Well, we'll do some loose demographics, and then we'll get started formally in just a minute. My name is Dr. Burrus, first name John, Rachel, and Bob. I have a slide with the formal stuff in a minute, but I just want to hear from you guys. What is your involvement with suturing at this time? How many people actively suture in their clinics? Are there any ringers? Any plastic surgeons amongst us? We had one last time. Yeah, no, I'm not joking. Any surgeons of any sort? Okay, all right. Well, we anticipated people being of various levels of acumen. We all have our own journeys, and sometimes you have all these skill sets when you're, I hate to say younger, but when you're younger, and then you lose them, and you're uncomfortable. This is the thought about this course in terms of why we came up with it. Was anybody at the 2019 course that I did? Bob was kind of there. Where's Bob? I was in and out. Should we wait just a little bit longer? Yeah, we can. Let me see if I can get you out the door. Okay. Yeah, Rachel precepted. She was in my clinic through the Harvard program recently. And yeah, Bob is an actual clinician. Right, Bob? He is. And I think he did surgery, emergency medicine, family medicine, and op med. And he basically took over his daddy's clinic in Louisiana. But the interesting thing is, he and I probably do as much suturing. Doug Martin does a lot, too, with the meat packing. Does anybody suture on a daily basis here? Okay. My clinic in Boston, I service construction workers and about $8 million worth. And it's an interesting clinic. I'm right near Mass General Hospital. And if you don't have a rapport with a hand surgeon or a plastic surgeon, you should get one. Because I literally have the ability to text pictures in real time. And if anybody is interested, I'll show you my text with this chair of hands at Mass General. Okay, is this fracture stable? Is this the way you would have done this? Did you see me do that while you were there? No, we had a lot of eye injuries while I was there. But anyway, it's very helpful. And the workers want good care, right? They prefer not to spend all day in the emergency room. So if I can treat them, you know, it's a nice show. I think we should just get going because, you know, we've got a whole... I can do these announcements there. Well, they'll come in. I'll start off with the obligatory announcements that ACOM would like us to make. Can people hear Rachel? Is this mic on? Yeah. The session's recorded, so... So welcome, everyone. This is the Suture Skill Workshop from 8 to 10, regardless of what that booklet says. If you haven't already, please download the AOHC 2023 event app. It's called Swapcard. You can see all of the different sessions that you'd like to attend there, and you can network with other individuals. You can evaluate and claim credit by using the Swapcard. Essentially, you're just going to click on whichever sessions that you attend. Restrooms are located on either side of the main foyer outside of the ballroom. Don't forget to silence your phone or other devices. And at any time, if you need any help throughout conference, ACOM staff have red lanyards so that they can be identified and you can ask them any questions that you have. So I'll introduce myself. My name is Rachel Zaks. I'm the current chief resident at Harvard's Occupational Environmental Medicine Residency Program, and I'm internal medicine trained, and I've done a lot of suturing both with Dr. Burress and also in a lot of the global international work that I do. And we will let Dr. Burress kind of get you guys started, and we'll have a nice, fun two hours together. Rachel's being humble. She did the Epi. The Epidemic Intelligence Service. It's the disease detectives for the U.S. government, a two-year fellowship with the CDC. She was in Seattle when the first round of COVID hit out there. Wouldn't recommend. Yeah. Okay, so do you want me to... I'll advance a little bit if I can. And how do you do that? Okay. So... Oh, by the way, how many of you guys have ever taken care of a subungual hematoma? A few. How many have used a BOVI? Okay. Yeah. Heather, if we could get those, that'd be great. Just a couple. Not very many. So... I was a fellow at Harvard like Rachel, and I was very interested in ergonomics. So I'm all about what is the rate-limiting ergonomic, you know, challenge. So what's limiting your practice right now? Okay? Please do not stick that needle in that finger without doing a digital block. Okay? That person is not going to be happy with you. Can you do a digital block? Yes or no. Can you do a layered closure? Well, yes or no. Can you handle the tension in the wound? Okay? The neat thing about this kit is it actually tries to simulate the tension of a wound. I've had nurse practitioners call me and say, I can't get the fat back in. It's too much tension. How do I get the fat back in? Right? They're covering my clinic, and I'm thinking, okay, wish I was there now. So, you know, can you prevent one edge of the wound submarineing underneath another one if it's in a web space? Can you do that? Do you have the technical know-how to do that? After the session, you should. Can you handle nail trauma? How common is that in a work setting? Very common. I've done three in the last couple of weeks. I'll show you pictures in a minute. What about basic plastic techniques? Bob's going to show you some of those up here. I hope it projects well. But can you undermine, can you change the shape? I'll show you some pictures before and after. Triangle shape, no good? Ellipse, good. Right? And do you have the courage to take that scalpel and actually make that wound twice as big to get that shape? You know? Can you do that? Can you force yourself to take that 11 blade in your hand and do that? Okay, so the picture I had before was much more graphic. You remember that picture of the partial amputation? This one is something that you could do. Okay? So what are our objectives? You want to refresh and advance your suture techniques here. You want to train the trainer. It's very interesting. How many people precept residents and medical students? Yeah. When Rachel rotated through, I had one of these kits and she used it. The kit I have in my office now is with one of my daughters. She hasn't given it back yet. So the treatment goals when you see someone with an injury obviously is you'd like to take care of them with the minimum amount of pain. That's why I think it's so imperative that you give them a block when it's appropriate. You want to prevent infection? I do gladiator medicine. It's opposite of what most people think in workers' compensation. The people I care for will work so they will show up the next day unless I absolutely tell them not to. So I have to suture them in a way that will facilitate those occupational interests. These are highly paid union workers from Boston. The goal is to restore function and optimize cosmesis. The latter is the least of their worries. So you'll see industrial strength suturing on my part. So how do you make let's see oops that was not good laser on this is this guy? The big one. So how many people can do a fingernail or toenail? Don't see very many hands. You'll see a few pictures. If you talk to a plastic or a hand surgeon you must take the nail off and suture the bed. You must. That's it. They say you must. Can I talk every worker into letting me take that nail off? No. But if it's a bolst at the root back at the eponychial fold you must. It's going to come off anyway. And this is how this one was. And I'll show you other pictures in a minute. So the thing that you're going to hear from me is what about the rehab? They use their hands for a living. It's like a runner. You're not going to rehab their calf muscles? So you'll see before and after pictures 14 days look pretty good range of motion and the guy was four weeks out as of Friday and he caught his fingernail on something. You want to have him crisscross the bandaid on the tip of that fingernail trimmed or he'll bolst it. So I just took the stitches out. But you could leave them in even longer. So that's four weeks out. So again, this is just a set up. A little short didactic and then we're going to open the kits and move on. But I want to caution you. Good care means you avoid stiffness and immobilization. This is a man one of those lights that light up an area on a construction site and it whacked his hand even though he's a foreman. The guy saw me a few weeks later and his left hand is just like you see there. He couldn't hardly move it. He thought he had some fractures but he didn't. So I reassured him and got him going with a therapy ball. Does anybody use a therapy ball in your practice? The little balls? So helpful. I'll show you an example right here. This is a grinder. Anybody take care of a grinder injury? Lots of grit. You can't even scrub them out. Sometimes you have to just cut the wound out. I'll show you a picture in a minute. Here's an example of the industrial strength suturing. This guy did work the next day. So you go from that to that. All right. This is a bandsaw. Pretty wide curve. You think, oh my God, how can I take care of that? I'm just an occupational medicine doctor. By the way, how many physicians, how many nurse practitioners, how many PAs? Any PAs? How many NPs? Okay. Three? Good. So the bottom line is, yes, you can take care of that. And I did. And I achieved a pretty good range of motion. I avoided having prolonged immobilization unnecessarily. Good morning. And this is at a year. Okay. No. No. It's beyond where the tendon puts on. So this is what you don't want. This is from an ED I saw. And look at it. It's dry. The suturing didn't hold. There was another suture right there. And you might not even bother. You might as well not even bother with it. I mean, the guy's a construction worker. He's going to work the next day with a little bitty cut like that. Okay. And this technique was just not sufficient. The wound, you have to make sure the suture is well away from the wound edge. You have to think about the forces at play over the course of when those sutures are in. And the more force, the more gripping, the more repetitive use, the further you need to put those sutures away from the wound edge and the higher amount, the higher strength of suture material. Don't use 5-0 in a hand, by the way. Not in a construction worker. They're going to break that. Learn that the hard way. So why suture in a practice? You want to be full scope if you can. It's marketing. Every guy that goes on a construction site is the best marketing on the planet for me. He wants to show them all his suturing. He wants to talk about it. And I have this thing. If they've had a tattoo, I like to try to preserve the markings of it. But, you know, there's advantages. Professional gratification amongst them. And who knows where our field is going to go? Are we all going to get consumed into the episodic care world? Are we going to be urgent care providers with an interest in occupational medicine? Will you have to get a job at an urgent care clinic? And what is the urgent care clinic going to ask you? Can you suture? So it doesn't take that much space. It doesn't take that much equipment. How many people use surgical loops? Bob does. I was sub-leasing when I started my company from a spine surgeon. He saw what I was doing. And he said, why don't you get surgical loops? And the rep was in his office. And I said, oh, no, I can't do that because I'm not a surgeon. I was about ready to buy a $1,400 gooseneck lamp. This is $2,400. The best purchase I've ever gotten. I've got my loops right here. You should try them. It's like going from an old Zenith TV