Closure of Minor Skin Wounds With Sutures - UpToDate

24/8/2019 Closure of minor skin wounds with sutures - UpToDate
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Cierre de heridas menores de la piel con suturas.

Autor: David M. deLemos, MD
Editores de sección: Anne M Stack, MD, Allan B Wolfson, MD
Subdirector: James F Wiley, II, MD, MPH
Todos los temas se actualizan a medida que hay nuevas pruebas disponibles y nuestro proceso de revisión por pares está
completo.
Revisión de literatura actualizada hasta: julio de 2019. | Última actualización de este tema: 28 de junio de 2018.
INTRODUCCIÓN La
reparación de la laceración con suturas se discutirá aquí. La información sobre la preparación de

heridas y la irrigación, la anestesia tópica e infiltrativa y el adhesivo tisular y las grapas se encuentran
por separado. (Ver "Preparación e irrigación de heridas menores" y "Uso clínico de anestésicos
tópicos en niños" y "Reparación de heridas menores con adhesivos tisulares (cianoacrilatos)" y "Cierre
de heridas menores de la piel con grapas" .)
ANTECEDENTES
Los principios básicos de la reparación de laceraciones no han cambiado significativamente en el siglo

pasado, pero las opciones terapéuticas ahora disponibles son más innovadoras y rigurosamente
estudiadas. El desarrollo de anestésicos tópicos, adhesivos tisulares y suturas de rápida absorción ha
hecho que el tratamiento de las laceraciones sea menos traumático para el paciente. Además, el uso
de sedación de procedimiento para laceraciones difíciles o para el niño extremadamente ansioso ha
hecho que la experiencia sea más tolerable para el paciente, la familia y el médico. Los objetivos del
tratamiento de la herida son simples: evitar la infección de la herida, ayudar en la hemostasia y
proporcionar una cicatriz estéticamente agradable [ 1]] La mayoría de los estudios ahora se centran
en la naturaleza estética de la cicatrización de heridas en lugar de las tasas de infección, porque las
tasas de infección siguen siendo bajas, independientemente del tratamiento.
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FISIOLOGÍA Y CURACIÓN DE LAS HERIDAS
La epidermis, la dermis, la capa subcutánea y la fascia profunda son las capas de tejido que
preocupan en el cierre de la herida [ 2 ]:
● La epidermis y la dermis están firmemente adheridas y son clínicamente indistinguibles, y juntas

constituyen la piel. La aproximación dérmica proporciona la fuerza y la alineación del cierre de la
piel.
● La capa subcutánea se compone principalmente de tejido adiposo. Las fibras nerviosas, los
vasos sanguíneos y los folículos capilares se encuentran aquí. Aunque esta capa proporciona
poca resistencia a la reparación, las suturas colocadas en la capa subcutánea pueden disminuir
la tensión de la herida y mejorar el resultado cosmético.
● La capa fascial profunda se entremezcla con el músculo y ocasionalmente requiere reparación en

laceraciones profundas.
El proceso de curación de la piel ocurre en varias etapas [ 3 ]:
coagulación
● La comienza inmediatamente después de la lesión. Se produce vasoespasmo, así como
agregación plaquetaria y formación de coágulos fibrosos. Durante la fase inflamatoria, las
enzimas proteolíticas liberadas por los neutrófilos y los macrófagos descomponen el tejido
dañado.
epitelización
● La ocurre en la epidermis, que es la única capa capaz de regenerarse. El puente
completo de la herida ocurre dentro de las 48 horas posteriores a la sutura.
● El crecimiento de nuevos vasos sanguíneos alcanza su punto máximo cuatro días después de la
lesión.
● La formación de colágeno es necesaria para restaurar la resistencia a la tensión de la herida. El

proceso comienza dentro de las 48 horas posteriores a la lesión y alcanza su punto máximo en la
primera semana. La producción y la remodelación de colágeno continúan hasta por 12 meses.
● La contracción de la herida ocurre tres o cuatro días después de la lesión, y el proceso no se

comprende bien. El grosor completo de la herida se mueve hacia el centro de la herida, lo que
puede afectar la apariencia final de la herida.
Las alteraciones sistémicas pueden influir en la cicatrización de heridas. Estos factores del huésped
incluyen insuficiencia renal, diabetes mellitus, estado nutricional, obesidad, agentes
quimioterapéuticos, corticosteroides y fármacos anticoagulantes o antiagregantes plaquetarios. Los
trastornos de la síntesis de colágeno, como el síndrome de Ehlers-Danlos y el síndrome de Marfan,
también pueden afectar la cicatrización de heridas [ 1 ]. Además, los pacientes de etnia africana o
asiática pueden ser propensos a la formación de cicatrices hipertróficas o queloides. (Consulte
"Preparación e irrigación de heridas menores", sección sobre "Riesgos para un mal resultado" y
"Queloides e cicatrices hipertróficas", sección sobre "Epidemiología" .)
Las alteraciones locales son contribuyentes más comunes a la curación anormal de heridas. Estos
factores incluyen temperatura, isquemia, traumatismo tisular, denervación e infección:
temperatura,
● La el suministro de sangre y la isquemia están interrelacionados. Cuanto mayor es la
temperatura del área anatómica, mayor es el suministro de sangre y el suministro de oxígeno
resultante. La temperatura de la piel de la cara puede ser hasta 9 ° F más cálida que la del pie, lo
que permite que las suturas permanezcan por períodos más cortos y también permite tasas de
infección más bajas. Las diferentes técnicas de sutura pueden contribuir a la isquemia del tejido,
en particular la sutura vertical del colchón. Las suturas verticales del colchón han demostrado en
estudios con animales que causan más isquemia que las suturas interrumpidas continuas o
simples [ 4 ]. (Ver 'Colchón vertical' a continuación).
infección
● La puede ocurrir en cualquier herida traumática, y todas las heridas agudas están
contaminadas hasta cierto punto. Una infección ocurre cuando hay un desequilibrio entre la
resistencia del huésped (sistémica o local) y el inóculo bacteriano. El mecanismo de la lesión y el
tiempo desde la lesión hasta la posible reparación son consideraciones importantes. Las lesiones
por aplastamiento pueden causar necrosis celular extensa y tasas de infección más altas que las
lesiones por corte debido a la mayor energía distribuida en un área más grande [ 4 ]. Una lesión
muy contaminada con tierra, grava u otros desechos también tiene un mayor riesgo de infección.
El período de tiempo entre la lesión y la evaluación también afecta el riesgo de infección.
(Consulte "Preparación e irrigación de heridas menores", sección "Edad de la lesión" ).
EVALUACIÓN DE LA HERIDA
El tratamiento de las laceraciones menores comienza con la evaluación y preparación de la herida. La

evaluación de la herida incluye:
● Determinación del mecanismo de la lesión.

● Edad de la lesión.
● Identificación de posibles contaminaciones o cuerpos extraños.
● Evaluación de la extensión de la herida.
● Evaluación de compromiso neurovascular o lesión del tendón en el área circundante.
● Necesidad de profilaxis antitetánica ( tabla 1 )
● Identificación de los factores de riesgo que pueden afectar la curación.

