Wound: Ctosure
Wound: Ctosure
Wound: Ctosure
Extrinsic tension relates to tension applied to the in- The clinical importance of this phenomena is that the
cised wounds by closure materials. Some influential fac- wound or incision site does not have adequate natural
tors are the tension placed upon the suture and the protection from the external environment. The incision
amount of tissue it surrounds. lf a suture is too tight local becomes vulnerable to entry from microorganisms.
pressure will lead to ischemia, tissue necrosis, and scar Because of this it is prudent to avoid dressing changes
formation. With heavier suture material it is much easier until the second postoperative day.
to create greater amounts of tension than with finer
sutures. This does not imply that finer sutures will not Most texts on wound closure recommend that the skin
Iead to ischemia, necrosis, and scar formation. It must margins be everted at closure. The edges willgradually
be realized that the suture material transmits its tension flatten to produce a level wound surface. Wound edges
to the apposed wound edges. Excessive tension or per- may also be evenly apposed or inverted. The use of in-
sistent tension on normal skin may result in stretching, verted skin edges when healed will result in a skin fold
skin rupture, or blanching of skin. Avoidance of tension appearance. There is very limited use for this closure
is paramount to wound closure. technique in podiatric surgery.
42
Classification of Wound Closure
This is a safe method of late repair for contaminated,
Wound closure or healing is dependent upon the rate dirty, traumatic, and infected wounds. The management
and pattern of different tissues under different cir- of the open wound will not be addressed.
cumstances. Three types of wound closure or healing are
recognized; first or primary intention, secondary inten- The optimum time for delayed closure is 4 to 6 days
tion, third or tertiary intention. post injury or debridement or when the wound is
clinically ready for closure. Accurate approximation of
Primary lntention skin edges and underlying tissues is essential. The end
result often times is a wider, thicker scar. Closure by this
Primary intention is the desired method of wound heal- method may involve use of buttress sutures and antiten-
ing. This healing process has three distinct phases and sion sutu res.
was discussed elsewhere in the seminar. Healing by
primary intention follows the initial closure of an incis- Materials
€d, aseptic, accurately approximated wound with
minimal edema, no discharge, or local infection. An in- Suture material, needles, and other materials used for
cision that heals by first intention does so with minimal wound closure have been discussed in great detail by
scar formation, minimal time, and with no separation of Yu and Cavaliere (1982, 1983, 1986 Doctors Hospital
wound edges. This is what each surgeon strives for and Seminar Syllabi) and will be briefly reviewed.
expects each time surgery is performed.
Suture Types
Secondary lntention
Surgical sutures are sterile filaments or fibers used to
Healing by second intention takes place when there approximate and maintain tissues until the healing pro-
is a wound defect or physical gap between the wound cess has endowed the wound with sufficient strength to
edges. This method of healng is accomplsihed through withstand mechanical stress. Attached to needles they
the formation of granulation tissue containing are employed for stitching wounds, surgical incisions,
fibroblasts. This wound closes by contraction with a and used as ligatures to tie off tubular structures.
secondary growth of epithelium. Cuidelines and standards are set by the United States
Pharmacopeia (USP).
This method of wound closure is delayed when com-
pared to primary intention, scar tissue may be excessive Sutures can be classified as nonabsorbable and ab-
and the site of wound union is weaker. This form of sorbable. These can be divided into subgroups (Table 1).
wound closure is often referred to as "inside out heal-
ing" because of the process of epithelial cell migration. Absorbable sutures that are currently available: cat gut,
col lage n, polyglycol ic, and polyglacti n-91 0, polyd ioxane.
Secondary wound closure may be used whenever The latter three represent the synthetic materials (Table
there is excessive necrotic tissue in the wound, in the 2). Practically speaking absorbable sutures are con-
presence of purulence, or in cases where there is mor- sidered as temporary sutures. The degradation process
bidity of adjacent structures, or when primary or delayed and absorption of these materials differs. All sutures are
primary closure do not seem prudent. foreign bodies.