to a new flat screen. It's like way different. I do all these partial tendon lacerations. I need to look down in the wound. I need to see what it is I'm working on. You'll see these pictures. The pictures wouldn't be as good if I didn't have a light on that wound. If you're going to do a lot of suturing, it's not stupid to think about that. Especially as we get a little bit up in years. What equipment do you need? I would submit that in an occupational medicine clinic you need this type of material. You need this. I brought with me those two things. If you've never squeezed a pair of pliers, a good pair of pliers, with enough force to cut the head off of a nail, you should try it. You have to cut the head off, especially if it's from a pneumatic gun, because they have little barbs on it. If you don't cut the head off and pull it through, it's just like you're pulling a fish hook out the wrong way. Bob knows all about that. By the way, I'm from rural Kentucky and Bob is from somewhere in Louisiana. Hearing a lecture for me is a little bit interesting because you don't know what I'm going to say and you don't know how I'm going to say it. My wife asks me all the time, are you really a doctor? She does. She's from Boston. Actually, this picture here is from Bob. He has a special thing. It's a special kind of metal. You can't even cut it, right? Is it on now? Yeah. That's actually from a blowout preventer from an oil well. They use a lathe to machine this metal. It's a real strong alloy and it's really, really tough. This guy was walking, tripped and fell into the scrap bucket where all the shards and all that was. He had three different pieces of shrapnel in there. The one in the ring finger was just sticking in it. That spiral wrap, I went out and got these big lineman pliers but the big, big ones. I got them out of my truck and I squeezed as tight as I could and I couldn't even make a dent in them. Like John does, I called the plastic surgeon, the hand guy and I said, hey, I got a picture that's coming to your phone. Look at it. Tell me how you think either one of us can get this out because I can't get it out right now. He said, if you can't get it out, why are you calling me? Anyway, the funny thing about it is I did a digital block. We'll show you in a minute how to do. Numbed up that whole finger. With that, you can actually take the end of the finger off. He wouldn't feel it but when I went to wiggle and pull on it, the whole spiral side of it had just gone in, straight in. It was so sharp, it sliced it. When I just did that, the whole thing fell out. It just came right back out of the hand. It looks way worse than it was but I was trying to figure out if I'd numb them up. Can I corkscrew it out? What can I do? It didn't corkscrew in. It just went in with the edges. You'll see interesting things like that sometime when you scratch your head and say, better take a picture of this because nobody is going to believe it. In your clinics, if you think about the equipment you need, this is called an elevator. It's really helpful when you do a nail like I'm showing you there. You can get through with the hemostat but it's not as it's much easier with that. Just a quick, again, this is not supposed to be all didactic but just to set the stage, what are we doing when we take care of these wounds? I have a point of going over this. You want to do your assessment? You want to get your anesthesia local versus regional versus both? How many people use epinephrine on tips of fingers? Guess what? You can do it. I do it all the time. Doug Martin only has lidocaine with epinephrine. We did a course, Bob and I, a few years ago and we debunked a bunch of those myths but you can use epinephrine on a fingertip. I often do just to help with hemostasis because I prefer not to use a lot of tourniquets on it. Preparation for closure, critically important. The whole purpose is to decrease the chance of infection. What keeps a worker in my practice from working is if his hand gets infected and he has to go like this in a hospital with IV antibiotics. You don't want to avoid that. The closure is important. If you can use a non-suture technique, great. But often if it's someone that's working for a living, you can't. Aftercare I think is what should be our forte. I give the workers my card. It's got my cell phone number on it. I say send me a text of the wound if you have any questions. I go through what a stitch reaction looks like. I think we can offer a better aftercare. I think this is a differentiator for us compared to an urgent care. I'll close this part with saying if you have better technique I might have to move some of that stuff. If you have better technique, the chances of that worker staying at work is better, is increased, okay? So again, my name is Dr. Burrus. We can just move that. My trajectory is family medicine in the South. Emergency, I worked in emergency rooms and I ended up at Harvard, where Rachel is now. And I do heavy industry. Bob does a lot of maritime, oil rigs. And Dr. Zaks is the chief resident, as we talked about. I wanna just say a moment for a second. There's two people I like to refer to. The gentleman on the right happens to be my grandfather. And he was a World War II doc. And you only know your grandparents sometimes from what other people say about them. And there's a very famous Houston Clinic orthopedist who owes his career to my grandfather, having sutured his hand when he was a kid. He got it all mangled up. The guy on the left, Dr. Murdad Himadani, did you ever meet him? You probably didn't. He's now deceased. He trained in Iran and was with Iraq during the Iraq-Iranian War as a trauma orthopedist. He immigrated to the U.S., did internal medicine, and worked the rest of his life caring for injured workers. And he taught me a technique I'm gonna share with you today. So, thank you for being courageous first timers with this new program here. If you can, go ahead and open up that kit there. Our goal is to have a hands-on experience. And we have a few extra stations, but the real goal is to get you comfortable with this kit. And we also wanna kinda do a little train the trainer, because I think that's important. You'll see today we're gonna incorporate some nice video footage from a Dr. Michael Zinn, who's a real deal plastic surgeon at Duke, by the way. I interviewed a plastic surgeon that my wife works with, and he knew him. Did you find one? So, we're gonna go through these different types of suturing with the exception of subcuticular. We don't think that there's that much utility in the occupational setting for that. It's much better if you're doing a plastics case where you're taking out a lump and then you, you know, it's all clean. We don't get that. So, why did I choose this Vata kit? I just researched it when I did the course before. I talked to the principal. You'll see that if you pull out the mat, it has five layers and it simulates real tissue. I don't think there's any other one that does that. And if you look at the consistency of it, like you'll see in a little while, I'll come in and I'll put a foreign body in there and you can actually push on it and it has a, it feels like it. I think this reduces the barriers to hands-on training. When Dr. Zaks rotated through my clinic, she was able to take this kit and practice her suture technique. Now, yeah. So, essentially what we're gonna do is I'm gonna show you the first two videos, which is just the instrument tie and a simple suture. The goal is that as you're watching these, you are welcome to play with your own kit. So, we're gonna show this. Dr. Burris and Dr. Bourgeois are going to demonstrate up here as well. But the whole point is that you are working with your hands while you're seeing this. We're just giving you multiple different modalities to learn the technique. Just this, oh, it's all one size in the kit. By the way, this is gonna be like a combination of show and tell in a yoga class, right? Because I'm gonna come around and adjust this, adjust that, okay? So, just take the stuff out, start playing with it. You'll listen to Dr. Zins here. He'll orient you a little bit more. All right, before we get started with teaching different types of suturing, I wanna teach how to tie the knot. The simplest way to do this is with an instrument tie. You simply pass whatever suture we're doing into the skin. And when you're ready to tie it, what I'd like you to do is pull the suture all the way through, but leave a small, short tail, about a quarter inch, half inch is plenty. So, you'll have a short end and a long end. And we're gonna keep this pretty simple. You take your needle driver, and you're just gonna simply place it between the two. Take the long end and then wrap it. You wanna wrap it twice, and then grab the short end, and then pull the short end across the wound to the other side. And what that does is it locks the wound down. See how it sits there and doesn't move? For the next throw, I'm gonna wrap the needle driver again, and this time, just wrap it once. I'm gonna grab the short end and pull it across, but don't pull up on it. You just wanna tie it down till it gets down to the knot, and then lock it down, okay? And simply put your needle driver between the two again, wrap it with the long side, grab the short side, and pull it across. So, you're doing the same thing every time. The first time, you're wrapping it twice, and that's called a surgeon's knot, and that'll lock it in place. Because what you don't want is you don't want the knot to be loose, you want your skin well approximated. So, we call that an air knot when it's not approximated. So, just to review one time, once your suture is placed, leave a short tail, wrap the needle driver twice, pull the short end to the other side, locking it. Now, don't pull up on it. Wrap just once around the needle driver, pull it back to the other side, lock it down. Now, for your next throw, you can go ahead and wrap it once again and pull it to the other side. Now, some absorbable suture, you may need to do it four times, but three times for permanent suture, like the suture that comes in your kit, is fine. So, you wanna shut that down? Did you just wanna do the simple suture first and then I was gonna start? Oh, yeah, yeah. I think so. So, the first suture I wanna teach you is the simple suture. Oh, yeah, go for it. Simple because there's really only one part to it. You're simply gonna put the needle in on one side and then put it through on the other side. So, it's important to hold the needle in the middle, enter at 90 degrees, exit, and then try to enter again so you can come into the tissue and come up at 90 degrees. Having it 90 degrees on both sides, when you tie it, will approximate the skin beautifully. So, that's why I like to do it in two and not try to just run the needle all the way across. Do the instrument tie, as I've already taught you, and see how nicely the skin is approximated. And you'll see, as you start doing this more and more, you'll just get faster and faster. It is an acquired skill. So, the key, enter at 90 degrees. Sometimes you can keep it in, but you push the skin just to make sure you're getting through it at 90 degrees. And again, that's gonna help you to re-approximate your skin. Now, you'll decide how far apart each stitch needs to be. The closer they are together, the more stitching you're gonna be doing, the more scar you may have. Some tissues are already just about approximated, so you don't need that many. Okay, so the first two things that we want you guys to practice is the instrument tie and just a simple suture. Do you wanna show them up here how they can set up? Oh, yeah. Yeah, you'll