A patient once asked me, in Dubai, what I was thinking about during the last twenty minutes of her operation. The honest answer was: needle geometry. Whether to switch from a cutting edge to a tapered point, whether the thread was one gauge too heavy for the skin of her lower eyelid, whether the knot would sit down or work its way up.
This is the part of surgery nobody photographs, and the part I have spent twenty-five years refining in Dubai. It is also, in my experience, where the visible difference between one surgeon and another is decided. What follows is an account of the craft itself — the threads, the needles, the four stitches and the specific job each one does — and an honest admission of how little of it has ever been properly tested.
Key takeaways: the craft of closure
- The buried dermal suture carries the load; the skin should carry none.
- Monofilament slides clean; braided holds knots and harbors bacteria.
- A gauge too heavy leaves a track visible a year later.
- Cutting needles for skin, tapered points beneath it.
- Wound eversion is taught universally and tested poorly.
- A trial found no difference between everted and flat closure.
A note on scope: this article is about the stitches themselves. Why tension is what widens a scar, and how a layered closure sends that tension onto the fascia rather than the skin, is the subject of my article on scar placement and closure technique. What to do with a scar once it exists — silicone, laser, and what the evidence actually grades — is covered in my article on scar revision.
Four stitches, four different problems
A stitch is not a fastening. It is a solution to a particular mechanical problem, and using the wrong one is not a stylistic preference but a category error. Four cover most of what plastic surgery requires.
- The buried dermal suture takes the load. Its knot is tied downward, deep in the tissue, so that nothing can be felt through the skin or spat out through the wound months later. This is the stitch that holds the closure together; the skin stitches hold nothing.
- The running subcuticular suture runs continuously within the dermis and never crosses the surface. Because nothing exits the skin, nothing can leave a mark: no cross-hatching, no railroad tracks.
- The vertical mattress suture takes a far bite and a near bite, rolling the wound edges upward against one another. Its purpose is eversion, and I will come to the awkward question of whether eversion actually helps.
- The simple interrupted suture is one knot, one bite, one point of control. It earns its place at a corner, at a flap tip, wherever a single millimeter must be positioned exactly.
Left in the skin too long, an interrupted stitch leaves a permanent dot on either side of the scar. Among my patients in Dubai I remove them at five days on the face, and at ten to fourteen on the body. That is not fussiness. It is the difference between a line and a ladder.
The four stitches, the three decisions before the first pass, and what the evidence supports, by Dr. Nazmi Baycin, Dubai.
Three decisions before the first pass
Before a needle touches skin, three choices have already been made, and each of them will be visible in a year.
The thread. Braided suture holds a knot willingly, because its weave grips itself — and that same weave offers bacteria somewhere to live. Monofilament slides through tissue cleanly and gives bacteria nothing, and it knots reluctantly, which is why it demands more throws and better hands. Beneath the skin I want absorbable material that will disappear once the dermis has taken over the work. On the surface, where the stitch is temporary, I want polypropylene: it is slippery, it is inert, and it lifts out cleanly.
The gauge. Too fine for the tension it must hold and the thread will cut through the tissue like cheesewire. Too heavy and it leaves a visible track long after the stitch is gone. On eyelid skin I work with a suture finer than a hair. On the back, where the skin is thick and unforgiving, I use several gauges heavier. The number on the packet is not a preference.
The needle. A cutting needle has a sharpened edge that parts skin cleanly, and can tear it if drawn carelessly. A tapered needle has no edge; it pushes tissue apart rather than dividing it, which is what deep layers require. Choosing the wrong one does not fail immediately. It fails as a wider scar.
The doctrine, and the trial that questioned it
Every plastic surgeon is taught that wound edges must be everted — rolled slightly upward, so that as the scar contracts over months it settles flat rather than depressed. It is stated as fact in textbooks, and I have repeated it to residents.
Then somebody tested it. A randomized split-scar trial everted one half of each patient’s wound and closed the other half flat, so that every scar acted as its own control. At three and six months, two blinded observers could find no difference in cosmetic outcome. Neither could the patients, assessing their own scars. The commentary published alongside it asked whether wound edge eversion is surgical dogma or diversion.
And yet. A second randomized trial from the same group compared two everting stitches against one another rather than against nothing, and found that the set-back suture produced both greater eversion and significantly better cosmetic outcomes than the buried vertical mattress. So the choice of stitch demonstrably mattered. What could not be demonstrated was that eversion itself was the reason.
I still evert. I do it because the technique that produced better scars in that trial happens to evert, and because a depressed scar is far harder to correct than a flat one. But I hold the explanation loosely, and I would rather tell you that than pretend a century of teaching has been tested when it has not.
| Decision | What is asserted | What is established | What I do |
|---|---|---|---|
| Eversion | It prevents depressed scars | No difference in a split-scar trial | Evert, hold the reason loosely |
| Choice of stitch | Preference | One everting stitch beat another | Match stitch to the problem |
| Barbed sutures | A time-saver | Better patient-rated scars in a trial | Use where they suit |
| Suture removal | A formality | Late removal marks skin | Five days on the face |
What has actually been measured
Very little, which is worth saying plainly. Most of what surgeons argue about at meetings has never been through a randomized trial, and much of what we believe rests on plausibility and repetition.