Tertiary lntention The derived materials are gut and collagen, chromic
or plain. They are absorbed and degradated through
Tertiary intention, also referred to as delayed prinrary cellular and tissue proteases. They elicit a wide range of
closure, is a technique that has received more attention biological reactions depending on the type and condi-
than previously. This technique was developed by the tion of the tissue in which they are implanted. Their
wartime surgeons for repair of military wounds. prediqtability as to rate of absorption and loss of strength
is inferior to that of the synthetic products. From a
The technique has evolved and has many applications podiatric standpoint their use is Iimited.
today. The process involves apposing granulating sur-
faces. The basis for delayed primary closure is that the The synthetic materials are polyglycolic (Dexon-S and
open healing wound gradually gains sufficient resistance Dexon Plus), polyglactin-910 (Vicryl), and polydioxane
to infection to permit an uncomplicated closure. The (PDS) are absorbed and degraded through hydrolysis, a
resistance to infection is attributed to the proliferation noncellular, nonenzymatic, virtually noninflammatory
of granulation tissue. process at a predictable rate although polydioxane does
43
show a more moderate inflammatory reaction. or multifilament.
Polyglycolic acid and polyglactin 910 are multifilament All nonabsorbable suture may be modified with
materials have been reported as having minimal absorp- respect to body or texture, or to reduce capillarity and
tion until the 30th to 45th day and are essentially com- may be suitably bleached or dyed.
pletely absorbed in 60 to 90 days. Because they elicit
minimal inflammatory reaction they are useful for skin Recall that all suture elicits an inflammatory reaction
closure unlike the natural absorbable sutures. because it is a foreign body. Most of the initial reaction
may reflect the passage of needle and suture through
The recently introduced synthetic monofilament skin. The initial reaction lasts for approximately 5 to 7
polydioxane has slightly different characteristics. The days and is the same for all sutures. Cenerally monofili-
most remarkable is that the absorption of these sutu res ment sutures are less reactive than multifilament sutures,
is minimal until about the 90th post implantation day and uncoated less than coated, and synthetic less than
complete by six months. natu ral.
From a mechanical standpoint the synthetic absorbable Biological properties of nonabsorbable sutures are
sutures are far superior to the natural sutures with tissue reactibility and resistance to infecting organisms.
respect to tensile strength, loss or retention, knot securi-
ty, and handling properties. At two weeks postimplan- Nylon and silk are Iisted as nonabsorbable but both
tation approximately 55% of the originaltensile strength undergo degradation and absorption over a period of
remains while at three weeks 20% of original tensile time.
strength is retained. The tensile strength of absorbable
sutures is not a function of absorption rate. These sutures The coated sutures or impregnated sutures (Teflon or
are not influenced by exposure to aqueous tissue fluids Silicone) tend to shed fragments over several months.
as is surgical gut which shows a rapid loss of tensile As a class the polyester sutures are well tolerated with
strength and knot security. Polydioxane suture will be mild tissue response except when they shed fragments
discussed in more detail later but it has been formulated more of an inflammatory response is noted. The best
for prolonged wound support. At two weeks the tolerated coated polyester suture seems to be Ethibond
polydioxane suture retains approximately 70% of its as the polybutilate has a high affinity for the polyester
original retention strength, while at four weeks 50% is and shows little to no shedding.
retained, and at six weeks approximately 15% of original
tensile strength is retained. Tissue reactivity of nonabsorbable sutures least reac-
tive to most reactive are in this order: monofilament pro-
In cases where prolonged wound support is desired lene, monofilament nylon, stainless steel wire,
and an absorbable suture is desired polydioxane may be polybutilate coated polyester, u ncoated braided
preferable to polyglycolic acid or polyglactic 910. The syn- polyester, teflon/silicone coated polyester, natural fiber
thetic absorbable sutures in podiatric surgery are useful materials.
for all layers of wound closure including skin. The
surgeon needs to be reminded that a suture is not need- Sutures that show best resistance descending to least
ed after a wound has healed. Therefore suture selection resistance to bacterial contamination are: monofilament
should be based upon the healing process of the tissue prolene, monofilament nylon, polybutilate coated
to be sutured. polyester, uncoated braided polyester, teflon/silicone
coated polyester, monofilament stainless steel, natural
Nonabsorbable sutures are divided into three classes fiber materials.
all of which are resistant to the action of Iiving mam-
milian tissue and generally considered permanent in Mechanical properties of nonabsorbable sutures in-
natu re. clude tensile strength, elasticity, and plasticity, knot and
knot secu rity.
