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Introduction There is general agreement that a thick zone of the keratinized tissues around implants promotes accurate prosthetic procedures, permits oral hygiene maintenance, resists recession, and enables esthetic blending with surrounding tissues. A new procedure called Choukroun's technique has been suggested, and it consists of a combination of horizontal apical mattress suture with regular suture to increase the keratinized tissue in the mandibular arch during the first stage after implantation. The proposed procedure has not been evaluated yet in a cohort of patients. Therefore, this prospective study aimed to evaluate the impact of Choukroun's technique on the width and thickness of the keratinized gingiva after oral surgery. Materials and methods A one-group prospective cohort study was conducted on patients referred to the Department of Oral and Maxillofacial Surgery at the Dental College of Al-Wataniya Private University who had been referred to undergo dental implant surgery. The inclusion criteria for the study group were as follows: patients with mandibular missing teeth, good oral health, good general health, 18-70 years old, at least 1 mm thickness of keratinized gingiva, and at least 1 mm width of the attached gingiva. A total of 14 patients aged 27-67 years were included in the study. After inserting the dental implants, the suturing was accomplished according to Choukroun's method. The width and thickness of the keratinized gingiva were assessed before surgery and at one and two months post-surgery. Repeated measures analysis of variance (ANOVA) was applied to detect significant differences between assessment times. Results The study sample comprised 14 patients, of which four were females (28.6%) and 10 were males (71.4%). Patients' ages ranged from 27 to 67 years, with a mean age of 54.86 ± 11.73 years. The surgical procedure was performed in three different regions: the upper posterior teeth with four patients (28.6%), the upper anterior teeth with three patients (21.4%), and the lower posterior teeth with seven patients (50%). The mean gingival width before surgery was 5.78 mm, whereas the mean gingival thickness was 2.82 mm. There was no significant difference between the three evaluation times in the mean gingival width (P=0.222), and there was a significant difference between the three evaluation times in the mean gingival thickness (P<0.001). The mean mean gingival thickness one month after surgery was significantly greater than its mean value before surgery (mean difference: 0.749 mm). Additionally, the mean gingival thickness two months after surgery was significantly greater than its mean value before (mean differences: 0.636 mm). Conclusions Using horizontal apical mattress sutures (Choukroun's technique) does not provide any advantage in increasing the width of the keratinized gingiva. However, it does lead to an increase in the thickness of keratinized gingiva in the surgical area. Therefore, the use of horizontal apical mattress sutures is recommended.

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Background: In recent years, single-hole thoracoscopic surgery technology is widely used in major medical centers and chest-specialized hospitals for the treatment of lung diseases. However, the single-hole minimally invasive surgery method focuses on one incision, and all surgical instruments need to pass through the same hole, resulting in repeated extrusion and tissue damage of the surgical incision. Therefore, we have improved the suture method of conventional surgical incision in order to reduce the probability of wound infection and dehiscence, promote early healing, and reduce the severity of postoperative wound scar, thereby enhancing the postoperative rapid recovery of patients. The purpose of this study is to explore the clinical efficacy of a modified surgical incision suture technique applied to uniportal thoracoscopic pulmonary resection. Methods: This study retrospectively analyzed 151 patients who were admitted to the Department of Thoracic Surgery and underwent pulmonary resection from January 2019 to October 2021 in the North District of Suzhou Municipal Hospital. The patients were divided into two groups according to the different surgical incision suture methods: a modified group and a conventional group. The postoperative general clinical indexes, incision infection rate, secondary suture rate, postoperative incision pain score, and the severity of postoperative incision scar were compared and analyzed between the two groups. Results: There were no statistically significant differences between the two groups in terms of chest tube duration or postoperative drainage and postoperative incision pain scores; the incision infection rate (1.3% vs. 6.7%, P<0.05), secondary suture rate (2.6% vs. 9.4%, P<0.05), and postoperative scar score (4.853 vs. 5.543, P=0.03) were better in the modified group than in the conventional group, and the differences between the two groups were statistically significant. Conclusions: Our modified suture method reduces the chance of infection and splitting and the severity of postoperative incision scar formation, promoting early healing. It can be safely and effectively applied to the incision suture of uniportal thoracoscopic pulmonary resection, enhancing the rapid postoperative recovery of patients.

