Wound Healing

The process of wound healing is generally divided into four stages:

inflammation, fibroblast proliferation, contraction, and remodeling. There
are three types of wound healing:

First intention. The wound is closed by routine primary suturing,

stapling, or gluing. Epithelialization occurs in 2448 h.

Secondary intention. The wound is not closed by suturing,

stapling, or gluing but closes by spontaneous contraction and
epithelialization at a rate of 1 mm/d). Most often used for wounds
that are infected and packed open.

Third intention (also called delayed primary closure). The wound

is left open for a time and then sutured at a later date. Often used
with grossly contaminated wounds.

Vacuum-Assisted Closure
Used for healing both acute and chronic wounds. Continuous negative
pressure is distributed over the wound surface. The system consists of a
soft sponge cut to fit and occupy the volume of the wound, a plastic tube
imbedded in the center of the sponge and extending out of the wound to a
controlled suction pump, and a gas- and fluid-impermeable plastic outer
film that adheres to the back of the sponge and the surrounding normal
skin. Vacuum-assisted closure allows active removal of extracellular
debris (exudate). Soft-tissue defects heal faster when subatmospheric
pressure is applied. Used for wounds resulting from pressure, trauma,
infection, IV extravasation, AV insufficiency, and skin grafting.

Suture Materials
Suture materials can be broadly defined as absorbable and
nonabsorbable. Absorbable sutures can be thought of as temporary and
include plain catgut, chromic catgut, and synthetic materials such as
polyglactin 910 (Vicryl), polyglycolic acid (Dexon), and polyglecaprone
(Monocryl). Left inside the body, these materials are resorbed after a
variable period. Polydioxanone (PDS) is a long-lasting absorbable
suture. Nonabsorbable sutures can be thought of as permanent
unless they are removed; these materials include silk, stainless steel wire,
polypropylene (Prolene), and nylon.

The size of a suture is defined by the number of zeros. The more zeros in
the number, the smaller is the suture. For example, 5-0 suture (00000) is
much smaller than 2-0 (00) suture. Most sutures come prepackaged and
mounted on needles (swaged on). Cutting needles are used for tough
tissues such as skin, and tapered needles are used for more delicate
tissues such as intestine. The most common needle for skin closure is the
3/8-circle cutting needle.

Suturing Procedure
The following guidelines cover repair of lacerations in the emergency setting.
Similar principles hold true for closure of wounds in the OR. The choice of
suture material is based on many factors, including location, extent of the
laceration, strength of the tissues, and preference of the physician.

Face: 5-0 or 6-0 nylon or polypropylene when appearance is important

Scalp: 3-0 nylon or polypropylene

Trunk and extremities: 4-0 or 5-0 nylon or polypropylene

Use 3-0 and 4-0 absorbable sutures such as Dexon or Vicryl to

approximate deep tissues. Close skin with interrupted sutures placed with
good approximation and minimal tension or with a running subcuticular
suture. Use tissue adhesives selectively (seeTissue Adhesives). Suture
patterns are discussed in the next section. Suture marks (tracks) are the
result of excessive tension on the tissue or leaving the sutures in too long.
In most cases the length of time and the technique used are more
important in determining the final result than is the type of suture used.

1. Remove all foreign materials and devitalized tissues by sharp excision

(debridement). Clean the wound with plain saline solution (avoid
antiseptic solutions for wound cleansing because they can be toxic to
viable cells). A useful technique involves irrigation with at least 200 mL
of saline through a 35-mL syringe and a 19-gauge needle. Anesthesia

may be necessary before any of these steps. If all the debris is not
removed, traumatic tattooing of the skin can result.

2. Obtain a surgical consultation before suturing infected or contaminated

wounds, lacerations more than 612 h old (24 h on the face), missile
wounds, and human or animal bites.

3. Anesthetize the wound by infiltrating it with an agent such as 0.5% or

1%lidocaine (Xylocaine). The maximum safe dose is 4.5 mg/kg (about
28 mL of a 1% solution in an adult). Lidocaine and other local anesthetic
agents are available with epinephrine(1:100,000 or 1:200,000) added to
produce local vasoconstriction that prolongs the anesthetic effect and
helps decrease systemic side effects and bleeding. Use epinephrine with
caution, particularly in treatment of patients with a history of
hypertension, and do not used epinephrine on the fingers, toes, or penis.
One milliliter of 1:10 NaHCO3 can be mixed with 9 mL of lidocaine to
help minimize the discomfort of the injection. Commonly used local
anesthetics are compared in Table 173.

4. When using local anesthetics, always aspirate before injecting to

prevent intravascular injection of the drug. Anesthetize with a 26- to 30gauge needle. Symptoms of toxicity from local anesthetics include
twitching, restlessness, drowsiness, light-headedness, and seizures.

5. Close the wound using one of the suturing patterns discussed in the next
section. To decrease trauma, use a fine-toothed forceps (Adson or
BrownAdson) with gentle pressure to handle the skin edges. A toothed
forceps is less damaging to the skin than other forceps with flat surfaces
that can crush the tissue.

6. Cover the wound and keep it dry for at least 2448 h. Dry gauze or
Steri-Strips are sufficient. On the face, simply cover the wound with
antibiotic ointment, especially around the eyes and mouth. After that

time, epithelialization is complete in healthy patients with uninfected

wounds, and the patient may shower and wet the wound without
increasing the risk of infection.

