Best Wound Closure Techniques - An Overview

Introduction

Management of wounds is an integral part of any surgery. Various wound closure techniques are being followed. The primary aim is to let the wound heal appropriately with aesthetic scar formation. Wound closure techniques have evolved, including synthetic sutures, absorbable sutures, tapes, staples, and other adhesive compounds.

The amalgamation of synthetic sutures with materials like catgut or silk has also shown good results that are aesthetic. The development of topical skin adhesives, staples, and tapes has upgraded wound closure techniques. A proper wound closure technique leads to the formation of a barely noticeable aesthetic scar. Thus, opting for an adequate wound closure methodology and materials would lead to appropriate healing.

What Is Wound Healing?

Wound healing is a natural process of the body. It is achieved through four phases: hemostasis, inflammation, proliferation, and remodeling. Proper wound healing occurs when these four phases coordinate with each other.

What Are the Intentions of a Wound Closure?

Primary Intention: The primary intention of wound closure is to make wound healing manageable with reduced tissue loss. The methods that come under primary intention are sutures, staples, adhesive tapes, and surgical glue. This type of wound closure has reduced the chances of infection and separation of wound edges. Primary intention leads to faster healing and negligible scarring.

Secondary Intention: In secondary intention, the wound is not closed surgically. This occurs when a large quantity of tissue is lost, or the wound edges cannot be brought together for closure. With time the wound gets filled more with viable tissues, such as granulation tissues, and less with non-viable tissues, such as slough. The healing during secondary intention is prolonged.

Tertiary Intention: The tertiary intention is also known as delayed primary intention, which is preferred where there is a need to postpone the wound closure. The superficial layers of the wound are kept open for some time. The layers are subsequently sealed using a method identical to the primary intention. The tertiary intention includes skin grafts for wound closure.

What Are the Best Techniques for Wound Closure?

1. Sutures: Sutures are one of the best wound closure techniques. Surgeons have long employed them for wound closure, particularly in post-surgical scenarios.

The sutures can be classified based on the nature of the material into the following:

• Absorbable Sutures - Absorbable sutures are made of substances easily absorbed by the body's enzymes. Therefore, removing them is not required once the wound has healed. These sutures seal deep wounds, reducing tension and adequately closing the wound edges. This results in an aesthetic outcome.

• Non-absorbable Sutures - The non-absorbable sutures need to be removed from the body after wound healing. These are preferred due to their excellent tensile strength. They are used to close superficial wounds. These sutures tend to retain the shape of the packaging they came into. This makes them difficult to manipulate during wound closure. The technique of suture depends on the type of wound, amount of tension, depth of the wound, and the results.

Based on the types of suturing techniques:

• Simple Interrupted Sutures - This suture technique uses different stitches to approximate the skin and underlying tissue to provide an aesthetic outcome. They offer increased tensile strength and have reduced chances of injuring the skin's blood circulation. If an infection occurs, removing the entire length of the sutures may not be necessary.

• Running Sutures - These sutures are preferred in places where there is a need for hemorrhage control or in long wounds with very little tension. They are placed easily and quickly, spreading the tension along the wound. The only disadvantage is the risk of splitting even if one part of the suture ruptures.

• Mattress Suture - These sutures can be placed to approximate the deeper wound edges. These can be placed vertically or horizontally. They have the advantage of providing better strength and wound closure. The tension is reduced due to deeper penetration into the skin. They can also be placed temporarily and removed once the tension is equally distributed across the wound. If tension persists even after wound closure, the mattress stitch can be retained to minimize the risk of splitting.

• Subcuticular Sutures - This suture can be placed as a continuous or a simple suture. In this type of suture technique, the skin is not pierced and thus shows aesthetically pleasing outcomes. One should be careful while placing these sutures in deep wounds, as they can form a cavity under the suture line.

2. Staples: Staples are used for closing wounds like lacerations on the extremities or scalp. Staples are essential in situations with copious bleeding and when there are several wounds to be attended to. They are also used to close postoperative wounds. The advantages of using staples are that they can be placed quickly. The benefits of using pins are that they can be rapidly placed, are cost-effective, need negligible training, and have good healing.

3. Adhesive Tapes: The adhesive tapes are the least reactive of all the wound closure techniques. These tapes can be used in place of sutures or staples and after suture removal for additional support. The adhesive tapes can be placed on a flat, dry, non-mobile surface where the wound's edges approximate without tension.

The tapes can be applied in areas where there is a potential for the sutures to impede blood circulation or where the skin is thin and unable to hold the sutures in place securely. Compared to the sutures, they are quite resistant to infection. As the wound heals, the tapes eventually detach on their own.

What Are the Complications of Wound Closure?

Wound closure comes with its share of complications, like any other procedure.

The following could be the complications of wound closure:

• Hematoma (the formation of a blood clot under the skin).

• Infection.

• Hypertrophic scar or keloid (a thick and uneven scar).

• Necrosis (the death of the tissues resulting from reduced blood supply to them).

Conclusion:

Wound closure is essential in any surgery to avoid blood loss, infection, and complications. The wound is primarily closed with the help of sutures, staples, adhesives, or tapes. The wounds heal with the formation of scars. Meticulous wound approximation is necessary to form aesthetic scars that are barely noticeable. Care must be taken while closing an injury to avoid dehiscence and infection.