Myofascitis

Acute traumatic myofascitis is a very painful condition that can affect any area
of the body. The most prevalent area affected is the area over the shoulder bla
de (scapula). This muscle pain syndrome will affect almost everyone at one time
or another. Very often this condition will be misdiagnosed as being related to a
rthritis. Acute traumatic myofascitis is not due to arthritis and is a myalgia,
meaning muscle pain.
Very often the trauma causing a myofascitis can be of such a minimal degree that
it can be unrecognized at the time of occurrence. At other times the individual
will be quite aware of it happening due to the severity of the trauma. The occu
rring pain can be on a scale of 1 to 10, from slight to severe, again depending
on the trauma sustained.
The pain can start on the low number of the scale and if left unattended, it can
become more painful as time goes on. The longer the pain exits, inflammation an
d possible swelling and redness of the tissues will become a serious factor in t
he condition. Inflammation is the body’s response to tissue damage. There is als
o a very good chance that at this stage the condition can become chronic. As thi
s develops into the chronic stage, treating the condition becomes more difficult
and can take longer to resolve.
Several areas of the body can be affected at the same time. Should this occur, t
he condition might be diagnosed as polymyositis, an inflammation of many muscles
? In the older patient it is often called polymyalgia rheumatica. Muscles are co
vered by sheets of tissue, and is called fascia, a fibrous tissue. The fascia fa
cilitates the movement of the muscles between other structures. When the inflamm
ation occurs in the fascia it is called fibrositis. An injury can occur affectin
g only the fascia and not the muscle itself. An injury or damage to the fascia w
ill impact the movement of the underlying muscle. There are many types of injuri
es that can cause an acute traumatic myofascitis. There are several ways these i
njuries can occur. An example would be pushing an object, pulling an object, rea
ching above your head for something, lifting a package (no matter how light), or
even a whiplash injury. Household chores, gardening, etc. can also be a source
of getting injured. Occupations where repetitive actions are necessary are ferti
le ground for injuries to muscles.
When an injury occurs, a “knot” forms in the muscle itself. This knot is called
a “trigger point”. A trigger point can cause pain, not only at the injured site,
but can also send a radiating pain to points emanating far from the site that w
as injured. A pain caused by a trigger point in the area of the shoulder blade (
scapula), top of the shoulder or upper arm, can cause pains radiating into the c
hest. Very often these pains have been mistaken for heart problems and even a po
ssible heart attack. Trigger points can also be caused by poor posture, lack of
exercise, repetitive motion injuries and even poor nutrition.
As previously mentioned, inflammation is natures first step to the healing proce
ss. When this occurs, there is a proliferation of certain cells called “fibrobla
sts” that act as patches to the injured muscle fibers, much like a patch on a le
aking tire tube. These patches result in the formation of scar tissue and adhesi
ons, causing the loss of flexibility of normal muscle tissue. As the healing pro
cess progresses, the muscle will lose its full range of motion because of the sc
ar tissue formation and adhesions.
Treatment at the earliest stages of an injury is extremely important so that pre
vention of the scar tissues and adhesions will be lessened or completely prevent
ed. It is therefore advisable to see your healthcare provider as soon as possibl
e. The longer the condition is left unattended, the greater the possibility of e
xtensive scar tissue and adhesions forming, and a greater loss of normal range o
f motion. At this stage, more extensive treatment will become necessary to resto
re normalcy. Treatments by the healthcare provider, may consist of several types
of treatment such as, electric muscle stimulation (EMS), ultrasound (US), and m
assage therapy. If the injury occurred within a 48-hour period, cold packs or ic
e massage may also be used. If, after the 48-hour period, heat packs (preferably
moist) can be used. The healthcare provider will also instruct the patient on s
tretching exercises to help prevent loss of range of motion and restore normal r
ange of motion.
The individual must also take an active role immediately after an injury and at
the onset of pain. Here too, they should use ice packs, or they can even apply i
ce massage to the injured area. This should be applied for 15 to 20 minutes on a
nd an hour off, several times daily. After the 48-hour period they should use he
at, preferably moist heat, applied 20 to 30 minutes, several times daily. From t
he onset of injury the patient should also use a good analgesic gel applied 3 to
4 times daily. This will prove very soothing and help relieve pain. It also inc
reases circulation to the injured area, helping the healing process to begin.
As the pain lessens, stretching exercises can be started, slowly at first and gr
adually increased as pain tolerance permits. The bottom line is that when an inj
ury occurs, it should not be ignored. First see your healthcare provider to have
it examined and evaluated. If they do not feel they have to take an active role
in treating the injury, then the patient should definitely follow through by tr
eating the condition as mentioned above. Many individuals will just take an atti
tude that in time it will just go away. True, the pain may lessen as time goes o
n, but there will definitely be remaining scar tissue and adhesions left to some
degree. Most of this is preventable by devoting a little time to your own care.
Necrosis (from the Greek νεκρός, "d ad") is th p
matu
d ath of c lls ad liv
ig tissu . N c
osis is caus d by xt
al facto
s, such as if ctio, toxis o

