Wound Closure Technique

– 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
Wound Closure Technique
– 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 as well
as on an appreciation of suture material and
closure technique
– Choosing the proper materials and wound
closure technique ensures optimal healing
Phases of wound healing
– identified and studied based on
• cellular
• molecular level
– depend on an elaborate cascade of
growth factors and cellular components
interacting in a directed manner to
achieve wound closure
 Distinct Phases of wound healing

• Inflammation
• Tissue formation
• Tissue remodeling
 INFLAMMATORY PHASE
• initial injury leads to the recruitment
of inflammatory cells into the wound
– clot forms in response to disrupted
blood vessels
• scenario entails a complex
interaction between local tissue
mediators and cells that migrate into
the wound
 INFLAMMATORY PHASE
• occurs first few days as inflammatory
cells migrate into the wound
• migration of epithelial cells occurs
within the first 12-24 hours
• further new tissue formation occurs
over the next 10-14 days
 TISSUE FORMATION
• Epithelialization and
neovascularization
– result from the increase in cellular
activity
• Stromal elements are secreted and
organized
– extracellular matrix materials
 TISSUE FORMATION
• new tissue, called granulation
tissue, depends on specific growth
factors for further organization to
occur in the completion of the
healing process
• physiologic process occurs over
several weeks to months in a healthy
individual
 TISSUE REMODELING
• 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
 Types of Wound Healing
• Traditionally
– primary intention
– secondary intention
 PRIMARY INTENTION
• 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
• remodeling of the wound does occur and tensile
strength is achieved between the newly apposed
edges
• closure can serve both functional and aesthetic
purposes
 PRIMARY INTENTION
• 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 new tissue has limited room
for growth
• atraumatic handling of tissues combined
with avoidance of tight closures and undue
tension contribute to a better result
 SECONDARY INTENTION
• method (spontaneous healing) is
ancient and well established
• It can be used in lieu of complicated
reconstruction for certain surgical
defects
• depends on the 3 stages of wound
healing to achieve the ultimate result
 History
– begins more than 2,000 years ago with
the first records of eyed needles
– 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
 History
– In 30 AD, the Roman Celsus 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
 History
– 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
– 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
General Classification of
Sutures
– natural and synthetic
– absorbable and nonabsorbable
– monofilament and multifilament
 Sutures
– Natural materials are more traditional
and still are used in suturing today
– Synthetic materials
• less reaction
• resultant inflammatory reaction around the
suture material is minimized
 Absorbable Sutures
– applicable to a wound that heals quickly
and needs minimal temporary support
– purpose is to alleviate tension on wound
edges
– newer synthetic absorbable sutures
retain their strength until the absorption
process starts
– Nonabsorbable sutures offer longer
mechanical support
Monofilament Sutures
– less drag through the tissues
– susceptible to instrumentation damage
– Infection is avoided with the
monofilament
• braided multifilament potentially can
sustain bacterial inocula
 Natural Materials
• gut, silk, cotton
– Gut is absorbable
– cotton & silk are not

– Gut is a monofilament
– silk & cotton are braided multifilaments
 Synthetic Sutures
• absorbable sutures
– monofilamentous Monocryl
(poliglecaprone)
– Maxon (polyglycolide-trimethylene
carbonate)
– PDS (polydioxanone)
 Synthetic Sutures
• Braided absorbable sutures
– Vicryl (polyglactin)
– Dexon (polyglycolic acid)
 Synthetic Sutures
• Nonabsorbable sutures
– nylon
– Prolene (polypropylene)
– Novafil (polybutester)
– PTFE (polytetrafluoroethylene)
– Steel
– Polyester
 Synthetic Sutures
• Nylon and steel sutures can be
monofilaments or multifilaments
• Prolene, Novafil, and PTFE -
monofilaments
• Polyester suture - braided
 Absorbable sutures
– lose their tensile strength before
complete absorption
– Gut can last 4-5 days in terms of tensile
strength
– chromic form gut (ie, treated in chromic
acid salts) can last up to 3 weeks
 Absorbable sutures
– Vicryl and Dexon
• maintain tensile strength for 7-14 days
• complete absorption takes several months
– Maxon and PDS
• considered long-term absorbable sutures
• last for several weeks
• 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

– Nylon has the highest
– Prolene is comparable
Nonabsorbable sutures
– Both Nylon and Prolene require extra
throws to secure knots in place