Class lconsists of silk or synthetic fibers of monofila-
ment, twisted, or braided construction. Tensile strength is a constant derived from the force
necessary to break a strand of material divided by its
Class ll consists of cotton or linen fibers or coated cross sectional area. This constant permits comparison
natural or synthetic fibers where the coating forms a cas- of relative strength between different suture materials
ing but does not contribute significantly to strength. (Table 4). Elasticity and plasticity are inherent qualities
of the suture material and can be expressed as a
Class lll is metallic suture and may be monofilament stress/strain curve. The elastic behavior is the inherent
44
ability of the internal tension (stress) to return to its suture manufacturers. Those mentioned below reflect
original length after stretching (strain). The plastic nature some of the needles produced by Davis & Geck, Ethicon,
of suture refers to the tension increase seen when the and others.
material is stretched beyond its Iimit up to the breaking
point and is not reversible. Some suture materials such Tapered needles are designed for suturing soft, pliable,
as nylon and prolene possess memory which permits easily penetrable tissues such as paratenon, tendon
them to elongate under tension and then recover to the sheaths, some deep fascia tissues, but more commonly
original dimensions when the tension subsides. the superficial fascia or subcutaneous layer. Common
needles include: T-5, SH, T-16, SH1. The needle selected
Knot and knot security are more dependent upon the will depend upon the location on the foot or leg which
structural configuration than upon the material used. A is being sutured.
material's coeff icient of f riction will affect knot security,
the greater the constant the greater friction between the Cutting needles are designed with ground and honed
material when a knot is tied. Monofilament synthetic edges to cut through and penetrate thicker connective
sutures and coated sutures tend to have lower coeffi- tissue layers. The conventional cutting needle contains
cients and greater incident of knot slippage. Other fac- two opposing edges and a third cutting edge on the in-
tors that affect knot security are the Iength of the ears, ner side or concave surface of the needle. This type of
and presence or absence of moisture. needle may cause greater tissue damage along the con-
cave surface of the needle which is usually in the direc-
Surgical Needles tion of the tissue edge to be approximated. This leads
to a greater tendency of sutures to pull through the
Design and Application tissue. The use of conventional cutting needles is limited
at our institution. The reverse cutting needle has its third
The selection of a surgical needle, like selection of imposed edge on the convex or curved surface. This is
suture material should be based on scientific, clinical, a multipurpose needle useful in thick connective tissues
and personal preference. The primary function of a and difficult to penetrate tissues such as the skin. This
surgical needle is to carry and deliver the suture material needle creates a flat surface on the concave side of the
through specific tissues. The tissue to be sutured should needle and the tissue most adjacent to edge being
be minimally altered by the passage of the needle. sutured thereby resulting in fewer pullthroughs. Com-
lmportant factors from the surgeon's standpoint are ten- monly employed needles are CE-6, C-6, CP-2, FS-1.
sile strength, weave, shear strength, penetrability, den-
sity, elasticity, and thickenss of the tissue. The taper cut, diamond point needle is a combination
needle usefulfor penetrating virtually alltissues that are
Current surgical needels are manufactured from high composed of dense, thick, connective tissue; capsule,
quality stainless steel wire chosen to provide strength, Iigament, tendons, deep fascia. The only exception is
temper hardness, malleobility, ductility, and surface skin. Recommended needles include DT-19, KC-5 for ma-
f inish. jor Iigament/tendon repair or DT-12, KC-6, V-35. Others
are DT-5, KC-2, V-7.