t
auma. This is i cot
ast to apoptosis, which is a atu
ally occu

ig caus
of c llula
d ath. Whil apoptosis oft  p
ovid s b  ficial ff cts to th o
ga
ism,  c
osis is almost always d t
im tal, ad ca b fatal.
C lls which di du to  c
osis do ot usually s d th sam ch mical sigals to
th immu syst m that c lls ud
goig apoptosis do. This p
v ts  a
by phag
ocyt s f
om locatig ad gulfig th d ad c lls, l adig to a build up of d ad
tissu ad c ll d b
is at o
 a
th sit of th c ll d ath. Fo
this
aso, i
t is oft   c ssa
y to
mov  c
otic tissu su
gically.
Caus s
C llula
 c
osis ca b iduc d by a umb
of xt
al sou
c s, icludig iju

y, if ctio,cac
, ifa
ctio, poisos, ad iflammatio. Fo
xampl , a i
fa
ctio (bloc ag  of blood flow to muscula
tissu ) caus s  c
osis of muscl t
issu du to lac of oxyg to th aff ct d c ll, such as occu
s i amyoca
dial

ifa
ctio -- a h a
t attac . C
tai spid
(b
ow
clus ) ad sa (
attl s
a , Both
ops) v oms ca caus  c
osis of th tissu  a
th bit woud, as
ca a G
oup A st
ptococcus if ctio (o of th "fl sh- atig" bact
ia).
N c
otic tissu do s ot ud
go th sam ch mical
actios that "o
mally" dyi
g apoptotic tissu do s. Th sudd  failu
of o pa
t of th c ll t
igg
s a

cascad of v ts. I additio to th lac of ch mical sigals to th immu sys
t m, c lls u d
goi g c
osis ca
l as ha
mful ch micals ito th su

oudi
   
g tissu . I pa
ticula
, c lls cotai small o
ga ll s call d lysosom s, which
a
capabl of dig stig c llula
mat
ial. Damag to th lysosom m mb
a ca
t
igg

l as of th cotai d zym s, d st
oyig oth
pa
ts of th c ll. Wo

s , wh  th s zym s a

l as d f
om th o-d ad c ll, th y ca t
igg
a
chai
actio of fu
th
c ll d ath. If a suffici t amout of cotiguous tissu
 c
otiz s, it is t
m d gag
 . P
op
ca
ad t
atm t of wouds o
aim

al bit s plays a y
ol i p
v tig this typ of wid sp
ad  c
osis. Du
ig
a su
gical biopsy, this  c
osis chai-
actio is halt d by fixatio o
f
zi
g.
N c
osis typically b gis with c ll sw llig, ch
omati dig stio, dis
uptio of
th plasma m mb
a ad o
ga ll m mb
a s. Lat  c
osis is cha
act
iz d by
xt  DNA hyd
olysis, vacuolatio of th doplasmic
ticulum, o
ga ll b