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BACKGROUND: Treating complex middle cerebral artery (MCA) trifurcation aneurysms requires a delicate balance between achieving aneurysm obliteration and preserving vascular integrity. Various cerebral revascularization techniques, including bypass, and clip reconstruction are considered individually or in combination. METHODS: This case report outlines a successful repair of a ruptured neck and base of MCA trifurcation aneurysm using a suturing-clip reconstruction technique. Temporary aneurysm trapping was implemented, with maintained elevated blood pressure to ensure collateral perfusion during repair of ruptured base and neck of MCA aneurysm. CONCLUSION: The suturing-clip reconstruction exhibited long-term radiological stability, emerging as a valuable alternative for managing challenging MCA trifurcation aneurysms.

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The purpose of this animal study was to verify the effect of suturing on graft function in ovarian tissue transplantation. Ovaries from 2-week-old rats were transplanted orthotopically into the ovaries of 8-week-old female Wistar rats. The various transplantation methods used were insertion into the ovarian bursa without suturing (group A: control), suturing with a single 6-0 Vicryl stitch (group B: 6-0*1), suturing with a single 10-0 Vicryl stitch (group C: 10-0*1), and suturing with three 10-0 Vicryl stitches (group D: 10-0*3). Two weeks after transplantation, the transplanted ovaries were evaluated histologically and for gene expression. Engraftment rates of the donor ovaries 14 days after transplantation were 62.5%, 100%, 91.7%, and 100% in groups A, B, C, and D, respectively, significantly lower in group A than in the other groups. In terms of gene expression, TNFα levels were significantly higher in group D, and GDF9 and follicle-stimulating hormone receptor (FSHR) levels were significantly lower in group D than in groups A and B. The number of primordial follicles evaluated by HE staining was significantly lower in groups B, C, and D than in group A. Compared to orthotopic transplantation without sutures, direct suturing to the host improved the engraftment rate, although increasing the number of sutures increased inflammatory marker levels and decreased the number of primordial follicles. We believe that it is important to perform ovarian tissue transplantation using optimal suture diameter for good adhesion, but with a minimum number of sutures to preserve ovarian function.

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Objective: Perineal trauma is a serious and frequent problem after childbirth which is experienced by millions of women worldwide. The technique used for perineal repair may have an impact on pain and wound healing. The aim of the present study was to compare the continuous non-locking technique with interrupted suturing for the repair of episiotomy or second-degree perineal tears. Methods: A single-blind randomized-controlled trial was conducted from October 2021 to August 2022 in Sina Hospital, Ahvaz, Iran. Three hundred women were selected and randomly assigned into control and intervention groups using block randomization technique. The main outcomes included pain and wound healing that were assessed using visual analog scale (VAS), as well as redness, edema, ecchymosis/bruising, discharge, and approximation scale (REEDA). The secondary outcomes were the use of analgesics, duration of perineal repair, material used for suturing, pain during urination and defecation, and resumption of sexual intercourse. The participants were followed up on the first and seventh days and in the 6th week postpartum. Mann-Whitney, Chi-square, and Generalized Estimating Equations (GEE) model were used for data analysis. Results: Wound healing was significantly better in the continuous non-locking suture technique compared to the interrupted technique (ß = -1.98; P > 0.0001). Women also experienced less pain in the continuous non-locking suture technique (ß = -2.46; P > 0.0001). There was a reduction in the use of analgesics, the duration of perineal repair, and the material used for suturing in the continuous non-locking suturing technique as opposed to the interrupted method (P < 0.0001).The odds of pain during urination and defecation significantly reduced in women who underwent the continuous non-locking method (P < 0.001). Also, women in the continuous non-locking group resumed their sexual intercourse earlier (P < 0.0001). Conclusion: The findings of this study revealed that use of continuous non-locking technique for suturing was associated with reduced perineal pain and improved wound healing. Furthermore, it was associated with a shorter duration of perineal repair, less suture material used, and less need for analgesics compared with the interrupted method. There is, however, need for more studies to confirm the results of the present study.Iranian registry for randomized controlled trials (Ref. ID: IRCT20190415043283N1).