Estos temas se discuten en detalle por separado. (Ver "Preparación de heridas menores e irrigación",
sección "Evaluación" y "Tétanos" .)
INDICACIONES
Las suturas son apropiadas cuando la profundidad de la herida conducirá a un exceso de cicatrización
si los bordes de la herida no se oponen adecuadamente. Por lo general, esto es cierto cuando la
laceración se extiende a través de la dermis. La tabla describe aspectos clave de las heridas que
afectan la selección de un método de cierre de la herida (suturas, grapas, adhesivos de tejido o cinta
quirúrgica) ( tabla 2 ). Algunas heridas susceptibles de cierre con suturas pueden tratarse mejor con
una técnica alternativa. Por ejemplo, las grapas se usan con frecuencia para heridas del cuero
cabelludo y para heridas en regiones no cosméticas, especialmente cuando son lineales y> 5 cm
porque permiten un cierre más rápido. Las heridas <5 cm que no están bajo tensión pueden cerrarse
con adhesivos de tejido que evitan el dolor de la sutura.
Las laceraciones limpias y no infectadas en cualquier parte del cuerpo en pacientes sanos pueden
cerrarse principalmente hasta 18 horas después de la lesión sin un aumento significativo en el riesgo
de infección de la herida [ 1 ]. Las heridas faciales pueden cerrarse principalmente hasta 24 horas
después de la lesión. En casos seleccionados, el cierre de heridas faciales puede ocurrir hasta 48 a
72 horas después de la lesión si no hay signos de infección, el paciente no tiene factores de riesgo de
infección y los bordes de la herida se pueden aproximar fácilmente.
CONTRAINDICACIONES La
preocupación por la infección de la herida es la razón principal para no cerrar una herida
principalmente [ 1 ]. Las heridas que han sido gravemente contaminadas con desechos extraños que
no pueden eliminarse por completo, el tejido infectado o las heridas no cosméticas que han acudido a
la atención médica tarde deben curarse por granulación (intención secundaria) después de una
limpieza adecuada. Además, los pacientes con factores de riesgo para la curación adecuada de la
herida (p. Ej., Inmunocompromiso, enfermedad arterial periférica, diabetes mellitus) pueden justificar
el cierre primario retrasado dependiendo de la edad de la herida (p. Ej.,> 18 horas de edad) o del sitio
de la herida (p. Ej., Manos o pies). (Ver "Principios básicos de curación de heridas" .)
Otras situaciones en las que el cierre con suturas puede no ser apropiado incluyen (ver "Preparación
menor de heridas e irrigación", sección "Tipo de cierre" ):
● Mordeduras de animales, especialmente en áreas no cosméticas (p. Ej., Manos, pies) (ver
"Mordeduras de animales (perros, gatos y otros animales): Evaluación y manejo", sección sobre

"Cierre" y "Mordeduras humanas: Evaluación y manejo", sección sobre 'Cierre' )
● Heridas punzantes profundas en las que no puede producirse un riego efectivo.
● Heridas en las cuales la sutura causará demasiada tensión a través de la línea de sutura. En este
caso, la curación por segunda intención con una revisión posterior de la cicatriz puede ser un
mejor enfoque
● Heridas que sangran activamente, especialmente si la fuente es arterial (con la excepción de las
heridas del cuero cabelludo). El clínico debe establecer la hemostasia para que un hematoma
subcutáneo no se acumule y cree un posible nido para la infección, además de impedir la
curación adecuada.
● Heridas superficiales que se espera que sanen sin cicatrices significativas, como laceraciones o
abrasiones que solo afectan a la epidermis. La sutura en estas heridas puede causar una mayor
formación de cicatrices y riesgo de infección.
PREPARACIÓN DE HERIDAS
La irrigación de heridas, la extracción de cuerpos extraños y el desbridamiento de tejidos necróticos

son las principales medidas preventivas contra la infección de tejidos. (Ver "Preparación de heridas
menores e irrigación", sección sobre 'Riego' ).
Los limpiadores tensioactivos, como el tensioactivo no iónico poloxamer 188 (ShurClens), también son
seguros y útiles para la descontaminación de heridas. No poseen actividad antibacteriana, pero
disminuyen el trauma mecánico del lavado al tiempo que reducen la carga bacteriana y la incidencia
de infección. Una esponja de alta porosidad (Optipore) se usa generalmente en conjunto para limitar
el trauma local [ 1 ]. Este sistema es ideal para fregar grandes áreas de superficie como "erupción en
la carretera" o quemaduras.
Muchos consideran que el desbridamiento es igual o más importante que el riego en el tratamiento de
la herida contaminada. (Ver "Preparación de heridas menores e irrigación", sección sobre
'Desbridamiento' ).
MATERIALES SUTUROS
Terminología : se utilizan varios términos para describir las propiedades de varios tipos de suturas.
● La configuración física de una sutura describe si es monofilamento (Prolene o Ethilon) o

multifilamento (seda). Las suturas multifilamentosas vienen en tipos trenzados y retorcidos. Los

tipos trenzados son generalmente más fáciles de manejar y atar, pero pueden albergar bacterias
entre las hebras y causar tasas de infección más altas.
resistencia
● La a la tracción se define como la cantidad de peso requerida para romper una sutura
dividida por su área de sección transversal. La designación para la resistencia de sutura es el
número de ceros. Cuanto mayor sea el número de ceros (1-0 a 10-0), menor será el tamaño y
menor será la fuerza.
● La resistencia del nudo es la medida de la cantidad de fuerza requerida para hacer que un nudo
se deslice y es directamente proporcional al coeficiente de fricción para un material dado.
elasticidad
● La se refiere a la capacidad intrínseca de la sutura para mantener su forma y longitud
originales después de estirarse. Esto permite que la sutura se expanda con edema de la herida o
retraiga y mantenga la aposición del borde de la herida durante la contracción de la herida. La
plasticidad se refiere a un material que, cuando se estira, no vuelve a la longitud original.
memoria
● La está estrechamente relacionada con la plasticidad y la elasticidad. Se refiere a la
capacidad inherente de un material para volver a su forma anterior después de ser manipulado, y
a menudo es un reflejo de su rigidez. Una sutura con un alto nivel de memoria es más rígida, más
difícil de manejar y más susceptible de desatarse que una sutura con poca memoria. El
polipropileno (Prolene) es un buen ejemplo de sutura con un alto nivel de memoria [ 5 ].
Suturas absorbibles : una sutura absorbible generalmente se define como aquella que perderá la
mayor parte de su resistencia a la tracción dentro de los 60 días posteriores a la implantación debajo
de la superficie de la piel [ 6 ]. Las más utilizadas actualmente son las suturas sintéticas (poliglactina
910 [Vicryl], ácido poliglicólico [Dexon], polidioxanona [PDS] y carbonato de politrimetileno [Maxon]) (
tabla 3 ). Catgut todavía se usa con frecuencia en cierres de heridas pediátricas. Fast Absorbing Gut
es ideal para cierres faciales percutáneos y Vicryl Rapide puede usarse para reparar laceraciones
debajo de férulas o yesos.
La sutura absorbible ideal tiene baja reactividad tisular, alta resistencia a la tracción, tasas de
absorción lentas y seguridad confiable en el nudo. Clásicamente, las suturas absorbibles solo se
usaban para suturas profundas. Sin embargo, muchos han abogado por el uso de suturas absorbibles
para el cierre percutáneo de heridas en adultos y niños [ 7-10 ]:
● El intestino de absorción rápida para el cierre percutáneo de algunas laceraciones faciales es

razonable, particularmente si la extracción de suturas será traumática. Las suturas subcutáneas
con una sutura absorbible sintética pueden mejorar la tensión de la herida y proporcionar apoyo a
la herida curativa una vez que el intestino se haya disuelto.