 siv
a dow , a d c ll lysis. Th
l as of it
ac llula
cot t aft
plasma m mb

 
a
uptu
is th caus of iflammatio i  c
osis.
Mo
phologic patt
s
Th
a
s v  distictiv mo
phologic patt
s of  c
osis:
Coagulativ  c
osis is typically s  i hypoxic (low oxyg ) vi
om
ts, such as a ifa
ctio. C ll outli s
mai aft
c ll d ath ad ca b obs

v d by lightmic
oscopy.
Liqu factiv  c
osis (o
colliquativ  c
osis) is usually associat d w
ith c llula
d st
uctio ad pus fo
matio ( .g. p umoia). This is typical of
bact
ial o
, som tim s, fugal if ctios b caus of th i
ability to stimulat
a iflammato
y
actio. Cu
iously, isch mia (
st
ictio of blood supply) i
th b
ai p
oduc s liqu factiv ,
ath
tha coagulativ ,  c
osis, du to th l
ac of ay substatial suppo
tiv st
oma.
Gummatous  c
osis is
st
ict d to  c
osis ivolvig spi
ocha tal if

ctio s ( .g.syphilis). 
Ha mo

hagic  c
osis is du to bloc ag of th v ous d
aiag of a o

 
ga o
tissu ( .g. i t sticula
to
sio ). 
Cas ous  c
osis is a sp cific fo
m of coagulatio  c
osis typically ca
us d bymycobact
ia ( .g. tub
culosis), fugi, ad som fo
ig substac s. It
ca b cosid
d a combiatio of coagulativ ad liqu factiv  c
osis.
Fatty  c
osis
sults f
om th actio of lipas s o fatty tissu s ( .g.
acut pac
atitis, b
ast tissu  c
osis).
 Fib
ioid  c
osis is caus
 d by immu
 -m diat d vascula
damag . It is m
a
d by d positio of fib
i -li p
ot i ac ous mat
ial i a
t
ialwalls, whic
  
h app a
s smudgy ad osiophilic o light mic
oscopy.
A
achog ic  c
osis
Spid
bit s a
cit d as causig  c
osis i som a
as, but such claims a
wi
d ly disput d. I th US, oly b
ow
clus spid
s (g usLoxosc l s) hav b 
p
ov  to cosist tly caus  c
osis.[1] Oth
spid
s of th sam g us, such
as th Chil a
clus i South Am
ica, hav simila
ly b  show to caus  c

osis i oth
cout
i s.[2][3]
Claims of  c
osis caus d by oth
spid
s' bit s a
commo, but suppo
tig vi
d c is lac ig. Coclusiv vid c is difficult to obtai, pa
tly b caus ma
y spid
bit s a
iitially pail ss ad thus th sp ci s go s uid tifi d, a
d pa
tly b caus may docto
s will p
mptiv ly
mov v  possibly  c
otic fl
sh


ath
tha
is fu
th
tissu damag . A f w spid
s commoly susp ct d (but o
t coclusiv ly p
ov ) of havig  c
otic v om iclud :
Hobo spid
i o
thw st
 USA[4]
Sac spid
i Uit d Stat s ad Aust
alia[5]
Whit -tail d spid
s i Aust
alia ad N w Z alad[6]
R clus spid

How v
, a study of 130 cofi
m d whit -tail d spid
bit s foud that  th ff c
ts w

lativ ly mild, ad coclud d that th i
bit is v
y uli ly to caus
 c
osis.[6]
T
atm t
T
atm t of  c
osis typically ivolv s two distict p
oc ss s. Usually, th u
d
lyig caus of th  c
osis must  b t
at d b fo
th d ad tissu itslf ca


