Suturing is by far one of the most valuable skills in oral and maxillofacial surgery. Suturing skillfully requires the investment of significant time, dedication, and patience, and the process of mastering suturing can be frustrating at times. As a dental student, a firm grasp of the fundamentals and ample practice is key. The majority of your suturing practice will be encountered on externships unless you spend a lot of time within your home department, which I recommend. As you repair more lacerations, you will feel more comfortable and confident telling the resident you are capable of repairing them well. If you have had practice, it will be obvious, and residents will allow you to do more. Additionally, your repairs will look better as you get more practice. My intention with this article is not to teach you how to suture. There are far better resources out there than myself to help educate you in proper techniques, materials, and approaches. What I would like to do in this article is guide your thought process when approaching laceration repairs and provide you with some resources for improving your skills. The goal as a reader is to be equipped to provide the proper care to the patient and be knowledgeable enough to answer any questions thrown your way by an attending or resident.
This video by NEJM is a good starting point for the discussion below and does a good job of explaining the basics of suture repair.
Probably the most pertinent guide is a 2015 JOMS article. A must review for any OMFS hopeful.
Part 1: Examination and Preparation
Before you jump in and begin repairing a laceration, you have to first know what you are repairing. Is it a simple repair or complex? What is the mechanism of injury? Second, what materials do you need to repair the laceration? Will you need sutures for a deep repair or is it just superficial? As an extern, you can be very valuable during this phase. Gathering the resources necessary to perform the laceration repair can take a wasteful amount of time, depending on how busy the resident is on call. If you can collect these items beforehand to have ready, you’ll ingratiate yourself to this resident and make it even more likely that they will let you do the repair. In order to do that, you have to know what to collect. Things to consider for the preparation include:
- Items for draping, irrigating the wound, and sterile prep
- Lighting and suction
- Instruments, including laceration repair kit
- Anesthetics and supplies for their delivery
- Sterile gloves
Resources:
https://www.youtube.com/watch?v=AL0EE8zhNVM
Local Anesthetics and Injections Part I
https://www.youtube.com/watch?v=5Ujl1VbAcgc
Local Anesthetics and Injections Part I
https://www.youtube.com/watch?v=eWXuKFSnkIY
- Overview of Informed Consent
https://www.emedicinehealth.com/informed_consent/article_em.htm - Sutures
Common Sutures Used in Oral Surgery
https://www.youtube.com/watch?v=CHMO-fUi8Js
- Wound Closure Materials (OMS Clinics of North America)
- Systematic Assessment of the Patient with Facial Trauma (OMS Clinics of North America)
- Primary and Secondary Management of Pediatric Soft Tissue Injuries
Table of Common Suture Needles Used in Oral Surgery
| Needle Type | Abbr. | Size |
|---|---|---|
| Reverse Cutting (below are 3/8 circle) | ||
| PS-1 | “Plastic Surgery” | 11mm |
| PS-3 | “Plastic Surgery” | 13mm |
| G-3 | “Grieshaber” | 13mm |
| FS-2 | “For Skin” | 19mm |
| Conventional Cutting | ||
| PS-4 (1/2 circle) | “Plastic Surgery” | 12mm |
| PS-5 (1/2 circle) | “Plastic Surgery” | 15mm |
| PC-3 (3/8 circle) | “Precision Cosmetic” | 16mm |
| Taper (below are 1/2 circle) | ||
| RB-1 | “Renal Bypass” | 17mm |
| SH | “Small Half-circle” | 26mm |
In many cases, these materials are spread out among different supply rooms in the hospital or clinic, and will obviously differ from institution to institution. Taking the time as an extern to organize a laceration repair “kit” is a good exercise in teamwork, and useful for mentally going through the steps of the procedure. This will both be helpful to the resident, make you look good, and will serve as a useful learning experience. Plus, there are few things you can do as an extern to be truly helpful, and this is one of those things.
