SIMPLE WOUND CLOSURE 101:
***DISCLAIMER: Whenever you require medical attention, unless you are a trained medical professional, I would seek out medical help. This information is intended for application during a less ideal situation where medical attention may not be readily available and you need to treat yourself or your loved ones in an emergency.
There are essentially two ways to heal a wound:
1) Primary intent: bringing the wound edges together via bandage, suture, or glue.
2) Secondary intent: allowing the wound to heal “as is” when primary intent is not indicated (such as a very contaminated, dirty wound with multiple deep entry points).
It’s important to close a wound by primary intent for several reasons:
1) Hemostasis (stopping bleeding): because if you lacerated a vessel with your injury, you will need to ligate it somehow. Granted, if you lacerate a major artery, you will just need to apply pressure because ligating it may compromise blood flow to whatever body area it feeds.
2) Infection prevention: since our skin provides a barrier to bacteria, this is pretty obvious why closing a wound is important to restoring that barrier. There are, however, exceptions to this rule when the wound is fairly contaminated, and by closing the wound you may actually trap bacteria under the skin and cause a deeper infection. I will explain how to minimize this chance.
3) Cosmesis: if you have a deep laceration in an area where “looking good” or “not looking like Frankenstein” is important, then repair is indicated.
REPAIR MATERIALS: *Any suture kit will include a needle driver, forceps, and scissors.
1) Tape / Bandage closure: butterfly and steri-strips are excellent ways to close a wound for the simple reason that they require no anesthetic to employ. Their downfall is that they cannot always establish good hemostasis with deeper wounds.
2) Dermabond: a synthetic bio-glue that differs from krazy glue in that it won’t cause tissue damage on contact. Also an excellent choice since it can be used without anesthetics, and can close deeper wounds than bandages alone since you can place it inside the crevices of wounds to get a deeper closure. Again, like bandages, you cannot guarantee hemostasis with this method. Never put a bandage over it, and be careful around the eyes since you can glue an eye shut. This material will dissolve within about 48-72h depending on moisture exposure.
3) Staples: great for quick closure of the skin. Not for use in deeper layers since you never want to have any non-absorbable materials permanently under the skin when you do a wound closure.
4) Sutures: there are different types depending on 2 major parameters:
1. Type: Non-absorbable vs. absorbable – important because surface skin closures for skin repair will be non-absorbable and hence will need to eventually be removed. Absorbable sutures are used for deeper layer closures if you require closure of a deeper layer (if you have a deep wound, you always want to try and repair each layer that was injured such as muscle, fascia, subcutaneous fat, and then skin).
2. Thickness: 0-7.0, 0 being the thickest, 7.0 being very fine (for vascular repairs). Depending on the area of the body you are repairing, you will use different thicknesses like thicker to provide mechanical support over a high stress area like a joint or thinner to reduce scar formation and get finer approximation of the skin edges. For example, on the face you would use a fine thickness like 5.0 or 6.0.
REPAIR TYPE AND LOCATION:
SCALP: Staples or 3.0 non-absorbable suture
FACE: 5.0 (or 6.0 for children’s faces or eyelid), LIP/MOUTH/TONGUE: 4.0 absorbable suture
BODY: 4.0 for most areas
OVER JOINTS (KNEE/ELBOW): 3.0
HANDS: 4.0 – *Make sure in any type of hand laceration repair you stay very SUPERFICIAL to avoid tendon/nerve/vessel damage since there is not much subcutaneous tissue to protect those underlying structures.
REPAIR TECHNIQUE: Simple interrupted suturing technique will never fail you for any skin closure, and is the easiest/most reliable to learn. When I started learning I learned on hot dogs, chicken breasts, any type of meat really. There are lots of You-tube videos out there describing this technique as well as how to tie the knots with instruments.
Since a lot of people will be storing antibiotics as a component of their medical supply kit, it’s important to remember that unless you develop a skin infection (cellulitis – which is red, tender, warm skin after a skin wound), you do not need to routinely give antibiotics after a wound since copious irrigation with simple tap water is sufficient to ensure clean healing. We routinely put bacitracin over the wound once we close it, and that is OK because it is something that can easily be obtained unlike antibiotics. Neosporin is something more common but contains neomycin (antifungal), which some people can get allergic reactions to which is why we use bacitracin in the emergency department and clinic.