What to Know About How Wounds Are Closed

Staples, Sutures, and Adhesives

Surgeon closing stitches
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If you are having surgery, or if you have a wound, your skin may be closed in a variety of ways. There are many methods used to keep a surgical incision or wound tightly closed so that it can heal quickly with minimal scarring and without infection.

In some cases, wounds and incisions are not closed during surgery but are closed later after healing has started, but the vast majority are closed at the end of the procedure.

Wound closure is important, because an open wound is an open door for infection. Our skin is a barrier between bacteria and our bodies, and having an opening in the skin increases the risk of having an infection.

Regardless of how a wound is closed, proper incision care will help improve healing by reducing the chances of infection and providing the wound with a clean environment for healing. Changing your bandage as directed by your surgeon, washing your hands properly, and eating well after surgery will all help improve wound healing. 

Closure by Primary Intention 

Most wounds heal with primary intention, which means closing the wound right away. Wounds that fit neatly together are referred to as “well approximated.” This is when the edges of a wound fit neatly together, such as a surgical incision, and can close easily. 

Bringing the edges together may require stitches (sutures), or another method to close the wound, or the wound may be small enough that no outside assistance is needed, such as a paper cut.

For wounds that have irregular edges, the skin may be “trimmed” to make the wound more regular in shape, to make closure easier.  This is especially true when placing sutures, and, thankfully, is done after the wound site is numb.

For these types of wounds, there is an expectation that the wound will heal quickly and easily, with minimal scarring.

This type of break in the skin is the easiest to heal, as the new skin cells can close the gap quickly, as the gap that is being filled is narrow. When this method is used, wound healing can take place in a few days for minor injuries, and a few weeks for surgical incisions that are large.  

Remember that surgical incisions are like an iceberg—much of what has been done is under the surface.  The skin on the surface heals quickly, but the muscle and tissue that was cut underneath may take much longer to heal and to reach full strength. Skin closure is still important because the risk of having an infection drops significantly when the skin is no longer open to bacteria.

Closure by Secondary Intention 

Secondary intention indicates that the wound cannot be brought together neatly to be closed. This is often due to a wound or surgery that removes a section of tissue, so it can no longer be pulled back together in a neat shape.  This method may also be used when a wound will require debridement.

  Debridement is a process that removes dead tissue from a wound in an attempt to leave behind only healthy tissue and speed healing.

An example of closure by secondary intention is when a patient has an area of skin cancer removed. The area is irregular, and the area removed is 1 inch by 2 inches in size. It isn’t possible to pull the edges of the skin together to make them meet, so the wound is left to fill in on its own.

This process of wound filling is called granulation, and the amount of granulation that has to take place in a wider, more open wound is greatly increased. This makes the process take longer, as the new skin cells have a greater area to fill.  

This type of wound will heal more slowly, based on the patient’s ability to heal, the size of the wound, and the nature of the wound. A small round skin biopsy, the size of a pencil eraser and shallow, will heal quickly.  A large infected wound will heal at a reduced rate. In most cases, the new skin filling in the wound can be seen making steady progress week by week, and in some cases, will be notably improved day by day.  

These wounds should be cared for gently, washed with soap and water and not scrubbed, as they are delicate and prone to scarring. Do not scrub any scabs that appear, as this is a sign of healing and part of the process of skin filling in the wound. 

Closure by Tertiary Intention (Delayed Wound Closure)

Delayed wound closure, also known as closure by tertiary intention, is a method of wound healing where the wound is not closed immediately. So, it is closed at a later date because research shows that there is a better outcome if the wound is closed in the future. 

The vast majority of wounds are closed as soon as possible, but some wounds benefit from a delay.  This may be done after surgery, to treat a wound that is likely to become infected, or a wound that is contaminated and will need repeated cleansing. In some cases, if the skin surrounding the wound may not be viable, there may be a wait and see approach, rather than closing skin that may not survive and lead to the process being repeated later.

An excellent example of wound closure by tertiary intention is a dog bite puncture wound.  Imagine a patient has several deep puncture wounds in their hand from the dog’s teeth. These wounds are deep and narrow, which increases the risk of infection. Bite wounds are also extremely likely to be infected, due to the amount of bacteria found in the mouth and saliva. Rather than stitch the top of these wounds, leaving a small cavern underneath that could become a pocket of infection, the wounds are left open.  They can be cleaned more easily, pus and infectious materials can drain easily, medication can be applied directly into the wound and the wound is less likely to develop an infection. This type of bite wound may be closed after the threat of infection has passed, or may never be closed, just bandaged and allowed to heal on its own.  

In surgery, this type of healing may be necessary with major abdominal procedures. Imagine a major surgery being done on the intestines. A large incision is made, the work  of surgery is performed, but the patient’s intestines are very swollen from their illness and continue to swell even more during the surgical procedure because the skin is open and there is more room for swelling. At the end of the surgery, the intestines have swollen significantly, and now the intestines are literally too large to fit back in the abdomen without placing tremendous pressure on the organs and the incision. In fact, it may not be possible to fit them in at all, if the swelling is severe enough. In this case, the wound will be covered with a sterile dressing, typically a clear dressing so the site can be observed. When the swelling goes down enough for the wound to be closed safely, the patient returns to surgery for the incision to be closed.  

Common Methods of Closing Wounds

Surgical Staples: 

Much like the staples used to hold paper together, surgical staples are used to hold a wound together.  Staples are easy to place, strong enough to hold a wound closed in an area that moves frequently like the abdomen, and often painless to remove. These staples, unlike office supplies, are sterile to help prevent infection in the wound.

Staples should be removed by medical staff and should be removed on schedule so that healthy tissue doesn’t grow over the staple.  

Sutures

Also known as stitches, sutures are a synthetic thread that is used to sew a wound closed. They are used to close deep cuts, and are also used to close surgical incisions. Sutures are inexpensive and can be placed quickly once the area is numbed.  

Sutures should be removed by a medical professional, and the length of time they remain in place is determined by the type of wound. Some sutures, called absorbable sutures, are made to dissolve over time and are not removed. This type of thread is typically used on the inside layer of a deep or large wound and are not visible once the wound is closed.   

Dermabond Surgical Glue

This type of wound closure uses an adhesive much like SuperGlue to hold an incision closed. This is frequently done on small incisions that don’t require a tremendous amount of strength to be held in place for healing. The glue wears off in the days and weeks following placement, so a healthcare professional is not needed to remove it.  

In some cases, a small dab of surgical glue may be placed on sutures. This is done to keep the stitches from unraveling during normal activity.

Steristrips

Steristrips are small stripes of sterile adhesive material that are used to “tape” a wound closed. They are typically used on small incisions that do not experience a great deal of stress during the wound healing process. These strips of material are worn until they fall off, typically staying in place for about a week and falling off during or after routine bathing. A stubborn strip that is no longer needed can be gently removed after a shower when the adhesive is soft. 

Individuals with known issues with adhesive should make their surgeon aware of the issue prior to surgery, as alternative methods without adhesives can be used.  

Source:

3M Wound Resource Center. Accessed April 2016. http://solutions.3m.co.uk/wps/portal/3M/en_GB/skin-care/wound-resource-centre/

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