There are exceptions. A prospective, single-blind randomized trial of skin closure compared barbed sutures with interrupted sutures and found the patients’ own scar assessment scores significantly better in the barbed group. It is a modest result, from a single orthopedic operation, and it is more evidence than exists for most of the things I do with a needle.
The things that are not theories
Set the dogma aside and a short list of certainties remains, none of which requires a trial because the skin demonstrates them reliably:
- A knot tied upward in the dermis will one day be felt, or seen, or extruded.
- A surface stitch left in beyond a week leaves a permanent dot on either side of the line.
- A gauge heavier than the tissue requires leaves a track that outlives the stitch.
- A wound closed with the skin bearing the load will widen, whatever thread was used.
- Tissue crushed by forceps at the wound edge heals as a thicker scar.
I close under loupe magnification for the same reason a watchmaker does not work with the naked eye: a millimeter of malalignment is invisible at arm’s length and permanent on a face. Undermining the wound edges, so the skin can meet without being pulled, belongs to the same category. Neither is glamorous. Both are why the line disappears.
Holding the dogma loosely
A surgeon who tells you his suturing philosophy is evidence-based has not read the evidence, because for most of what we do there is none. What there is instead is mechanics, accumulated observation, and a great deal of repetition — which is not nothing, and is not the same as proof.
So I choose the stitch for the problem, the gauge for the skin, the needle for the layer, and I remove them before they mark. I evert, and I do not claim to know why it works. That honesty about the limits of my own craft is what I bring to every closure as an experienced plastic surgeon in Dubai, and it is a better foundation than certainty would be.
FAQs about surgical suturing in Dubai
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Which stitch actually holds my wound together?
The buried dermal suture, tied deep in the tissue with its knot facing downward. That stitch takes the entire load of the closure. The stitches you can see on the surface hold almost nothing. If the skin is bearing the tension, the closure has already failed and the scar will widen regardless of what thread was used. So when I close, my attention is on the layer you will never see. The surface is only the last, smallest step.
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Why do some scars have little dots either side?
Because the surface stitches were left in too long. Each stitch passes through the skin, and if it remains beyond a week or so, that puncture heals as a permanent mark. On the face I remove sutures at around five days, and on the body at ten to fourteen. Any longer and the line becomes a ladder. So this is one of the few things in scar surgery that is entirely preventable and entirely predictable. Timing, not technique.
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Does the type of thread matter?
Considerably. Braided suture grips itself, so it holds a knot willingly, and that same weave gives bacteria somewhere to live. Monofilament slides through tissue cleanly and offers bacteria nothing, but knots reluctantly. Beneath the skin I want absorbable material that disappears once the dermis has taken over the work. On the surface, where a stitch is temporary, I use polypropylene, which is slippery and inert and lifts out cleanly. So the choice is between properties, not brands. Each has a cost, and each belongs somewhere.
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What is wound eversion, and does it work?
Eversion means rolling the wound edges slightly upward so that as the scar contracts over months it settles flat rather than depressed. Every plastic surgeon is taught it as fact. Then somebody tested it properly. In a randomized split-scar trial, half of each wound was everted and half closed flat. At three and six months, two blinded observers found no difference, and neither did the patients assessing their own scars. So the doctrine is far less established than the confidence with which it is repeated. The commentary published alongside that trial asked whether eversion is surgical dogma or diversion.
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Then why do you still evert wounds?
Because a second trial from the same group compared two everting stitches against one another, and found that the set-back suture produced both greater eversion and significantly better scars than the buried vertical mattress. So the choice of stitch demonstrably mattered. What could not be shown was that eversion itself was the reason it mattered. So I evert, because the technique that produced better scars happens to evert, and because a depressed scar is far harder to correct than a flat one. But I hold the explanation loosely.
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Are barbed sutures better?
There is at least some evidence, which is more than can be said for most of what surgeons argue about. A prospective single-blind randomized trial compared barbed sutures with interrupted sutures for skin closure. Patients rated their own scars significantly better in the barbed group. So it is a modest finding, from a single orthopedic operation, and I would not overstate it. I use them where they suit the wound, and I would not claim they transform a result.
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Why do you use magnifying loupes to close?
For the same reason a watchmaker does not work with the naked eye. A millimeter of malalignment between two wound edges is invisible at arm’s length and permanent on a face. Under magnification I can see whether the dermis meets the dermis, whether one edge sits fractionally proud of the other, whether the needle is entering at the angle I intended. So it is not affectation. The differences that separate a fine scar from an ordinary one are at the limit of what the unaided eye can resolve.
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Is any of this actually proven?
Honestly, very little of it, and I would rather say so. Most of what surgeons believe about suturing rests on mechanics, accumulated observation and repetition rather than randomized trials. But some things are not theories, because the skin demonstrates them reliably. A knot tied upward will one day be felt. A stitch left too long marks the skin. A gauge too heavy leaves a track. Tissue crushed by forceps heals as a thicker scar. So a surgeon who tells you his suturing philosophy is evidence-based has not read the evidence. What he has, if he is good, is mechanics and attention. That is a better foundation than certainty.
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