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Background: Hypospadias is among the common congenital anomalies in boys. Snodgrass urethroplasty is one of the most popular techniques for correcting distal and mid hypospadias. Although there is consensus among pediatric surgeons on using absorbable sutures for urethroplasty, there are no established guidelines about the suturing techniques (interrupted suturing [IS] or continuous suturing [CS]) for neourethra creation in Snodgrass urethroplasty. This analysis aims to compare the reported outcomes of both the urethroplasty suturing techniques. Materials and Methods: This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses guidelines. A systematic, detailed search was carried out by the authors in the electronic databases - MEDLINE, PubMed Central, Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected and compared based on primary outcomes - development of urethrocutaneous fistula (UCF), meatal stenosis, and secondary outcomes - wound infection, urethral stricture, and operative time. Statistical analysis was performed using a fixed-effect model, pooled risk ratio, and I2 heterogeneity. Results: Five randomized studies with a total of 521 patients met our inclusion criteria. Pooled analysis for total complications, UCF, meatal stenosis, and wound infection showed no significant difference between the CS and IS groups. Subgroup analysis of patients with the use of polyglactin sutures showed a decrease in total complications and UCF in the IS group. Conclusion: There is no difference in total complication rates among the CS and the IS group with the use of absorbable sutures in Snodgrass urethroplasty; however, there is a decrease in the incidence of total complications and UCF in the IS group when polyglactin was preferred over polydioxanone suture for urethroplasty.

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Objective: The objective of this study was to compare short- and midterm clinical and echocardiographic outcomes according to the use of pledgeted sutures during aortic valve replacement. Methods: Patients with aortic stenosis or regurgitation requiring aortic valve replacement were enrolled in a prospective cohort study to evaluate the safety of a new stented bioprosthesis. Outcomes were analyzed according to the use of pledgets (pledgeted group) or no pledgets (nonpledgeted group). The primary outcome was a composite of thromboembolism, endocarditis, and major paravalvular leak at 5 years of follow-up. Secondary outcomes included multiple clinical endpoints and hemodynamic outcomes. Propensity score matching was performed to adjust for prognostic factors, and subanalyses with small valve sizes (<23 mm) and suturing techniques were performed. Results: The pledgeted group comprised 640 patients (59%), and the nonpledgeted group 442 (41%), with baseline discrepancies in demographic characteristics, comorbidities, and stenosis severity. There were no differences between groups in any outcome. After propensity score matching, the primary outcome occurred in 41 (11.7%) patients in the pledgeted and 36 (9.8%) in the nonpledgeted group (P = .51). The effective orifice area was smaller in the pledgeted group (P = .045), whereas no difference was observed for the mean or peak pressure gradient. Separate subanalyses with small valve sizes and suturing techniques did not show relevant differences. Conclusions: In this large propensity score-matched cohort, comprehensive clinical outcomes were comparable between patients who underwent aortic valve replacement with pledgeted and nonpledgeted sutures up to 5 years of follow-up, but pledgets might lead to a slightly smaller effective orifice area in the long run.

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This study analyzed risk factors for postoperative cerebrospinal fluid (CSF) leak after graded multilayer cranial base repair method with dural suturing. We performed surgery via the endoscopic endonasal approach (EEA) from 2012.6 to 2018.4, and those consecutive clinical data were prospectively accumulated and retrospectively analyzed. We tailored the repair method according to the intraoperative CSF leak grade. Among 388 surgeries via the EEA, there were 10 (2.6%) cases of postoperative CSF leak after graded repair with suturing. Postoperative CSF leak occurred in two of the 150 cases without intraoperative CSF leak (grade 0), one of the 104 cases with small (grade 1) intraoperative CSF leak, two of the 60 cases with moderate (grade 2) leak, and five of the 74 cases with large (grade 3) leak. Univariate analysis indicated that chordoma (P = 0.023), estimated tumor volume ≥ 7400 mm3 (P = 0.003), and maximum tumor diameter ≥ 32.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Additionally, among cases with intraoperative grade 3 CSF leak, chordoma (P = 0.021), estimated tumor volume ≥ 23000 mm3 (P = 0.003), and maximum tumor diameter ≥ 45.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Maximum tumor diameter, estimated tumor volume, and chordoma tumor pathology are related to a higher risk of postoperative CSF leak.