Part 2: The Repair
The patient has been cleaned, draped, and prepped for repair of the laceration and you are ready to begin. Now, you need to execute your plan for repair. What type of laceration is it? Does it require layered closure? Is there any avulsed tissue? Being able to answer these questions is not only necessary to correctly repair the laceration, but also to save you time. If you constantly have to make a run to the supply closet, then you are inefficiently using your time as well as delivering a poorer patient experience. If it is a child being sedated for a laceration repair, then time is even more valuable and you cannot waste it retrieving items.
There are many different ways to repair a laceration and each practitioner will differ slightly in their technique. At the most basic level, you are putting the puzzle pieces back together. At a more advanced level, make sure you have all the pieces and they are not damaged. In other words, know your anatomy. Is the parotid duct involved or the canthus? Are you in facial nerve territory? Below are some resources that I looked at and thought were a good foundation. Nevertheless, assume nothing and always check with your resident about how they want it repaired. It is a good exercise to run a resident through the procedure that you are about to do before doing it. When describing your plan, include the anatomical and technical considerations you will keep in mind, so they will trust your ability to not harm the patient. If you know what you are doing, then the resident will be impressed. If you missed a key component in your report, then you avoided a mistake, as the resident will have the opportunity to correct you. Nothing is worse than being halfway done with a repair and having to take it out (whether you should or not) because you find out the resident didn’t like your approach. Even worse, you could hurt a patient.
For a high-quality video course of all the basic suturing techniques, I highly recommend Duke’s Suture Skills Course.
https://www.youtube.com/watch?v=TFwFMav_cpE
Mayo also offers a version of similar length that includes hand-tied knots
https://www.youtube.com/watch?v=osgndmRBjsM
Facial Lacerations: Practical Plastic Surgery
-Intended for non-surgeons but covers good basic technique and considerations. Free PDF.
If you prefer to read, Wounds and Lacerations: Emergency Care and Closure is a great book.
Part 3: Recommendations for Care and Follow-up
The suturing is complete and the patient is (almost) like new. Good job! However, your work is not done here. There are important steps to complete after a procedure and there are care recommendations to give to the patient. Some of these include scheduling a follow-up appointment in clinic, discussing laceration cleansing and care, prescribing antibiotics if necessary, and cleaning up after the procedure. Also, always make sure to clean the patient’s face when done with a procedure. Nothing is tackier than a patient looking in the mirror and seeing blood smeared everywhere. Taking the charge to clean up and disposing of sharps is not only respectful of the facility and program you are working for, but it is also a matter of safety. If there is another consult or page to take care of at that moment, tell the resident you will clean up and meet them there. All parties will be appreciative. Also, if the program is good about documenting cases, remember to take before and after photos to give to the resident and document your work. Make sure to follow HIPAA guidelines.
Practicing
As with any skill, it takes plenty of practice to become proficient at suturing. It is unlikely that even with a decent amount of practice in dental school you will be anywhere near as good as the residents you will be following. Don’t let this frustrate you. If anything, it is a level to aspire to in the future. There are plenty of ways to practice in the clinic and at home. Repetition is everything. There are many types of suture boards and other ways to practice outside of school. I guarantee you that your OS department has expired suture that you can use as well as old or disposable instruments you can take home. I know many of us used pigs’ feet to practice suturing, and I still believe this is a good way to practice. Below are some resources that I found. I’m not going to include any of the products you can buy on Amazon or elsewhere because I believe they are a waste of money. There are plenty of things lying around your house you can practice suturing together or tying knots. Also, nothing beats the real thing.
Here are some additional resources:
WHAT NOT TO DO
I have mentioned before that there are simple things to do and not to do on an externship that are common sense. However, common sense isn’t always abundant, so here are a few things to never do.
- Suture without permission (patient, faculty, or resident)
- Hide suturing mistakes or lie about your repairs
- Bury non-resorbable sutures underneath the superficial tissue layer
- Lose track of sharps
- Unsafely administering anesthesia (dose, location, or incorrect patient selection)
- Fail to seek help when needed
I hope the resources presented and the suturing overview is helpful. I will continue to add more resources and articles for discussion as they come to mind or are suggested. If you have anything to contribute, please reach out and I will be happy to include it. Best of luck!
Additional information on externing in oral surgery is available in the Externship Guide.