Closure of skin wounds with sutures

INTRODUCTION

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 [1]. 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 "Tissue adhesives".)

WOUND PHYSIOLOGY AND HEALING

The epidermis, dermis, subcutaneous layer, and deep fascia are the tissue layers of concern in wound closure [2]:

• 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.
• The subcutaneous layer is mainly comprised of adipose tissue. Nerve fibers, blood vessels, and hair follicles are located here. Although this layer provides little strength to the repair, sutures placed in the subcutaneous layer may decrease the tension of the wound and improve the cosmetic result.
• The deep fascial layer is intermixed with muscle and occasionally requires repair in deep lacerations.