b d alt with. Fo
xampl , a s a o
spid
bit victim will
c iv a ti-v
om to halt th sp
ad of th toxis, whil a if ct d pati t will
c iv ati
biotics.
Ev  aft
th iitial caus of th  c
osis has b  halt d, th  c
otic tissu
will
mai i th body. Th body's immu
spos to apoptosis, th automati
c b
a ig dow ad
cyclig of th c ll mat
ial, is ot t
igg
d by  c
otic
c ll d ath.
Th stada
d th
apy of  c
osis (wouds, b dso
s, bu
s tc.) is su
gical
mo
val of  c
otic tissu . D p dig oth s v
ity of th  c
osis, this may
ag
f
om
moval of small patch s of s i, to compl t amputatio of aff ct d limb
s o
o
gas. Ch mical
moval, via a zymatic d b
idig ag t, is aoth
optio
. I s l ct d cas s, sp cial maggot th
apy has b  utiliz d with good
sults
.
Fascia
Fascia (făsh'ē-ə), pl. fas•ci•a (făsh'ē-ē), adj. fascial (făsh'ē-əl) (f
om lati
: a bad) is th soft tissu compo t of th co ctiv tissu syst m that p

m at s th huma body. It it
p  t
at s ad su

ouds muscl s, bo s, o
gas,

v s, blood v ss ls ad oth
st
uctu
s. Fascia is a uit

upt d, th
-di

m sioal w b of tissu that xt ds f
om h ad to to , f
om f
ot to bac , f
om
it
io
to xt
io
. It is
sposibl fo
maitaiig st
uctu
al it g
ity; fo

p
ovidig suppo
t ad p
ot ctio; ad acts as a shoc abso
b
. Fascia has a
ss tial
ol ih modyamic ad bioch mical p
oc ss s, ad p
ovid s th m dium
that allows fo
it
c llula
commuicatio. Fascia fuctios as th body's s co
d li of d f s agaist pathog ic ag ts ad if ctios aft
th si[citat
io  d d]. Aft
iju
y, it is th fascia that c
at s a vi
om t fo
tiss
u
pai
.
Lay
s of th fascia
NA 1983 TA 1997 D sc
iptio Exampl
Sup
ficial fascia
This is foud i th subcutis i most
gios of th body, bl dig with
th
ticula
lay
of th d
mis. [3]
Fascia of Sca
pa
D p fascia
Fascia of muscl s
This is th d s fib
ous co ctiv tissu that it
p  t
at s ad su

ouds t
h muscl s, bo s, 
v s ad blood v ss ls of th body. T
asv
salis fa
scia

isc
al fascia
isc
al fascia,pa
i tal fascia
This susp ds th o
gas withi th i
caviti s ad w
aps th m i lay
s of co
ctiv tissu m mb
a s.
P
ica
dium
Th
a
may ci
cumstac s i which sutu
s a
us d to
pai
tissu ad fac
ilitat h alig. Th t chiqu s that you us , th sutu
mat
ial you us , ad t
h sp cific typ of  dl you us will va
y d p dig o wh th
you a
closi
g a simpl lac
atio o th foot, a compl x lac
atio o th fac , a gast
oit
stial aastomosis, a vascula
aastomosis, o
closig a m dia st
otomy.
Tissu R spos to Iju
y:
Th
Phas s of H alig
• h mostasis ad iflammatio
• fib
oplasia
• woud matu
atio
Th
is cosid
abl ov
lap amog th s phas s.
Phas I – H mostasis adIflammatio
With vascula
dis
uptio th
is t
asi t vasocost
ictio, follow d by vasodi
latatio ad ic
as d capilla
y p
m ability. Cotact of plat l ts with collag
 ad g
oud substac caus s activatio ad agg
gatio of plat l ts. Th it
i
sic ad xt
isic coagulatio cascad s a
t
igg
d, ad ch motaxis att
acts i
flammato
y c lls.

N ut
ophils, which a
th fi
st ucl at d c lls to com ito play, iitiat pha
gocytosis ad atimic
obial d f s , but by th 3
d o
4th day mac
ophag s hav

plac d th  ut
ophils as th domiat c ll typ .
• Mac
ophag s play a c t
al
ol i woud h alig. Th y
mov mic
ob s
a d c llula
d b
is th
ough phagocytosis ad zymatic b
a dow of th xt
ac l

lula
co ctiv tissu mat
ix, ad th y labo
at cyto i s which stimulat ag
iog  sis ad fib
oplasia.
Phas II – Fib
oplasia
Th iflammato
y
spos abat s as th iflammato
y stimuli a

mov d, ad th
fib
oplastic phas is usually w ll stablish d by th 5th day. Th
is fib
ob
last mig
atio ad p
olif
atio that is m diat d by a va
i ty of ch motactic fa
cto
s ad g
owth facto
s ( .g., fib
o cti, C5A, PDGF, ad FGF). As fib
oblasts
populat th woud, th y b gi to syth siz ad s c
t p
ot oglycas, collag
, ad lasti.

