1-Small toothed forceps, such as the Addison forceps shown here, should be used to grasp the skin edges during suturing. Forceps with teeth provide a secure grasp with minimal pressure, thereby avoiding crushing of the skin edge. The forceps should be held in the first three fingers as one would hold a pen, using the first three fingers. 2-The needle holder should be held in a way that is comfortable and affords maximum control. Most surgeons grasp the needle holder by partially inserting the thumb and ring finger into the loops of the handle. Note that the index finger provides additional control and stability. 3-As a rule, the needle should be grasped at its center or perhaps 50-60% back from the pointed end. The needle should be grasped 1-2 mm from the tip of the needle holder. 4-One should avoid grasping the suture material or the distal end of the needle with the needle holder, since this will damage the suture. 5-Placement of the 1st suture is begun by grasping and slightly everting the skin edge. The right hand is rotated into pronation so that the needle will pierce the skin at a 90o angle. 6-The needle is driven through the full thickness of the skin by rotating the needle holder (supinating). By keeping the shaft of the needle perpendicular to the skin surface at all times, one takes advantage of the needle's curvature in traversing the skin as atraumatically as possible. 7-The needle has been released and is about to be regrasped. Note that the forceps maintain their grasp, thereby preventing the needle from retracting. The right hand has been fully pronated in preparation for regrasping the needle. 8-Pronation in the previous step makes it possible to complete passage of the needle with a smooth, natural supination which rotates the needle upwards and away from the surgeon. Again, this minimizes trauma to the tissues. 9-Here the needle is being regrasped in preparation for passage through the opposite skin edge. This was traditionally done by grasping the needle with the non-dominant hand. However, given the risks of HIV and hepatitis, it is probably advisable to train yourself to use the forceps for this instead of fingers. 10-The skin edge closest to the surgeon has been grasped and everted slightly, while the right hand is pronated to "cock" the needle and position it for passage through the skin. 11-Again, the right hand is supinated in order to rotate the needle through the full thickness of the skin, keeping the shaft at a right angle to the skin surface. 12-The suture material is drawn through the skin, leaving 2-3 cm. protruding from the far skin surface. The forceps are then dropped or "palmed" so the left hand can grasp the long end in preparation for an instrument tie. Note that the needle holder is positioned between the strands over the wound.
