Wound Closure Guidelines

Introduction to Wound Closure

• Wound closure guidelines are supported by various medical societies, including the British Journal of Dermatology, American College of Obstetricians and Gynecologists, and World Journal of Emergency Surgery, to promote optimal healing and minimize complications 1, 2, 3, 4

Suture Selection

• Monofilament sutures are preferred for facial wounds as they cause less bacterial seeding and may be less likely to cause infection, according to the American College of Obstetricians and Gynecologists 2
• The British Journal of Dermatology recommends using 4-0 sutures for deeper tissue layers in facial wounds, but notes they are too large for facial skin closure 1
• Antimicrobial-coated sutures should be considered for contaminated wounds, as suggested by the World Journal of Emergency Surgery 4

Layered Closure Approach

• A layered closure approach is recommended, where deeper tissues are closed with 4-0 absorbable sutures and skin is closed with 5-0 or 6-0 sutures, as suggested by the British Journal of Dermatology 1
• Meticulous irrigation to eliminate all visible residue or foreign material is recommended, followed by closure by planes using techniques to minimize tension and promote optimal healing, using copious amounts of running water or sterile saline solution until all visible residue is eliminated, as recommended by the American Heart Association 3
• Antiseptics such as povidone-iodine should be avoided for irrigation as they do not offer additional benefits and may delay healing 3

Wound Care and Dressing

• An occlusive dressing should be applied to promote healing and maintained for a minimum of 48 hours, unless there is leakage, as recommended by the American Heart Association and World Journal of Emergency Surgery 3, 5
• Patients should be instructed to keep the wound clean and dry, and to monitor for signs of infection (redness, swelling, foul-smelling discharge, increased pain or fever) 3
• Wounds caused by human or animal bites, or contaminated with saliva, should be evaluated at a medical center as soon as possible, and if signs of infection appear, the dressing should be removed, the wound inspected, and medical attention sought 3

Suture Techniques and Materials

• Horizontal mattress sutures are recommended for patients with factors that may impair wound healing, while subcuticular continuous sutures have lower rates of wound dehiscence and surgical site infections (SSI) compared to staples, making them a preferred choice for abdominal surgeries, as recommended by the World Journal of Emergency Surgery and World Health Organization 4, 6, 5
• Interrupted sutures are easier to partially remove if signs of infection appear, as suggested by the World Journal of Emergency Surgery and Infectious Diseases Society of America 5, 7
• Skin staples should be used selectively for wound closure, with subcuticular continuous sutures being preferred for most abdominal surgeries due to lower rates of SSI and wound dehiscence, as recommended by the World Journal of Emergency Surgery guidelines 6
• Absorbable subcuticular sutures do not require removal and maintain 50-75% of tensile strength after one week, providing a convenient alternative to traditional sutures, and consider steri-strips for additional support after staple removal, as recommended by the World Journal of Emergency Surgery and American Academy of Pediatrics 6, 8

Post-Operative Care and Follow-Up

• The American Academy of Pediatrics recommends using Steri-Strips to provide additional support to facial wounds, such as those in the temple area, where cosmetic outcome is important and the skin may benefit from extra support after suture removal 8
• The Infectious Diseases Society of America suggests ensuring the wound is not showing signs of infection before applying Steri-Strips to reduce the risk of complications, and patients should be instructed to seek medical attention if they notice signs of infection or wound complications after Steri-Strip application 7
• Cleaning the wound thoroughly with betadine or chlorhexidine before applying skin glue is recommended by the American College of Obstetricians and Gynecologists, and ensuring the wound base is completely dry is essential for proper adhesion, as suggested by the American Academy of Ophthalmology 2, 9
• Keeping the wound hydrated and protecting it from sun exposure for at least 6 months is crucial for proper healing, as recommended by the World Journal of Emergency Surgery and other guidelines 6, 10
• Patients with impaired healing, nutritional deficiencies, advanced age, or higher tension areas may require longer retention of staples, and nutritional deficiencies can delay wound healing, as stated by the Academy of Nutrition and Dietetics and World Journal of Emergency Surgery 6, 10, 4

Suture Removal and Complications

• The optimal window for removing non-absorbable transcutaneous sutures is typically after 7-9 days, according to the World Journal of Emergency Surgery and World Health Organization guidelines, and the optimal time for suture removal is 7-10 days after placement, as it allows for adequate wound healing, minimizes the risk of dehiscence, and reduces the likelihood of hypertrophic scarring, recommended by the American Academy of Dermatology and World Journal of Emergency Surgery 6, 5, 10
• Evaluating for signs of proper healing, such as wound edges well approximated, and absence of infection, is essential before removing staples, as recommended by the World Journal of Emergency Surgery and Centers for Disease Control and Prevention 6, 7
• Too early removal of staples may lead to wound dehiscence if removed before adequate healing, while too late removal may result in "railroad track" scarring or tissue overgrowth around staples, and incomplete removal or ignoring signs of infection can lead to further complications, as warned by the World Journal of Emergency Surgery and Infectious Diseases Society of America 6, 7
• If signs of infection are present, consideration should be given to partial or total wound opening, drainage of infected material, and antibiotics if systemic signs of infection are present, as recommended by the Infectious Diseases Society of America, and delayed primary closure for contaminated wounds, with a second look and closure between 2-5 days postoperatively, is recommended by the World Journal of Emergency Surgery 7, 4