● Vicryl Rapide o Chromic Gut es ideal para el cierre percutáneo de laceraciones debajo de yesos o
férulas, pero está limitado para uso facial debido a sus tiempos de absorción más largos.
● El intestino crómico o Vicryl funciona bien para el cierre individual o en capas de laceraciones de
la lengua o la mucosa oral.
● Vicryl o Monocryl es ideal para el cierre dérmico de laceraciones faciales profundas.
● Elcierre del lecho ungueal se realiza mejor con tripa crómica o Vicryl.
Catgut - Catgut es un producto natural derivado de la íntima ovina o bovina. El catgut simple
retiene una resistencia a la tracción significativa durante solo cinco a siete días. El intestino crómico
se trata con sales de cromo para resistir las enzimas del cuerpo, lo que retrasa el tiempo de
absorción. El intestino crómico retiene la resistencia a la tracción durante 10 a 14 días [ 5 ].
El uso principal del intestino crómico es cerrar las laceraciones en la mucosa oral. El intestino crómico
se absorbe más rápidamente en la cavidad oral que la mayoría de las suturas sintéticas, lo que lo
hace ideal para este entorno. Chromic Gut también se usa en nuestra institución para el cierre de la
piel en laceraciones de la punta de los dedos con o sin lesiones concurrentes en el lecho ungueal. Es
menos óptimo para su uso en cierres dérmicos (subcutáneos) y de la capa muscular debido al
aumento de la reactividad tisular [ 11 ].
El intestino de absorción rápida es un material más nuevo que no se trata con sales crómicas. Está
tratada térmicamente para acelerar la pérdida de resistencia a la tracción y la absorción. Se utiliza
principalmente para la sutura epidérmica, donde las suturas solo se requieren durante cinco a siete
días [ 12 ]. El uso de esta sutura de rápida absorción se estudió en 654 heridas durante los
procedimientos de cirugía plástica. La sutura se disolvió adecuadamente en la mayoría de los casos
durante las visitas de seguimiento a los cuatro o seis días [ 8] La tripa de absorción rápida es ideal
para suturar laceraciones faciales cuando no se pueden usar adhesivos tisulares o la extracción de la
sutura será difícil. Sin embargo, se debe tener cuidado de ser suave con los nudos de amarre cuando
se utiliza el intestino de absorción rápida más pequeño (6-0), debido a su baja resistencia a la
tracción. Es razonable reforzar esta sutura con cintas de piel. El uso del intestino de absorción rápida
5-0 es razonable para los cierres faciales debido a la resistencia a la tracción mejorada.
Poliglactina 910 (Vicryl) - Vicryl es un material sintético trenzado lubricado con excelente manejo
y propiedades de amarre suave. Conserva una resistencia a la tracción significativa durante tres o
cuatro semanas. La absorción completa ocurre en 60 a 90 días. Ha disminuido la reactividad del tejido
en comparación con catgut, así como una mejor resistencia a la tracción y resistencia al nudo [ 5 ].
Vicryl es una opción ideal para suturas subcutáneas.

Vicryl Rapide : Vicryl Rapide tiene propiedades similares a las del intestino de rápida
absorción. Es la sutura sintética de absorción más rápida y está indicada solo para su uso en la
aproximación superficial de tejidos blandos de la piel y la mucosa. Toda su resistencia a la tracción se
pierde en 10 a 14 días, y la sutura comienza a "caerse" en 7 a 10 días a medida que la herida se cura.
Es ideal para el cierre de la piel en pacientes en los que la extracción de suturas sería difícil o para el
cierre de laceraciones bajo yesos [ 12 ]. El mayor tiempo de absorción puede limitar su utilidad en
algunos cierres faciales.
Vicryl Rapide se ha propuesto como una alternativa a las suturas no absorbibles para ciertos sitios de
laceración. Como ejemplo, en un pequeño ensayo que comparó Vicryl Rapide con suturas de
polipropileno en 73 pacientes con laceraciones en el tronco o las extremidades, Vicryl Rapide tuvo
resultados cosméticos similares [ 13] Sin embargo, las tasas de infección y el seguimiento del tren
(cicatrización perpendicular al borde de la herida) fueron más altas en los pacientes que se
sometieron a cierre con Vicryl Rapide en comparación con la sutura no absorbible (tasa de infección
11 versus 3 por ciento, respectivamente; tasa de seguimiento del tren 17 versus 8 por ciento,
respectivamente) aunque el tamaño de la muestra era demasiado pequeño para mostrar significación
estadística para estos hallazgos. Por lo tanto, Vicryl Rapide puede estar asociado con más
complicaciones cuando se usa para el cierre de laceraciones de tronco o extremidades y se necesitan
más estudios para determinar si es una opción de sutura adecuada para el cierre de estas heridas.
Poliglecaprone 25 (Monocryl) — Monocryl is a monofilament suture that has superior pliability for
easier handling and tying of knots. Its monofilament quality gives it a theoretical advantage over
braided sutures for contaminated wounds requiring deep sutures. This suture is often used by plastic
surgeons at our institution for facial lacerations closed with subcuticular running sutures. All of its
tensile strength is lost by 21 days postimplantation [12].
Polyglycolic acid (Dexon) — Polyglycolic acid was the first synthetic absorbable suture to become
available. It is a braided polymer, is less reactive than gut sutures, and has excellent knot security. It
maintains at least 50 percent of its tensile strength for 25 days [14]. The main drawback is a high
friction coefficient causing "binding and snagging" when wet. Newer forms of this suture have been
developed, Dexon Plus and Dexon II, which have an added synthetic coating to improve handling
properties while maintaining knot security [5].
Polydioxanone (PDS) — PDS is a synthetic monofilament polymer marketed as having improved

tensile strength compared with Vicryl. It retains the majority of its tensile strength at five to six weeks.
Because it is a monofilament, it has the theoretical advantage of creating a lower potential for infection.
In addition, it appears to have a lower friction coefficient and better knot security than Vicryl [15]. A
disadvantage of using PDS is that it is more difficult to use than the braided synthetics because of
intrinsic stiffness. In addition, it costs about 14 percent more than either Dexon or Vicryl [5].

Polytrimethylene carbonate (Maxon) — Maxon is a synthetic monofilament. It was developed to

combine the excellent tensile strength of PDS with improved handling properties. The majority of its
tensile strength is present at five to six weeks. It has minimal tissue reactivity, excellent first-throw
holding capacity, and smoother knot tie-down than Vicryl. The only disadvantage is the approximate 7
percent increased cost compared with Vicryl or Dexon [5].
Nonabsorbable sutures — Knot security, tensile strength, tissue reactivity, and workability of the
various nonabsorbable sutures used for skin closure are provided in the table (table 4).
● Silk – Silk is a natural product that is renowned for its ease to handle and tie. It has the lowest
tensile strength of any nonabsorbable suture. It is rarely used for suturing of minor wounds
because stronger synthetic materials are now available. However, it is frequently employed to
secure percutaneous central lines, chest tubes, and other similar cannulas.
● Nylon (Dermalon, Ethilon) – Nylon was the first synthetic suture introduced; it is popular due to
its high tensile strength, excellent elastic properties, minimal tissue reactivity, and low cost. Its
main disadvantage is prominent memory that requires an increased number of knot throws (three
to four) to hold a suture in place [14].
● Polypropylene (Surgilene, Prolene) – Polypropylene is a plastic, synthetic suture that has low
tissue reactivity and high tensile strength similar to nylon. It is slippery and requires extra throws to
secure the knot (four to five). Prolene is especially noted for its plasticity, allowing the suture to
stretch to accommodate wound swelling. When wound swelling recedes, the suture will remain
loose. The cost of Prolene is approximately 13 percent more than nylon [5]. Prolene can be
purchased in a blue color, which can be advantageous in localizing sutures in the scalp and dark-
skinned individuals.
● Polybutester (Novafil) – Polybutester suture is composed of a monofilament synthetic copolymer