notice that there's a scalpel in there. And the scalpel's there to make any kind of cut you want. In fact, at some point, we'll make a triangular shape so we can practice a half buried. But right now, just make a simple straight cut. And I see that a lot of you have the tensioning device already in place. There's no other kit that does that that I know of. And yeah, so if you're not an accomplished suturer, you might try it without the tensioning device first and then work up to that. So just make a straight cut. And yeah, anywhere you want. And then just in terms of a safety thing, when you're done with that blade, if you could put the safety guard back on, it'd be great. Yeah, I'm just gonna go around and I'm gonna stick a nail in your kit just to give you an idea of a foreign body sensation. So you can feel it. I'm gonna stick a nail in there, okay? Yeah. Suturing is all about managing the suture material. And oh, good for you. See, she knows how to just drop the needle off to the side when she's getting ready to do an instrument tie. My suggestion is when you're doing suturing for a patient, if you have a sterile field, which by the way, there's not a great evidence base for. Yeah, go show, yeah. My suggestion is you run the needle through the skin and then you put the needle aside and focus on the suture material itself. If you watch an experienced suturer, it's a very smooth motion. Yeah. It's fun to see Dr. Zins do it, but his hands are so fast and facile. What a small, is it? Okay, the big one? Okay, all right, okay. Can y'all see down there what we're doing up here? Oh, I've got lots of them. I'll get them for you. So if you grab the needle, what we're trying to do, you want the needle to work for you. You don't torque the needle. So you can either grab it in the middle. If you do grab it to the back, you have to come through with a really nice, smooth motion all the way around. You can't go in and then torque it back because you'll bend your needle. So you always want to follow the curve around. And what you're trying to do is go in the same distance from the wound margin on one side, come out the same distance on the other. And then in the bottom, you want the depth to be the same also. Because to approximate the wound, you want everything to be really symmetric. Yeah. Bob, if I may, a gentleman asked about where you put the first suture. And I always thought that you would put it in the middle and bisect. But Dr. Zins actually suggests, especially if it's under tension, to go about 20% in, and about 20% in from the ends. Start with that and then go to the middle. And I'll show you some examples of that. Alignment. Alignment, yes. Alignment's important. If I could have the thing. Yeah. So, at some point, you can look up and I'll show you, this is a little diagram. Some people like that. That's what we're doing. We're making a circle under the skin. This is an example of a suturing that I did on a finger. And you can see where I ended up. But how did I get there? And to answer this person's question, because there was some tension, I went, I went here and then there. And then I did the middle. You see? It's easier when it's a regular scarf wound, right? Yeah. Jigsaw. Yeah. Yeah. The other question. Go ahead. The distance of entry from the margins, right? I wish it was based on a suture, you know, right? Yes. How far away from the margins did you go? Ah, that's a critical question. What was your first name? Dan has a question. How far away from the wound would you take your bite? The answer to that is, it's a contextual answer. If it's on a face, you want to have a nice plastic closure, very close to the wound edge, each suture having not much tension. If it's on a back, an arm, a hand, that person's gonna have a lot of tension through there. I'd pull away from the wound edge. And when I teach residents, I try to get them over putting that suture far from the wound edge. Because the sophomoric mistake is to put it too close and it pulls through. Like the picture from the ED that I showed. So your decision is largely driven by the tensions that are expected. Yes, yes. That's a judgment call. And you might also think about the health of the person's skin as well. The thickness of the skin, depending on where it is. Some of the skin I suture is like leather. It's literally an eighth of an inch thick, keratinized. Yes. To go in at 90, curvature of the needle, yes. Dan has a number of questions. And because the session is recorded, I'm going to say the question, to repeat the question. And Dan is asking, when should I take the suture out if I'm not happy with either how it looks or how it functions? And the answer to that is, I do it all the time. I do it all the time. In fact, if I put 10 sutures on a wound, I'm probably taking out one or two of them because I don't like the way they perform. Each type of suture will go through simple, like you're doing now, will go through vertical mattress, horizontal mattress. They all have their own strengths and purposes. They're like weapons. And if I don't like how an interrupted or simple suture performs, I'll switch it out for a vertical, okay? And I'll show you some examples of that. Is it okay if I'm talking while you're working? Again, it's just like a yoga class. Okay. Yes, ma'am. Oh, yes. Ah, what is your first name? Samantha, Samantha asked a very good question. And I have some pictures of this as well. Samantha asks, should I put the suture through traumatized skin? And how do you guys feel about that? How do you feel about putting a suture through a traumatized skin, something that's abraded? I don't like it. I try hard to avoid it. Yeah. Yes, yes. I'll make great pains to avoid that. That's an excellent question, Samantha, thank you. I was gonna ask, when the cuticle's disrupted and the nail's still there, do you wanna tack it down? The cuticle? Yeah, the epithelium fold is. Okay, there's two different things. So we'll talk more specifically about nails in a minute. That's a good question. I can see where you're going with it. And you know, my wife's an anesthesiologist. She does thoracic and regional. She hates it when I talk about repairing a nail. She can't stand it. She can tell me all her stuff. But if I even start to talk about repairing a nail, she doesn't wanna hear about it at all. I don't know why that is. People get all grunged out about nails. They're beautiful. What's wrong with a nail? People get all flustered about it. Not easy, is it? Okay, let me help you. Take this, is that the needle? Okay, throw that over there. Forget about that. Yeah, just leave it over there. Worry only about this suture in front of you. Do your tie, two loops of that. I'd submit you don't need that now. I know, I know. How are you doing? We've met, right? What's your first name? Cicile. Cicile. Cicile makes a very good point. If everybody can hear me, you notice that the pickups in your kit have teeth, right? That's a good point. You notice that the pickups in your kit have teeth, right? That's for the grasp of the tissue. You want to be gentle with the tissue, but there's a reason why they're pickups with teeth. When I've sutured for medical school, they want us to teach the students to use the pickups when you handle the needle, okay? You notice I haven't harped on that. All the disposable kits have pickups with teeth. All the disposable kits have pickups with teeth. Show me someone amongst all of you who can pick up a suture needle with pickups with teeth consistently. It's very difficult, okay? Now, if you have a sterilizer in your office and you have a whole surgical tray, you can have pickups that you want. But in most clinics, they are these pickups with teeth. So that's part of my thought is, get those out of your hand for now. And just focus on this and that, this and that. Yep, yep, two loops for the first one. You did one, two loops for the first one. Oh, you did, okay, fine, okay, fine, okay. But I hope that answered your question about the pickups with teeth. Yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah. Pickups with teeth? Yeah, now, I will say, there are instances where you have to grasp stuff. So what you do is you take the needle and you grab it back here. If you have to go down in a wound, like you've done a buried, you need to grab it. If it's okay with you guys, I'll just, if I have a little pearl that I wanna pass on, I'll just say it. You, the pickups with teeth, if you have to reach down in a wound and grab the suture needle, you can grab it, not with the teeth, but with a little bit back from the teeth by just over-pinching it. I don't know if you can understand. You grab it, you grab it like this. Yeah. Like this. It's awkward. Go ahead. Yes, the simple, yeah. I don't think you want it that long on the ends. But let me see. Interesting. Oh, we've run amiss here. Okay. Somewhere, somewhere there's some glasses. Oh, here they are. There's some glasses somewhere. Here they are. All right. Pretty good. I don't know if you're alternating going back and forth, but it might be something you can work on. Okay. And see how close to the wound edge you are? that's great. If you're doing a face plastics Not so great. If you're doing a back or something Yeah, and try it with the tensioning device Yeah, yeah, yeah Yeah, it's a fine point it'll still hold but it just looks better if you do it holds better How you doing is it fun it's interesting how you can feel it Yeah, that's how it feels, you know when you have a splinter underneath the skin How are people doing with that well We'll spend a little bit extra time now because this is a building block. You need to be able to do a simple or interrupted No, do we need it? Oh do we have a We should get one yes, sir I do too Yeah, Dan it Dan is is referring to it to what I would consider an advanced technique He puts his knots over to one side Yeah Yeah, you know I I'd love to be able to show you a technique actually that pictures up there Let me see if I can get up here and show you Here Can can you guys take a break and watch me do one thing real quick I'm just gonna show you how to do a lock and Consistent with what Dan described how he puts the knot over to one side I've been around. I've asked a few people to just drop your drop your Your suture needle off to the side and just focus on the suture material And Now see where my hands are right here, can you see it on the projector Rachel? Okay, can you see the suture you see how it's flat? Okay watch this See Now it's locked I can see the performance of what that suture is going to do The tension is holding Did you see what I did? Okay, I'm gonna do it again Okay, so I'm about ready to do my first knot there I'm gonna pull it through It's flat and Now I'm gonna pull this hand over this way Here's my instrument. Here's my hand my hands on the suture material Okay, and now I can see the tension Before I set the second knot I Can make sure I like that tension and what the suture is doing and now I can finish see and now I've got it and See how I'm alternating And why can't they see Rachel Okay, thank you could they see the when I locked it, okay. All right Go ahead Yes Yes, yes, am I doing it like you're saying now Yeah, I'm going this way and then that way If you if you look really closely at the knot, it looks better when when you do that alternation Yes, yes great I hope that's useful So you just wrapping it clockwise one way kind of clockwise the next way back and forth just alternate that On the on the video he says three is that useful? Can you see what I'm doing up there? Somebody working See how if you put a nail in there you can feel it And that fulfill that Bob See you can kind of get