Closure of skin wounds with sutures
- David deLemos, MD
David deLemos, MD
- Assistant Professor
- Baylor College of Medicine
- Section Editors
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
The basic principles of laceration repair have not changed significantly in the last century, but the therapeutic options now available are more innovative and rigorously studied. The development of topical anesthetics, tissue adhesives, and fast-absorbing sutures has made the management of lacerations less traumatic for the patient. In addition, the use of procedural sedation for difficult lacerations or for the extremely anxious child has made the experience more tolerable for the patient, family, and physician.
The goals of wound management are simple: to avoid wound infection, assist in hemostasis, and to provide an esthetically pleasing scar . The majority of studies now are focusing on the esthetic nature of wound healing rather than infection rates, because infection rates remain low, regardless of management.
Laceration repair with sutures will be discussed here. Information concerning wound preparation and irrigation, topical and infiltrative anesthesia, and tissue adhesive and staples is found separately. (See "Closure of minor skin wounds with staples" and "Minor wound preparation and irrigation" and "Minor wound repair with tissue adhesives (cyanoacrylates)".)
WOUND PHYSIOLOGY AND HEALING
The epidermis, dermis, subcutaneous layer, and deep fascia are the tissue layers of concern in wound closure :
●The epidermis and dermis are tightly adhered and clinically indistinguishable, and together constitute the skin. Dermal approximation provides the strength and alignment of skin closure.
- Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999; 34:356.
- Kanegaye JT. A rational approach to the outpatient management of lacerations in pediatric patients. Curr Probl Pediatr 1998; 28:205.
- McNamara, RN, Loiselle, J. Laceration repair. In: Textbook of pediatric emergency procedures, Henretig, F, King, C (Eds), Williams and Wilkins, Baltimore 1997. p.1141.
- Robson MC. Disturbances of wound healing. Ann Emerg Med 1988; 17:1274.
- Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol 1992; 18:785.
- Lober CW, Fenske NA. Suture materials for closing the skin and subcutaneous tissues. Aesthetic Plast Surg 1986; 10:245.
- Guyuron B, Vaughan C. A comparison of absorbable and nonabsorbable suture materials for skin repair. Plast Reconstr Surg 1992; 89:234.
- Webster RC, McCollough EG, Giandello PR, Smith RC. Skin wound approximation with new absorbable suture material. Arch Otolaryngol 1985; 111:517.
- Shetty PC, Dicksheet S, Scalea TM. Emergency department repair of hand lacerations using absorbable vicryl sutures. J Emerg Med 1997; 15:673.
- Start NJ, Armstrong AM, Robson WJ. The use of chromic catgut in the primary closure of scalp wounds in children. Arch Emerg Med 1989; 6:216.
- Andrade MG, Weissman R, Reis SR. Tissue reaction and surface morphology of absorbable sutures after in vivo exposure. J Mater Sci Mater Med 2006; 17:949.
- Ethicon wound closure manual, Ethicon, Inc. 1998-2000.
- Tejani C, Sivitz AB, Rosen MD, et al. A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures. Acad Emerg Med 2014; 21:637.
- Trott, AT. Special anatomic sites. In: Wounds And Lacerations: Emergency Care and Closure, 3rd edition, Elsevier Mosby, Philadelphia 2005. p.153.
- Bang RL, Mustafa MD. Comparative study of skin wound closure with polybutester (Novafil) and polypropylene. J R Coll Surg Edinb 1989; 34:205.
- Rodeheaver GT, Borzelleca DC, Thacker JG, Edlich RF. Unique performance characteristics of Novafil. Surg Gynecol Obstet 1987; 164:230.
- Austin PE, Dunn KA, Eily-Cofield K, et al. Subcuticular sutures and the rate of inflammation in noncontaminated wounds. Ann Emerg Med 1995; 25:328.
- Mehta PH, Dunn KA, Bradfield JF, Austin PE. Contaminated wounds: infection rates with subcutaneous sutures. Ann Emerg Med 1996; 27:43.
- Jones JS, Gartner M, Drew G, Pack S. The shorthand vertical mattress stitch: evaluation of a new suture technique. Am J Emerg Med 1993; 11:483.
- Dire DJ, Coppola M, Dwyer DA, et al. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med 1995; 2:4.
- HINMAN CD, MAIBACH H. EFFECT OF AIR EXPOSURE AND OCCLUSION ON EXPERIMENTAL HUMAN SKIN WOUNDS. Nature 1963; 200:377.
- Agren MS, Karlsmark T, Hansen JB, Rygaard J. Occlusion versus air exposure on full-thickness biopsy wounds. J Wound Care 2001; 10:301.
- Phillips LG, Heggers JP. Layered closure of lacerations. Postgrad Med 1988; 83:142.
- Heal C, Buettner P, Raasch B, et al. Can sutures get wet? Prospective randomised controlled trial of wound management in general practice. BMJ 2006; 332:1053.
- Noe JM, Keller M. Can stitches get wet? Plast Reconstr Surg 1988; 81:82.
- Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med 1995; 13:396.
- Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am 2003; 21:205.
- Selbst, SM, Attia, MW. Minor trauma - lacerations. In: Textbook of Pediatric Emergency Medicine, 5th edition, Fleisher, GR, Ludwig, S (Eds), Lippincott Williams and Wilkins, Philadelphia 2006. p.1571.
- WOUND PHYSIOLOGY AND HEALING
- WOUND ASSESSMENT
- WOUND PREPARATION
- SUTURE MATERIALS
- Absorbable sutures
- - Catgut
- - Polyglactin 910 (Vicryl)
- Vicryl Rapide
- - Poliglecaprone 25 (Monocryl)
- - Polglycolic acid (Dexon)
- - Polydiaxanone (PDS)
- - Polytrimethylene carbonate (Maxon)
- Nonabsorbable sutures
- SUTURING TECHNIQUES
- Percutaneous skin closure
- Dermal closure
- Alternative suture techniques
- - Running suture
- - Subcuticular running suture
- - Vertical mattress
- - Horizontal mattress
- SPECIFIC WOUND SITES
- GUIDELINES FOR CONSULTATION
- Dressing and bathing
- Prophylactic antibiotics
- Suture removal
- Follow-up visits
- UNIQUE PEDIATRIC CONSIDERATIONS
- Anxious parent
- Anxious and uncooperative patient
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS