Introduction:
Wound management is an important part of the surgery. Suturing techniques differ widely in their procedures. Sutures close open wounds, prevent infection and reduce scarring.
Surgeons should thoroughly know suture techniques, as wounds can range from a minor cut to a major laceration. Also, wound closure has significantly evolved from simple sutures to advanced techniques.
What Are the New Techniques for Optimal Wound Closure?
Multiple new materials are used in wound closure. The techniques will also be described.
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Sutures: Sutures are the gold standard for many minor wounds. Furthermore, sutures form the foundation of optimal primary wound healing. Sutures are of two types, namely, non-absorbable and absorbable.
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Non-absorbable Sutures: Non-absorbable sutures are multifilament or monofilament, flexible, natural, or polymeric threads. They consist of polyethylene, polyamide 6, and polypropylene. These are used mainly for closing superficial wounds. Other uses are soft tissue closure, hernia repair, abdominal wound closure, and blood vessel repair. Non-absorbable sutures are preferred due to their high tensile strength and ability to resist degradation. A new type of non-absorbable sutures is the hybrid polymeric braided sutures. The fiber hybridization technique is used to improve tensile strength.
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Absorbable Sutures: These are monofilament or multifilament, flexible, sterile, and synthetic threads for soft tissue ligation. Absorbable sutures are used for double-layer closure in deep wounds. As a result, surgeons can achieve decreased tension and better wound approximation. Hence, the wound separation is minimal and aesthetic results can be attained. However, these sutures retain the shape of the packaging. Hence, they have a memory problem that makes it difficult for suture manipulation during wound closure.
Abboud et al., in 2020, revealed a new technique for wound closure with barbed sutures and bilayer tension-free closure. Barbed sutures provide multiple anchoring points due to the presence of barbs. Distribution of forces along the closure is maintained. Proper wound closure with aesthetically pleasing results is obtained. The authors reported barbed sutures as a rapid and secure suturing technique. Furthermore, it is a knotless procedure.
New suturing techniques greatly reduce postoperative complications, namely, pathological scarring. An example is superficial and deep subcutaneous tissue flaps for wound reduction. The rationale behind this technique is the ability of subcutaneous tissue to minimize tension and reduce subsequent scarring. First, the skin and subcutaneous tissue are excised in high-tension areas such as chest wall injury. Then, the deep and superficial subcutaneous tissue are separately sutured. About 90 % of the tension is reduced by deep tissue suturing, followed by 10 % due to superficial tissue suturing.
Another novel technique is Z plasty. Z plasty employs a zigzag suturing technique, particularly useful in joint or limb surgery. It is because of thin fatty areas in the limbs. Also, it is suitable for long wounds. In addition, it results in decreased tension on the suture. First, triangular flaps are raised and superimposed, followed by skin sutures.
The points to be considered in achieving a scarless and healed incision are
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The wound edges must be lined up properly.
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The surgeon should not pull the edges too hard with sutures. It can further lead to wound breakdown.
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Skin adhesives or staples are a valuable adjunct to sutures to strengthen wound closure.
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Adhesives: Sutures are the most widely used method for wound closure. However, wound closure becomes challenging due to pain intolerance in young and uncooperative patients. Adhesives or skin glues are a better alternative to sutures in such cases. These are quick, painless, aesthetically acceptable, and have lower infection rates than sutures. Another advantage is their use as an adjunct to sutures. Hong et al., in 2022, reported a new technique for adhesive wound closure in uncooperative patients. Patients aged 5 to 15 years were divided into two groups: simple interrupted suture and continuous locking with the steri‐strip technique. Steri-strip is an adhesive bandage used as an adjunct to sutures or after the removal of sutures. It seals the wound by bringing the two sides of the skin together.
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Staples: Surgical staples are ideal for a linear wound along the extremities or the scalp. They can be placed quickly. Staples are used instead of sutures in patients with rapid bleeding and mass injuries. They are cost-effective, easy to place, require negligible training, and have a similar healing period.
What Factors Influence Optimal Wound Healing?
Optimal wound healing depends upon the direct closure of healthy tissue edges, adequate blood supply, minimal tension, no infection, and good nutrition. In addition, the good suture material is strong, creates minimal friction, easy to manipulate, and resists infection. A wound goes through different phases of healing. Moreover, there are various determinants in scar response other than skin tension.
1. Local Factors:
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A good blood and oxygen supply to the wound is necessary to ensure optimal wound healing. Primary intention healing occurs when the wound edges are brought together and sutured. This technique is used in small wounds. Healing occurs rapidly if the wound size is small. Hence, wound size is affected by local factors. The face is a good example of a rich blood supply area. Hence, it heals with finer scars.
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Infection and inflammation are additional factors. Infection delays wound healing. Newer suture techniques aim at reducing wound infection.
2. Systemic Factors:
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Increased age is a major risk for delayed wound healing. Young individuals tend to have more nutrition and exercise. Active children and adults heal quickly due to better circulation and nourishment to the wound. Also, scars are less common in young patients due to raised cellular activity, rapid physical growth, and good skin elasticity.
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Diabetes mellitus patients have poor healing capacity.
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Steroids, blood thinners, and anti-cancer agents delay healing.
3. Surgeon-Related Factors: A proper suturing technique should contain adequate tension distribution across deeper tissue layers, minimal tissue trauma, and movement of the wound margins. Besides, the surgeon should know when not to close the wound. Some wounds are large and close by secondary intention. Secondary intention healing happens when a wound is left open. Additionally, anesthesia delivery is important as wound closure is not painless. Epinephrine is usually administered. However, surgeons should be cautious not to inject it around ears, fingers, nose tip, and penis due to chances of tissue death.
Conclusion:
Optimal wound management begins with a thorough knowledge of wound closure techniques. Therefore, the healthcare team members, such as surgeons, clinicians, nurses, and assistants, must know the different techniques. In addition, regular patient monitoring post-wound closure is essential to ensure a positive outcome.
