The suture is the last five percent. What actually determines the outcome is everything before it: the exam you did before anesthetizing, the irrigation you didn't skip, and the tension you refused to close against.
Technique reference only — local anesthetic agents, maximum doses, and buffering are institutional-reference territory and are deliberately not covered here.
Needle driver, forceps with teeth, scissors, gauze, sterile towels, syringe with splash shield for irrigation, suture by site (see chart below).
Patient lying down — vasovagal syncope happens to the standing and seated. Bed raised, wound at your working height, overhead light aimed before you glove.
Neurovascular and tendon exam documented before anesthesia. Then anesthetize per your institutional reference, then clean.
Sensation · motor · perfusion · through full range of motion
Document distal sensation, motor function, and capillary refill before any anesthetic touches the patient. Test tendons against resistance — a partially cut tendon can still move the digit weakly.
Through the wound edge · slow injection · per institutional dosing reference
Inject through the exposed wound edge rather than intact skin — it hurts less. Small needle, slow push, aspirate near vessels. For fingers, toes, lips, and ears, a regional or digital block gives better anesthesia without distorting the landmarks you're about to align.
Roughly 50–100 mL per cm of wound · moderate pressure · splash shield
Irrigation is the single most important infection-prevention step — more than antibiotics, more than sterile gloves. Use a syringe with a splash shield or an 18-gauge angiocath for pressure. Potable tap water performs comparably to saline in clean wounds; contaminated wounds get more volume, not less.
Bloodless field if possible · look at the bottom of the wound
You have not explored a wound until you have seen its base. Control bleeding with pressure or brief tourniquet, spread the edges, and look for foreign bodies, tendon or joint involvement, and devitalized tissue. Sharply debride ragged, crushed, or clearly dead edges — but be stingy on the face.
Simple interrupted · enter at 90° · equal bites · edges everted
Enter perpendicular to the skin so the bite is wider at the base than the surface — that flask shape is what everts the edges (Fig. 1). Match bite depth and width on both sides or the edges step off. Tie with just enough tension to appose; blanched skin inside the loop means it's too tight and will necrose as it swells.
Ointment · non-adherent dressing · return precautions · removal date
Thin layer of ointment, non-adherent dressing, and written instructions: keep dry 24–48 hours, then gentle washing is fine. Give a specific suture-removal date by site (chart below) and explicit return precautions for redness, streaking, drainage, or fever. Update tetanus status before discharge.
| Site | Typical suture | Removal |
|---|---|---|
| Face | 6-0 | 3–5 days — earliest removal, lowest tension, cosmesis matters most |
| Scalp | Staples / 3-0, 4-0 | 7–10 days; hair apposition technique avoids hardware entirely for small linear wounds |
| Trunk | 4-0 | 7–10 days |
| Arm / leg | 4-0, 5-0 | 10–14 days |
| Hand / foot | 5-0 | 10–14 days — high mobility, slow healing |
| Over a joint | 3-0, 4-0 | ~14 days, often with splinting to offload the line |
Absorbable versus non-absorbable matters less than dogma says: absorbable gut on the face of a child who won't sit for removal is a legitimate choice. Tissue adhesive works for low-tension, clean, linear wounds — never near the eye without protecting it, never on hands or over joints.
Volume and mechanical washout do more for infection risk than any prophylactic prescription. When in doubt, irrigate more, and reserve antibiotics for bites, heavy contamination, open fractures, and the immunocompromised.
Place the first stitch at the vermilion border or eyebrow margin before edema and anesthetic distort it. A 1 mm step-off at the lip line is visible across the room forever.
A small laceration over the MCP after a punch is a human bite into the joint until proven otherwise. Irrigate, image for tooth fragments and fracture, leave it open, and have a low bar for hand consultation.
Anesthetize first and you have permanently lost the sensory exam — and with it your documentation that the nerve deficit predated your needle. Exam first, every time.
Retained foreign bodies are a leading source of wound litigation. Glass and metal show on x-ray; wood and plastic usually don't — ultrasound or exploration finds them. Document that you looked.
If the edges won't meet without pulling, the answer is deep sutures, undermining, or a consultant — not a tighter knot. Tight sutures cut through swelling tissue and leave railroad tracks.
A starting template for the procedure note. Text in brackets [ ] and pick-lists in { } are fields to complete. Save it as a SmartPhrase, then edit every field to match the actual procedure.
PROCEDURE: LACERATION REPAIR
Site: [***] Length: *** cm Character: {linear : stellate : flap}
Consent: {verbal : written} consent obtained; risks including
infection, scarring, and need for revision discussed.
Timeout performed. Operator: @ME@
Pre-repair exam: distal neurovascular status intact [***];
tendon function intact through range of motion [***].
Foreign body: {none seen on exploration : imaging obtained ***}
Anesthesia: [agent/volume per institutional protocol ***]
Preparation: wound irrigated with *** mL {saline : tap water},
explored to base, {no : ***} devitalized tissue debrided.
Repair: {*** simple interrupted : running : buried deep +
interrupted} sutures with ***-0 {nylon : polypropylene :
absorbable}, edges everted, good approximation without tension.
{Staples *** : tissue adhesive : hair apposition}
Complications: {none : ***}
EBL: minimal
Aftercare: wound care and return precautions given; suture
removal in *** days. Tetanus: {up to date : administered today}.
Electronically signed: @ME@ @TD@ @NOW@
Sample template only — not a validated institutional SmartPhrase. Verify wording, consent, and attestation requirements against your department's documentation, coding, and compliance policies before clinical use.