7. Address tetanus and antibacterial prophylaxis, particularly for

contaminated wounds (Table 174).

Suturing Patterns
Opinions vary greatly on the ideal technique for skin closure. The
following are the common techniques of skin approximation. Critical to

any suturing technique is making certain that the edges of the wound
closely approximate without overlapping or inversion and that there is no
tension. Remember approximation without strangulation or eversion of
the skin edges gives the best results (Figure 171). Figures 17-2, 173,17-4, 17-5, and 17-6 illustrate the commonly used suturing patterns.
These include simple interrupted suture (Figure 172), running (locked or
unlocked) suture (Figure 173), vertical mattress suture (Figure 174),
horizontal mattress suture (Figure 175), and subcuticular suture (Figure
176).

Surgical Knots
There are three basic knot-tying techniques: one-handed and two-handed
ties and the instrument tie. The most advanced knot-tying technique is a
one-handed tie, not recommended for medical students or junior
residents. Although one-handed ties can be more useful in certain
situations (eg, deep cavities or need for speed), the two-handed tie is
easier to learn. Instrument ties are more useful for closing skin and for
emergency department laceration repair. Figure 177 shows the
technique for tying a two-handed square knot, the standard surgical knot
that should be learned first. Figure 178 shows the technique for a onehanded tie. Figure 179 shows the technique for an instrument tie.

Fig.17 -7 Technique for tying two-handed square knot. Suture ends are uncrossed as
step A begins. Hands must be crossed at the end of the first loop tie (step F) to give a
flat knot; hands are not crossed at the end of the second loop tie (step J).

Fig 17-8 One-handed tie. The right hand sets up the loop and manipulates the working
strand.

Fig 17 -9 The instrument tie. Begin with either a single or double (illustrated) looping of
the lower end of the suture around the needle holder. The first loop is laid flat without
crossing the hands. Hands must be crossed after the second loop tie (step G) to
produce a flat square knot.

Suture Removal
The longer a permanent suture material is left in place in the skin, the
more scarring it produces. Using a topical antibiotic ointment (eg,
Polysporin) on the wound is helpful in decreasing suture tract
epithelialization. Epithelialization results from crusting around the suture
that increases suture marks and subsequent scarring. Sutures can be
safely removed when a wound has developed sufficient tensile strength.
Situations vary greatly, but general guidelines for removing sutures from
different areas of the body are as follows: face and neck, 35 d; scalp and
body, 57 d; extremities, 712 d. Any suture material or skin clips can be
removed earlier if they have been reinforced with a deep absorbable
suture or with application of Steri-Strips after the suture is removed. SteriStrips stay in place more securely if tincture of benzoin(spray or solution)
is applied to the skin and allowed to dry before the Steri-Strips are
applied. The length of time absorbable sutures remain in tissues is shown
in Table 171.

Suture Removal Procedure

1. Gently clear away any dried blood with saline solution and
gauze. Verify that the wound is sufficiently healed to allow suture

removal. Use a forceps to gently elevate the knot off the skin. This
step can be uncomfortable for the patient.

2. Cut the suture as close to the skin as possible so that a minimal

amount of dirty suture is dragged through the wound. When
removing continuous sutures, cut and pull out each section
individually. Never pull a knot through the skin. Often the suture
material is pulled tight to the skin, and it is difficult to remove the
stitch with thick scissors. A no. 11 scalpel with the blade pointed
up is helpful in this situation.

3. Use of skin staples is commonplace in the OR because of the

rapidity of closure and the nonreactive nature of the steel staples.
Staples are typically removed 35 d after surgery (abdominal
incisions) as shown in Figure 1710. Because staples are
removed fairly quickly, reinforce the incision with Steri-Strips
andbenzoin. When removing skin staples, make sure that the
staple is completely reformed (see Figure 1710) before pulling it
out of the skin to decrease patient discomfort. Before removal,
verify that the wound is epithelialized and that there is no sign of
infection or wound leakage. If the wound gaps or if a discharge
appears as the staples are removed, stop the removal procedure
and ask a senior physician to evaluate the wound.

Tissue Adhesives
Octyl cyanoacrylate (Dermabond) and n-butyl-2-cyanoacrylate (Indermil)
are topical skin adhesives similar to cyanoacrylate glue that hold wound
edges together. These substances are useful in closure of topical skin
incisions and lacerations in areas of low skin tension that are simple,
thoroughly cleansed, and have easily approximated skin edges.
Adhesives can be used in conjunction with, but not in place of, deep
dermal stitches. They are particularly useful in treatment of young
children, for whom suture removal may be a problem. The wound should
be nonmucosal on the face, torso, or extremity. Adhesives are
recommended for wounds < 8 cm with minimal tension (skin gap < 0.5
cm) and for stabilizing wounds after early suture removal to minimize

suture marks. Do not use tissue adhesives for puncture wounds, bites, or
wounds that need debridement or in anatomic regions subjected to
frequent movement (eg, joints). The patient may shower for brief periods
with this type of closure.

1. Gently approximate the wound edges with fingers or a forceps

and place a small coating of the glue directly on the wound.
Dermabond has a direct-contact applicator tip; Indermil has a
noncontact applicator tip.

2. Wait 23 min for the glue to dry, and apply an additional one or
two coats if needed. The glue sheds in 510 d.

3. Once the glue is in place and stable, it is not necessary to use

topical medication or ointment. If the adhesive remains tacky, too
much glue has been applied.