– Polyester has a high degree of tensile

strength
– Novafil is appreciated for its elastic
properties
 Adhesives
– simplify skin closure in that problems
inherent to suture use can be avoided
• Problems can occur with sutures and lead to
an undesirable result both cosmetically and
functionally
– reactivity
– premature reabsorption

– Several adhesives have been developed

to alleviate this problem and to facilitate
wound closure
Adhesives - cyanoacrylate
– used for 25 years and easily forms a
strong flexible bond
– implanted subcutaneously
• induce a substantial inflammatory reaction
in some forms
– superficially on the epidermal surface
• little problem with inflammation
Adhesives - cyanoacrylate
– Octyl-2-cyanoacrylate (Dermabond,
Ethicon, Somerville, NJ.)
• only cyanoacrylate tissue adhesive approved
by the U.S. Food and Drug Administration
(FDA) for superficial skin closure
– Octyl-2-cyanoacrylate
• used only for superficial skin closure and
should not be implanted subcutaneously
Subcutaneous Sutures
– used to take the tension off the skin
edges prior to applying the octyl-2-
cyanoacrylate
– aid in everting the skin edges
– minimize the chances of deposition of
cyanoacrylate into the subcutaneous
tissues
 Demabond Adhesives
– surgical adhesive indication
– January 2001 US FDA granted approval
• used as a barrier against common bacterial
microbes
– Staphylococci
– Pseudomonads
– Escherichia coli
 Fibrin-based tissue
adhesives
– created from autologous sources or
pooled blood
– typically used for hemostasis and can
seal tissues
– do not have adequate tensile strength
to close skin
– can be used to fixate skin grafts or seal
cerebrospinal fluid leaks
 Fibrin-based tissue
adhesives
• Commercial preparations -
US FDA approved
– made from pooled blood sources
• Tisseel (Baxter)
• Hemaseel (Haemacure)
 Fibrin-based tissue
adhesives
– relatively strong and can be used to
fixate tissues
• Autologous forms made from patient's
plasma
– concentration of fibrinogen in the
autologous preparations is less than the
pooled forms
• have a lower tensile strength
 Other materials
• Staples
• Adhesive tapes
• Adhesive strips
 Staples
– provide a fast method for wound closure
– associated with decreased wound
infection rates
– composed of stainless steel
• less reactive than traditional suturing
material
– stapling requires minimal skin
penetration
• fewer microorganisms are carried into the
lower skin layers
 Staples
– more expensive than traditional sutures
– require great care in placement
• especially in ensuring the eversion of wound
edges
– with proper placement
• resultant scar formation is cosmetically
equivalent to that of other techniques
 Adhesive tapes
– 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
– method allowed the wound edges to be
joined and splinted
 Adhesive tapes
– porous paper tapes (Steri-Strips)
• reminiscent of these earlier splints
• used to ensure proper wound apposition
• provide additional suture reinforcement
– can be used either with sutures or alone
– skin adhesives (eg, Mastisol, tincture of
Benzoin) aid in tape adherence
 Adhesive strips
– Newer products - ClozeX (Wellesley,
Mass)
• allows for rapid and effective wound closure
that results in adequate cosmesis
– significantly cheaper than suturing or
using a tissue adhesive
– not appropriate for many types of
lacerations
 Closure by secondary
intention
– an adequate alternative to other wound
closure techniques
• especially on concave areas
– Head
– neck
– results achieved are aesthetic and
functional
– spare the patient more complex
procedures such as flap or skin graft
reconstruction
 Closure by secondary
intention
– Concave surfaces
• auricle
• occiput
• medial canthus
• nasal alar crease
• nasolabial fold
• temple,
– heal well with minimal scarring
 Closure by secondary
intention
– Useful especially in defects (either
superficial or deep) resulting from
dermatological surgery
– final scar is less noticeable
• older patients with skin laxity
• lighter-skinned patients
– 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
– entail the placement of deep sutures
subcutaneously or in the deepest layer
of disrupted tissue
– in some situations a single-layer closure
is adequate
 Basics of facial wound
closure
– placing deep sutures
• absorbables typically are used
– gut
– Dexon
– Vicryl
– Monocryl

