Wound closure techniques have evolved from the earliest development of suturing materials to

comprise resources that include synthetic sutures, absorbables, staples, tapes, and adhesive
compounds. The engineering of sutures in synthetic material along with standardization of
traditional materials (eg, catgut, silk) has made for superior aesthetic results. Similarly, the
creation of natural glues, surgical staples, and tapes to substitute for sutures has supplemented
the armamentarium of wound closure techniques. Aesthetic closure is based on knowledge of
healing mechanisms and skin anatomy (see the image below), as well as an appreciation of
suture material and closure technique. Choosing the proper materials and wound closure
technique ensures optimal healing.

Anatomy of the skin.

Wound healing
Three phases of wound healing have been identified and studied on the cellular and molecular
level. These 3 distinct phases, ie, inflammation, tissue formation, and tissue remodeling, depend
on an elaborate cascade of growth factors and cellular components interacting in a directed
manner to achieve wound closure.
The initial injury leads to the recruitment of inflammatory cells into the wound, once a clot forms
in response to disrupted blood vessels. This scenario entails a complex interaction between local
tissue mediators and cells that migrate into the wound. The inflammatory phase occurs in the
first few days as inflammatory cells migrate into the wound. Migration of epithelial cells has
been shown to occur within the first 12-24 hours, but further new tissue formation occurs over
the next 10-14 days.
Epithelialization and neovascularization result from the increase in cellular activity. Stromal
elements in the form of extracellular matrix materials are secreted and organized. This new
tissue, called granulation tissue, depends on specific growth factors for further organization to
occur in the completion of the healing process. This physiologic process occurs over several
weeks to months in a healthy individual.
Finally, tissue remodeling, in which wound contraction and tensile strength is achieved, occurs in
the next 6-12 months. Systemic illness and local factors can affect wound healing. Traditionally,
at least 2 types of wound healing have been described, ie, primary intention and secondary
intention.
In the primary intention method, surgical wound closure facilitates the biological event of
healing by joining the wound edges. Surgical wound closure directly apposes the tissue layers,

which serves to minimize new tissue formation within the wound. However, remodeling of the
wound does occur, and tensile strength is achieved between the newly apposed edges. Closure
can serve both functional and aesthetic purposes. These purposes include elimination of dead
space by approximating the subcutaneous tissues, minimization of scar formation by careful
epidermal alignment, and avoidance of a depressed scar by precise eversion of skin edges. If
dead space is limited with opposed wound edges, then new tissue has limited room for growth.
Correspondingly, atraumatic handling of tissues combined with avoidance of tight closures and
undue tension contribute to a better result.
The secondary intention method (spontaneous healing) is ancient and well established. It can be
used in lieu of complicated reconstruction for certain surgical defects. This method also depends
on the 3 stages of wound healing to achieve the ultimate result.

Equipment

History

The history of sutures begins more than 2,000 years ago with the first records of eyed needles.
The Indian plastic surgeon, Susruta (AD c380-c450), described suture material made from flax,
hemp, and hair. At that time, the jaws of the black ant were used as surgical clips in bowel
surgery. In 30 AD, the Roman Celsus again described the use of sutures and clips, and Galen
further described the use of silk and catgut in 150 AD. Before the end of the first millennium,
Avicenna described monofilament with his use of pig bristles in infected wounds. Surgical and
suture technique evolved in the late 1800s with the development of sterilization procedures.
Finally, modern methods created uniformly sized sutures.[1]
Catgut and silk are natural materials that were the mainstay of suturing products, and they
remain in use today. The first synthetics were developed in the 1950s, and further
advancements have led to the creation of various forms. The different types of sutures offer
different qualities in terms of handling, knot security, and strength for different purposes. No
single suture offers all of the ideal characteristics that one would wish for. Often the trade-off is
in tissue handling versus longevity versus healing properties.

Sutures

General classification of sutures includes natural and synthetic, absorbable and nonabsorbable,
and monofilament and multifilament. Natural materials are more traditional and are still used in
suturing today. Synthetic materials cause less reaction, and the resultant inflammatory reaction
around the suture material is minimized.
Absorbable sutures are applicable to a wound that heals quickly and needs minimal temporary
support. Their purpose is to alleviate tension on wound edges. The newer synthetic absorbable
sutures retain their strength until the absorption process starts. Nonabsorbable sutures offer
longer mechanical support.
Monofilaments have less drag through the tissues but are susceptible to instrumentation
damage. Infection is avoided with the monofilament, unlike the braided multifilament, which
can potentially sustain bacterial inocula. Natural materials include gut, silk, and even cotton. Gut
is absorbable, but cotton and silk are not. Gut is considered a monofilament, whereas silk and
cotton are braided multifilaments.