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Post autopsy reconstruction (PAR) plays a vital role in the external appearance of dead bodies while handing over to grieving family members. Autopsy surgeons should not only be restricted to autopsy findings/techniques but should also give importance to PAR. Autopsy incision includes various conventional incisions like I, Y, and Modified Y-shaped. The most commonly used incision is I -shaped in most of the autopsy because it is easy for quick suturing but it produces a poor cosmetic appearance because suturing produces visible suture over the front of the neck and chest of a corpse and improper suturing in the skin flaps leads to gapping causes leakage of body fluids at the suture site. More often that leads to avoidable, unnecessary emotional distress for grieving family members. That creates a negative image of forensic practice in society and sometimes with administrative complaints. The authors conducted an observation based study on the medicolegal autopsy that included ten cases that involved "Stethoscope" and various conventional incisions and explored suturing techniques and body packing methods. The study observed that the proposed "Stethoscope" incision was feasible, less time-consuming for suturing, had an excellent cosmetic effect, and was cost-effective. The suturing technique revealed that invisible sutures leads to good cosmetic outcomes but is more time-consuming and costly. The body packing method showed the excellent result of no leakage of body fluid from the suture site. The authors proposed a "Stethoscope" method of incision that can be practiced and adopted for a better cosmetic appearance and humanitarian aspect for grieving relatives. The body packing method renders the body non-hazardous to the public and attendants while handling and transporting. The authors highlight the importance and sensitization of autopsy surgeon/mortuary staff to restructure the corpse with the best cosmetic appearance for the Dignified Management of the Dead and Humanitarian Forensics.

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Background and Objectives: Many treatment modalities are available for juvenile hallux valgus. However, all of them have some disadvantages. Therefore, we developed a transosseous suturing procedure. Materials and Methods: Six patients (seven feet) with juvenile hallux valgus received transosseous suturing procedure. Clinical and radiological examinations were performed preoperatively and postoperatively. All patients underwent the soft tissue release procedure, followed by transosseous suturing with Fiberwire (in which sutures are anchored with mini plates). Results: The mean IMA and HVA decreased from 15.6° ± 2.6° to 7.3° ± 1.1° and 39.2° ± 3.3° to 12.5° ± 3.1°, respectively. Corrections achieved in the IMA and HVA of all patients were maintained through the last follow-up. The mean American Orthopedic Foot & Ankle Society score improved from 53.3 ± 3.5 to 86.9 ± 4.7 points. Conclusions: Based on these preliminary data, the transosseous suturing technique demonstrated satisfactory results and apparent improvements in the IMA and HVA without early complications.

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Aims and Objectives: Although laparoscopic surgery for submucosal tumours (SMTs) may require multiple support threads, the traction direction of a single thread is only one option and cannot be freely changed. To solve this problem, we introduced a novel innovative technique for tumour handling, named 'the parachute method'. Subjects and Methods: Prior to suturing, the surrounding vessel was treated when the tumour was located near the lesser or greater curvature. A monofilament thread was ligated in the serous muscle layer along the peritumoural markings with approximately five stitches in a row, with moderate deflection. Next, the other monofilament thread was passed through the deflection and ligated; this resembled a parachute shape that could be pulled in any direction over the entire circumference with uniform tension. Results: We performed this procedure in three patients with extramural growth-type gastrointestinal stromal tumours of approximately 2-3 cm. The median suturing time was 10 minutes. Laparoscopic local resection of the stomach was safely performed, and the patients were discharged without any complications. Conclusion: In this study, we demonstrate a novel, simple, inexpensive, useful and reasonable technique for handling SMTs, named 'the parachute method'. We believe that this technique will have additional applications in cooperative surgery with endoscopy.

