Ensure that incision with a scalpel occurs at a 90° angle to the skin so that the wound edges may be approximated easily with the first attempt at tying a knot. If needed, de-bevel wound edges with a #15 blade or scissors (Fig. 9.2).

Sutures are placed in a hurried fashion in a bloody wound bed (Fig. 9.3).

Perform meticulous hemostasis prior to suturing (Fig. 9.4).

Suturing on delicate tissue with large instruments. Using inappropriate equipment can result in poor outcomes that may need future revision.

When suturing around the eye or on other fragile tissue, the spring-loaded Castroviejo needle driver may allow for enhanced precision and a more delicate feel.

A small caliber suture is used on a wound under high tension. The suture breaks due to tension mismatch, resulting in unanticipated recoil of the arms during cinching of the knot. This can result in a needle stick. After the suture ruptures, another attempt must be made, thus increasing the possibility of a needle stick.

The type and size of suture(s) selected should be determined by the anatomic location, the size of the defect, and the amount of anticipated tension on the wound. The smallest caliber deep suture that will relieve the most tension should be used (i.e., 3-0 caliber on torso, 5-0 caliber on face).

A simple cuticular suture is used to repair a full-thickness defect under tension.

As a rule of thumb for full-thickness defects, tension should be relieved by deep, buried vertical mattress sutures.

A monofilament cuticular suture is used on thin, atrophic sun-damaged skin. If the closure is under tension, the suture may tear through the skin.

Relieve tension with appropriate dermal sutures.

Use braided sutures to close the epidermal portion of the defect.

Attempting to reshape a bent suture needle to its original form (Fig. 9.5).

Discard the damaged needle and get a new one.

A small needle driver (e.g., Webster or Halsey) (Fig. 9.6) is used with a large caliber suture needle (e.g., 3-0). The jaws of the delicate needle driver will deform over time and not be able to grip smaller suture needles (Fig. 9.7). This can result in the needle’s twisting within the needle driver. Repositioning of the now obliquely placed needle increases the risk of injury.

Critically think about the instruments before placing them on the surgical tray. In general, sturdy instruments/materials are necessary for skin of the torso and proximal extremities while fine instruments/materials are necessary for delicate areas such as the face. Large excisions on the back call for a Baumgartner needle driver with a large caliber suture (e.g., 3-0) to minimize twisting of the needle in the instrument. Likewise, wounds on the face call for a Webster needle driver and a smaller caliber suture (e.g., 5-0 or 6-0).

The needle is pulled out of the suture packet by grabbing the swage or suture material (Fig. 9.8). This forces unnecessary needle handling.

The needle driver should grasp the needle out of the packet one-half to three-quarters proximal from the point. The manufacturer packaging facilitates this optimal gripping.

Readjusting the needle by grasping the tip with the fingers (Fig. 9.9).

The needle driver should intervene between the point and the fingers holding the swage (Fig. 9.10).

A finger or thumb is placed in the path of the needle in an attempt to stabilize the skin being sutured (Fig. 9.11).

Gently use an instrument (forceps or skin hook) to handle and evert tissue in order to create an adequate target for the suture needle (Fig. 9.12).

Skin hooks are used unsafely during suturing. While skin hooks decrease crush injury to the epidermis and facilitate eversion of wound edges, they are an additional sharp on the surgical tray and they force the surgeon to grasp the needle with the fingers in order to reload.

Be mindful of the hook’s presence while operating.