Various synthetic materials are available for suturing. The absorbable sutures include the
monofilamentous Monocryl (poliglecaprone), Maxon (polyglycolide-trimethylene carbonate),
and PDS (polydioxanone). Braided absorbable sutures include Vicryl (polyglactin) and Dexon
(polyglycolic acid). Nonabsorbable sutures comprise nylon, Prolene (polypropylene), Novafil
(polybutester), PTFE (polytetrafluoroethylene), steel, and polyester. Nylon and steel sutures can
be monofilaments or multifilaments. Prolene, Novafil, and PTFE are monofilaments. Polyester
suture is braided.
Absorbable suture materials lose their tensile strength before complete absorption. Gut can last
4-5 days in terms of tensile strength. In the chromic form (ie, treated in chromic acid salts), gut
can last up to 3 weeks. Vicryl and Dexon maintain tensile strength for 7-14 days, although
complete absorption takes several months. Maxon and PDS are considered long-term
absorbable sutures, lasting several weeks and likewise requiring several months for complete
absorption.
Nonabsorbable sutures have varying tensile strengths and may be subject to some degree of
degradation. Silk has the lowest strength and nylon has the highest, although Prolene is
comparable. Both nylon and Prolene require extra throws to secure knots in place. Polyester has
a high degree of tensile strength, and Novafil is appreciated for its elastic properties.

Adhesives

Use of surgical adhesives can simplify skin closure in that certain problems inherent to suture
use can be avoided. Problems (eg, reactivity, premature reabsorption) can occur with sutures
and lead to an undesirable result, both cosmetically and functionally. Several adhesives have
been developed to alleviate this problem and to facilitate wound closure. One substance,
cyanoacrylate, has been used for 25 years and easily forms a strong flexible bond. In some
forms, it can induce a substantial inflammatory reaction if implanted subcutaneously. If used
superficially on the epidermal surface, little problem with inflammation occurs. In a study on the
use of adhesives in the emergency department, adhesives were more likely to be used in facial
lacerations and in children and less likely to be used in longer scars.[2] The concomitant use of
either a topical anesthetic or no anesthetic, as opposed to an injectable, was cited as an
advantage in the use of adhesives.[2]
Octyl-2-cyanoacrylate (Dermabond, Ethicon, Somerville, NJ) is the only cyanoacrylate tissue
adhesive approved by the U.S. Food and Drug Administration (FDA) for superficial skin closure.
Octyl-2-cyanoacrylate should only be used for superficial skin closure and should not be
implanted subcutaneously. Subcutaneous sutures are used to take the tension off the skin edges
prior to applying the octyl-2-cyanoacrylate. Subcutaneous suture placement aids in everting the
skin edges and minimizing the chances of deposition of cyanoacrylate into the subcutaneous
tissues.
In addition to its surgical adhesive indication, the FDA granted approval in January 2001 for
Dermabond to be used as a barrier against common bacterial microbes including certain
staphylococci, pseudomonads, and Escherichia coli.
Fibrin-based tissue adhesives can be created from autologous sources or pooled blood. They are
typically used for hemostasis and can seal tissues. Although they do not have adequate tensile
strength to close skin, fibrin tissue adhesives can be used to fixate skin grafts or seal
cerebrospinal fluid leaks. Commercial preparations such as Tisseel (Baxter) and Hemaseel
(Haemacure) are FDA-approved fibrin tissue adhesives made from pooled blood sources. These
fibrin tissue adhesives are relatively strong and can be used to fixate tissues. Autologous forms
of fibrin tissue adhesives can be made from patient's plasma. The concentration of fibrinogen in

the autologous preparations is less than the pooled forms; therefore, these forms have a lower
tensile strength.

Other materials

Staples provide a fast method for wound closure and have been associated with decreased
wound infection rates. Staples are composed of stainless steel, which has been shown to be less
reactive than traditional suturing material. The act of stapling requires minimal skin penetration,
and, thus, fewer microorganisms are carried into the lower skin layers. Staples are more
expensive than traditional sutures and also require great care in placement, especially in
ensuring the eversion of wound edges. However, with proper placement, resultant scar
formation is cosmetically equivalent to that of other techniques.
Closure using adhesive tapes or strips was first described in France in the 1500s, when Pare
devised strips of sticking plaster that were sewn together for facial wounds. This method
allowed the wound edges to be joined and splinted. The porous paper tapes (eg, Steri-Strips) in
use today are reminiscent of these earlier splints and are used to ensure proper wound
apposition and to provide additional suture reinforcement. These tapes can be used either with
sutures or alone. Often, skin adhesives (eg, Mastisol, tincture of Benzoin) aid in tape adherence.
Newer products such as the ClozeX (Wellesley, Mass) adhesive strip allows for rapid and
effective wound closure that results in adequate cosmesis. Additionally, wound closure with
adhesive strips can be significantly cheaper than suturing or using a tissue adhesive. However,
adhesive strips are not appropriate for many types of lacerations.