a sense of it But you can feel that there's a foreign body And that's about all you get when you you know That's and then you could figure out the trajectory of it and then you could cut down on it if you had to Yeah Yeah Yeah, yeah. Well, you know, I mean you're gonna turn around and use this for to teach other people You're already at a point where you can do that See now put your finger on it See Just determined to lose these glasses It's what happens when you turn 50 Yeah Yeah, I put it off until I was about 55 How are you doing Yeah, go off to the side and put it Yes, that's this that's the secret, isn't it? Ah Yes, that's What is your first name Aaron? Can you put your finger on that and feel that it's like a foreign body underneath there. Isn't that cool? So if you're teaching someone you can you can show them that feel it You can even keep the nail if you like Um So Aaron asked well, how do I get the right amount of tension on my on my You know when I'm suturing because you know see how this tension bar is making it, you know So that you actually have to it's more realistic. That's how it is. And the answer to that is Practice technique If you're not happy with your simple I'm gonna sheet teach you how to do a vertical mattress and there you'll be able to get more strength and It's actually I think nice to interpose simple and and and vertical and that's what we'll do Yes, sir. You have a question? No. Okay. How's this going so far? Good you you feel comfortable with that Everybody is so close to the wound. Everybody is a practice a practicing plastic surgeon here Nobody is an industrial gladiator medicine strength Provider of suturing. Okay, get get over being so close to that wound edge See how she oh good. So you do it here here and then you're gonna do one in the middle. Oh Yeah Yeah the next day again, okay And Let's see, I might run out of nails here This I'm just gonna put a nail in here just so you have a sense of it Oh Just long enough to grab not that long So I have some examples of different needles and suturing over there. This is what they brought in the kit It's a it's a good size It's not a stupid size So you'd have to do two bites instead of one One bite is to go all the way across but you can't do that in a well-tensioned wound, you know, in fact Now that I'm thinking about it for the simple suture we're doing it's probably smart to not even use the tensioning device Because if you think about it, I've walked around now a little bit and a lot of you are having trouble Handling that tension with a simple suture and that's an excellent segue to moving An ink pen, oh, oh or you could take off there's actually two layers of the tensioning device That's actually a smart thing. Bob was suggesting take off the tensioning device and And just put either a pen nothing or even just one of the two things on it. So This is a great example for to do the interrupted a simple suture. You're talking about a Relatively straight cut not much tension and This simple suture is sufficient for anything with tension on it. We're actually going to move on and use use a Some other technique That was actually smart that we did it like that Rachel let's let's move along because really the So if I could get your attention if you want to take a break from that simple suture Let's talk about and we're building up to doing a complex layered closure. By the way, that's our goal right complex layer closure So, let's look at this simple buried suture, let's watch dr. Zen real quick Okay, and we'll you'll you'll have plenty of chance to come back and perfect your simple or interrupted suture technique. Okay? Now I'm going to show you a simple buried suture These are the sutures that we use when we're trying to reapproximate the skin usually with absorbable suture and then either Gluing or sterile stripping where we're not doing a skin layer So the key here is you want to get some of the deeper tissues and here you see in the model We can get some of the deeper dermis. There's actually a little piece of mesh in that deep dermis We want to grab that deeper stuff come out superficially So we're starting deep and then we enter superficially and end deep So both threads of the suture are now deep And what that's going to do when we tie this now is it's going to pull everything together But the knot itself is actually going to be underneath And this is important because we want to take all the tension off the skin whether we're sterile stripping it over there We're just closing it with another suture and we don't want these little ends of this of the suture to poke up through the skin We call that spitting so you need to get it get deep grab some of that deep dermis which in this case is that little piece of mesh and Make sure you're entering the same place where you exited on the other side So just as superficial as you are on one side You must be superficial on the other side or else your skin edge. It'll be uneven notice Also when I'm pulling oftentimes, I'll pull it along the wound It allows you to get the tie all the way into the wound and it's not being prevented by the skin edges So this is a simple buried suture. This is something that we use all the time in plastic surgery a couple of points When you're doing a buried suture, that's a you're going to be using absorbable suture Okay, it feels differently. You don't need as many knots. In fact, you don't want as many knots because it's a foreign body I have some examples of Absorbable suture has anybody not used absorbable suture before Chromic or vikral never okay This is for all chromic you want to you want to try that? Yeah. Is anybody else not used? Anybody wants to try it You know, listen pass it around This is vikral. It's another type of an absorbable suture Now if you if you did if you do one then Then give it to somebody else let them try anybody over here never used to absorbable suture Let me see if I can get a couple more So again, this is a buried suture it's actually really important to be able to do this I Think that's all I have Yeah Yeah Yeah But I put this up so that you can kind of see what's happening underneath the surface So right on a you're coming deep first and then coming up towards Bob I would cut out what's there? Maybe make a bigger cut Is there enough like and guys Now I would suggest using your tensioning device. So it's open and Make a bigger cut We want to have a we want to have a good size cut to work with here Because we're gonna we're gonna work up to doing our layered closures. Okay? Hi, did you just get here are you? That's smart, yeah, I've tried to lose mine several time today So so if you want to watch this just for a second I'll show you when you do this Can y'all see the needle? Yep. Okay, so you're going in down here deep Was it there it is It's just got lost There you go So the mesh looks like it's way deeper than Just that fat so you need to get way down in there and in the same depth on the other side Way deep inside He's starting superficial though, yeah So he's in where I'm going. Yeah, he's inverting his circle so that the knot is low low in the wound And with these with with some of the absorbable used or three throws Total And that's to take the tension off The deeper tissues so because if it's that that wide and you don't start closing up from the bottom up You'll never get good closure Yeah Yeah, but you put the mesh is actually below that Dan what's your question It depends I would I would make a bigger cut than that Yeah, cuz you're gonna need it. Oh, you look at you made me a huge cut Yeah, yeah get it and let's let's put this away And but you're doing it the other way it's almost you got it, sorry Well different wounds have different number of layers, I'll show you a couple pictures where I'm doing three layers We'll spend a little time on that go ahead Yeah Yeah, this might be too superficial you're gonna tent in a real person you attempt the skin Yeah, you want it. There's something called Scarpies ligament, which is within the subcutaneous tissue This way this side underneath This way it's only actually deep and came up, okay, and I came oh, yeah Right Yeah, how many people have never done a buried suture before like this Wow Wow It's hard to tell That's amazing You bite okay you bite Well, it just depends on so so like you have a deeper you'll get out there that cuts wide enough But yeah, I would just have to be wide enough The fat is the yellow try it you're actually going down below the fat To have that that that mesh under there is basically like fascia. You you want to go below that come up through it But just catching the edge of it around You come back in and go right through the bottom of the fat into that mesh Which is fascia and back out So you're it's you're going in from here coming in here and the the two ends are actually at the bottom This is a this is a kind of a Difficult concept and I realize it's almost like trying to ride a bicycle You know once you know how and then you go back and try to teach someone else Yeah, perfect perfect and just to just to add to what Bob's saying Depends on the tissue. There's a Scarpies ligament that's within the subcutaneous sometimes and without even Without even the wound being through the fascia you can close a deep wound Using that something called Scarpies fascia The goal is to to reduce tension on the external aspect of the wound and Reduce the chance of developing a seroma a collection of fluid You go way deep, yeah way deep into the wound. Yeah. Yeah. Yeah, you might want to have a little bit bigger cut Just a little bit bigger because we're gonna use it Oh Yeah, that's right. Yeah in deep. That's right Yeah, has anybody ever seen a seroma in a person after surgery or something? Not fun Not fun doesn't look good doesn't feel good and now you've got some collection of fluid that you have to drain or deal with Yes, sir Yeah Grab it on the tip of your needle driver and grab it a little bit closer to the end of the needle No this way and you might you've already bent the needle. I'd get another needle by the way I have a little plastic container for these sharps because I'm sure the Marriott would not like us to leave these needles around So if anybody has a needle they need to dispose of just holler I'll come by and collect and if you if you take your needle driver and squeeze that and And squeeze the the suture needle in a certain way you'll you'll straighten it and then then it will be not not any good for you Yes, yes, remember everything underneath the skin is a foreign body and in fact on Certain hand cases even though I'd like to use I'd like to do a layered closure. Sometimes I do not. Just because I don't want a foreign body. Yeah. Is this useful guys? Is this, are we getting into some? So am I supposed to be trying to come out next to my original entry point? Yeah. Okay. Yeah. Okay. Yeah. Ideally it's perpendicular to the wound edge. Okay. But whatever you can do. I noticed that Dr. Zen was a little bit loose with his being perpendicular to the wound edge, so. Yeah, so first I, where do I bite? Yeah. You mean where do you put the needle driver? Yeah. How do you load it? Yeah. So that's a good question. I would load it close to the suture, close to the hilt. And I would drive it like so. Like that. And by the way, you don't have to put your fingers in those little hole in the needle driver. You're actually cool if you don't. Okay. Just, no. Okay, I'll go for a second. Go ahead. What is the rationale for interrupting and going the other way as opposed to just going all the way across? Well, if you can do it, you're special. I think it's just a matter of getting the job done. But in all sincerity, sometimes