with tensile strength and healing properties similar to nylon and polypropylene [16]. Polybutester
also handles well but has greater elasticity than either nylon or polypropylene. Its use may be
associated with decreased potential for suture marks because of its ability to expand if wound
edema occurs [17].
SUTURE SELECTION
In a metaanalysis of 19 trials (1748 patients) comparing the efficacy of nonabsorbable sutures with
absorbable sutures for skin closure of surgical and traumatic lacerations, absorbable and
nonabsorbable sutures had equivalent cosmetic outcomes and no significant difference for wound

infection or wound dehiscence although follow-up was insufficient in several studies [18]. Thus, the
type of suture material should be individualized for patients based upon clinician discretion.
NEEDLES
Choosing the proper needle can be confusing because of varying nomenclature. The two most
prominent manufacturers of suture, Ethicon and Davis and Geck, use different nomenclature for their
needles [5]. The basic anatomy of a needle remains the same, however:
● The eye is the end of the needle attached to the suture. All sutures used for acute wound repair
are swaged (ie, the needle and suture are connected as a continuous unit).
● The body of the needle is the portion that is grasped by the needle holder during the procedure.
The body determines the shape of the needle and is curved for cutaneous suturing. The curvature
may be one-fourth, three-eighths, one-half, or five-eighths circle. The most commonly used
curvature is the three-eighths circle, requiring only minimal pronation of the wrist for large and
superficial wounds. The one-half and five-eighths circles were devised for suturing in confined
spaces, such as the oral cavity.
● The point of the needle extends from the extreme tip to the maximum cross section of body. For
soft tissue and fascia, the taper needle, round in cross section, is ideal.
Needle points are also available in cutting, conventional cutting, or reverse cutting form:
● Cutting – Cutting needles have at least two opposing cutting edges. Cutting needles are ideal for
skin sutures that must pass through dense, irregular, and relatively thick dermal connective tissue.
● Conventional cutting – Conventional cutting needles have a third cutting edge on the inside
concave curvature of the needle. This needle type may be prone to cutout of tissue because the
inside cutting edge cuts toward the edges of the incision or wound.
● Reverse cutting – Reverse cutting needles have a third cutting edge located on the outer convex
curvature of the needle, which theoretically reduces the danger of tissue cutout [12]. Reverse
cutting needles should be used for thick skin like the palm and soles.
Standard skin needles (FS series, CE series) are suitable for the scalp, trunk, and extremities. Finer
sutures on the face require a smaller and more sharply honed needle (P, PS, PC, and PRE series) [2].
SUTURING TECHNIQUES
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Percutaneous skin closure — The simple interrupted suture is used to close most uncomplicated
wounds. For proper healing, the edges of the wound must be everted. This is best accomplished using
the following technique (figure 1 and figure 2):
● The needle should penetrate the skin surface at a 90 degree angle.
● The suture loop should be at least as wide at the base as it is at the skin surface.
● The width and depth of the suture loop should be the same on both sides of the wound.
● The width and depth of the suture loop should be similar to the thickness of the dermis and will
therefore differ from wound to wound, according to the anatomic location.
The number of sutures needed to close a wound varies depending upon the length, shape, and
location of the laceration. In general, sutures are placed just far enough from each other so that no gap
appears in the wound edges. A useful guideline is that the distance between sutures is equal to the
bite distance from the wound edge [14].
Dermal closure — Dermal closure is typically used when wounds are deep such that closing the
cutaneous layer will leave significant dead space with the potential for hematoma or abscess formation
or when the wound is gaping and approximation of the dermis permits less tension at the skin level.
The dermal or buried suture approximates the dermis just below the dermal-epidermal junction,
thereby improving the cosmetic result in both situations.
Absorbable suture material must be used for dermal or buried sutures. The knot should be buried
away from the skin surface of the wound so that it will not interfere with epidermal healing. This can be
accomplished by inverting the suture loop using the following technique (figure 3):
● The needle should be inserted in the dermis and directed toward the skin surface, exiting near the
dermal-epidermal junction on the same side.
● The needle should then be inserted on the opposite side of the wound near the dermal-epidermal
junction, directly across from the point of exit.
● The suture loop should be completed in the dermis, directly opposite the origin of the loop, and the
knot tied.
Dermal sutures do not increase the risk of infection in clean, uncontaminated lacerations [19].
However, animal studies suggest that deep sutures should be avoided in highly contaminated wounds
[20]. There should be no more than three knots per suture and the fewest number of sutures possible
should be placed.
Alternative suture techniques

Running suture — A running suture is used for rapid percutaneous closure of longer wounds. It
provides even distribution of tension along the length of the wound, preventing excess tightness in any
one area. This technique is best reserved for wounds at low risk of infection with edges that align
easily.
The closure is started with the standard technique of a percutaneous simple interrupted suture, but the
suture is not cut after the initial knot is tied. The needle is then used to make repeated bites, starting at
the original knot by making each new bite through the skin at an angle of 45 degrees to the wound
direction. The cross stays on the surface of the skin will be at an angle of 90 degrees to the wound
direction. The final bite is made at an angle of 90 degrees to the wound direction to bring the suture
out next to the previous bite. The final bite is left in a loose loop, which acts as a free end for tying the
knot. A disadvantage to this suture is if the stitch breaks or if the physician wants to remove only a few
sutures at a time [14].
Subcuticular running suture — The subcuticular running suture is often used by plastic surgeons
to close straight lacerations on the face. An absorbable suture, such as Monocryl or Vicryl, is used.
The suture is anchored at one end of the laceration and then a plane is chosen in the dermis or just
deep to the dermis in the superficial subcutaneous fascia (figure 4). Mirror image bites are taken
horizontally in this plane for the full length of the laceration. The final bite leaves a trailing loop of
suture so a final knot can be tied. The wound is then reinforced with adhesive tape [14].
Vertical mattress — The vertical mattress suture is recommended for wounds under tension and
for those with edges that tend to invert (fall or fold into the wound) [21,22]. It acts as a deep and
superficial closure all in one suture. The first portion of the suture loop (far-far) approximates the
dermal structures. The second portion (near-near) closes the wound and everts the edges.
A vertical mattress suture is traditionally placed using the following technique (figure 5) [14]:
● The needle is initially inserted at a distance from the wound edge, crossing through the dermal
tissue and exiting through the skin on the opposite side at an equal distance from the wound
edge. This is the far-far portion.
● The needle is then rotated 180 degrees in the needle holder and the direction of the suture loop is
reversed (backhanded).
● On the return, small bites are taken at the epidermal/dermal edges, which become approximated
when the knot is tied. This near-near portion of the suture loop closes and everts the edges of the
wound.
Alternatively, in the shorthand vertical mattress technique, the small backhand bites at the wound
edges are completed first, followed by the deeper, wider forehand bites. In one trial that compared