Technique

Closure by secondary intention

Closure by secondary intention is an adequate alternative to other wound closure techniques,

especially on concave areas of the head and neck. The results achieved are aesthetic and
functional and can spare the patient more complex procedures such as flap or skin graft
reconstruction.
Concave surfaces, such as those presented by the auricle, occiput, medial canthus, nasal alar
crease, nasolabial fold, and temple, heal well by secondary intention with minimal scarring. This
approach is useful, especially in defects (either superficial or deep) resulting from
dermatological surgery. The final scar is less noticeable in older patients with skin laxity and in
lighter-skinned patients. This method is appropriate in conjunction with other reconstructive
techniques.

Basics of facial wound closure

Good approximation of wound edges is paramount to proper wound closure technique. This
may entail the placement of deep sutures subcutaneously or in the deepest layer of disrupted
tissue; however, in some situations, a single-layer closure is adequate. When placing deep
sutures, absorbables (eg, gut, Dexon, Vicryl, Monocryl) are typically used. The knot is buried. A
clear permanent suture, either Prolene or nylon, can be buried deeply in areas of tension. All
deep sutures serve to eliminate the dead space and relieve tension from the wound surface.

Deep sutures also ensure proper alignment of the wound edges and contribute to their final
eversion.
Before placement of the sutures, wound closure may require sharp undermining of the tissues
to minimize tension on the wound. Accomplish this maneuver by scalpel or scissors in the
subdermal plane. Additionally, achieve hemostasis prior to wound closure to avoid future
complications such as hematoma. Use atraumatic skin-handling technique with instruments
such as skin hooks and small forceps. Typically, a cutting needle is the needle of choice. Various
curvatures are available depending on tissue depth.
For wound closure in the head and neck region, small 5-0 or 6-0 sutures of nonabsorbable
Prolene, nylon, or absorbable catgut are appropriate. Take great care to avoid tension during
closure. Likewise, avoid strangulation with the suture at the superficial skin level. Take the
greatest care to ensure that wound edges are not only aligned but are also everted. Eversion of
all skin edges avoids unnecessary depression of the resultant scar. With simple sutures, place
knots away from the opposed edges of the wound. Normally, remove nonabsorbable suture
after 4-5 days. In certain situations, nonabsorbables can be removed at 10-12 days.

Suturing techniques

Simple suture or everting interrupted suture

o Insert the needle at a 90 angle to the skin within 1-2 mm of the wound edge and in the
superficial layer. The needle should exit through the opposite side equidistant to the
wound edge and directly opposite the initial insertion.
o Oppose equal amounts of tissue on each side.
o A surgeon's knot helps place the nonabsorbable suture.
o Strive to evert the edges and avoid tension on the skin, while approximating the wound
edges. Place all knots on the same side.
Simple running suture
o This suture method entails similar technique to the simple suture without a knotted
completion after each throw. Precision penetration and tissue opposition is required.
o The speed of this technique is its hallmark; however, it is associated with excess tension
and strangulation at the suture line if too tight, which leads to compromised blood flow
to the skin edges.
o Another variant is the simple locked running suture, which has the same advantages and
similar risks. The locked variant allows for greater accuracy in skin alignment.
o Both styles are easy to remove. Additionally, the running sutures are more watertight.
Mattress suture
o Vertical mattress sutures can aid in everting the skin edges. Use this technique also for
attachments to a fascial layer.
The needle penetrates at 90 to the skin surface near the wound edge and can
be placed in deeper layers, either through the dermal or subdermal layers.
Exit the needle through the opposite wound edge at the same level, and then
turn it to repenetrate that same edge but at a greater distance from the wound
edge.
The final exit is through the opposing skin edge, again at a greater distance from
the wound edge than the original needle entrance site.
Place the knot at the surface. A knot placed under tension risks a stitch mark.
o The horizontal mattress can be used to oppose skin of different thickness.

With this stitch, the entrance and exit sites for the needle are at the same
distance from the wound edge. Half-buried mattress sutures are useful at
corners.
On one side, an intradermal component exists, in which the surface is not
penetrated.
Place the knot at the skin surface on the opposing edge of the wound.
Subcuticular suture
o Sutures can be placed intradermally in either a simple or running fashion.
o Place the needle horizontally in the dermis, 1-2 mm from the wound edge. Do not pass
the needle through the skin surface.
o The knot is buried in the simple suture, and the technique allows for minimization of
tension on the wound edge.
o In a continuous subcuticular stitch, the suture ends can be taped to the skin surface
without knotting.

Both immediate and delayed complications may occur with wound closure.
Immediate complications include the formation of hematoma secondary to improper
hemostasis technique and the development of a wound infection. Prophylactic antibiotics
have a role in protecting against wound infection.
Late complications include scar formation, which may be due to either improper suturing
with excess tension or lack of eversion of the edges. Additionally, hypertrophic scarring
and keloid formation are unfortunate later complications of wound closure in some
individuals. Other complications include stitch marks and wound necrosis.