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Ocular trauma has been one of the leading causes of visual impairment, and choroidal avulsion is especially devastating. Surgical treatment of choroidal avulsion is challenging, and very few surgical techniques have been reported. We experienced two cases of globe rupture with 360-degree avulsion of the choroid-ciliary body from the peripheral section. After vitrectomy for a globe rupture, the choroid gradually slid down to the posterior pole over time and vision deteriorated even though the retina was attached. We treated the choroidal avulsion using two surgical methods: a mattress suturing technique using a 10-0 proline long needle and a 7-0 nylon single suture technique. In both methods, the retina-choroid, which had slipped down to the posterior pole, was suspended and fixed to the sclera assisted by a wide-angle viewing system, improving visual acuity. These two methods are considered to be useful surgical procedures for the treatment of an avulsed choroid.

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PURPOSE: Incisional hernias often follow open abdominal surgery. A small-stitch-small-bite suture might close the incision durably. We analyzed specific details of this closure technique and assessed their influence on the closure stability. METHODS: The effects of cyclic loads, simulating coughs were investigated on a bench test. We prepared porcine bellies in the median line and bovine flanks parallel to the muscle fibers with 15 cm long incisions. Then we punched round or rhomboid defects with a diameter of 5-10 cm into the center of the incision. Monomax® 2-0 and Maxon® 1 and 2-0 were used as suture materials. We tested the durability of the closure with pressure impacts of 210 mmHg repeated 425 times. Throughout the experiments, we modified the suturing technique, the surgeon, the tissue tension, the defect size and shape and the suture diameter. RESULTS: Standardizing the suture technique improved the durability of the closure significantly. Any other variations showed minor influences after standardization. All incisions with round defects up to 7.5 cm width withstood 425 impacts using standardized suturing. Unstandardized sutures failed in all cases. When closing an incision with a 10 cm wide defect, the tissues ruptured frequently next to the suture line. We defined criteria to standardize this suturing technique. For the first time, we developed a suture factor related to the durability of a sutured tissue closure. We integrated the suture factor into the concept of biomechanically durable repairs. CONCLUSIONS: Suturing the abdominal wall with a standardized suturing technique improves its durability significantly.

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BACKGROUND: Surgical repair of hypospadias deformity is a challenging and complex issue. However, the technique of Snodgrass and its modifications attend promising functional and cosmetic results. PURPOSE: To assess the Lembert suturing technique effectiveness as a modification of the Snodgrass technique in lowering an urethrocutanous fistula rate. PATIENTS AND METHODS: Fifty boys with mid-shaft and distal hypospadias were repaired using the modified Snodgrass technique utilizing the interrupted Lembert suturing technique in neourethroplasty. Patients with previous failed operations or severe chordee were excluded from the study. RESULTS: None of the patients develops UCF apart from one who developed complete wound dehiscence following severe wound infection. Mild meatal stenosis is seen in two patients, and one patient experienced a small area of superficial skin sloughing.

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PURPOSE: In this study, we aimed to evaluate the outcomes of the toric intraocular lens (IOL) and capsular tension ring (CTR) suturing technique in patients with cataract and astigmatism. METHODS: Group 1 comprised 37 eyes of 36 patients to whom the CTR-toric IOL complex was co-implanted after the CTR was sutured to the toric IOL haptic. Group 2 comprised 35 eyes of 33 patients in whom the toric IOL and CTR were implanted without suturing. Both groups were compared in terms of preoperative and postoperative astigmatism, best-corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), and IOL rotation. RESULTS: The mean rotation degree was 0.54° ± 2.29° in group 1 and 4.28° ± 8.84° in group 2 (p = .01). While there was no significant difference between the postoperative residual astigmatism and the estimated residual astigmatism in group 1, the postoperative residual astigmatism was statistically higher than the estimated residual astigmatism in group 2 (p = .47 and 0.000, respectively). The mean postoperative UCVA was 0.02 ± 0.04 (logMAR) in group 1 and 0.08 ± 0.13 (logMAR) in group 2 (p = .01). CONCLUSION: The toric IOL and CTR suturing technique provides excellent rotational stability and astigmatism correction.

