1. Avoid inversion of the wound edge. 
    This produces a depressed scar. The aim is to produce a wound with a slightly everted edge which tends
    to smooth out over time.

    This can result from: 

dead space

insufficient depth

unequal bites

    To avoid dead space close a wound in layers. The deep layer is closed in as many layers as necessary using 
    dissolvable sutures such as Dexon or Vicryl.

    To ensure sufficient depth of the bites. Turn the needle perpendicularly and preferably turning it slightly laterally
    to take a good bite of the dermis and therefore ensure eversion of the wound.

    Unequal bites produce an unsightly two-level scar. Ensure that both bites are of the same depth. 

    A final note here, after the suture is tied, move the knot to one side to avoid depressing the scar. 
 
 

a knot sitting on the wound can cause  wound depression

ideal sutures with slight wound  eversion

2. Suture from the loose to the fixed. 
    When suturing a free skin graft, go through the free skin graft first and then pin it to the fiexed edge of the 
    donor skin. This is preferable to through the fixed edge and attempting to catch and spear the elusive free
    graft with the needle.
 

3. When suturing a thin edge to a thick edge , take a deeper bite on the thin side and a more superficial bite on 
     the thick side to give a better alignment.
 

4. When the wound edges are of unequal height. Start on the high side superficially and then pick up the low side 
    a little deeper. Passing the suture from a high to low edge causes the suture to come out on the low side and 
    when the long suture limb is pulled with the first throw of the knot it will lift the lower wound edge up to a 
    matching level with the opposite side.
 

5. When closure demands tension requiring longer suture retention and in a position where stich marks are 
    particularly undesirable, a subcuticular suture (see picture below) of dissolable suture such as Vicryl can be 
    retained longer without danger of cross marks.