Which method of wound closure is most suitable for a good cosmetic result following surgery

Published on May 20, 2021 by Don Wollheim, MD, FAPWCA, WCC, DWC

You are called in to care for a patient with a full thickness wound. Now what?

Your goal should be to heal the wound as soon as possible and to keep it healed. There are three types of wound closure techniques to consider, and they include:

• Primary Intention
• Secondary Intention
• Tertiary Intention

When choosing which intention to utilize, consider the possibility of a post-procedural infection occurring. Your selection is related to how the wound presented. The four wound categories listed from the lowest risk to the highest risk for developing an infection with a wound closure are:

• Clean wounds
• Clean-contaminated wounds
• Contaminated wounds
• Dirty wounds

Primary Intention

With selecting Primary Intention, it is acceptable to proceed with closure at that time of a full thickness wound with sutures, staples, adhesive strips of tape, or maybe surgical glue. Closing the wound now, there is a low risk for infection as well as little concern for the wound’s edges separating (dehiscing) due to tension on the incision line.

The advantages of closing by Primary Intention are low risk for infection, minimal scarring, and faster wound healing.

In general, the wounds that will be acceptable candidates for primary closure are:

• Wounds that are classified as clean wounds
• Wounds that are classified as clean-contaminated wounds
• Wounds that are closed within four (maybe up to eight) hours from their development
• Wounds that sustained little tissue loss and can be closed without tension

A clean wound is one that did not enter any organ, and there was no break in sterile operative technique. These are often elective, non-traumatic surgical procedures.

A clean-contaminated wound is one where an organ has been entered but without any significant spillage of the organ’s contents. These surgical procedures might have been conducted as an urgent or emergent fashion.

Closure by Secondary Intention is when the wound is not surgically closed either completely or partially.

With time, the clinician will witness the wound bed filling in with more viable tissue, such as granulation tissue, and containing less non-viable tissue, such as slough or eschar. Ultimately, the clinician will witness the epithelial covering of the wound bed. This can be a very slow process.

Often the wound’s healing progress might be “stuck” in one of the phases of full thickness wound healing. These are the types of wounds that may be labeled “chronic” wounds, and the attending clinician may ask for a consultation by a wound care clinician.

Wounds that lend themselves to closure by Secondary Intention are:

• Wounds that present as contaminated wounds
• Wounds that present as dirty wounds
• Wounds where there was a delay in the clinical consultation
• Wounds that do not allow surgical closure without tension
• Wounds where there is a significant concern for a post-procedure infection

Examples of contaminated wounds are ones such as penetrating traumatic injuries, wounds with spillage from the gastrointestinal tract but are less than four (maybe six) hours old, and wounds in which there was a major break in the operative sterile technique.

Examples of dirty wounds are wounds that present with an abscess, wounds that present with perforated bowel with possibly pus and/or stool within the abdominal cavity, and “old” contaminated wounds (older than six hours or so).

If perforated bowel was encountered, repair under Secondary Intention, so the fascia would be closed to prevent evisceration and the rest of the abdominal wall layers are left open to allow them to heal without any further surgical closure.

Tertiary Intention

Tertiary Intention closure is often labeled as Delayed Primary Intention. With this type of closure, there was a planned period of time where the superficial layers of the wound were left open. If the situation allows, later these layers are closed in a similar fashion to what might have been performed initially in Primary Intention but now in a “delayed” fashion. Also, this delayed type of closure might include closing the wound bed using a skin graft, a skin flap, or a skin substitute.

Examples for selecting Tertiary Intention closure could include:

• Superficial portion of soft tissue wounds left open to allow time for an infection to clear
• Superficial portion of soft tissue wounds left open to allow time for edema to clear
• Abdominal or pelvic area wound where there was a perforated viscus found, only the abdominal wall’s fascia was closed initially to prevent evisceration, and the more superficial subcutaneous fat and skin were left open for a period of time to be closed later

Selecting from the three types of wound closure is the decision of the clinician based on their training, their experience, as well as their clinical assessment of the patient. To the best of my knowledge, there are no absolute rules governing which type of closer to utilize.

Wound Care Certification Courses

Closure by secondary intention  [12]

Closure by secondary intention is a viable alternative to other wound closure techniques, especially on concave areas of the head and neck and in wounds prone to infection (human and animal bites and grossly contaminated wounds that cannot be adequately cleansed). 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.

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.  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. Short-duration nonabsorbable sutures, especially in the face, are sufficient since the skin in these areas is very well vascularized and heals relatively quickly. Further, a shorter time span should diminish the scarring effect of sutures left in longer (ie, “railroad tracks"). However, in areas of higher skin tension or mobility, sutures should be left in longer to allow increased wound strength prior to removal of the sutures.

Simple suture or everting interrupted suture procedure (see the image below)

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. For wounds of wider diameter, larger "bites" to each side may be required to allow sufficient suture tension, bring together the edges, and not compromise capillary blood flow at the sites of maximal tissue tension.

Oppose equal amounts of tissue on each side.

A surgeon's knot helps place the nonabsorbable suture because this affords a relatively higher degree of friction, thus holding the first knot until an additional knot can be placed.

Strive to evert the edges and avoid tension on the skin, while approximating the wound edges. Place all knots on the same side.

A good technique for equidistant suture placement is to place the first suture at the half-way point of the wound. Then, place additional sutures in between the first suture and the ends of the wound. Minimal gaps should be seen; however, one should strive to use as few sutures as possible to mitigate the inflammatory effects of the suture material.

Two good rules about suture placement should be remembered. (1) Approximate, do not strangulate; that is, the wound edges need only to touch to begin proper primary healing. Sutures placed too tightly may compromise blood flow and result in local tissue necrosis, worse scarring, and a less-than-appealing cosmetic effect. (2) Sutures placed and tied tightly today will be tighter tomorrow. Regardless of how much care is taken in handling tissue and placing sutures, wound edema is ubiquitous. The wound edges will swell and the tension at the site of the suture(s) will increase.

Simple interrupted suture placement. Bottom right image shows a flask-shaped stitch, which maximizes eversion.

Simple running suture procedure

This suture method entails similar technique to the simple suture without a knotted completion after each throw. Precision penetration and tissue opposition is required.

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.

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, and, in some wounds, it can help with hemostasis. This can be particularly beneficial in patients who are on anticoagulation therapy and cannot be taken off these medications for simple surgical procedures.

Both styles are easy to remove. Additionally, the running sutures are more watertight.

Mattress suture procedure

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. See the image below.

Far-near near-far modification of vertical mattress suture, creating pulley effect.

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 procedure

Sutures can be 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.

The knot is buried in the simple suture, and the technique allows for minimization of tension on the wound edge.

In a continuous subcuticular stitch, the suture ends can be taped to the skin surface without knotting. [13]