New suture techniques for best esthetic skin healing

PURPOSE: To report two new suture techniques for best esthetic skin healing. METHODS: Using the pig skin slices routinely employed for surgical technique training two new types of skin sutures were performed. One defined as inverted or hidden X point suture and other as totally hidden intradermal running suture. The first were performed using 4-0 polypropilene stitch and the intradermal with 4-0 poliglicolic stitch. RESULTS: It was confirmed good skin layers union and contention with best esthetic result than observed with the traditional X and intradermal suture techniques. CONCLUSION: Macroscopic examination of the hidden X point and totally hidden intra-dermal sutures and centrifuge skin traction confirmed good skin layers union and contention with best esthetic result than observed with the traditional X and intradermal sutures techniques.


Introduction
The register of the development of sutures dates since 3.000 bC with the papyruse of Ebers describing use of the line in the Egypt to close wounds, The use of a categute wire for scarring of a wound had as first citation the comments carried through for Galeno (130 a.C.)., in his work "De Medicina" Cornelius, 53 aC -7dC describes vascular ligatures.It was recovered by order of Pope Nicholas and re-edited in 1478 after the invention of printing by Gutemberg 1 .At the century IX, Rhazes was the first one to use the categute wire in an abdominal suture.In century X, Avicenna evidenced that the hemp was breached in the presence of infection and Ambroise Paré, in century XVI described a way to approach the edges of wounds of the face by means of ribbons, having declared "Nature will do the healing, since the doctor does not disturb its evolution" 2 .John Hunter in century XVIII tells that the suture must be made with separate points and Joseph Lister, in century XIX, considers that the chemical sterilization of wires diminishes the infection and introduces the wire of categute coated with acid chromic 3 .
The manipulation of the wounds, objectifying better results on scarring, has challenged surgeons, whose attitudes have changed over the centuries.In a panoramic analysis, we can identify four stages on the evolution of suture, which are characterized due to peculiar therapeutical measures.In the first, which lasted until the beginning of Christianity, the physician did not propose an intervention other than cleaning the wound and application of honey on it, hoping to wound healing by secondary intention.
In mid-1586, Ambroise Pare returned the principle of minimal interference, emphasized in the following sentence: "Nature will do the healing since the doctor does not hinder its development" 2 .
The second phase may have its onset characterized by the actions of John Hunter, William Halsted and Alexis Carrel, who improved cleaning techniques and the depth of the wounds using sutures for approximation of its edges.
The third phase appeared on century XIX with Semmelweis, Lister and Pasteur, who introduced their principles of antisepsis for the control of the infections, thus facilitating the scarring.
The last phase can be observed in the current days.
Thanks to the advent of science, the human being starts to search new ways based on the biotechnology for wounds scarring 4 .Nevertheless advanced technology is not yet granted to the majority of patients in the mankind, being the surgeon skill the most important factor for the surgery success and patient happiness.In this particular aspect the results of the surgical skin healing plays a very significant role, being the objective of the present article to report two new sutures technique for best esthetic skin healing.

Methods
This study was approved by the Ethics Committee of our institutions and was conducted using the pig skin slices from meat stores routinely employed for surgical technique training.Two new types of skin sutures were performed.One defined as inverted or hidden X point suture and other as totally hidden intradermal running suture.For this purpose the first was performed using 4-0 polypropilene stitch and the intra-dermal with 4-0 poliglicolic acid stitch The Figure 1 (A,B) shows the correct way to do the inverted or hidden X suture: the needle enters perpendicularly for one of the edges, passes for dermis, reaches dermis of the opposing edge in an oblique direction and leaves for the epidermis.After that, it enters again perpendicular to the skin, in an opposing point to that one of exit (analogous the vertices of a rectangular triangle), passes obliquely in dermis, leaving for the epidermis in a perpendicular point to the first entry point.It ends up tying the free edges of the wire.To realize the totally hidden intra-dermal suture (Figure 2 A,B,C) the first step is to divulse dermis of the extremities of the lesion with a scissors.Then we introduce, in the dermis, the needle parallel to the angle of one end of the injury, tying up the knot, that will not be exposed on the surface.After that, it proceeds in a manner identical with that previously exposed, until reaching the other extremity.To finish it, the needle should pass perpendicular to the opening angle of this end, that is, containing all and only the dermis.Finally, it's important tying the knot, to fixing the free ends of the wires.

Results
Macroscopic examination of the hidden X point (Figure 3) and totally hiddent intra-dermal (Figure 4) sutures and centrifuge skin traction confirmed good skin layers union and contention with best esthetic result than observed with the traditional X and intra-dermal sutures techniques.

Discussion
Regarding the X stitch we must recall that it allows greater tension than the simple stitch, the Donatti and the suture with U points.To do it, the needle must pass perpendicularly for the epidermis of one of the edges, reaching dermis of the opposite edge in the same direction, leaving the epidermis.Then it must pass again through the epidermis of the first edge chosen in an obliquely direction (like a diagonal).Again the needle will come out in dermis of the edge in question and will enter in dermis of the opposite edge in the same direction, leaving the epidermis.
Finally, the wire from the free extremities, are tied.However, it is more harmful to the skin healing living a very impressive X mark visible after the skin healing; while with the proposed inverted or hidden X suture the skin healing will have only two sequential single points suture scars.

Conclusion
The hidden X point and totally hidden intradermal sutures promoted good skin layers union and contention with best esthetic result than observed with the traditional X and intradermal sutures techniques.

FIGURE 3 -
FIGURE 3 -Skin suture with hidden points in X.
The common Intra-dermal suture notoriously promotes a good synthesis of the skin layers only exposing edges of the first and last suture knots with an excellent aesthetic result.Nevertheless the exposed ends of the suture trough the skin may be a way for bacterial access and subcutaneous infection.The new totally hidden intradermal suture differs from the common intra-dermal above described basically because of the way it begins and ends without points in the surface of the suture, with best protection against infection complication and best emotional acceptance by the patient not needing any intervention for line or knots removal.Not withstand the limitation regarding surgical technique studies in dead tissues, the macroscopic examination of the hidden X point and totally hidden intra-dermal sutures and the centrifuge skin traction test confirmed good skin layers union and contention with best esthetic result than observed with the traditional X and intra-dermal sutures techniques.Results that are being confirmed in clinical cases of patients submitted to cardiovascular surgery.