ResidentNet/Wound Closure/closures

Types of Wound Closure
Contributed by Mika Sinanan, MD, University of Washington Medical School
sutures | staples | tapes | skin grafts | pedicle flaps

Sutures

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Sutures attached to needles are the most common method of approximating skin edges. Sutures are classified as absorbable or nonabsorbable and as either monofilament or multifilament. Sutures vary in their capability to provoke infection, with catgut being the most "reactive" and polypropylene being one of the least "reactive" suture materials.

Staples

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Staples are less reactive than the least reactive suture. Deeply implanted staples do not affect tissue defenses, although staple cross members that are flush with the skin can produce cross-hatched scarring. The development of disposable staplers with absorbable tacks obviates the need for removal of staples. Subcuticular closure of skin is now also possible through the use of a disposable stapler that uses twin gripper blades to approximate and evert the wound edges and insert a disposable pin into the dermis.

Tape

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Microporous tape is the least reactive of man-made wound closure materials. Tape with hypoallergenic adhesive on spun bonded nylon without reinforcing filaments has the best record for avoiding premature detachment. It also reduces the incidence of stress blister formation.

Skin grafts

Additional pictures illustrating this procedure may be viewed by clicking on the image (47K).

Skin grafts are used only when the wound cannot be closed by direct approximation. They are usually classified as split-thickness or full-thickness. Split-thickness skin grafts (STSGs) include the epidermis and some portion of the dermis. Full-thickness skin grafts (FTSGs) include the epidermis and the dermis.
Choice between them is based on the wound to be closed. Thin grafts take more easily and can be used on questionably reliable surfaces; thicker grafts maintain a more normal appearance and are particularly useful where a desirable cosmetic outcome is required, eg, the face.

Pedicle flaps

Additional pictures illustrating this procedure may be viewed by clicking on the image (47K).

Pedicle flaps can be used to provide soft tissue closure with a defined blood flow and innervation. These are particularly desirable when the wound tissue is relatively avascular (such as bone, cartilage, or tendon), or has been rendered avascular by radiation or scarring. In the accompanying image, a large debrided ulcer on the plantar surface of a diabetic foot has been closed with a "bridge" created from the soft tissue (digital artery preserved) formerly enclosing the head of the first metatarsal bone and tendon.

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Sutures Image expands to 39K JPEG	Sutures attached to needles are the most common method of approximating skin edges. Sutures are classified as absorbable or nonabsorbable and as either monofilament or multifilament. Sutures vary in their capability to provoke infection, with catgut being the most "reactive" and polypropylene being one of the least "reactive" suture materials.

Staples Image expands to 21K JPEG	Staples are less reactive than the least reactive suture. Deeply implanted staples do not affect tissue defenses, although staple cross members that are flush with the skin can produce cross-hatched scarring. The development of disposable staplers with absorbable tacks obviates the need for removal of staples. Subcuticular closure of skin is now also possible through the use of a disposable stapler that uses twin gripper blades to approximate and evert the wound edges and insert a disposable pin into the dermis.

Tape Image expands to 33K JPEG	Microporous tape is the least reactive of man-made wound closure materials. Tape with hypoallergenic adhesive on spun bonded nylon without reinforcing filaments has the best record for avoiding premature detachment. It also reduces the incidence of stress blister formation.

Skin grafts Additional pictures illustrating this procedure may be viewed by clicking on the image (47K).	Skin grafts are used only when the wound cannot be closed by direct approximation. They are usually classified as split-thickness or full-thickness. Split-thickness skin grafts (STSGs) include the epidermis and some portion of the dermis. Full-thickness skin grafts (FTSGs) include the epidermis and the dermis. Choice between them is based on the wound to be closed. Thin grafts take more easily and can be used on questionably reliable surfaces; thicker grafts maintain a more normal appearance and are particularly useful where a desirable cosmetic outcome is required, eg, the face.

Pedicle flaps Additional pictures illustrating this procedure may be viewed by clicking on the image (47K).	Pedicle flaps can be used to provide soft tissue closure with a defined blood flow and innervation. These are particularly desirable when the wound tissue is relatively avascular (such as bone, cartilage, or tendon), or has been rendered avascular by radiation or scarring. In the accompanying image, a large debrided ulcer on the plantar surface of a diabetic foot has been closed with a "bridge" created from the soft tissue (digital artery preserved) formerly enclosing the head of the first metatarsal bone and tendon.