you have, what is your first name? Arthelia. Arthelia is asking, what is the rationale for taking the buried suture in two bites instead of just one? And I think the answer is, whatever's most expedient, but also, what if there's asymmetric swelling? There's more swelling on one side than another. That has to do a lot with the face, and especially around an eyebrow, for example. But I would make a bigger cut, and I would practice getting, you know, you wanna, if there's tension on the wound, you wanna be able to get some of that tension off with that deep, you know, that deep buried suture. Oh, wait a second, guys. I'm gonna ask his, he's, go ahead. Is this the correct suture placement, or should this be underneath? So when I'm tying it off, this is in between? No, I like it to be on one side. Do your, James, James asked a good question. He asked, should the ends of the suture that you're gonna tie be on the side of, to the side of the suture coming across? And I think it should be, as opposed to in the middle, yes. Yeah. No, that's just, observable sutures are increasing the risk of infection, so you don't have to worry about the ends of the suture. No, we are only using this suture in this situation because that's what come with the kit. That's why I walked around and I said, has anybody ever not used observable suture? You would never, ever, well, you probably would never use non-observable suture deep in a wound. Does the surgeons ever use non-observable suture to close a fascia? The answer's yes. But you and I will never, ever do that. Not make it in the middle, but make it off to the side. The, um. Sort of the layer in between. Yeah, yeah, yeah, yeah. I've begun to do that since I watched Dr. Zinn do it, and I've used it several times now, and I like it, so. Yes, what is your name? Can I say Shay? Shay asked a good question. What's the risk with an observable suture, a buried knot, cutting the ends too short? The risk is, you've wasted your time. It comes undone. So you want to leave it long enough so that the knot remains viable. Right? So that's the answer. But not too long. If you leave it too long, then you'll have spitting, or when the ends come out of the skin. Was there another question over here that I missed? Sir, did you have a question that I missed? Oh, no? Okay. Okay, depends on the suture, depends on the amount of tension. Deep, I would use maybe three. Maybe four. On the outside, I'd go crazy, and I'll put eight. Okay? Yeah, yeah, yeah. Yeah, yeah, no, no, no. Did you use the absorbable? Do you have any left? Oh, good for you. Good for you. Thank you. Non-absorbable? Yeah, this is all absorbable. What, one second. Yes, thank you. That's absorbable? Yeah. It's interesting. If you've never tried with chromic, it's not very strong. Yeah, see how it feels? That'll give you a good idea. No problem, yeah. So chromic I use for buccal mucosa, for inside the mouth. It absorbs pretty fast. Vicryl absorbs a little slower. You guys doing okay? You done with that? Okay. Feel like I'm doing something useful here. Yeah. You guys are hard at work. I'm sorry we don't have more kits. This is horrible. Are you guys getting something out of this? Yes, yes, yes. So Dr. Zaks is reminding me that we have actually a time. So we are going to move on to my very, very favorite suture technique, and that's the vertical mattress. Which you'll use more, well, I think you'll use more than a buried suture. Well, you use them all. Do you want to put it on, you know, we want to put it on show. You want to, oh, oh, I see what you're doing. All right, so we're going to switch over to vertical mattress. Okay. Okay, you guys want to look up for this, okay? Next I'm going to show you a little more complex suture, the vertical mattress suture. Again, we're going to go ahead and open up the device that comes with your suture pad that helps to put tension on the skin. And when we go ahead and make a cut here, what happens is the skin gapes open. In order to take tension off this, sometimes a simple suture will just pull through and we'll do a vertical mattress, which some people call the far, far, near, near. So notice I've gone into the skin, along the bottom of the skin, I've gone far away, and now I turn the needle around and come back and do nearer and nearer to the incision. And what this does is it's going to pull the tissue between each of those throws together as opposed to just pulling the edges of the skin together. And again, you do your instrument tie and generally I'll pull it tight just so I see the skin kissing. And this is a more secure closure because now what you're doing is you're actually grabbing a bunch of tissue and a bunch of tissue and it's pulling the skin edges together, but there's no actual stitch in the actual edge of the skin. You see how that's pulled through? Along the bottom of the dermis, run along the bottom of the dermis and come out about the same distance on both sides, turn the needle around, and now you want to get pretty close to the edge of the skin because it's the distance between those two bites that gives you your strength. Do the same on both sides. And then again, go ahead and do your instrument tie. So this is important when we are doing different types of deeper closures and certainly wounds that are traumatic and maybe you have edema and are swollen and under a lot of tension. It's a force that you've been doing for years. Yes, yes, yes, yes. In fact- Do you want me to play it again? No, no. Listen, listen. You guys can watch this video on your own time. So many, many, as many times as you want, okay? That's the purpose. You can literally access it. It's on the, sorry. Yeah, it's on the little sheet. And the last page of this has the list of all the resources including that YouTube link. Yeah, but it's right here at the top. Yeah. Now. Okay, so let's, can we, I'll do it right here. I got it. I got it. Oh, how'd you go back so far? I don't know. What's that? Pictures? Not all of them. It's a too big a program. It's like 110 gigabytes. It's just too much. Okay, so vertical mattress. I'll just talk while you're starting. Oh, look at you. I'll talk while you're doing. Why do I like the vertical mattress so much? I love it because I can control the wound edges. It holds the tension the very best. And I love to interpose simples and vertical mattress sutures. And I'd make a couple comments. You saw Dr. Zinn. He's pretty fast and loose with the angle that he's coming in. And I think it's best to keep it, the vertical mattress perpendicular to the wound edge. It looks better, functions better. One of the principal benefits of using a vertical mattress for me is to avoid the submarine-ing. And Bob will show you an example in a minute, but submarine-ing means one edge is underneath another. And for the wound to heal, you want the healing tissues to be in opposition. He, Dr. Zinn used the word kissing. For the sake of practice today, please make your deep, your far, far, wide from the wound. Challenge yourself to get away from that, the actual wound edge, okay? Okay. Dan had asked the question before about, do you sometimes you remove a suture that you don't like? And the answer's yes. All the time. Dan, do you see that? I put it right here. Remove the simple suture and replace it with a vertical or horizontal mattress. Bob, do you do that too? If I don't like something, I take it. I'm so OCD. I want all my knots right. I want all my sutures in line. One of the biggest things with this mattress, just to show you, when you're doing them, if you start out wide like this, you go in and follow the needle around. Don't torque it. But when you come in, you come out, you grab it. Can you guys see it on the screen up there? And you come back, you want to be at the same depth. Same depth. And the same line is where you went in. So when you come out, you're wide. With both of them, if you look in the bottom, it's straight across. These are across. And when you come back, what you're doing is you're basically trying to bring the wound margin back. This is a little bit wider than sometimes I would do. So you actually have to turn the needle the other way, which you couldn't really see on the screen. You load it backwards. See how it's going backhand? Yeah. But everything should be in line. Do it two bites. Do it two bites. So everything should be in line. I was just trying to show how it lines up. How it lines up. So when it comes back, you're doing this. Tight, yeah. And one thing that you always want to make sure is, see this is a little bit wide on the incision side, but you need to have a little gap in here because if these are too close, you can't cut that knot. Guys, look up for a second. Look up at Bob's. If this isn't far enough apart, you need to have a gap like this so that when you tie the knot, you're going to be able to go back and cut it later on. If you have both of them right next to each other, that knot's going to start sinking into the tissue. And you got to yank it back up to get to the base of it to cut it out. You have to dig it out. So you don't want to do that. And so you've not left yourself a far, far enough of a grasp of that tissue to handle the tension, okay? So when you tie it... See what he's doing there, guys? He's going to lay it flat. Now, you want to re-approximate, not strangulate. In this one, because I didn't go quite close enough, the edges is open on the ends a little bit. And because of the tension on this thing, see how even though I was that wide on the knot, it's still trying to bury. So, but if I pull up, see, you can still see that I have a space there that I get to to cut it. Now, if you take a simple on each side of that, it'll take care of it. Yeah. It's more forgiving when you do that. You see what we're building up to, guys? Is this working out well to have this stuff in your hands and I'm not bothering you talking over stuff and doing the yoga teacher. I'd like to be a yoga teacher. For that, yeah, with that tension. Again, we're trying to simulate tensioning on a wound. Not every wound is going to have this much tension, but again, we're practicing. Yeah. This is not close enough. This is not far enough away from the wound edge. Yeah, I can see that. Wow, you have to go wide. Yeah, I can still see some of you guys are still really close to the wound edge. Remember, the mat doesn't care. Oh, that's right. We don't have enough light in here. What are we doing? Look at this young lady. She's got a pin light on. Here, let me find this light back here. Now, while we're doing this, if anybody wants to see what it feels like to have loops on, that's why I brought them. As long as your head is not bigger than mine. I'm going to push buttons back here. Hey. Whoa. Whoa. Whoa. Whoa. I told you I was going to push buttons. Hold on. You didn't say people buttons. You just said buttons. Ha, ha, ha. That's the Hawthorne principle. Has anybody ever heard of the Hawthorne principle? I can't believe you guys know about that. But you've never done a buried suture. It's still not enough light in here. One thing when you're doing these mattress sutures, after you get your two deep ones in, the first two on the outside, if you loosen that tensioner, it'll help you get the rest of it back together. You know, it's such a shame. I'm going to try to help find lights. She's going to call somebody. Some people didn't show up, and they've already purchased those. You know, it's a shame. We should have more tables. Okay. So, you know, take your time and really learn the vertical mattress. It can be your best friend when you're suturing. Yeah, surgical loops. You want to try them? Yeah, yeah, yeah. Let me get those. Oh, somebody