Th
is th  a g
adual d c
as i th siz of th woud as a
sult of woud c

ot
actio. I
spos to agiog ic stimuli,  w capilla
i s ivad th woud
ad la
g . At th sam tim , pith lial c lls b hid th woud dg p
olif
at
ad th
is mig
atio of th pith lial c lls ac
oss th collag  ad g
oud
substac at th su
fac of th woud.

Phas III – Matu
atio

Th matu
atio phas ivolv s
mod lig of th woudas a
sult of a it

play b tw  mat
ix syth sis ad d g
adatio. C
oss-li ig of collag  also
occu
s, ad ov
tim th
is a p
og
ssiv ic
as i t sil st
gth.

• At 2 w s th woud has achi v d about 20% of its p
-woud st
gth.
• By 5 w s it is at about 50%.
• By 10 w s it is at about 80% of p
-woud st
gth.
• R mod lig ad matu
atio of th sca
will cotiu fo
a y a
o
mo
.
Th P
i cipl s of Woud Closu
a
Dictat d by th Biology of H alig

• Miimiz bact
ial cotamiatio: Bact
ial cotamiatio ca b
duc d
by i

igatig th woud with la
g amouts of st
il sali o
Rig
’s soluti
on under moderate pressure. One method is to use a 50 cc syringe with a 16 or 18
gauge needle. Sterile saline can be aspirated, and a pulsatile irrigating strea
m can be created by depressing the plunger with force. Small wounds with little
contamination can be irrigated with 100-200 cc of saline, but larger volumes sho
uld be used for larger or more contaminated wounds. Generally, antiseptics shoul
d not be used to irrigate wounds, because they impair wound healing.
• Remove foreign bodies & devitalized tissue.
• Achieve hemostasis (blood is a culture medium).
• Handle tissue gently. Use fine-toothed forceps such as an Adson forceps;
do not use smooth forceps, since these crush tissue because they require greate
r pressure to grasp.
• Approximate; don’t strangulate. The wound edges should just be approxima
ted. Sutures that are too tight accentuate cross-hatching and cause ischemia of
the wound edges, increasing the risk of infection.
Handle Tissues Gently!
The goal of wound closure is to achieve healing with:
• no infection
• normal function
• an excellent cosmetic result
These goals are facilitated by handling tissues gently. As early as the 1500s a
barber- surgeon named Ambroise Paré demonstrated the importance of gentle handli
ng of tissue.
Needles
Most sutures come as a single piece, with the suture material swaged onto the ba
se of the needle. The needle should be grasped in the tip of the needle holder a
bout 2/3 of the way back from the point. Grasping further back at the swaged end
tends to weaken the needle and its attachment to the suture, and you are likely
to bend the needle.
There are many different needle types, but the chief distinction to be made here
is the difference between taper or “smooth” needles in contrast to cutting need
les. Taper needles do just what their name implies: they gradually taper to the
point, and a cross-section anywhere along the shaft would reveal a round shaft,
as shown in the inset. Taper needles are used for tissue that is easy to penetra
te, such as bowel or blood vessels.

In contrast, the tip of cutting needlesis triangular in shape, and the apex form
s a cutting surface, which facilitates penetration of tough tissue, such as skin
. Cutting needles make it much easier to penetrate tough tissue. Penetrating ski
n with a taper needle is very difficult and causes excess trauma to the skin bec
ause of difficulty in penetration and the need to grasp the skin edge very tight
ly with forceps. Consequently, you should never use taper needles to suture skin
.

The reverse cutting needle is similar to a conventional cutting needle, except t

hat the cutting edge faces down instead of up. This may decrease the likelihood
of sutures pulling through tissue in some cases.
Suture Materials
Non-absorbable sutures are made of materials that are not readily broken down by
the body’s enzymes or by hydrolysis. There are naturally occurring non-absorbab
le materials e.g., silk, cotton, and steel) and synthetic non-absorbable materia
ls (e.g., nylon and Prolene, Mersilene). In some cases they are left in place in
definitely (e.g., when used to close the abdominal fascia), and in other cases t
hey are removed after adequate healing has occurred (e.g., nylon sutures to clos
e a superficial laceration).
Absorbable suture materials are those that are broken down. The original absorba
ble suture materials were plain and chromic “cat gut,” which actually consisted
of processed collagen derived from the submucosa of animal intestines. Plain gut
 is broken down enzymatically after about 7 days. Chromic gut is collagen treate
d with chromium salts to delay break down. Chromic gut typically loses its stren
gth after 2-3 weeks is completely digested after about 3 months. Now there are m
any synthetic absorbable materials made from polymers (e.g., Vicryl and Monocryl
). These materials are broken down non-enzymatically by hydrolysis; water penetr
ates the suture filaments and causes breakdown of the polymer chain. As a result
, synthetic absorbables tend to evoke less tissue reaction than plain or chromic
gut.
Monofilament versus Multifilament:
It should also be noted that some of these suture materials consist of
a single smooth strand (monofilament) and others consists of multiple fibers wo
ven together (multifilament). Characteristically, multifilament suture material
(e.g., silk or Mersilene) tends to be easier to handle and tie, and knots in mul
tifilament material are less likely to slip. On the other hand, monofilament mat
erials (e.g., nylon or Prolene) are less traumatic, since they glide through tis
sues with less friction, and they may be associated with lower rates of infectio
n.
Since monofilament materials are more likely to slip, one generally ti
es knots with 5 or 6 “throws” when using monofilament materials (in contrast to
3 throws with silk or Mersilene). Despite the greater number of knots required,
monofilament materials such as nylon are generally preferred for skin closure be
cause they stimulate less tissue reaction, are less traumatic, may have less lik
elihood of infection, and provide a better cosmetic result.
Among the absorbable suture materials, Vicryl is a multifilament mater
ial, but there is also a coated Vicryl that provides decreased drag through tiss
ue. For this reason, coated Vicryl is used by some surgeons for the interior lay
er of bowel anastomoses. Monocryl is an absorbable monofilament material, but ha
s excellent pliability and provides easy handling and good knot security.
Scalpels:
The most commonly used scalpel blades are the #10 and the #15 blade. The #10 bla
de is better for long, straight incisions, and is held with the shaft of the sca
lpel in the palm of the hand with the index finger on top of the blade.
The smaller #15 blade is well suited for short, tortuous incisions; for this typ
e of incision holding the scalpel as if it were a pencil may facilitate control.
Forceps:
For skin closure use a fine-toothed forceps, such as an Adson forceps. The force
ps should be held so one arm is an extension of thumb and the other is an extens
ion of your index finger. The base of the forceps should rest on the dorsal surf
ace of the web space between the thumb and index finger.
Use only forceps with teeth. Use the arm with a single tooth to gently elevate t
he skin edge. Avoid crushing the skin edges with the forceps. This further traum
atizes the wound edge and impedes healing.
The forceps allow you to create counter traction and control the position of the
skin edge to facilitate passage of the needle perpendicularly through the skin.
The forceps should also be used to grasp the needle when repositioning it in the
needle holder. You should never touch the needle with your fingers.
Skin hooks:
Instead of using forceps, the skin edges can also be controlled using skin hooks
, which have the advantage that they do not crush the skin edge.
Needle holder:
There are several techniques for holding the needle holder. The most common meth
od is to place the thumb and ring finger slightly into the instrument’s rings. T
his allows you to pronate and supinate and to open and close the jaws of the nee
dle holder. Avoid inserting your fingers far into the rings of the instrument, s
ince this will tie up your fingers and impede your mobility. Some surgeons do no
t put their fingers into the rings at all and simply grasp the rings and body of
the needle holder in the palm of their hand.
Remember to create right angles:
The ideal skin suture should form a rectangle, penetrating the epidermis and der
mis perpendicular to the skin surface, then turning at a right angle to traverse
the depth of the wound parallel to the skin surface, and then turning again to
emerge from the opposite skin edge perpendicular to the skin surface.
The distance between the skin edge and the emerging suture should be the same on
both sides of the wound. When tied, a suture placed in this fashion will form a
rectangle and will provide optimal approximation of the wound edges.
Getting the suture path to follow the rectangular course described above may see
m counterintuitive, since the needle is curved. However, a rectangular path can
be achieved by taking advantage of the needle’s curvature and rotating the needl
e in such a way that the body of the needle stays perpendicular to the skin. Thi
nk of the skin as the tangent to the arc formed by the needle; in this case, the
tangent is stationary and the arc rotates.
Coordinated use of the forceps and needle holder:
Efficient and atraumatic placement of sutures which follow the rectangular path
described above requires coordinated use of the forceps and needle holder. One c
an best take advantage of the natural curvature of the needle by alternately pro
nating and supinating the hand with the needle holder.

