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-2cyanoacrylate 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
Pseudomonas 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