actually got them out. Yeah, you have to have this. Do you want to try them real quick? Hold on one second. Hold on one second. Hold on one second. Yeah, yeah. Oh, really? Okay. Oh. Yeah. We'll put the light up. There'll be somebody coming in a minute. That's a good point. And so you put... Let me just hold it like this. Okay, like that. Can you see? Just be careful with them, yeah. Yeah. Now, the amount of space between you and your head gives you the focus. So you want to go... If you're not in focus, then you're like a chicken. You go up or down. Yeah. Do you want to try it for a minute? Yeah, yeah, try it for a minute. And then I'll bring these loops around and let you... Just raise your hand when you're done and I'll come get them. I'll bring the loops in just a second, okay? We're getting the lights to turn on. Well, have you done your vertical? Yeah, see what it's like to put a simple between. Yeah, yeah, yeah. I think it's nice. It's powerful. Each one has strengths. But, yeah, you're ahead of the game here. Just stick it in here. Yeah, the vertical mattress, yeah. You want to go a little further. Just try it. Go deep, yeah, like that. Perfect. Grab it. Perfect. And then go in the same depth and go far over that way. So far, far, near, near, yep. Just a second. I would use this tinching device. Go. One second now. Where are you? I did my first deep. Now you're going to go deep and then shallow. Far, far. This is the second far. Remember, all suturing is making circles. Life is circles. Life is circular, right? You're born. You live. You die. That's it. It's a circle. What's that? Oh, You can. You can. So the near-near i would make much Nearer. Yes. So if it's helpful to see examples, if you guys want to Look up for a second at the screen, there's an example of Vertical mattress interposed with simple. This is an example of monocro. Is anybody able to work with That? this is what a plastic surgeon uses to do a breast Reconstruction, for example. I use that a lot. It's very, very Expensive. It's monofilament, but it works great. Here's a picture of the vertical mattress. I can put it Back on this, but i'll show you some examples. If you want to Look up for a second. Bob, are you in the room? these are Bob's. This is bob's handiwork here. You can see how he's Trying to evert the tissues. Here's a couple from what i did. You can see the tendon in the wound there. If you look at the Screen for a second, this is in a web space, so this will Submarine. So you can see how i use the vertical mattress. And you're controlling the wound edge. See that? that controls That wound edge nicely. Here's one that you can see really Well. Okay. So this is the vertical right here. Even just To put one in makes a big difference. Here's a Horizontal. Why did i put it horizontal? because it just fit Nicely. Here's early stitch reaction, by the way. See the Little bit of pink? has anybody seen stitch reaction before? Okay. It's good to tell the worker that that might happen. Remember, you don't take every suture out in seven days. It's Not like prescribing an antibiotic. Not everything comes Out in a week. Expected. And sometimes i'll ask a worker, Look, did you have a stitch reaction last time? Yes, sir? thank you. Is the lighting better, guys? Thank you. Thank you for your help. Okay. So the way we're going to do this is they just go over Your nose. Then we have to turn it on. Can you see through the Loops? see how it magnifies? by how close your face is to the There you go. You got it. You see it? Yeah. It takes some getting used to. Some people, it really Messes up their depth perception and they can't really adjust to It. Everything is easier without the tension. That's the whole Point. The point is, well, try it without it first, but then at Some point you need to be able to handle that tension. That's The whole purpose of it. Too much tension. Yeah. So what you Can do is you can take one of these off. Is there a second? Is there another? yeah, you can take the Yeah, yeah. Is this yours? Can i? thank you. It should have two of them. That's why i was looking to see If there's another one. It's just sitting on there. There you go. There you go. What's your name? eric and i discovered that with the Brand-new kits, the tensioning device, that's interesting. No, it's not supposed to do that. Maybe re-glue it. There we go. I actually have some glue. I do, actually. Yeah, it's really good glue. I used it to put on these Acrylic nails. You know what? We're doing so well, but we need to push on. Put up the next one. Okay, guys, so i'm going to put a new video up. This is going to be the horizontal mattress. So similar to what we just did with vertical, but a little bit Different orientation. Now, this type of suture is going to be part of your Armamentarium. Now, sometimes you can change it To a horizontal position. So these are all in the same line And hence the term vertical. Now we're going to do a Horizontal mattress. Here, the idea is not to go Near, near or far, far. Take the same size bite each time. But what you're going to do is it's effectively two simple Sutures in one suture. So what you'll do is you'll Enter the skin now as if you would for a simple suture. And instead of tying this as a simple suture, turn your needle Around, move the same distance you would for your simple suture And enter it the same way, almost like you're doing a simple Suture on the other side. So this is still a mattress Suture because there's two different rows of suturing. Now, instead of in a vertical line, it's in a horizontal line. And it's important that you pull together again only until the Edges kiss each other. So it has the advantage of Being faster than two simple sutures. And, you know, sometimes in some situations you want to pull Tissue to tissue together just like with a vertical. Vertical is nicer because it does evert the skin edges. But in a case like this where eversion is not a problem, Simply doing a horizontal mattress will help you. And sometimes in cosmetic surgery, we don't want any suture Marks on one side. And when you come to the second side here, What you would do is take the first half of your simple And then just take simply a dermal bite on the opposite side And then come back and come through the skin again. And when you tie it down, it'll simply pull the dermis toward it. And we often do that in cosmetic surgery in areas of hair bearing. So this is good again for tension. It's good when the skin Doesn't need inversion. I think the one thing about these, though, if you're going to do that, You absolutely have to make sure that everything lines up. Because if you don't, that's going to really be Markedly deformed, sort of. So you want to make sure you line it up perfect. So... So, guys, We're having so much fun. And, unfortunately, Our time is going to run short here. So i'm feeling a little bit pressured to make sure that we Get through, for the benefit of those who have some advanced Skills, some additional thoughts. Yeah. One second. Always. Just about. In a face, not quite as much, but a little bit. Yes, yes, yes, yes. So what i'm going to do now, remember, the good news is you're Going to take these kids home with you. And this is only the start. I would suggest you look at Dr. Zinn's video a few times and you sit down and you practice it. This is an introductory. This is how do i go about Furthering these skill sets. This is the first time we've Done this at a.Com. We could probably spend two days on this. Now, i do want to get your attention and show you a couple Of other techniques. This is something called the half buried. I found this to be very, very useful in my closures. You can pull skin from one side to another. Bob has used this, too. What you'll see being done there is you're going through the Subcuticular on that flap. Here's an example of a face i Did. I suspect that most of us would Not do this here. But again, i don't know if Bob would do that these days. Yeah. The infraorbital nerve is right there. Here we go. This is another one in a leg. You can see it's a multilayered Closure, but what i'd point out to you is there's that half Buried. See where i'm going through the tissue? okay. Do You want to play dr. Zen's thing? unfortunately we're going to Have to speed along here. I've just looked at my watch. If Somebody doesn't have their hands busy, if you want to come Over and try this bovie on this pig's foot, that would be great. How many people can do a digital block? if you've never done a Digital block, please let me walk you through it a little bit. Do the half buried real quick. From here i think we're going to switch to an introductory type Mode and let you guys practice on your own. If i'm not Mistaken, isn't it getting close to 20 to 10? can you believe We've been here for this long? he doesn't have a half buried. What time does it end? 10. He doesn't have a half buried. What's that? he doesn't have a half buried. Push on then. Let's skip through that and go to the complex one. Not the subcuticular. This one? Yes. That's right. I did put in the half buried instead of Subcuticular because i think it's very much more useful. Now, let's listen to dr. Zenz. He's given some clinical tidbits. One of the advantages of the vatopad is that all the layers of Closure are represented, so we not only have the skin and Dermis, we also have some fat, which feels very lifelike, and Then deeper we see the white, what i would call fascia, the Lining of the muscle, and below is some red, which represents Generally the strength of closure, especially in deeper Wound, is going to be that deeper white fascia. If we just close the skin here, there almost would be this Potential space underneath where fluid could collect or the skin Would have so much tension on it, it ultimately would pull apart. This is especially true over joints where you're bending the Arm or bending the knee and you might pull things apart. What we'll do here is we'll first close the fascia. Because fascia is generally so deep to the skin, i usually Don't bury the knot. You certainly could, but you don't Have to, so for simplicity's sake, i just do simple suture Here. In some situations we might use a Permanent suture here. Certainly you can use absorbable As well, so it's kind of surgeon's choice. And remember, you're pretty deep here, so you're going to want To not only lock the knot, but then once you're pulling things Down, it's almost easier to pull it along the wound itself, Otherwise the skin may prevent you from tying all the way down. So we're going to put a couple of interrupted simple stitches Here to close the fascia. And again, you sort of put a stitch In, see what it does, put a stitch in, see what it does. That's the way that we do it in surgery. Sometimes you need a lot of stitches, sometimes you don't. Stitches are a foreign body, so potentially if you worry about Infection and things like that, you'd use an absorbable suture So it's not going to hang around, or at least a less Permanent suture. If you're not able to do that, Remember, you can always throw an extra throw, like three Throws, or you can just do what I just did, which is sort of Lock it down by pulling on it. Once the fascia is closed, you kind of have a decision to make. You can go right to the dermis, or you can look for, in some Parts of the body, there's what's called scarpus fascia. So you could potentially close another layer. Here, I'm going to close the deep dermis, and it's going to Include some of that fatty tissue, which would be the Scarpus fascia, but the dermis is the strength here. Again, this is a buried knot, because this is the next layer Of closure, so we started deep and went superficial, and