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Wound Closure Techniques
By Marsena Collins FNP-C, ENP-C
A few months ago I posted a blog about “How to Close a Laceration.” This follow-up discusses specific wound closure techniques that will take your suturing skills to the next level. I will list the pros and cons of each technique.
First, I want to list key principles to consider prior to closure of any wound(s) in the clinical setting.
Key Principles of Wound Closure
Minimize Trauma to Tissues, assess the need for wound closure, and make sure you are not overusing sutures for minor lacerations. Remember that sutures themselves leave scars, and should only be used when needed.
Match the skin Layer and evert the wound edges.
Relieve Tension exerted on wound edges by undermining and layered wound closure.
Accurately realign landmarks and skin edges by layered closure and precise suture placement. Nothing causes abnormal scarring more than poorly lined closures.
“Approximate don’t strangulate” and “Build mountains not dig ditches.”
Basic Knot Tying
All wound closure techniques used to close skin wounds can be tied with the same knot. At our live workshop we teach the 2-1, 1-1 technique. This ensures a strong knot that will remain tied.
Common Wound Closure Techniques
The Simple Interrupted Stitch (It’s the Bread and Butter of Suturing)
The simple Interrupted technique is the technique I use the most in the wound closure in which separate loops of suture are tied individually. This technique is appropriate for wounds with well-approximated skin edges under no tension!
| Pros | Cons |
| Simple, Versatile If one stitch in the closure fails, the remaining stitches will continue to hold the wound | Can be time consuming |
Continuous Stitch “Running Stitch”
Continuous technique is an effective method for closing relatively clean, low risk wounds that are under no tension and flat immobile skin surfaces. I love using this wound closure technique on children (quick and simple). This is also a great technique for other wounds that require quick closure.
| Pros | Cons |
| -Quick, simple, and effective hemostasis -Useful as a “surface” suture in cosmetic closures | -Avoid use on wound overlying joints -If a loop breaks, the entire suture may unravel |
Mattress Stitch
Two Types: Vertical and Horizontal Stitch (My High Tension Wounds Stitches)
Vertical
Horizontal
The Vertical Mattress suture technique is useful for wound closure with edge eversion, I use this technique to reduce tension on gaping wounds. The width of the stitch should increase based on the amount of tension. That is, the greater the tension, the wider the stitch. The horizontal mattress suture is more frequently used in fascia than in skin. Commonly used in calloused areas like the palms or soles of the feet. Also Everts the wounds edges.
| Pros | Cons |
| -Effective methods for everting wounds edges -Great on higher tension, larger wounds with significant gaping -Eliminates the need for layered suturing | -Can cause more tissue ischemia and necrosis |
Running Subcuticular Stitch
| Pros | Cons |
| -Best in patients with Keloid skin, -Cosmetic -Can be left in place for a longer period of time than non-absorbable surface. -Good for buried sutures and pulling together the wound edges -Reduces overall tension and gapping | -Time Consuming |
Other Types of Wound Closure
Adhesive Strips for Wound Closure
Adhesive Strips are great for superficial wound closure that does’t require tension and need to be approximated. They can be cut to size and applied very easily after the wound has been cleaned and dried.
Stapling
Staples are my closure methods of choice for higher tension linear lacerations located on the extremity, the trunk, the scalp.
| Pros | Cons |
| -Speed of Closure- Fast!! -Great with Trauma, Agitated, and /or Intoxicated patients | -Can’t be used in patient expected to undergo MRI imaging -Avoid stapling on wounds located on the on face, hands, neck, feet -Will leave a more pronounced scar |
Tissue Adhesive
“The Glue” is a simple rapid method of closure. Care should be taken to approximate the wound margins as closely as possible. Tissue adhesives can become messy when in contact with blood. Take time to ensure that glue is dried and the wound is completely approximated before you send your patient home.
| Pros | Cons |
| -Speed of closure -Rapid and Painless -No suture marks -Antimicrobial effect on gram positive organisms -No follow-ups visits | -Not appropriate for deep layering wounds and bleeding must be controlled -No ointments or occlusive bandages can be applied -Avoid in wound cavity, hair, near joints, eyes, or mucosal surfaces |
Did you find this blog helpful? Do you want to perfect your suturing with personalized one-on-one hands on training? Take our Clinical Skills and Procedure Workshop!
