Chapter 4: Table of Contents
Subcutaneous closure & How to bury a knot
To bury a knot when beginning a suture line, the needle is first inserted deep in the tissues and exteriorized superficially on one side of the incision. Then the needle is inserted superficially on the opposite side of the incision and exteriorized deep in the tissues at the same level as the first bite. The two ends of suture (both of which should be deep within the wound) are tied with 5 throws. The first bite taken after burying a knot should typically be taken deep to superficial on either side of the incision to allow the knot to be buried further.
To bury a knot at the end of a suture line, the surgeon must stop the suture pattern of choice approximately 0.5-0.8 cm from the end of the incision. Note that if you leave only a few millimeters of open wound prior to beginning to bury your knot, you may not have enough space for the knot to sink deeply into the tissues. A first bite of tissue is taken from superficial to deep on one side of the incision (typically the side away from the surgeon). The suture is pulled through completely, in the middle of the incision to form the first side of the loop. Then, a second bite is taken from deep to superficial on the opposite side of the incision (typically the surgeon’s side of the incision). The suture is pulled through part way only in order to form a loop that is deep and will be used to tie the deep, buried knot. Then, the needle must be inserted a third time from superficial to deep (on either side of the incision) to allow the free suture end to also be deep (red strand, image A). Ensure that this strand of suture (red strand, image B and C) is not placed overtop of another superficial loop crossing the incision (green strand, image B and C) as this will prevent effective burying. Finally, the loop (blue strand, image C) and free end (red strand, image C) of suture (all deep within the wound) are tied by pulling the suture along the length of the incision, which helps bury the knot. Note that buried knot will never be deeper than your most superficial throw and that waiting too long to begin the process of burying the knot often results in an exposed final knot.