There are three basic components to surgical needles:
the eye, the body or shaft, and the point. Precision point or hand honed reverse cutting needles
are designed to assure smooth passage through tissue,
There are three types of eyes for surgical needles: clos- better placemnt of sutures, and a minute needle path
ed eye, French or split eye, and swaged (eyeless). The that heals quickly. These are particularly useful for skin
body or shaft varies considerably with respect to shape closure and reapproximation. Recommended needles
and configuration. Needles may be straight (Keith), or are SBE-4 (SBE-3), PS-2, PRE-4.
curved to some degree of a circle. The configuration of
the body may be round, oval, flat, triangular, or even Drains and Drain Placement
ribbed. Needle points vary in their geometric configura-
tion as well. The shape is important to allow for smooth Drains are an important part of wound closure. The
penetration of the needle and suture through the tissues. use of active and passive drains is well described in the
Basic needle points are blunt, tapered, triangular, and literature. The ideal drain should be soft and pliable and
diamond shaped. not encroach upon important structures. lt should be
non-irritating to tissues and should not weaken or
Commonly Employed Needles at Doctors Hospital decompose upon exposure to drained fluids.
The classifying or coding of needles varies among Closed suction drainage utilizing the TLS drain is the
45
most commonly employed drain at Doctors Hospital Deep Closure
when a drain is indicated. lndications include surgical
procedures in which dissection is extensive enough to
Ieave a dead space or leaves the potential to develop a The goals of deep closure are: 1) accurate anatomic
hematoma or seroma. Removal of oozing fluids from the reapproximation of the supporting layers of skin, 2)
surrounding tissues enhances wound healing, helps elimination of dead space, 3) decrease incidence of
minimize possibility of infection, and shortens recovery wound dehiscence/disruption by imparting physical
time. The tissue most vulnerable to hematoma/seroma strength to a decontinuous surface. Close approximation
collection following surgery is subcutaneous tissue of the various layers helps insure that a minimal amount
where blood and lymphatic vessels are easily damaged of new connective tissue will be required to restore func-
during the dissection process. tional and structural integrity in the shortest period of
time. Tension should be placed upon the deeper layer
Principles of closed suction drainage include as opposed to the skin. There should be as many sutures
hemostasis, external drainage, negative pressure, airtight as necessary so that the tension is evenly distributed. The
wound, proper placement of the drain. deep closure should hold the epithelium in approxima-
tion with slight eversion.
The drain should be placed across tissue planes if
possible with a significant portion in the subcutaneous Fascia heals relatively slowly, strength is not attained
tissue, i.e. a portion of the perforated silicone tube for nearly a year so consideration of the biological pro-
should traverse capsule, deep fascia, superficial fascia perties of suture materials and wound healing argue
(where applicable). Care should be taken to avoid sutur- strongly for closure with nonabsorbable materials.
ing the drain within the wound or encircling the drain.
Stone and associates in a recent study determined that
The drain exit should not be within the incision line a tight deep fascial closure with new syntehtic sutures
as this could lead to delayed healing, possibly even in- in rats was more detrimental than loosely approximated
fection or dehisence. Care should also be exercised to fascial wounds. The loosely approximated wounds were
avoid placing too much drain within the wound causing significantly stronger. The greatest incident of wound
layers to separate and delay wound healing. failure was due to sutures being pulled through the
tissue because of the increased tension required to main-
tain adequate friction on the first throw of the surgeon's
knot. The result was hypoxia to the tissue within one
suture loop diminishing the tissue holding capacity
Techniques of Wound Closure leading to wound failure. This indicates that there may
be a need for deeper retention sutures. Closure of deep
There are ten steps involved in the methods of sutur- layers of tissue at Doctors Hospital is usually accomplish-
ing. All are important to skillful performance. ed by simple interrupted over and over sutures. Specific
examples are joint capsules, ankle, first metatarsals, as
1. Request a suture; position of the needle on well as deep fascia along the medial and lateral aspects
the needle driver of the foot.
2. Crasp the needle driver with an appropriate
grip Some tissues lend themsleves to continuous closure
3. Position the free end of the suture (pass it to techniques. The surgeon's preference and experience
an assistant) usually play a significant role in deep closure techniques.