then Superficial and deep. You can see there is some Tension on this wound, and I think that's what I like about This demonstration and this type of model, is that it is Realistic, and you can set this tension as much as you want, And early on, you'll be able to close the ones without tension, And you'll be able to close the ones without tension. And as you start moving along, you'll want to put more and more Tension on and see how good your knots are and how good your Suturing is. Another word of advice I would Give you is notice how I'm going to the ends first. The ends have the least amount of tension. The middle of the wound gapes open the most, and I think most Of the time, people want to close the middle first. If you sort of sneak up on it, though, and start closing the Ends first, you'll take the tension off, so by the time you Close the middle first, it will have the least amount of tension on it. So here we have two, and I'm going to put one more. Notice I'm grabbing deep dermis, starting deep, coming Superficial, and I'll grab right above the dermis on the other Side, come out the same distance. See where he's putting that needle? Getting these skin edges closer together and getting them closer Together at about the same level so that when we're finally Closed and the skin is closed, we have a beautiful closure. Okay. So now we have the dermis closed. Now we're going to have our skin closure. This is your closure of choice. You can do a running suture, you can do interrupted. This will totally be up to you here because it's a complex Closure, and I believe it's under a lot of tension. I'm using the vertical mattress. I told you this is probably the Best suture for wounds that are difficult to close and under a Lot of tension because you're grabbing a lot of tissue to a Lot of tissue, and because you're starting far away, because Your second bite is close, what that does when you tie it, it Literally everts the wounds, and so the skin edges pout out, Which gives you proper healing. If you don't place your sutures Properly, the skin can turn in, and, you know, epidermis, the Outer layer of skin touching epidermis is not going to heal. So you'll take your stitches out and your wound will kind of break Open, and you'll wonder why. It's because you didn't Approximate your edges. It's pretty cool, isn't it? go back and look at that a few Times and practice that. Let's introduce a couple more Concepts. Very basic. Has anybody ever not used a staple Gun? everybody used one? never used one. You've got one. Let's Use it. Let's do it with not the full tension. Okay? let's Think about a scalp that's flat like this, and anybody else Want to try the loops? yeah. So just take out your staple gun And with one of the incisions that you've already made, do you Want to just put this video on in the stapling? Staples get a bum rap, but they're actually a fine way to Close the skin. It seems like it's a fairly simple thing to do, but what i Would tell you is approximation of the skin is key. Oftentimes i'll use either one or two pickups to position the Skin properly, everting it, bringing it together, and then Taking a stapling device similar to the one that comes With your kit, simply center the device on the skin, staple it Down, it will grab the edges and then turn them in, which Helps to evert their edges, which, again, is very helpful. So stapling is nice because it's fast and will turn the edges Out. So here i'm approximating the Skin, everting it, getting it close together so the skin edges Are touching, and then placing the stapler. You don't need necessarily to push down very hard. The motion is key, and when you're stapling, the end of the Staple is not moving at all. Try to grab it near the end of The stapler. You'll have more torque advantage. And, again, just like simple sutures, you have to decide how Many staples you need and what each wound needs for Approximation. In a case like this, it's cool to Practice with the tension on, but the first time if you've Ever done it, but you can see what's going on there. How do we take these out? this is a staple remover. Basically, it will grab the staple, which has turned its Edges in. So watch how he takes it out. You have a little tool to do that with. You can do it with a hemostat. Use your little tool. Don't do too many staples. You want to keep some for later. Push down, spreads it, and as it straightens it. That's pretty cool, isn't it? If you don't have a staple remover, you can also use a Needle driver or a clamp and place it under the staple and Spread. Basically, spreading is doing The same thing as straightening out. This is much less painful for your patient. You can use one of these devices. Sometimes if the bending apparatus doesn't straighten Completely, you can as you're stapling, rock it gently. Here's an example with a needle driver where you spread. You're trying to open those tines. As it does, it will come out. If you're going to do this, it's Usually better to do this on a patient who is asleep because it Can hurt to remove staples this way. Sometimes you need to rock from side to side. One side is not completely open. In the interest of time, i'm going to push on just a little Bit. Again, this course is to kind of Get us going in terms of suturing. Now, it's a couple of examples of sutures. This is a couple of pictures of stitch reaction, by the way. You see how the redness is focused on where the sutures Enter and exit the body? this is the body saying, hey, what's This stuff? it's foreign body reaction. You just take the stitches out and it's fine. Now, let me give you my bias. I think everybody needs to do a Digital block. And please do not try to suture That tip of that finger without doing a digital block. And please help that guy with the fracture. You know, the nerves are really close to the bone. It's amazingly how infrequently we cut them. But it's fairly easy to numb them up. Bob has a different way of doing a digital block. He can show you. But i've helped a nurse Practitioner do what i call a metacarpal technique. She's putting about 5 cc's on each side of the metacarpal Joint. You want to inject not under Pressure. You want to move the needle tip If you have pressure. You want to aspirate before you inject. I usually use a pivot cane or mar cane and a lot of cane. It's a nice tattooing job here. It helps with the anatomy, Doesn't it? but you can see this guy is in Terrible pain and digital block takes care of that. Here's a toe that i did recently. You can see what i did there. Dan, you can check that out. But, you know, the guy works The next day. Same thing with this. It's amazing how it heals in. I'll just go quickly. Let's talk about subogluhematoma. ACOM got the pig's feet for us over here. I've got a couple bobies. You guys should just come over and just touch the nail with that. I had these acrylic nails placed on these mannequins, but it's flammable. So we're not going to do that. If you'll notice this nail here, how many of you have not done a subogluhematoma relief? This is very easy. The trick is, and Bob can attest to this, if you go too deep, then it's painful. Nail is basically horn, right? It's insensate, but if you touch the bed underneath, the person's not going to be real happy with you. Now, the way I do it is I'll probably look at this. I'll send them to the x-ray. If they come back and there's more percentage of that nail involved, I'll say, okay, this is evolving. I'm going to do it. If it's a percentage, what's your percentage? What's your threshold? Yeah. Yeah. And if it's growing, if it's big, it'll evolve. They'll lose the nail. If you drain it, there's a chance they won't lose a nail. Okay. I hope that's clear for you. So basic plastic skills. I wish we had time to spend more on that. I mentioned about undermining. That's taking a pair of scissors and going around the wound edge and relieving some tension. Bob, you want to come up here and just show them how to do that? And I also mentioned about changing the shape of the wound. That's critically important. We should all be able to debride the devitalized tissue. Here's an example. Bob, you want to set up and you have a pair of scissors right here. You see where I just left that to heal by secondary intention, this one here? I made a purposeful decision to do that because it's too thin. It's non-viable. Okay. Even this is a little bit thin. You see the color of it? So you want to read the tissue. That's my point. Here's a couple examples. You see that shape? This is a carpenter, a Union carpenter that's also a barber. Okay. And so he used his hands. And so, you know, you had to change the shape. Okay. Do you guys feel confident doing that? What's that? No, no, no, no. I don't need to. I was able to re-approximate it. And the guy worked the next day. Okay. I usually ask the audience, how many days off do you think the guy had? And pretty soon they figure out that the answer is zero. So like a grinder injury where you have some loss of tissue or somebody fell on some grating or fell on a piece of cement and took some skin away. If you don't have something you can close, you can always undermine. So I just do this and use either forceps or, you know, hemostats or sutures or scissors and gently undermine under here and do the same thing on the other side. If you do the same distance on both sides, now you have some, a little bit of less tension on the tissue. So you can bring all that back together. You may have had this bigger gap, but since you've undermined all this and loosened it up, now you can bring it back together. You want to do that half buried real quick? Yeah. Bob can show you a half buried. So if you're doing these half buried sutures, anytime you have something like this, where it's a triangle, if you put stitches right in the middle, you can kill that part of the tissue. So what you would do instead is a half buried stitch. So you would go in like this back here and come out. This is not on Dr. Zinn's video. And then this is another one where it's really important that you, that you make sure that it goes in and comes out where it's supposed to, because what you're going to end up doing, try and do this left hand in this way. So if you see where it was on, on here on the, the, the, the outside of the triangle, you go in and come out real superficial there. So you see, it's about the same distance on both of them, the same depth. And when you, when you come back, you're going to do the same thing over here. These are all techniques that if you put them together, you can handle more varied types of wounds. So especially on a star bust, star, a star burst wound, like on a face, blunt trauma to the face, this will come in handy. So see, these are pretty symmetric. It came under here, just like it was supposed to. So it pulls that corner right back in without compromising the vasculature. And you just, just tie this off right here. Yeah. These are, these are basic, basic techniques that if you're going to do wound care, it's good to know. Here's another example of a guy having a triangular shape wound. You cannot close that. So you have to, you have to make an ellipse. You see what I've done there? And I did a layered closure to achieve that. It's not the prettiest, but the guy was able to work the next day. This, again, is gladiator medicine. For irrigating, like a hand wound? Yes. Well, I mean, you could, you know, just irrigate the heck out of it. Yes. Is there anything wrong with letting it soak in like half, get the cleanse, half water? What's your name? Brent, Brent has raised an important point. Soaking, betadine, alcohol, Hibiclens. It's all tissue toxic. Be careful. You're going to do more