– knot is buried
 Basics of facial wound
closure
– clear permanent suture can be buried
deeply in areas of tension
• Prolene or nylon
– deep sutures
• serve to eliminate the dead space
• relieve tension from the wound surface
• ensure proper alignment of the wound
edges
• contribute to their final eversion
 Basics of facial wound
closure
– Before placement of the sutures wound
closure may require sharp undermining
of the tissues to minimize tension on
the wound
• scalpel or scissors in the subdermal plane
– achieve hemostasis prior to wound
closure
• to avoid future complications such as
hematoma
 Basics of facial wound
closure
– Employ atraumatic skin-handling
technique with instruments
• skin hooks
• small forceps
– cutting needle - needle of choice
• Various curvatures are available depending
on tissue depth
 Basics of facial wound
closure
– wound closure in the head and neck
region
• small 5-0 or 6-0 sutures of nonabsorbable
– Prolene
– Nylon
• absorbable catgut are appropriate
– take great care to avoid tension during
closure
– avoid strangulation with the suture at
the superficial skin level
 Basics of facial wound
closure
– take the greatest care to ensure that wound
edges not only are aligned but also are 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
• Simple running suture
• Simple running suture – Lock variant
• Mattress suture
• Vertical Mattress
• Horizontal Mattress
• Subcuticular suture
Simple suture or everting
interrupted suture
– Insert the needle at a 90° angle to the
skin within 1-2 mm of the wound edge
and in the superficial layer
– needle should exit through the opposite
side equidistant to the wound edge and
directly opposite the initial insertion
– Oppose equal amounts of tissue on each
side
Simple interrupted suture
Simple suture or everting
interrupted suture
– surgeon's knot
helps place the
nonabsorbable
suture
– Strive to evert the
edges and avoid
tension on the skin
– Place all knots on
the same side
 Surgeons Knot
• Step1 - Lay two pieces of string or line together
• Step2 - Make a loop.
• Step3 - Draw one end of the strings through the loop. Pass the same end
through the loop a second time.
• Step4 - Pull on either end of the string until it's tight.
• Step5 - Form a figure-eight knot.
• Step6 - Wet the knot to help keep it secure.
• Step7 - Create a loop at one end of the knot by folding over one end of the
rope
• Step8 - Pass the folded end through a loop. Pass the folded end through
the loop a second time
• Step9 - Gently pull the loop and the other end of the knot until the knot is
tight
• Step10 - Trim off the excess rope when you are done tying the knot
Simple running suture
– method entails similar technique to the
simple suture without a knotted
completion after each throw
– precision penetration and tissue
opposition is required
– speed of this technique is its hallmark
• associated with excess tension and
strangulation at the suture line if too tight
– leads to compromised blood flow to the skin
edges
Simple running suture
Simple running suture –
Lock variant
– simple locked running suture
• has the same advantages and similar risks
– locked variant allows for greater
accuracy in skin alignment

– Both styles are easy to remove

– running sutures are more watertight
 Mattress suture
• Vertical Mattress Horizontal Mattress
 Vertical Mattress sutures
• aid in everting the skin edges
• Employ this technique
– attachments to a fascial layer
• 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
 Vertical Mattress sutures
• 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
• final exit is through the opposing skin
edge again at a greater distance from the
wound edge than the original needle
entrance site
• place knot at the surface
• knot placed under tension
• risks a stitch mark
 Horizontal Mattress
• used to oppose skin of different
thickness
• entrance and exit sites for the needle
are at the same distance from the
wound edge
• Half-buried mattress sutures are
useful at corners
 Horizontal Mattress
• On one side an intradermal
component exists in which the
surface is not penetrated
• knot is placed at the skin surface on
the opposing edge of the wound
 Subcuticular suture
– placed intradermally in either a simple
or running fashion
– Place the needle horizontally in the
dermis 1-2 mm from the wound edge
– Do not pass the needle through the
skin surface
 Subcuticular suture
– knot is buried in the simple suture
• technique allows for minimization of tension
on the wound edge
– continuous subcuticular stitch
• suture ends taped to the skin surface
without knotting
Running Subcuticular Suture
 Complications
– immediate and delayed complications
may occur with wound closure

– other complications
• stitch marks
• wound necrosis
 Immediate complications
• hematoma formation
– improper hemostasis technique
• development of a wound infection
– Prophylactic antibiotics
• against wound infection
 Late complications
• scar formation
• improper suturing with excess tension
• lack of eversion of the edges
• hypertrophic scarring
• keloid formation
– unfortunate later complications of
wound closure
Late complications