to the<br \/>\n06:04<br \/>\nother side that is our simple<br \/>\n06:09<br \/>\ninterrupted buried suture<br \/>\n06:18<br \/>\nnext is the vertical mattress suture<br \/>\n06:20<br \/>\nFurcal mattress suture is a very useful<br \/>\n06:23<br \/>\nsuture<br \/>\n06:24<br \/>\nespecially when wounds are hard to close<br \/>\n06:25<br \/>\nif they&#8217;re under a lot of tension or<br \/>\n06:27<br \/>\nmaybe there&#8217;s a lot of swelling or you<br \/>\n06:29<br \/>\nanticipate swelling<br \/>\n06:30<br \/>\nit&#8217;s especially valuable when skin is<br \/>\n06:32<br \/>\njust want to keep rolling in and you<br \/>\n06:33<br \/>\nwant to even some we&#8217;ll call this the<br \/>\n06:36<br \/>\nfar far near near stitch and this is the<br \/>\n06:38<br \/>\nconfiguration of your suturing we&#8217;re<br \/>\n06:40<br \/>\ngonna enter far from the wound travel<br \/>\n06:42<br \/>\nunder the skin come out far and then<br \/>\n06:45<br \/>\ncome back and go near near essentially<br \/>\n06:48<br \/>\nyou&#8217;re taking this part of the skin and<br \/>\n06:49<br \/>\nclosing it to this part of the skin and<br \/>\n06:51<br \/>\nthat&#8217;s the power of the suture simple<br \/>\n06:53<br \/>\nsuture is really relying on that much<br \/>\n06:54<br \/>\nsmaller area so we&#8217;ll start far and<br \/>\n06:58<br \/>\ntravel under the skin and the same thing<br \/>\n07:02<br \/>\non the other side and we&#8217;ll turn our<br \/>\n07:05<br \/>\nneedle around and now we&#8217;ll go near and<br \/>\n07:08<br \/>\nnear and what you&#8217;ll see when we tie<br \/>\n07:13<br \/>\nthis down is that this approximates an<br \/>\n07:17<br \/>\naverse to skin edges and we can make it<br \/>\n07:19<br \/>\njust as tight as we want we have our<br \/>\n07:21<br \/>\ngranny knot that&#8217;ll hold it and we&#8217;ll<br \/>\n07:24<br \/>\nsquare our knots<br \/>\n07:27<br \/>\nso I&#8217;ll show you that one more time it&#8217;s<br \/>\n07:31<br \/>\na vertical mattress suture<br \/>\n07:36<br \/>\nfar far near there<br \/>\n07:47<br \/>\nand as you tie it down decide how much<br \/>\n07:50<br \/>\ntension you need do you hurt your skin<br \/>\n07:53<br \/>\nedges and hold things together<br \/>\n08:01<br \/>\nand that&#8217;s your vertical mattress<br \/>\n08:09<br \/>\nour next suture is the horizontal<br \/>\n08:11<br \/>\nmattress suture it&#8217;s configuration is<br \/>\n08:14<br \/>\nhorizontal as opposed to our vertical<br \/>\n08:16<br \/>\nmattress you can think of this as two<br \/>\n08:18<br \/>\nsimple sutures so in some of that since<br \/>\n08:21<br \/>\nit&#8217;s a simple suture it just saves you<br \/>\n08:23<br \/>\nsome time it&#8217;s important here that you<br \/>\n08:27<br \/>\nstay close to the skin edge and you are<br \/>\n08:28<br \/>\nthe same distance on both sides you&#8217;ll<br \/>\n08:31<br \/>\ntake your bite on one side and then the<br \/>\n08:34<br \/>\nother side and then you&#8217;ll turn it<br \/>\n08:37<br \/>\naround and you&#8217;ll go back so you&#8217;ll end<br \/>\n08:41<br \/>\nup on the same side and there you can<br \/>\n08:45<br \/>\nsee our mattress the advantage of this<br \/>\n08:48<br \/>\nis speed compared to doing simple suture<br \/>\n08:50<br \/>\nit doesn&#8217;t you&#8217;ve ER it as effectively<br \/>\n08:52<br \/>\nsometimes as a vertical mattress here<br \/>\n08:54<br \/>\nyou see the way I&#8217;ve placed it it&#8217;s<br \/>\n08:55<br \/>\nreverting nicely so that&#8217;s one example<br \/>\n09:01<br \/>\nof a horizontal technique a variant of<br \/>\n09:05<br \/>\nthis is the figure-of-eight suture the<br \/>\n09:08<br \/>\nfigure-of-eight suture is the same<br \/>\n09:11<br \/>\ndistribution<br \/>\n09:12<br \/>\nyou take your simple bite in your simple<br \/>\n09:14<br \/>\nbite but rather than turning the needle<br \/>\n09:16<br \/>\naround you move on and take your next<br \/>\n09:18<br \/>\nsimple bite and simple bite what that<br \/>\n09:22<br \/>\ndoes when you tie this it&#8217;ll make a<br \/>\n09:25<br \/>\nsmall little eight and that&#8217;s why it&#8217;s<br \/>\n09:27<br \/>\ncalled a figure of eight suture the<br \/>\n09:29<br \/>\nadvantage of this again is speed instead<br \/>\n09:32<br \/>\nof doing two simple sutures and tying<br \/>\n09:34<br \/>\ntwo simple sutures you&#8217;ll see that<br \/>\n09:36<br \/>\nsometimes in some deeper closures like<br \/>\n09:38<br \/>\nfascial closures because again you&#8217;re<br \/>\n09:40<br \/>\ngrabbing a bunch of tissue to a bunch of<br \/>\n09:42<br \/>\ntissue and therefore it&#8217;ll be more<br \/>\n09:45<br \/>\nsecure the final variant of the<br \/>\n09:48<br \/>\nhorizontal mattress is called a<br \/>\n09:50<br \/>\nhalf-buried mattress and we use this a<br \/>\n09:52<br \/>\nlot in plastic surgery if there&#8217;s an<br \/>\n09:55<br \/>\narea where you don&#8217;t want suture holes<br \/>\n09:56<br \/>\nyou can actually start your horizontal<br \/>\n09:58<br \/>\nmattress on one side on the opposite<br \/>\n10:01<br \/>\nside stay within the dermis in a<br \/>\n10:04<br \/>\nhorizontal fashion in a sub-q ticular<br \/>\n10:06<br \/>\nfashion and then come back on the other<br \/>\n10:09<br \/>\nside again out like you wouldn&#8217;t a<br \/>\n10:11<br \/>\nnormal horizontal mattress so<br \/>\n10:13<br \/>\neffectively it&#8217;s your horizontal<br \/>\n10:14<br \/>\nmattress but half of it is buried tends<br \/>\n10:17<br \/>\nto name the half bare<br \/>\n10:19<br \/>\nhorizontal mattress and when you tie<br \/>\n10:21<br \/>\nthis here it&#8217;ll secure the skin and you<br \/>\n10:25<br \/>\nonly have suture marks on one side<br \/>\n10:26<br \/>\nyou&#8217;ll see we&#8217;ll do this at times when<br \/>\n10:29<br \/>\nwe have a hair bearing area and an on<br \/>\n10:30<br \/>\nhand bearing area we want to hide the<br \/>\n10:32<br \/>\nsuture marks or if it&#8217;s a very end or<br \/>\n10:35<br \/>\ntip of a flap and we&#8217;re afraid that<br \/>\n10:36<br \/>\nputting sutures in the tip is gonna<br \/>\n10:38<br \/>\ninterrupt the blood supply so our three<br \/>\n10:41<br \/>\nvariants of a horizontal the straight<br \/>\n10:43<br \/>\nhorizontal mattress the figure of eight<br \/>\n10:45<br \/>\nand the half-buried horizontal mattress<br \/>\n10:54<br \/>\nour next stitch is a simple running<br \/>\n10:56<br \/>\nsuture this will be the most common<br \/>\n10:58<br \/>\nsuture you&#8217;ll use to close incisions<br \/>\n11:02<br \/>\nit&#8217;s a simple suture so again 90 degrees<br \/>\n11:06<br \/>\nand 90 degrees same bites on both sides<br \/>\n11:09<br \/>\nand you&#8217;ll start with an instrument<br \/>\n11:12<br \/>\ntying and try to save length on your<br \/>\n11:15<br \/>\nsuture here you also want to measure the<br \/>\n11:19<br \/>\nlength of your wound and not make sure<br \/>\n11:21<br \/>\nyou&#8217;re not working with such