repair time and wound healing for patients randomized to receive either the traditional or the shorthand
technique, wounds were repaired in one-half the time using the shorthand technique [23]. There was
no difference between the two groups with respect to wound healing.
Horizontal mattress — A horizontal mattress suture can also be used to achieve wound eversion
in areas of high skin tension [21,22]. The needle is introduced into the skin in the usual manner and
brought out on the opposite side of the wound (figure 6). A second bite is taken along the opposite
side, approximately 0.5 cm from the first exit site, and is brought back to the original starting side, also
0.5 cm from the initial entry point.
The half-buried horizontal mattress suture combines elements of the horizontal mattress suture with a
dermal closure. It can be used to approximate the corner of a flap (figure 7) [14]. The needle is
introduced through the skin in the portion of the wound that does not include the flap. In the dermal (or
buried) portion of the suture, the corner of the flap is picked up horizontally through the dermis. The
suture loop is completed by bringing the needle out through the skin on the opposite side of the
nonflap portion. The knot is tied on the nonflap portion of the wound.
SPECIFIC WOUND SITES
● Lip – It is especially critical that lip lacerations are repaired correctly to preserve the cosmetic
appearance and functionality of the lip. The assessment and management of lip lacerations is
covered in greater detail separately. (See "Assessment and management of lip lacerations".)
● Tongue and intraoral – The decision whether or not to repair a tongue or intraoral laceration
depends upon the extent of the laceration and the risk of compromised function after healing, but
evidence suggests that outcomes for most of these lacerations are not improved by suturing. A
more in-depth discussion of the indications and technique for repair of tongue and intraoral
lacerations is found separately. (See "Evaluation and repair of tongue lacerations" and
"Assessment and management of intra-oral lacerations".)
● Scalp – The assessment and management of scalp wounds are discussed in detail separately.
(See "Assessment and management of scalp lacerations".)
● Eyebrow – The eyebrow should never be shaved, because regrowth of the hair is unpredictable.
Debridement and excision of the wound should be conservative and parallel to the direction of hair
follicle growth. The eyebrow is of major cosmetic significance and the wound edges should be
carefully approximated. Closure of eyebrow lacerations is described in more detail separately.
(See "Assessment and management of facial lacerations", section on 'Eyebrow'.)

● Eyelids – Assessment and management of eyelid lacerations are discussed in detail separately.
(See "Eyelid lacerations".)
● Cheek (zygoma) – Deep lacerations to the cheek, just anterior to the ear, have the potential to
injure the parotid gland or the facial nerve (figure 8). If the parotid gland is injured, bloody fluid can
be seen leaking from the parotid duct via the buccal mucosa at the level of the maxillary second
molar.
Closure of cheek lacerations is discussed in more detail separately. (See "Assessment and
management of facial lacerations", section on 'Cheek'.)
● Ear – Wound closure on the ear can proceed in standard fashion when the cartilage is not
involved. The cartilage should not be sutured if at all possible because of the risk of infection. If
suturing is necessary, the perichondrium must be included in the stitch in order for it to hold. The
goal in repairing a wound with exposed cartilage is to cover it with skin as completely as possible.
The closure of lacerations of the auricle (ear) is covered in greater detail separately. (See
"Assessment and management of auricle (ear) lacerations".)
GUIDELINES FOR SURGICAL CONSULTATION
Consultation with a plastic surgeon or other surgical specialist may be required in some
circumstances:
● Closure of large defects that might be more practical to close in the operating room or that might
require grafting
● Severely contaminated wounds requiring drainage
● Tendon, nerve or vessel damage that requires repair
● Open fractures, amputations, and joint penetrations
● Laceration over the site of a fracture (even if contamination of the fracture site seems unlikely, this
is still technically considered an open fracture)
● Compression between two rollers (eg, washing machine, industrial), which can cause delayed,
extensive soft tissue and muscle damage [14]
● Paint and grease gun injuries, which can initially appear as benign puncture wounds but later
develop widespread tissue injury due to high-pressure injection [14]
● Strong concern about cosmetic outcome by either the patient or family

Lacerations in some areas of the face may also require surgical consultation. (See "Assessment and
management of facial lacerations", section on 'Indications for subspecialty consultation or referral'.)
AFTERCARE
Dressing and bathing — Most wounds should be covered with an antibiotic ointment and a
nonadhesive dressing immediately after laceration repair. Limited evidence from one trial suggests that
antibiotic ointments such as topical bacitracin zinc or combination ointment containing neomycin
sulfate, bacitracin zinc, and polymyxin B sulfate significantly reduce the rates of wound infection when
compared to a petroleum ointment control (5 to 6 percent versus 18 percent, respectively) [24]. Small
crossover trials indicate that occlusion of the wound increases the speed of reepithelialization although
complete healing appears to occur at about the same time when compared to uncovered wounds
[25,26].
A nonadherent sterile gauze (eg, Xeroform) from which most of the grease is wrung, followed by cloth
gauze, is ideal [27]. A simple Band-Aid will suffice for many small lacerations. Scalp wounds can be
left open if small, but large head wounds can be wrapped circumferentially with Kerlix.
The dressing should be left in place for 24 hours, after which time most wounds can be opened to air.
Wounds closed with nonabsorbable (eg, nylon, polypropylene) suture may be gently cleaned with mild
soap and water or half-strength peroxide after 24 hours to prevent crusting over the suture knots. An
antibiotic ointment can be applied to the wound as well, with instructions to apply the ointment two
times per day at home until suture removal. In contrast, absorbable sutures rapidly break down when
exposed to water and should be kept dry.
Patients with nonabsorbable sutures (eg, nylon, polypropylene sutures) may be allowed to shower or
wash the wound with soap and water without risking increased rates of infection or disruption of the
wound based upon the following studies:
● A trial of 857 patients who underwent minor skin excisions found that allowing bathing more than
12 hours after suture placement without antiseptic or dressing use was not inferior to keeping the
wound dry and covered (infection rate 8.4 versus 8.9 percent, respectively) [28].
● An observational study of 100 patients who underwent primary excision of a skin or soft-tissue
lesion or local flap closure and began washing their wounds twice daily within 24 hours of surgery
found no wounds developed infection or dehiscence [29].
Although not well studied, prolonged soaking of nonabsorbable stitches including swimming in
chlorinated water should be avoided because of the theoretical risk of premature loss of suture tensile

strength with wound dehiscence. Patients with sutures should also not swim in natural bodies of water
because of a potential increased risk of infection.
Tetanus prophylaxis — Tetanus prophylaxis should be provided for all wounds as indicated (table 1).
Tetanus prophylaxis for pregnant women depends upon their immunization history and is discussed in
detail separately. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and
pertussis vaccination'.)
Prophylactic antibiotics — Proper wound preparation is the essential measure for preventing wound
infection after suturing simple lacerations. (See "Minor wound preparation and irrigation".)
We recommend that healthy patients with minor wounds, other than bite wounds, who undergo
laceration repair with sutures not be prescribed prophylactic antibiotics. A meta-analysis of seven trials
(1701 total patients with a total of 110 wound infections) found that prophylactic antibiotics in healthy
patients with wounds, other than bite wounds, were not associated with a significantly lower chance of
wound infection (summary odds ratio for the risk of infection in patients receiving antibiotics: 1.2, 95%
CI: 0.8-1.7) [30].
Prophylactic antibiotics may decrease the risk of infection in some animal and human bites, intraoral
lacerations, open fractures, and wounds that extend into cartilage, joints or tendons [31]. In addition,
some experts advocate prophylactic antibiotics in patients with excessive wound contamination (eg,
soil or water contamination), vascular insufficiency (eg, devascularized wound, peripheral artery
disease), or immunocompromise [31]. (See "Soft tissue infections following water exposure", section
on 'Empiric therapy' and "Animal bites (dogs, cats, and other animals): Evaluation and management",
section on 'Antibiotic prophylaxis' and "Human bites: Evaluation and management", section on
'Antibiotic prophylaxis'.)
Suture removal — The timing of suture removal varies with the anatomic site [32]:
● Eyelids – Three days

● Neck – Three to four days
● Face – Five days
● Scalp – 7 to 14 days
● Trunk and upper extremities – Seven days
● Lower extremities – 8 to 10 days
Follow-up visits — Most clean wounds do not need to be seen by a physician until suture removal,
unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 48 to 72
hours. It is imperative that clear discharge instructions are given to every patient regarding signs of
wound infection.