4. Place the needle point at the proper site with
the proper body attitude Skin Closure
5. Drive the needle through the tissue; follow Skin is not a simple tissue such as epithilium, fascia,
the curve of the needle or fat. lt is a highly complex organ containing multiple
6. Release the needle structures derived from multiple germ layers. The goal
7. Regrasp the needle for extraction of skin closure is to create a mature scar that is narrow
8. Needle extraction and levelwith the skin with a minimum of stitch marks.
As has been discussed here and in other sections the skin
9. Puil the desired length of suture through the incision does not have adequate strength until 42 days
wound post injury. From this point onward there is no new in-
10. Reposition the needle on the holder for the crease in collagen content but a measurable increase in
next stitch tensile strength lor 24 months.
46
There are numerous methods devised to close skin; body. Synthetic monofilament nonabsorbable sutures
simple interrupted sirtures, horizontal and vertical mat- are the least reactive, but they too can result in suture
tress sutures, continuous locking and running sutures, marks if not removed from the wound early enough. The
subcuticular suture with application of adhesive skin- synthetic multifilament absorbable sutures polyglycolic
tapes, corner sutures, and open loop sutures. acid and polyglactin-910 exhibit minimal tissue reactivi-
ty even when used for subcuticular suture. Sutures that
It has been stated that after subcutaneous tissue has pass through the epidermal dermal junction permit
been closed and prior to the skin margins being approx- epithelial migration and will result in suture marks unless
imated with tape then whatever gap exists at that time removed from the skin 5-12 days postsurgery. Sutures
will be reflected as a wide depressed scar. removed in that time frame generally exhibit very
minimal scar formation. Other variables that relate to
Some authors advocate the use of the subcuticular suture marks are size and configuration of suture needles
suture; placed at the dermal epidermal junction, employ- used.
ing fine nonabsorbable suture, then approximating the
epidermis with a smaller finer suture. The greatest value In summary, skin closure can be influenced by a
of the subcuticular suture is reducing both the need for number of different factors. The surgeon should be
and the time epithelial sutures are utilized. From a aware of the many factors and their presentation. More
biological standpoint the need for a subcuticular suture sophisticated closure techniques will be addressed in
is greatest when the cutaneous sutures are removed. another presentation. The ideal skin closure technique
The remodeling collagen will respond appropriately and and material may not presently exist. The most common-
a widening of the scar will take place. ly employed skin closure technique at the lnstitute is a
subcuticular suture of either Dexon "5", 5-0, or 6-0, or
Suture selection depends on the surgeon's preference. Prolene pullout of 4-0 or 5-0. Skin tapes are often used
Any suture that is placed cutaneous (through the epider- in conjunction with subcuticular closure.
mis) must be removed prior to fourteen days from a
cosmetic viewpoint or else risk the development of
suture tracts from epithelial migration.
Dog Ear Management
The development of dependable adhesive strips or sur-
face tapes limits the necessity of epidermal suture. Closure of elipitical wounds on occasion can result in
Adhesive strips will be discussed in more detail later, but formation of a dog ear or pucker which represents a
some authors feel as if epidermal sutures provide a fine bunching of skin. This can be easily and simply manag-
adjustment or leveling device for the epidermis. ed. The excessive tissue is retracted by a skin hook plac-
ed at the ends of the incision. The tissue is retracted
Factors Affecting Skin Suture Marks laterally. Utilizing a #15 or #11 blade an additional skin
incision is performed directly in line with the sutured
There are a number of factors affecting skin suture wound creating a small tissue flap, triangular in nature.
marks. These include keloid tendency, stitch abscess, The resultant skin flap of excess tissue is overlapped over
skin type, suture material, and tension. the proposed line of suture while a skin hook retracts
the distal end of the incision. A Iine of tension should
Patients who exhibit a keloid tendency for whatever be evident and the flap is excised. Final closure of the
reason may also form keloids at the site of skin sutures. wound is performed.
The formation of stitch abscess may result from 1) inflam-
matory reaction in the dermis secondary to implantation Alternative methods of dog ear repair depend on their
of small amounts of keratin material, and 2) Iow grade etiology. lf the long axis of an elipse is too short the sides
skin contaminants owing to the activity of bacteria. This will form too great an angle with one another and ex-
may also be associated with necrosis secondary to the cess bunching will result. These can be corrected by ex-
tension of a tied suture with the suture behaving as a tending the elipse to include the excess tissue.
foreign body eliciting a greater inflammatory response.