a long<br \/>\n11:22<br \/>\nsuture that it becomes unruly you&#8217;ll<br \/>\n11:28<br \/>\ntake you&#8217;ll advance on the wound in<br \/>\n11:30<br \/>\nsymmetric fashion again trying to take<br \/>\n11:34<br \/>\n90 degree bites each time try to move<br \/>\n11:38<br \/>\nalong at the same pace and same amount<br \/>\n11:41<br \/>\neach time almost mimicking a sewing<br \/>\n11:46<br \/>\nmachine<br \/>\n11:47<br \/>\nif you move along the same distance each<br \/>\n11:49<br \/>\ntime and take the same bites on each<br \/>\n11:51<br \/>\nside have a beautiful cosmetic closure<br \/>\n11:56<br \/>\npeople will ask well how much do you<br \/>\n11:58<br \/>\nmove along my answer is as long as it&#8217;s<br \/>\n12:01<br \/>\nthe same on both sides it&#8217;ll end up<br \/>\n12:04<br \/>\nlooking very nice so be consistent in<br \/>\n12:08<br \/>\nyour bites notice I&#8217;m exaggerating my 90<br \/>\n12:11<br \/>\ndegrees because I want this to e vert I<br \/>\n12:13<br \/>\nif I go too far back on the skin or I<br \/>\n12:15<br \/>\ntake too shallow a bite I&#8217;ll end up<br \/>\n12:18<br \/>\ninverting the skin and it won&#8217;t heal<br \/>\n12:19<br \/>\ncorrectly notice also I&#8217;m just pulling<br \/>\n12:22<br \/>\nup enough on the suture just so that the<br \/>\n12:24<br \/>\nskin edges touch pulling up on the<br \/>\n12:26<br \/>\nsuture very hard it&#8217;s just ischemic and<br \/>\n12:28<br \/>\ncan cause bad scarring I&#8217;ll end it with<br \/>\n12:31<br \/>\na simple little bite at the end make<br \/>\n12:35<br \/>\nsure we have enough tension along the<br \/>\n12:36<br \/>\nincision and then do our instrument tie<br \/>\n12:39<br \/>\nat the end<br \/>\n12:44<br \/>\nand this is a simple running closure<br \/>\n12:56<br \/>\na variation of the simple<br \/>\n12:58<br \/>\nsuture is the simple running locking<br \/>\n13:01<br \/>\nsuture we start off the same with simple<br \/>\n13:04<br \/>\nbites and a nice instrument tie<br \/>\n13:12<br \/>\nand this is a very helpful suture when<br \/>\n13:14<br \/>\nyou&#8217;re sewing under some tension<br \/>\n13:17<br \/>\nespecially when you don&#8217;t have an<br \/>\n13:18<br \/>\nassistant who can help hold the suture<br \/>\n13:20<br \/>\nfor you and follow you you&#8217;ll take your<br \/>\n13:24<br \/>\nsimple bites again 90 degrees 90 degrees<br \/>\n13:27<br \/>\nyou&#8217;ve hurt the skin edges but before<br \/>\n13:29<br \/>\nyou pull up you&#8217;ll make sure and<br \/>\n13:32<br \/>\nactually lock the suture and take your<br \/>\n13:36<br \/>\nsimple bite and simple bite and again<br \/>\n13:39<br \/>\nbefore pulling up the last little bit<br \/>\n13:41<br \/>\nyou&#8217;ll lock your suture and you can go<br \/>\n13:46<br \/>\non from here and the beauty of this is<br \/>\n13:48<br \/>\nthat you see although it&#8217;s loose here it<br \/>\n13:50<br \/>\nis locking back here and so when you&#8217;re<br \/>\n13:53<br \/>\nunder a lot of tension especially it&#8217;ll<br \/>\n13:58<br \/>\nhold for itself<br \/>\n13:59<br \/>\nnow sometimes I&#8217;ll do a running stitch<br \/>\n14:02<br \/>\nand I don&#8217;t plan on doing a running<br \/>\n14:03<br \/>\nlocking but at some point in the middle<br \/>\n14:06<br \/>\nof the suture it starts loosening on me<br \/>\n14:08<br \/>\nand then you can just throw in one of<br \/>\n14:09<br \/>\nthese locking sutures I always keep it<br \/>\n14:12<br \/>\nnice and