The tip of the needle holder should grasp the needle about 2/3 of the way back f
rom the point. The needle holder and needle should be roughly perpendicular.
The far skin edge is elevated with the forceps in the left hand, while the rig
ht hand is pronated to “cock” the needle in preparation for taking the first “bi
te”. The tip of the needle should penetrate the skin perpendicularly about 5-10
mm from the wound edge, and the needle should be rotated all the way through the
epidermis and dermis by supinating the right hand to rotate the needle through
its arc.
A Key Maneuver:
The tip of the needle should now be seen protruding into the wound fro
m the subcutaneous tissue. At this point, it is important to maintain the positi
on of the skin edge using the forceps. A common error here is to release the for
ceps from the skin edge, but this allows the skin to retract, and the needle may
move and retract beneath the skin edge.
The key is to maintain the position of the skin edge while releasing the needle
from the needle holder. This will maintain the position of the needle tip. After
the needle is released from the needle holder, the right hand should be fully p
ronated before regrasping the needle. The “bite” can then be completed by supina
ting the right hand in order to complete the rotation of the needle through the
skin.
If it is necessary to reposition the needle in the needle holder before taking
the second “bite,” the needle should be grasped with the forceps, not with your
fingers.
The forceps then elevate the near skin edge in preparation for the second “bite.
” Once again, the right hand is cocked by pronating it, and the needle is passed
upward through the near skin edge by supinating the right wrist in order to kee
p the body of the needle perpendicular to the tissue it is passing through at al
l times. The needle should emerge about 4-5 mm from the wound edge (equidistant
on both sides of the wound).
Scissors:
Scissors are generally held with the thumb slightly in one ring and the ring fin
ger in the other. The index finger stabilizes the instrument by resting on the s
haft.
When cutting sutures, some recommend sliding the tips of the scissors down the s
trands to the point where they will be cut, but it probably makes more sense to
simply move the tips of the scissors directed to the point where the cut will be
made. For external non-absorbable sutures it is important to leave 4-5 mm “ears
” to facilitate suture removal.
Suture Removal:
When?
Face: 3-4 days
Scalp: 5 days
Trunk: 7 days
Arm or leg: 7-10 days
Foot 10-14 days
How?
Many patients are very apprehensive about suture removal, so the first
step is to reassure the patient that the procedure is not painful. The skin sho
uld be cleansed. Hydrogen peroxide is a good choice for gently removing dried bl
ood and exudate.

Then grasp one of the “ears” of the suture with a forceps to elevate the suture
just enough to slip the tip of a small scissor under the suture in order to cut
it. This should be done close to the skin edge in order to minimize the amount o
f contaminated suture that will be dragged through the stitch path. The suture i
s then gently removed by pulling with the forceps. It is frequently a good idea
to reinforce the wound with Proxi-Strips. These are narrow adhesive strips that
are placed perpendicularly across the wound at intervals.