harm than good. I use tap water, tap water. I'm going to repeat, tap water. Okay. I have an older surgeon, an older physician that wants to come in my office. He must have sterile saline. He must. So I stock it for him. But the evidence base from Cochran, et cetera, is that you do not have to have sterile saline. In the United States of America, if you can drink it, you can use it to irrigate with. Okay. So if you're in Africa, maybe not. Or Flint, Michigan, maybe not. No. So, so anyway, there's, there's, um, here's a, here, I'm going to, I'm going to whip through some things. I'll just, I'm introducing, this is something you can't get from Dr. Zenz. Okay. So here's a guy with a knuckle, a circular shape, you know, show me how you would close that without changing the shape of that wound. Okay. Again, these are, these are construction workers. They want to work the next day. This is the best approach. Okay. Foreign bodies. I wish we had time. If, especially for, if you have a smaller hand and you've never had a tool in your hand, take a moment, come over this way and literally, literally take this and, and cut the tip of this nail off and, and assure yourself that you're, you can do it. Okay. So these are foreign bodies. Here's a boot. That's a pneumatic gun. This is how people nail. They don't take a hammer nowadays. They have a pneumatic gun and it drove through his boot. These are brand new Chippewas. His daddy, the first question was, how about the boot? How about the boot? All right. This was the case that Rachel and I presented at, at Harvard School of Public Health and Grand Rounds. We got roasted about it, I'm sure, but, but so how did I, how do we address that? You have to cut the, cut the head of the nail off and pull it through. Okay. Not a big deal. Here's what they did. It did to the bone. Okay. How many days off of work did the person have? None. Would you have felt comfortable with that in your office? But it can be done. Here's Dermabond on a hand. What's wrong with this picture? A lot. A lot. I've got some Dermabond here. If you've never used it, I can let you try it, but do not use that on a hand, please. I've seen it tried too many times. Specific tissues, we talked about, we talked about the, you know, the nails. Here's, this is my first patient when I started my new company. Vermilion border is what's critical here. Okay. Interesting thing about this particular lip, there's the vermilion border. You put your first stitch there. This is vicryl. I go back and take it out. I don't know, Bob, do you leave the vicryl in? Because people bite it out. Yeah. I use vicryl, but I take it out. The interesting thing about this lip, if you want to look up at this, you see this over here? I did that the year before. The guy came back, same lip. That's how it works. You know, this is cosmetics, this is a plastic closure here. You want to line things up. There's cartilage in there, so you want to irrigate, irrigate, irrigate. These are some nice references, but the take-homes are, if you have better technique, you can avoid the two weeks out of work that's unnecessary. Now, come over here for a minute, if you can. In terms of, there was a mannequin that I ordered, but didn't come in. Don't do that. I wanted to put that in there, because you really probably cannot cut that. It's too big an ant. You cut them all. Look at you. Now, thanks a lot. So, if you've never done a digital block, you know, you would, you know, you get your, your, you know, you make, you get your mix together, and then you'd use, instead of this larger gauze needle, I would suggest you use a 25, one-and-a-half-inch. Now, Bob has different ways of doing digital blocks. I see people do all kinds of things, and, in fact, I'll actually augment and go through the wound edge. Like, if I have a cut down here, I'll do a digital block, and then I'll go for the digital nerve and a nerve ester bundle and put lidocaine with epinephrine there. But what I'll do is I'll, I'll have my hand like this. I'll, I'll put my, my thumb on the, on the knuckle, and if it's on, on the ulnar, on the radial side, I'll go right in like this. Along your thumb? Like that. Yeah, and what I want to do is get close to the bone, but not on it. I'll aspirate, and then I'll put fluid in. I'll make a big skin well. You're just proximal to the metacarpal hole? No, just at it, just right at it, just right at it. I'll go there, and then I'll go here, right between, right in that space. If there's a vein, just go right through it, and then I'll aspirate and put five, six, seven cc's in, depending on how big the hand is. What's that? Well, you know, I used to be big on going deep and then superficial, but it doesn't matter. Just get in there in a space without a lot of pressure, put enough fluid, and then take the needle out, get rid of it, and then massage it a little bit, and wait 10 minutes. What? Fan? What the hell? I'm not doing any of that. I'm just putting the medicine where it needs to be, and then send him to x-ray, and do the procedure. It's not going to wear off if you use Bipivacaine, but that's it. I mean, it's more simple than drawing blood, and that's it. After I block it, or let him wait, and I'll see another patient or two. Now, this is for the subalgal hematoma. I thought I could do this. Watch what happens. Yeah, it melts and makes a little puff of smoke and stuff. I've got some docs that take an 18-gauge and just a lighter. Yeah, I know. I know. But I mean, that'll work, right? See how it makes it hot, and then you just touch it like this. That's it. You know, you should put your hand on it and activate it. It's called a bovie. It stays in your cabinet for years. It's battery-operated. It's pretty simple. It's so fast. You just touch it. They used to have something called a pin drill, and the pin drill was a nail drill, and it worked great, but they've been off the market forever. Subalgal hematoma, yeah. Yeah, just don't touch your hand with it. If anybody else wants to try it, I have a second one there. Somebody ought to come over here, especially if it's not to, but if your hand's not huge, just try it. Sir, let these guys come over and try the, just try to cut the head of the nail off. Could I try the digital hand? Yeah, yeah, yeah. It's more of the technique than anything else. Okay, so medical, right after medical? No, that's the PIP. This is the MCP. So you want to put your finger on the knuckle right here, right? You don't want to hit the tendon. You want to come right there and right here. So in mine, it'll be right here and right here. If it's the middle finger, you go on both sides of it. Just put it right in there deep. It's the least painful. Yep, just put it right in there, right in there. You want to get enough volume that then you can just let it sink in and do its job. Yeah, so if you were doing this one, you would go right in here and right in here. And right in here. Yeah, start the needle here so you can do a block. You can do a, put the medicine underneath the skin right there and there. Yeah, right there. Yeah, and just do it. Yeah, and then you just, yeah, a lot, a lot more fluid than you're used to. I wish I had a way to simulate that because you want to put enough volume in. Yeah, now depending on how the size of the hand, you might need 10. I mean, you might need more. I've got people that use. Yeah, yeah, yeah. That's been debunked actually. Yeah, that's not, it's not, it's not likely. Guys, this is the monocryl. If you do a lot of deep suturing, this is really good stuff. Very expensive. I'm not going to open that. That's the Dermabond. If you, if you're, I want to put this somewhere safe. Thank you so much. Ah, yes. There was a nail elevator that I used. It's a flat spoon like thing and you just go up underneath it and put, and it just pops off. After you did your block. Yeah, don't do that. That's called torture. Yeah. If you, if you don't do a digital block and you take somebody's nail off, that, that, that's, we call it torture. Yeah. Yeah. That's what digital block? No. Anytime you got a, a, um, here, let me get out of the way. Um, anytime you have a painful thing in a finger, a fracture or anything, um, let me see the tip of it. Is it broken off now? It's okay. I'll do the other one. Nobody's kicking us out. What's that? The pig's feet? The bovie. Yeah. Yeah. Yeah. Yeah. Here, take the package. So what you do is just very gently touch it like this. Yeah. Yeah. Yes. Yes. Oh yeah. Squirts. That's what you want. Yeah. Now what's your name? Dysa makes a point with a sub-ungual hematoma. The goal is to make this hole, right? Then afterwards, don't get anywhere near it with the bovie. You can take an alcohol wipe, put it back on, and then you can open it back up because it may reaccumulate. Okay. So, but you can't use alcohol before you do the bovie. It's better to use betadine before you do the bovie, but afterwards you can give them some little alcohol wipes, send them home. And that way later they can put it on there and they can re-relieve it. Does that make sense? I'm sorry we ran out of time. I knew that would happen. There's so much to do. Thank you very much. You're welcome. I hope that was useful for you. Yeah. You can see now you can, now you can practice. You've got, you can show someone else. You can, you know, there's a whole program there. You can, you can advance. There's a lot to learn. Thank you for your questions. Yeah. Thank you for the introduction. I hope that was useful. It was very. It's a good, good start. If you take that, look at that video and do some other stuff. Yeah. You said on the fingers that I just did something to it. Did you actually cut more tissue off? Yes. That's what I wanted to know. Yes. You mean on the finger with the circle? You're like, you're like, I can't. It was because at first it wasn't. It was a circle. I'm going to go back and teach some of that. You know what? I think they're about, I think there might be $200 or something like that. How much you pay? We didn't have to pay extra for it. We just paid. Yeah. Just go to that website. I've got the, I've got the, the glue. One second. It's pretty cool. Hey, hey guys. Look, I, I didn't mention, I got one more little thing to say. You should have a plastic surgeon or a hand surgeon that you can call on for stuff, but you know, Bob and I will, we'll take a, we'll take a text, you know, if you've got a question. But you should have a local guy that you work with, you know, and then you can feel more comfortable doing more stuff. Right. And if you're lucky like me, you, you go and do stuff with them. Yeah, no, I actually, I actually went after that because I was going to go home to my hometown in Kentucky. There, there were no hand surgeons at the time. So, I mean, it's just another technique, but yeah. So if it's here, there, there, and you want to, the technique is you want to, you want to stick it in and you, you want to think about going about halfway between here. So about this far and aspirate and then try to inject. If there's no pressure, you're good. If there's pressure, you need to readjust the needle tip a little bit. And then you want to inject enough fluid. You don't want to be in a ligament. In other words, you want to inject enough fluid that it will disperse nicely, but that's it. And you want to muck around the least amount that you can. Oh, yes, sir.

suture techniques

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Dr. Burrus

Dr. Rachel Zaks

Dr. Bob Bourgeois

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buried sutures

proper technique

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sutures and needles

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