UNIQUE PEDIATRIC CONSIDERATIONS
Anxious parent — A parent is an important advocate for his or her child, and his or her concerns
need to be addressed with patience and understanding. It is inevitable that the clinician will encounter
some parents who demand a plastic surgeon for simple laceration repairs or sedation for a laceration
that easily could be managed with patient distraction and topical and/or injectable anesthetics. The
best approach is to listen first and to suggest reasonable alternatives later. In some instances, there is
no choice but to call a plastic surgeon. At other times, parents will listen to the explanation that the
cosmetic outcome will be no different if repaired by a surgeon in the case of a simple, clean laceration.
At times, it is also an issue of plastic surgeon availability. Often their viewpoint changes when the
parents are truthfully told that it will be two to three hours before a surgeon can see their child.
In cases where a parent demands sedation for a simple laceration, he or she must understand that
sedation has risks that are unnecessary if a reasonable and safe alternative exists. The use of
distraction methods and the use of topical anesthetics should also be explained to the parent. Child life
specialists, if available, can provide invaluable assistance in this scenario. The child life specialist can
adequately distract many patients by reading books with the patient, playing a video, or providing
visual imagery.
Anxious and uncooperative patient — The anxious and uncooperative patient is a challenge that at
times can be managed with similar methods of distraction and imagery, but at other times leaves no
choice but to sedate the patient to repair the laceration. Sedation choices vary depending upon age,
mechanism of injury, and time required for repair and are discussed in detail separately. (See
"Procedural sedation in children outside of the operating room" and "Selection of medications for
pediatric procedural sedation outside of the operating room", section on 'Minimally painful
procedures'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the
world are provided separately. (See "Society guideline links: Minor wound management".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles

are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topic (see "Patient education: Stitches and staples (The Basics)").
SUMMARY AND RECOMMENDATIONS
● The management of minor lacerations begins with assessment and preparation of the wound,
including the need for tetanus prophylaxis (table 1). (See 'Indications' above.)
● Sutures are appropriate when the depth of the wound will lead to excessive scarring if the wound
edges are not properly apposed. Concern about wound infection is the main reason not to close a
wound primarily. (See 'Indications' above and 'Contraindications' above.)
● The use of tissue adhesives and staples for closure of minor wounds, including indications and
contraindications, is discussed separately. (See "Minor wound repair with tissue adhesives
(cyanoacrylates)" and "Closure of minor skin wounds with staples".)
● Wound irrigation, foreign body removal, and necrotic tissue debridement are the main preventative
measures against tissue infection. (See 'Wound preparation' above.)
● Previously, absorbable sutures (table 3) were used only for deep sutures. However, absorbable
sutures are now advocated in some adult and pediatric patients for percutaneous closure of
wounds as an alternative to nonabsorbable sutures (table 4). In particular, fast-absorbing gut is
ideal for skin closure of facial lacerations in patients in whom suture removal would be difficult or
tissue adhesives are not an option. Chromic gut or Vicryl are recommended to close lacerations in
the oral mucosa, and Vicryl Rapide or Chromic Gut is ideal for closure of lacerations under casts
or splints. (See 'Suture materials' above.)
● Cutting needles are ideal for skin sutures that must pass through dense, irregular, and relatively
thick dermal connective tissue. Standard skin needles (FS series, CE series) are suitable for the
scalp, trunk, and extremities. Finer sutures on the face require a smaller and more sharply honed
needle (P, PS, PC, and PRE series). (See 'Needles' above.)

● The simple interrupted suture is the standard technique used for the closure of most
uncomplicated wounds (figure 1 and figure 2). A running suture is used for rapid percutaneous
closure of longer wounds. It is best reserved for wounds at low risk of infection with edges that
align easily. The vertical mattress suture is appropriate for wounds under tension and for wounds
with edges that tend to fall or fold into the wound (figure 5). A horizontal mattress suture can also
be used to achieve wound eversion in areas of high skin tension (figure 6). (See 'Suturing
techniques' above.)
● Most wounds should be covered with an antibiotic ointment and a nonadhesive dressing
immediately after laceration repair. The dressing should be left in place for 24 hours, after which
time most wounds can be left open to the air. (See 'Dressing and bathing' above.)
● Tetanus prophylaxis should be provided for all wounds as indicated (table 1). (See 'Tetanus
prophylaxis' above.)
● We recommend that healthy patients with minor wounds, other than bite wounds, who undergo
laceration repair with sutures not be prescribed prophylactic antibiotics (Grade 1A). (See
'Prophylactic antibiotics' above.)
● The timing of suture removal varies with the anatomic site. (See 'Suture removal' above.)
● Separate topics discuss the assessment and management of minor wound closure of the scalp,
face, and mouth in greater detail. (See "Assessment and management of scalp lacerations" and
"Assessment and management of facial lacerations" and "Assessment and management of intra-
oral lacerations" and "Assessment and management of lip lacerations" and "Assessment and
management of auricle (ear) lacerations" and "Eyelid lacerations" and "Evaluation and repair of
tongue lacerations".)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999; 34:356.
2. Kanegaye JT. A rational approach to the outpatient management of lacerations in pediatric

patients. Curr Probl Pediatr 1998; 28:205.
3. McNamara, RN, Loiselle, J. Laceration repair. In: Textbook of pediatric emergency procedures, H
enretig, F, King, C (Eds), Williams and Wilkins, Baltimore 1997. p.1141.

4. Robson MC. Disturbances of wound healing. Ann Emerg Med 1988; 17:1274.
5. Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg
Oncol 1992; 18:785.
6. Lober CW, Fenske NA. Suture materials for closing the skin and subcutaneous tissues. Aesthetic
Plast Surg 1986; 10:245.
7. Guyuron B, Vaughan C. A comparison of absorbable and nonabsorbable suture materials for

skin repair. Plast Reconstr Surg 1992; 89:234.
8. Webster RC, McCollough EG, Giandello PR, Smith RC. Skin wound approximation with new
absorbable suture material. Arch Otolaryngol 1985; 111:517.
9. Shetty PC, Dicksheet S, Scalea TM. Emergency department repair of hand lacerations using
absorbable vicryl sutures. J Emerg Med 1997; 15:673.
10. Start NJ, Armstrong AM, Robson WJ. The use of chromic catgut in the primary closure of scalp
wounds in children. Arch Emerg Med 1989; 6:216.
11. Andrade MG, Weissman R, Reis SR. Tissue reaction and surface morphology of absorbable
sutures after in vivo exposure. J Mater Sci Mater Med 2006; 17:949.
12. Ethicon wound closure manual, Ethicon, Inc. 1998-2000.
13. Tejani C, Sivitz AB, Rosen MD, et al. A comparison of cosmetic outcomes of lacerations on the
extremities and trunk using absorbable versus nonabsorbable sutures. Acad Emerg Med 2014;
21:637.
14. Lammers RL. Methods of wound closure. In: Clinical Procedures in Emergency Medicine, 5th ed,
Roberts JR, Hedges JR (Eds), Saunders Elsevier, Philadelphia 2010. p.592.
15. Good MM, Good LB, McIntire DD, et al. Surgical knot integrity: effect of suture type and caliber,
and level of residency training. J Surg Educ 2013; 70:156.
16. Bang RL, Mustafa MD. Comparative study of skin wound closure with polybutester (Novafil) and
polypropylene. J R Coll Surg Edinb 1989; 34:205.
17. Rodeheaver GT, Borzelleca DC, Thacker JG, Edlich RF. Unique performance characteristics of
Novafil. Surg Gynecol Obstet 1987; 164:230.
18. Xu B, Xu B, Wang L, et al. Absorbable Versus Nonabsorbable Sutures for Skin Closure: A Meta-
analysis of Randomized Controlled Trials. Ann Plast Surg 2016; 76:598.