tight<br \/>\n14:18<br \/>\nso it&#8217;s not a suture necessarily that<br \/>\n14:20<br \/>\nyou&#8217;ll use primarily because I think for<br \/>\n14:22<br \/>\nscoring purposes you prefer a regular<br \/>\n14:24<br \/>\nsuture and I will say also as you become<br \/>\n14:27<br \/>\nmore and more expert at suturing you&#8217;ll<br \/>\n14:29<br \/>\nbe able to control your simple suits<br \/>\n14:31<br \/>\nyou&#8217;re much better each time locking the<br \/>\n14:35<br \/>\nsuture and we&#8217;re going to end this with<br \/>\n14:38<br \/>\na simple stitch<br \/>\n14:45<br \/>\nand again when we tie this we want to<br \/>\n14:47<br \/>\nmain to make sure we have good tension<br \/>\n14:48<br \/>\non the rest of the suture<br \/>\n14:57<br \/>\nand that is our running walking suture<br \/>\n15:07<br \/>\nour next stitch is a running<br \/>\n15:08<br \/>\nsubcuticular sutures how do all those<br \/>\n15:11<br \/>\nsutures were teaching you this is<br \/>\n15:13<br \/>\nprobably the hardest to master this is<br \/>\n15:15<br \/>\nprobably for the most cosmetic closure<br \/>\n15:17<br \/>\nas they&#8217;re running within the dermis<br \/>\n15:20<br \/>\ndeeply so there&#8217;s no sutures on the<br \/>\n15:22<br \/>\noutside at all so you won&#8217;t see any of<br \/>\n15:24<br \/>\nthe railroad tracking that you would see<br \/>\n15:26<br \/>\nfrom any other outside sutures this is a<br \/>\n15:30<br \/>\nabsorb assuit sure and we will start by<br \/>\n15:32<br \/>\nburying the knot so I&#8217;ll go deep in the<br \/>\n15:35<br \/>\ncorner away from the skin maybe just a<br \/>\n15:38<br \/>\nvery deepest part of the dermis and<br \/>\n15:40<br \/>\nwe&#8217;ll do our instrument tie and this<br \/>\n15:42<br \/>\nallows the knot to be buried so we can<br \/>\n15:45<br \/>\nsuture over it this is important because<br \/>\n15:47<br \/>\nwe don&#8217;t want knots coming up to the<br \/>\n15:50<br \/>\nskin they can stick out it&#8217;s called<br \/>\n15:52<br \/>\nspitting patients do not like it when<br \/>\n15:55<br \/>\nthe knots bit now with knot is deep so<br \/>\n15:59<br \/>\nwe&#8217;re gonna go deep and we&#8217;re gonna come<br \/>\n16:00<br \/>\nsuperficial and that brings us right up<br \/>\n16:02<br \/>\nto the corner and this is where we&#8217;re<br \/>\n16:03<br \/>\ngonna start our so particularly run when<br \/>\n16:07<br \/>\nyou start to get close to a corner<br \/>\n16:09<br \/>\ndefinitely recommend smaller bites to<br \/>\n16:10<br \/>\nstart see I&#8217;m just within the dermis<br \/>\n16:12<br \/>\nhorizontal bites need to advance a<br \/>\n16:16<br \/>\nlittle bit on the other side and take<br \/>\n16:17<br \/>\nanother small bite against a wall within<br \/>\n16:20<br \/>\nthe dermis<br \/>\n16:20<br \/>\nnow with this stitch Simoes asked us how<br \/>\n16:23<br \/>\nmuch do you advance each time what I<br \/>\n16:24<br \/>\nlike to do is to see here with my suture<br \/>\n16:27<br \/>\nwhere the next bite should be and that&#8217;s<br \/>\n16:29<br \/>\nwhere I&#8217;m going to put it so in some<br \/>\n16:31<br \/>\nsense it depends on how much tension<br \/>\n16:33<br \/>\nthere is on this wound there&#8217;s not a lot<br \/>\n16:35<br \/>\nof tension now we&#8217;re gonna start to take<br \/>\n16:38<br \/>\nregular bites on each side I&#8217;m trying to<br \/>\n16:39<br \/>\ntake the same depth and the same amount<br \/>\n16:41<br \/>\nof tissue each time