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An extended endoscopic endonasal approach (EEA) has become standard for parasellar and midline skull base lesions. However, postoperative leakage of cerebrospinal fluid (CSF) can result from dural defects after lesion removal. We present a simple and effective technique, the Osaka sliding knot, to prevent CSF leakage. Between November 2018 and March 2021, a total of 41 patients underwent reconstruction of skull base defects with intraoperative high-flow CSF leaks after extended EEA by using this closure technique, of whom only 1 patient experienced postoperative CSF leakage. This technically simple and efficient method seals the dural defect to prevent CSF leakage after surgeries using an extended EEA.

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Brittle cornea syndrome is among the few special scenarios in ophthalmology that are a nightmare not only for the operating surgeon but also for the patient. Here, the thin and fragile corneas are unable to maintain the shape and structural integrity of the globe and are more prone to minor traumatic or spontaneous corneal perforations. Suturing a brittle cornea and closure of the corneal perforation in a brittle cornea are very challenging requiring the utmost care and special precautions. If proper measures are not taken during the surgery, it may be difficult to salvage the eye. Hence, it is imperative to diagnose appropriately, suture effectively, taking necessary preventive measures in salvaging these corneas. This manuscript aims at providing tips for handling brittle corneal perforations. It will also discuss the problems encountered during surgery, highlight the suturing techniques that can be customized, and finally give an insight into postoperative care.

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BACKGROUND: Cleft lip with or without cleft palate is one of the most common birth defects and is certainly the most visible. Fistula rate after primary palatoplasty was ranging between 10 and 23% and could be detected in the first three weeks after surgery. The cleft width is the frequent factor which was assumed to correspond to fistula occurrence. This study aimed to find correlation between fistula occurrence with cleft width and palatum width ratio after primary palate repair. METHODS: A prospective cohort study was conducted on 16 subjects, which consisted of 10 males and 6 females. We measured width of cleft palate, width of rest palate and width of palate arch on three level measurements (posterior, junction and anterior). The surgery was performed using the two-flap and three layers suturing technique. RESULTS: Sixteen patients were enrolled in this study during January and February 2008 . Ten patients were diagnosed with unilateral cleft palate while six patients had bilateral cleft palate. Mean of age was 22.31 ± 5.86 month. Correlation analysis between fistula occurrence and cleft width, cleft width-remnant palate width ratio and cleft width-palate arch width ratio using logistic regression did not show statistical correlation, and the same result was found between fistula occurrence and hemoglobin level, white blood count, nutritional status, cleft type and caries dentis factors (p > 0.05). CONCLUSION: Width of the cleft is not a factor associated with fistula occurrence. Two-flap three layers technique could be considered as a simple technique and gives a low rate of fistula occurrence.

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BACKGROUND: Postoperative complications such as wound infection and scarring are some of the major concerns regarding suturing techniques. This study is designed to evaluate postoperative outcomes of adhering subcuticular sutures in comparison to the interrupted suturing method in patients who underwent appendectomy for uncomplicated acute appendicitis. METHODS: 240 patients were randomly assigned into two groups; 120 with interrupted and 120 subcuticular sutures after an appendectomy, at Shohada Ashayer hospital, Khorramabad, Iran. The prevalence of wound infection, three days after the surgery in the hospital and a week after discharge was determined and evaluated statistically. RESULTS: No wound infection was seen within three days of hospitalization in the subcuticular group whereas, 1 patient reported infection in the interrupted group, however, the difference was not statistically significant. A week after discharge, a patient was reported to have wound infection in the subcuticular group and 2 in the interrupted group. No significant difference was seen in this regard either. 55 females and 66 males received subcuticular sutures whereas, 74 males and 46 females were given interrupted sutures for wound closing. One male in interrupted and 1 male and female in the subcuticular group were referred for wound infection, after discharge, respectively. Among these groups, no significant differences were seen. In catarrhal appendicitis, the infection was reported in the interrupted group only which was not statistically significant. CONCLUSION: Subcuticular sutures provide better cosmetic outcomes without any additional complications in comparison to interrupted sutures.

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