19. Austin PE, Dunn KA, Eily-Cofield K, et al. Subcuticular sutures and the rate of inflammation in
noncontaminated wounds. Ann Emerg Med 1995; 25:328.
20. Mehta PH, Dunn KA, Bradfield JF, Austin PE. Contaminated wounds: infection rates with
subcutaneous sutures. Ann Emerg Med 1996; 27:43.
21. Zuber TJ. The mattress sutures: vertical, horizontal, and corner stitch. Am Fam Physician 2002;
66:2231.
22. Lloyd JD, Marque MJ 3rd, Kacprowicz RF. Closure techniques. Emerg Med Clin North Am 2007;
25:73.
23. Jones JS, Gartner M, Drew G, Pack S. The shorthand vertical mattress stitch: evaluation of a
new suture technique. Am J Emerg Med 1993; 11:483.
24. Dire DJ, Coppola M, Dwyer DA, et al. Prospective evaluation of topical antibiotics for preventing
infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med 1995; 2:4.
25. HINMAN CD, MAIBACH H. EFFECT OF AIR EXPOSURE AND OCCLUSION ON

EXPERIMENTAL HUMAN SKIN WOUNDS. Nature 1963; 200:377.
26. Agren MS, Karlsmark T, Hansen JB, Rygaard J. Occlusion versus air exposure on full-thickness
biopsy wounds. J Wound Care 2001; 10:301.
27. Phillips LG, Heggers JP. Layered closure of lacerations. Postgrad Med 1988; 83:142.
28. Heal C, Buettner P, Raasch B, et al. Can sutures get wet? Prospective randomised controlled
trial of wound management in general practice. BMJ 2006; 332:1053.
29. Noe JM, Keller M. Can stitches get wet? Plast Reconstr Surg 1988; 81:82.
30. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis
of randomized studies. Am J Emerg Med 1995; 13:396.
31. Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med
Clin North Am 2003; 21:205.
32. Selbst, SM, Attia, MW. Minor trauma - lacerations. In: Textbook of Pediatric Emergency Medicine,
5th edition, Fleisher, GR, Ludwig, S (Eds), Lippincott Williams and Wilkins, Philadelphia 2006. p.
1571.
Topic 6319 Version 25.0


GRAPHICS
Wound management and tetanus prophylaxis
Clean and minor wound All other wounds ¶

Previous doses
of tetanus Tetanus toxoid-
Human tetanus
Tetanus toxoid-
Human tetanus
toxoid* containing containing
immune globulin immune globulin ◊
vaccine Δ vaccine Δ
<3 doses or unknown Yes § No Yes § Yes
≥3 doses Only if last dose given No Only if last dose given No

≥10 years ago ≥5 years ago ¥
Appropriate tetanus prophylaxis should be administered as soon as possible following a wound but should be given
even to patients who present late for medical attention. This is because the incubation period is quite variable; most
cases occur within 8 days, but the incubation period can be as short as 3 days or as long as 21 days. For patients who
have been vaccinated against tetanus previously but who are not up to date, there is likely to be little benefit in
administering human tetanus immune globulin more than 1 week or so after the injury. However, for patients thought
to be completely unvaccinated, human tetanus immune globulin should be given up to 21 days following the injury; Td
or Tdap should be given concurrently to such patients.
DT: diphtheria-tetanus toxoids adsorbed; DTP/DTwP: diphtheria-tetanus whole-cell pertussis; DTaP: diphtheria-tetanus-
acellular pertussis; Td: tetanus-diphtheria toxoids adsorbed; Tdap: booster tetanus toxoid-reduced diphtheria toxoid-acellular
pertussis; TT: tetanus toxoid.
* Tetanus toxoid may have been administered as DT, DTP/DTwP (no longer available in the United States), DTaP, Td, Tdap, or
TT (no longer available in the United States).
¶ Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; or wounds
resulting from missiles, crushing, burns, or frostbite.
Δ The preferred vaccine preparation depends upon the age and vaccination history of the patient:
<7 years: DTaP.
Underimmunized children ≥7 and <11 years who have not received Tdap previously: Tdap. Children who receive Tdap
between age 7 and 11 years should receive another dose of Tdap at age 11 through 12 years.
≥11 years: A single dose of Tdap is preferred to Td for all individuals in this age group who have not previously received
Tdap. Pregnant women should receive Tdap during each pregnancy.
◊ 250 units intramuscularly at a different site than tetanus toxoid; intravenous immune globulin should be administered if
human tetanus immune globulin is not available. Persons with HIV infection or severe immunodeficiency who have
contaminated wounds should also receive human tetanus immune globulin, regardless of their history of tetanus immunization.
§ The vaccine series should be continued through completion as necessary.
¥ Booster doses given more frequently than every 5 years are not needed and can increase adverse effects.
Adapted from: Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United
States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2018; 67:1.
Graphic 61087 Version 31.0

Choice of closure method for minor wounds
Use for
Use if
wounds in
wound Use in
hair or
Wound under patients
near
with tension with Pain Speed Difficulty
Wound moist
Method actively (eg, conditions of of of
selection* regions of
oozing hands, associated repair closure technique
the body
blood feet, or with poor
(eg,
over healing ¶
axilla,
joints)
perineum)
Sutures Any laceration Yes Yes Yes Yes +++ Slower +++
through the
dermis,
especially
wounds that
require
careful wound
approximation
(eg,
vermillion
border)
Staples Scalp Yes Yes Yes Yes +++ Fast ++

wounds,
wounds in
noncosmetic
areas,
especially
long, linear
wounds
Tissue Linear No No Δ No ◊ Yes None/+ Fast +

adhesives wounds under
low tension,
skin tears and
flaps in
patients with
fragile skin
(eg, older
adults)
Wound- Linear, low- No No No Yes None/+ Fast +

closure tension
tapes lacerations,
skin tears and
flaps in
patients with
fragile skin
(eg, older
adults)
* Wounds eligible for closure must be appropriately irrigated, debrided of all devitalized tissue and foreign bodies, and have no
signs of infection. Refer to UpToDate topics on minor wound preparation.
¶ For example, diabetes mellitus, peripheral vascular disease, chronic steroid use, or history of keloids. The clinician should use
judgment regarding whether wound closure is preferred to healing by secondary intention in such patients. Factors to take into
account include the size of the wound, age of the wound, degree of wound contamination, and the severity of the underlying
disorder.

Δ Tissue adhesives may be used on hairy areas such as the scalp, if the hair is first trimmed.
◊ Tissue adhesives can be used on hands, feet, or over joints, if the involved area is immobilized with a splint or cast.

Absorbable sutures
Wound
Suture Knot Security Tissue
tensile Anatomic site
material security (days)* reactivity
strength
Fast-absorbing Poor Least 4 to 6 Most Face

gut
Vicryl Rapide Good Fair 5 to 7 Minimal Face, scalp, under cast/splint
Surgical gut Poor Fair 5 to 7 Most Face (rarely used)
Poliglecaprone Good Fair 7 to 10 Minimal Face, consider in contaminated

25 (Monocryl) wounds needing deep closure
Chromic gut Fair Fair 10 to 14 Most Mouth, tongue, nailbed
Polyglactin Good Good 30 Minimal Deep closure, nailbed, mouth

(Vicryl)
Polyglycolic acid Best Good 30 Minimal Deep closure

(Dexon)
Polydioxanone Fair Best 45 to 60 Least Deep closure

(PDS)
Polyglyconate Fair Best 45 to 60 Least Deep closure

(Maxon)
* Retention of 50 percent of tensile strength.
Adapted with permission from: Hollander, JE, Singer, AJ. Laceration management. Ann Emerg Med 1999; 34:356. Copyright ©
1999 The American College of Emergency Physicians.