The size of the resultant suture mark will depend upon A dog ear can also result if one side of the elipse is
the size of the abscess. much longer than the other, i.e. one side is similar to
a semicircle while the other is straight. These can be
A person's skin type is a variable of race and age. repaired by making a short right angled incision at the
Suture marks will be more prominent in areas where scar end of the elipse. The overlapping skin at the wound
formation is greater. Suture material may also affect the edge can be trimmed away. Wound closure is then
size and formation of suture marks because it is a foreign shaped like an "L".
47
Special Considerations postoperative day but in debilitated patients it may be
necessary to leave them in place for two or three weeks.
Decreasing wound tension can be accomplished in a
variety of ways. Most beneficial to decreasing wound ten-
sion at the skin level is accomplishing good layered Age
closure of the deeper tissues, i"e. capsule, deep fascia,
and superficial fascia. Another adjunct is the use of Older patients have less fibrous content in their tissue.
adhesive skin tapes. These were previously mentioned This is significant in that it is easier to close mobile skin
for use of epidermal closure and in conjunction with sub- under less tension. Children and young individuals have
cutaneous closure for fine adjustment of the der- a much greater natural tension to their skin with a higher
mal/epidermal layer. fiber content, i.e. increased elastic and collagen fibrils.
48
Table 4 Crabb WC, Smith HW (eds): Plastic Surgery,3rd edition,
chapter 1. Little, Brown, Co., Boston MA, 1979.
Jay JA, Doddi N, Regula D, Williams JA, Melveger A.:
Relative Tensile Strengths Polydioxanone (PDS), a novel monofilament syn-
Nonabsorbable Suture thetic absorbable suture. Surg Cynecol Obstet
(listed from greatest to least) 153:497-507, 1981.
Lerwick E: Studies on the efficacy and safety of polydiox-
anane monofilament absorbable suture. Surg
Stainless steel wire Cynecol Obstet 156:51, 1983.
Coated braided polyester Miller SJ: Surgicalwound drainage system using silicone
Uncoated braided polyester tubing. J Am Podiatry Assoc 71:287,1981.
Monofilament nylon Peacock EE: Wound Repair, ed 3. WB Saunders,
Polybutester Philadelphia, PA, Chapters 1,2, 5, 6,9, 10.1984.
Braided nylon Rodehaver CT, Nesbit WS, Edlich RF: Novaf il (a dynamic
Monofilament prolene suture for wound closure). Ann Surg 204:193, 1986.
Monof i Iament polyethylene Sabiston DC (ed): Textbook of Surgery,l3th edition. WB
Natural fiber Saunders, Philadelphia, PA, pp 216-220,1986.
Stone IK, von Fraunhofer .fA, Matterson BJ: The
biomechanical effects of tight suture closure upon
fascia. Surg Gynecol Obstet 163:448-452, 1986.
Bibliography Yu GV, Cavaliere RC: Wound closure. ln McGlamry (ed):
Fundamentals of Foot Surgery. Williams & Wilkins,
A Manual for Wound Closure. MMM Co., 1980. Baltimore MD,1987.
Albers W, Geldmacher J, Ciedl H, Boyer W: Tendon Yu CV, Cavaliere RC: Suture materials J Am Podiatry
sutures with a new absorbable synthetic monofila- Assoc 73:57, 1983.
ment material (PDS Suture 6-0). Results of animal ex- Yu GV: Suture materials: properties and uses. Doctors
periments. Ch i rug 53:168-171, 1982. Hospital Podiatry lnstitute Seminar Syllabus. Doctors
Anderson Rm, Romfh RF: Technique in the Use of Hospital Podiatric Education and Research lnstitute,
S u rg i cal Too I s. App leton-Ce ntu ry-C rofts, N ew York, Atlanta, CA,1982.
NY, 1980. Werth JL: Basic skin closure. Ear Nose Throat J 60:43-46,
Converse J (ed): Plastic and Reconstructive Surgical 1981.
Techniques, vol 1. Chapters 1,2, 16, 1977. Wound Closure Manual . Ethicon Co., 1985.
50