as we begin to<br \/>\n16:45<br \/>\nadvance<br \/>\n16:47<br \/>\nkeep pulling everything up and keeping<br \/>\n16:49<br \/>\ntension<br \/>\n16:56<br \/>\nnotice I&#8217;m not pulling up very tight<br \/>\n16:58<br \/>\neither just getting the skin to<br \/>\n17:00<br \/>\napproximate no buttonholing of the skin<br \/>\n17:04<br \/>\nthis is just pure horizontal dermis<br \/>\n17:14<br \/>\nwants to come right there<br \/>\n17:23<br \/>\ncan get a good play the dermis<br \/>\n17:38<br \/>\nwants to come right there<br \/>\n17:48<br \/>\nand just like when we started as you<br \/>\n17:51<br \/>\nbegin to approach the corner you want to<br \/>\n17:54<br \/>\nstop taking such big bites and start<br \/>\n17:56<br \/>\ngoing to some smaller bites because you<br \/>\n17:58<br \/>\nreally want these skin edges to be well<br \/>\n18:00<br \/>\napproximated at the corner and not<br \/>\n18:02<br \/>\ncreate any dog ears we also want to bury<br \/>\n18:05<br \/>\nour knot so if we&#8217;re on a berry or not<br \/>\n18:07<br \/>\nwe have to start thinking about now<br \/>\n18:09<br \/>\nabout getting deep with both of the two<br \/>\n18:13<br \/>\nends that are gonna get tied so at this<br \/>\n18:15<br \/>\npoint here I&#8217;m superficial and I&#8217;m gonna<br \/>\n18:16<br \/>\ngo superficial on this side and then<br \/>\n18:19<br \/>\nhead deep that&#8217;ll get me down just sort<br \/>\n18:24<br \/>\nof where we started down deep and I&#8217;m<br \/>\n18:28<br \/>\ngoing to take one more bite that&#8217;s deep<br \/>\n18:31<br \/>\nnow I want to tie that and that&#8217;ll help<br \/>\n18:36<br \/>\nto bury the knot<br \/>\n18:46<br \/>\nand now what I&#8217;m gonna do to help bury<br \/>\n18:48<br \/>\nthe knot as well is to cut the short end<br \/>\n18:50<br \/>\nhere right on the edge of the knot and<br \/>\n18:52<br \/>\nnow take the needle and very that not<br \/>\n18:56<br \/>\nfurther so I&#8217;m gonna pick up here and<br \/>\n18:58<br \/>\nsee where that knots going I can come<br \/>\n19:00<br \/>\nout through the skin nearby and just<br \/>\n19:02<br \/>\nsimply pull up on this I can just cut it<br \/>\n19:05<br \/>\nflush with the skin that helps the duck<br \/>\n19:08<br \/>\nare not from our suture<br \/>\n19:12<br \/>\nthat concludes this course we at Duke<br \/>\n19:15<br \/>\nfeel strongly that excellent surgeons<br \/>\n19:17<br \/>\nbegin with excellent basic technique and<br \/>\n19:20<br \/>\nI hope you&#8217;ve learned some of that<br \/>\n19:21<br \/>\nduring this video come back often as you<br \/>\n19:24<br \/>\nbegin to perfect your own technique if<br \/>\n19:27<br \/>\nyou&#8217;d like to learn more about Duke<br \/>\n19:28<br \/>\nPlastic Surgery or the human tissue lab<br \/>\n19:30<br \/>\nhere at Duke visit us on the web at<br \/>\n19:33<br \/>\nPlastic Surgery duke.edu<\/p>\n<p><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Duration 19:44<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":781,"menu_order":102,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-292","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/292","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=292"}],"version-history":[{"count":0,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/292\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/781"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=292"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}