Nonabsorbable sutures
Wound
Suture Knot Tissue Anatomic
tensile Workability
material security reactivity site
strength
Nylon (Ethilon) Good Good Minimal Good Skin closure

anywhere
Polybutester Good Good Minimal Good Skin closure

(Novafil) anywhere
Polypropylene Least Best Least Fair Skin closure

(Prolene) anywhere. Blue
dyed suture
useful in dark-
skinned
individuals.
Silk Best Least Most Best Rarely used
Adapted with permission from: Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999; 34:356. Copyright ©
1999 The American College of Emergency Physicians.

Needle insertion for eversion technique
For proper healing, the edges of the wound must be everted. To accomplish
this, the needle should penetrate the skin at a 90 degree angle to its surface.

Proper technique for wound edge eversion
The proper technique for everting the edges of a wound is illustrated in the panels on
the left.
(A) The needle has been inserted at a 90 degree angle.
(B) The suture loop is as wide at the base as it is at the skin surface. The width and
depth of the suture loop are the same on both sides of the wound. In the panels on the
right, improper technique has resulted in inversion of the wound edges, which will
interfere with wound healing.
(C) The needle has entered the skin at an angle.
(D) The base of the wound is narrower than the skin surface.

Technique for placing a dermal suture
Absorbable suture material should be used for dermal sutures. The knot is buried by placing the
suture using an inverted technique in which the suture loop begins in the dermis. The needle is
directed toward the skin surface, exiting near the dermal-epidermal junction. It is then inserted
into the opposite side of the wound directly across from the point of exit. The loop is completed
in the dermis at the level where the needle was initially placed.

Subcuticular suture
The suture is anchored at one end of the laceration (A). The plane chosen is either the
dermis or just deep to the dermis in the superficial subcutaneous fascia. While
maintaining this plane, "mirror image" bites are taken horizontally the full length of the
wound (B). The final bite leaves a trailing loop of suture, as shown, so that the knot can
be fashioned for final closure (C). This technique is commonly supplemented with
wound tapes, particularly if there remains some degree of gapping of the edges.
Reproduced with permission from: Trott, AT. Wounds and lacerations: emergency care and
closure, 2nd ed, Mosby Year Book, St. Louis 1997. p.160. Copyright ©1997 Elsevier.

Technique for placing a vertical mattress suture
To place a vertical mattress suture, the needle is initially inserted at a distance from the
wound edge, exiting through the skin on the opposite side, at an equal distance from the
wound edge (far-far). The needle is then rotated 180 degrees in the needle holder and the
direction of the suture loop is reversed. On the return, small bites are taken at the
epidermal/dermal edges (near-near).
Modified from: McNamara R, DeAngelis M. Laceration repair with sutures, staples, and wound
closure tapes. In: Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM
(Eds), Lippincott Williams & Wilkins, Philadelphia 2008.

Technique for placing a horizontal mattress stitch
A horizontal mattress suture can be used to achieve wound eversion in areas of high skin
tension. The needle is introduced into the skin in the usual manner and brought out on the
opposite side of the wound. A second bite is taken along the opposite side, approximately
0.5 cm from the first exit site, and is brought back to the original starting side, also 0.5 cm
from the initial entry point.
Modified from: McNamara R, DeAngelis M. Laceration repair with sutures, staples, and wound
closure tapes. In: Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM
(Eds), Lippincott Williams & Wilkins, Philadelphia 2008.

Technique for closing the corner of a flap: half-buried horizontal mattress
The half-buried horizontal mattress suture combines elements of the horizontal mattress suture with a
dermal skin closure and can be used to approximate the corner of a flap. The needle is introduced
through the skin in the non-flap portion of the wound. In the dermal (or buried) portion of the suture,
the corner of the flap is picked up horizontally through the dermis. The suture loop is completed by
bringing the needle out through the skin on the opposite side of the non-flap portion.

The parotid gland and facial nerve underlie the zygomatic and
cheek areas
The parotid gland and facial nerve branches are superficial to the masseter muscle and
can be damaged in lacerations to the cheek and zygoma that are anterior to the ear.

Contributor Disclosures
David M deLemos, MD Nada que revelar Anne M Stack, MD Nada que revelar Allan B Wolfson, MD Nada
que revelar James F Wiley, II, MD, MPH Nada que revelar
Las divulgaciones de los colaboradores son revisadas por conflictos de intereses por el grupo editorial. Cuando
se encuentran, se abordan examinando a través de un proceso de revisión multinivel y a través de los requisitos
para que se proporcionen referencias para respaldar el contenido. Se requiere el contenido de referencia
apropiado de todos los autores y debe cumplir con los estándares de evidencia de UpToDate.
Política de conflicto de intereses

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24/8/2019 Closure of minor skin wounds with sutures - UpToDate

Reimpresión oficial de UpToDate ®

Cierre de heridas menores de la piel con suturas.

reparación de la laceración con suturas se discutirá aquí. La información sobre la preparación de

Los principios básicos de la reparación de laceraciones no han cambiado significativamente en el siglo

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FISIOLOGÍA Y CURACIÓN DE LAS HERIDAS

● La epidermis y la dermis están firmemente adheridas y son clínicamente indistinguibles, y juntas

● La capa fascial profunda se entremezcla con el músculo y ocasionalmente requiere reparación en

El proceso de curación de la piel ocurre en varias etapas [ 3 ]:

● La formación de colágeno es necesaria para restaurar la resistencia a la tensión de la herida. El

● La contracción de la herida ocurre tres o cuatro días después de la lesión, y el proceso no se

El tratamiento de las laceraciones menores comienza con la evaluación y preparación de la herida. La

● Determinación del mecanismo de la lesión.

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"Cierre" y "Mordeduras humanas: Evaluación y manejo", sección sobre 'Cierre' )

● Heridas punzantes profundas en las que no puede producirse un riego efectivo.

La irrigación de heridas, la extracción de cuerpos extraños y el desbridamiento de tejidos necróticos

● La configuración física de una sutura describe si es monofilamento (Prolene o Ethilon) o

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● El intestino de absorción rápida para el cierre percutáneo de algunas laceraciones faciales es

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● Vicryl o Monocryl es ideal para el cierre dérmico de laceraciones faciales profundas.

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Polydioxanone (PDS) — PDS is a synthetic monofilament polymer marketed as having improved

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Polytrimethylene carbonate (Maxon) — Maxon is a synthetic monofilament. It was developed to

● Polybutester (Novafil) – Polybutester suture is composed of a monofilament synthetic copolymer

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● The needle should penetrate the skin surface at a 90 degree angle.

Alternative suture techniques

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SPECIFIC WOUND SITES

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GUIDELINES FOR SURGICAL CONSULTATION

● Severely contaminated wounds requiring drainage

● Tendon, nerve or vessel damage that requires repair

● Open fractures, amputations, and joint penetrations

● Strong concern about cosmetic outcome by either the patient or family

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● Eyelids – Three days

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UNIQUE PEDIATRIC CONSIDERATIONS

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

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SUMMARY AND RECOMMENDATIONS

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Use of UpToDate is subject to the Subscription and License Agreement.

2. Kanegaye JT. A rational approach to the outpatient management of lacerations in pediatric

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7. Guyuron B, Vaughan C. A comparison of absorbable and nonabsorbable suture materials for

12. Ethicon wound closure manual, Ethicon, Inc. 1998-2000.

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25. HINMAN CD, MAIBACH H. EFFECT OF AIR EXPOSURE AND OCCLUSION ON

Topic 6319 Version 25.0

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Wound management and tetanus prophylaxis

Clean and minor wound All other wounds ¶